personality disorders

Question 1

why does experience matter?

Answer 1

• diversity of experience across individuals
  –> beware of stereotypes
• need to get away from stigmatising representations
  –> dangerous
  –> willful
  –> self-obsessed
• high prevalence of personality disorder diagnosis

Question 2

experiences of personality disorder

Answer 2

• multiple voices and perspectives in your head
• positive and negative personal attributions

Question 3

emotional and interpersonal sensitivity

Answer 3

• conditions and core beliefs
  –> condition = what i do impacts people’s interpretations
• core beliefs
  –> regardless of what i do and say people with think of me in this way
  –> unconditional
• things can act as triggers to certain emotional responses

Question 4

interpersonal relationships and lack of trust

Answer 4

• linked to personality disorder
• high lack of trust
• less relationships
• those with fear of abandonment may cling onto current relationships regardless of the quality
• born out of past experiences and maintained by current behaviour

Question 5

diagnosis can be paradoxical

Answer 5

• some people feel written off after diagnosis (problem person with no chance of change)
• for some it can be a huge relief
  –> recognises there is a problem
• lack of clarity in diagnosis and treatment can be frustrating too

Question 6

how do we define personality?

Answer 6

• long term
• not mood
• collection of traits across multiple situations, contexts and time
• tendency towards patterns of behaviour, emotion, cognition and interaction that come through regardless of the situation we are in
  –> trait not state

Question 7

influence of personality

Answer 7

• can have positive influence if it fits the demands of the world
• can be negative influence if it does not fit the world around us or its rules

Question 8

personality problems in context

Answer 8

• sometimes it doesn’t fit the context
• sometimes it doesn’t fit any context
• an aggressive nun and an anxious surgeon can both be problems due to the context

Question 9

socio-political perspectives of personality disorders

Answer 9

• a way of saying ‘that person is weird’?
• a way of saying ‘that person is not acceptable?
• a way of saying ‘that person is not within social bounds’?
• a way of saying ‘that person is not diagnosable, but it pretty close and will have an issue soon’?

Question 10

early definitions of borderline personality disorders

Answer 10

• early definitions were about being borderline psychotic
• not in an episode yet but might be soon so lets act now
  –> behaviour as changed

Question 11

the medico-legal perspective

Answer 11

• are we entitled to jail/detain people on the basis of what we believe they might do?
• what if we do not and they go on to offend?
• levels of caution and politics can still get in the way

Question 12

categories vs dimensions

Answer 12

• personality varies along dimensions
• are personality disorders just clumps at either extreme end?
• or are those with a disorder those clumped at just one end
• efforts to define disorders used to assume that it was simple categories (DSM-IV)
  –> but now a more mixed approach is used (DSM-5)

Question 13

DSM-IV definition of personality disorder (1994)

Answer 13

• An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture

Question 14

DSM-5 definition of personality disorder (2013)

Answer 14

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits

Question 15

criteria for DSM-5 (2013) definition

Answer 15

• impairments in self or interpersonal functioning
• one or more pathological personality trait domains or trait facets
• stable across times and situations
• impairments are not better understood as normative for developmental stage or socio-cultural environment
• not directly due to substance or medication

Question 16

issues with DSM-5 (2013) personality disorder

Answer 16

• defining ‘significant’ and ‘normative’
• clinicians tend to use diagnosis regardless of substance use, nutrition issues, injury etc…

Question 17

similarities and differences between 1994 and 2013 definitions

Answer 17

• both have the same 10 personality disorders
• But DSM-5 included research proposals to allow for future potential change in diagnosis
  –> level of personality functioning
  –> personality trait domains and facets
  –> personality disorder types

Question 18

alternative DSM-5 proposal for diagnosis

Answer 18

• look at personality functioning and the severity of impairment
• look at 5 different personality traits (negative and core) and rate them on a four-point dimensional scale
• the scores relate to personality types
• then the diagnosis of a personality disorder type is linked to the ratings on impairment and on personality traits

