personality disorders Flashcards
what are the 4 ICD-10 criteria for personality diorder
- affects more than one domain of functioning: behaviour, thinking, occupational and social functioning.
-Significant Disharmony: There’s a significant disharmony in attitudes and behaviors, often manifesting in multiple areas (e.g., affective, arousal, impulse control) that deviate from cultural norms and expectations.
-Enduring and Pervasive: These patterns are enduring, pervasive, and inflexible, manifesting across a wide range of personal and social situations.
-Onset: The onset can be traced back to adolescence or early adulthood.
-Distress and Impairment: These patterns lead to personal distress or significant impairment in social, occupational, or other important areas of functioning.
Not Due to Other Mental Disorders: The enduring patterns are not better explained by another mental disorder.
Not Due to Substance Use or a Medical Condition: The behaviors are not due to substance use (such as drugs or alcohol) or a medical condition (such as brain injury).
describe the classification of personality disorders based on ICD-10 and DSM-5? what are some of the problems with this classification system
CLUSTER A:
*ICD-10 - paranoid, schizoid
*DSM-5 - paranoid, schizoid
CLUSTER B:
*ICD-10 - emotionally unstable, dissocial
*DSM-5 - borderline, antisocial
CLUSTER C:
*ICD-10 - anxious (avoidant)
*DSM-5 - avoidant
Problems:
-There is a lot of overlap in the criteria.
Individual PD disorder can present differently in different people.
-Poor coverage – the most common PD diagnosis is not specified. Somebody has traits from many different diagnoses and so can’t meet criteria for one type of PD. therefore it’s called not otherwise classified
-There is waxing and waning of the symptoms. They make come in episodes (sometimes you present symptoms that is on and off, so can’t diagnose as its not persistent- not aligning with diagnostic criteria)
how do we assess personality disorders
Interview based measures:
Long, semi-structured interviews, questions about individual traits with follow up questions, ask question about paranoia and say that other people said you may have paranoia, allowing for a definitive PD diagnosis
IPDE (international personality disorder examination) is mainly used in the UK.
Long interview.
Self-report measures:
Questionnaires with the patient about different PD traits
Directly with the patient and you help them rate it
what are some of the negative impacts/ effects as a result of Personality Disorder interms of burden
Higher mortality rates. Up to 20 years younger
More prone to accidents.
Why may this be the case? They may have traits that make it more likely that they take risks, do more dangerous things, are less likely to have supportive relationships, more likely to use substances, behaviours associated with chaotic lifestyle.
PD are more likely to have depression, anxiety, substance use disorder.
Poor treatment outcome -> may not show up to appointments less likely to be complaint with medication.
Increased service utilisation -> present out of hours, police, emergency, costs a lot.
Antisocial behaviour -> some PD increase this type of behaviour
Deliberate self-harm -> some increase likelihood of self-harm. Managing emotions, communication distress, taking control of the situations.
Which cluster is associated with increased antisocial behavior and which one is linked with decreased antisocial behavior?
increased antisocial behaviour - CLUSTER B
(cluster B: 10x more likely to have a criminal conviction and 8x more likely to have spent time in prison - associated with violent acts like vandalism and robbery)
decreased antisocial behaviour - CLUSTER C
(cluster C is less likely to be violent but more likely to have obsessive-compulsive personality disorder.)
(Cluster a: in adolescence associated with burglary and threatening behaviour)
What factors are associated with increased risk of violence?
*Poor impulse control – not thinking about consequences and not caring.
*Affect regulation – a