Question 19

the 5 trait domains in the DSM-5 alternative proposal

Answer 19

1. negative affectivity
2. detachment
3. antagonism
4. disinhibition
5. psychoticism

Question 20

the 6 personality disorder types

Answer 20

1. antisocial personality disorder
2. avoidant personality disorder
3. borderline personality disorder
4. narcissistic personality disorder
5. obsessive compulsive personality disorder
6. schizotypal personality disorder

Question 21

justification for the proposed changes

Answer 21

• poor conceptualisation and low prevalence of diagnoses (paranoid, schizoid, histrionic and dependent)
• need for scores on measures of personality functioning
  –> indicate the presence of a personality disorder
• scores on specific personality traits/facets
  –> e.g. detachment; disinhibition; antagonism
  –> tells you which personality disorder you have

Question 22

summary of changes of DSM-4 to DSM-5

Answer 22

• DSM-5 maintains diagnostic criteria from DSM-4 and continues to define personality disorders on categorical basis
• but it discusses a dimensional approach to the diagnosis of personality disorders and encourages further research on these

Question 23

key issues in reaching diagnosis

Answer 23

• long-term presentations
• independent of biological factors
  (e.g., drug use; starvation; actual threat)
• usually do not diagnose in childhood and adolescence
• diagnoses cannot be made at a single clinical meeting

Question 24

the different personality disorder clusters

Answer 24

1. cluster A
2. cluster B
3. cluster C

Question 25

personality disorders in cluster A

Answer 25

• paranoid
• schiziod
• schizotypal

Question 26

personality disorders in cluster B

Answer 26

• antisocial
• histrionic
• narcissistic
• borderline

Question 27

personality disorders in cluster C

Answer 27

• avoidant
• obsessive-compulsive
• dependent

Question 28

cluster A

Answer 28

• odd and eccentric
• personality disorders (PD) with some schizophrenia-like features
  –> lacking active symptoms, such as hallucinations
• paranoid PD
  –> pattern of distrust and suspiciousness
  –> resistant to challenge by others
• schizoid PD
  –> pattern of separation from social relationships
  –> limited emotional expression and experience
• schizotypal PD
  –> pattern of eccentric ideas, magical thinking

Question 29

cluster B

Answer 29

• dramatic/erratic
• personality disorders characterised by impulsive/erratic and/or self-centred behaviours, emotions and thinking
• antisocial PD
  –> pattern of disregard of other’s rights
  –> strong links to conduct disorders and criminality
  –> selfishness and lack of empathy
• borderline PD
  –> pattern of unstable relationships, mood, and behaviour
  –> efforts to control emotion (e.g., drink; self-harm) and avoid rejection

Question 30

cluster B continued

Answer 30

• narcissistic PD
  –> pattern of overestimation of own abilities and accomplishments
  –> pervasive need for admiration, while not caring about others
  –> anger when not recognised for their ‘specialness’
  –> fragility of self-esteem
• histrionic PD
  –> attention-seeking, need to be the centre of attention
  –> dramatic behaviour, undue emotional expression
  –> exaggerated presentation

Question 31

cluster C

Answer 31

• personality disorders characterised by anxiety that is lifelong
  –> not related to any trigger
• avoidant PD
  –> pattern of social avoidance
  –> inadequacy, and sensitivity to others’ views of them
• dependent PD
  –> pattern of dependence on others’ care
  –> submissive, clinging, seek others’ approval/support
• obsessive-compulsive PD
  –> excessive perfectionism (focus on doing the task: forget the goal)
  –> need for order, patterns and control

Question 32

summary of diagnostic clusters

Answer 32

• three broad clusters with ten diagnoses:
  1. odd/eccentric (A)
  2. dramatic/erratic (B)
  3. anxious/fearful (C)
• big overlap across clusters and diagnoses – it is rare for people to only meet one personality disorder criteria
• expected to identify which cluster a diagnosis belongs to but not the criteria for each personality disorder

Question 33

prevalence

Answer 33

• focus on prevalence not incidence
  –> no clear onset
• rate depends on how thorough the assessment is
  –> many are weak and overestimate prevalence
  –> gender bias in diagnosis?
• most reliable studies suggest rate of 10-15% for all personality disorders
  –> most common = borderline, schizotypal, antisocial and obsessive-compulsive
• figure vary hugely

Question 34

comorbidity

Answer 34

• high rate of co-occurring personality disorders
  –> likely to meet criteria for more than one

Question 35

mental health issues comorbid with personality disorders

Answer 35

• depression
• substance misuse
• panic disorder
• PTSD
• social phobia
• eating disorders
• neurodiversity

Question 36

is personality disorder for life?

Answer 36

• old viewpoint
  –> yes but the symptoms tend to fade after 40 years of age
  –> untreatable
• new viewpoint
  –> no as a large number of cases are not diagnosable a few years later
  –> some treatments are efficient and helpful

Question 37

aetiology framework

Answer 37

• biological/neurological factors
• personality disorder
  –> specific personality disorders
• environmental factors

Question 38

biological/neurological factors underpinning cluster A PDs

Answer 38

general factors:
- genetics
- enlarged ventricles
- enhanced startle response
- cognitive deficits
- lack of link to specific PDs

Question 39

environmental factors underpinning cluster A PDs

Answer 39

general factors:
- parental relationships
- rejection
- abuse

Question 40

biological/neurological factors underpinning cluster B PDs

Answer 40

1. antisocial PD
   - childhood conduct disorder
   - genetics
   - low anxiety
   - weak fear conditioning
2. borderline
   - genetics
   - limbic system dysfunction

Question 41

environmental factors underpinning cluster B PDs

Answer 41

1. antisocial
   - modelling
2. borderline
   - trauma
   - emotional invalidation
3. narcissistic
   - doting parents?
4. general factors
   - our experience drives schema development

Question 42

biological/neurological factors underpinning cluster C PDs

Answer 42

1. avoidant
   - genetics
2. general factors
   - physiological predisposition to anxiety?

Question 43

environmental factors underpinning cluster C PDs

Answer 43

1. avoidant
   - childhood negative experiences
2. dependent
   - fear of rejection
3. general factors
   - our experience drives schema development

Question 44

limited evidence for most disorders

Answer 44

• range of clinical suggestions about treatment
  –> all evidence is psychological and not neurological
• Beck et al. (2016) provide a range of clinical guidance based on CBT
• some evidence for other, more integrative therapies
  –> cognitive analytic therapy (Ryle)
  –> mentalization-based treatment (Bateman)

Question 45

the best 2 distinct treatment approaches

Answer 45

1. Dialectical behaviour therapy (Linehan, 1993)
2. Schema therapy (Arntz & van Genderen, 2009; Young, 2003)

Question 46

Dialectical behaviour therapy (Linehan, 1993)

Answer 46

• behaviourally-based programme
• managing impulsive behaviours and thought processes in borderline PD
• elements of contingency management, operant conditioning, mindfulness etc…
• very resource intensive
• designed to manage symptoms effectively, but not to remove the cognitions

Question 47

Schema therapy (Arntz & van Genderen, 2009; Young, 2003)

Answer 47

• addresses the cognitions that underpin the behaviours and emotions
  –> core beliefs/schemas
• a lot of exploration of how those beliefs developed, and modification of the beliefs and emotions
  –> very commonly related to long-term responses to trauma and experience of being parented inadequately

Question 48

most common personality disorder?

Answer 48

borderline personality disorder
- field focuses on this type

Question 49

summarise

Answer 49

• PDs are not well defined
• diagnoses still bein refined
• causes are more linked to developmental experiences than about neurological factors
• effective treatments for borderline PD
• limited understanding of factors underpinning PDs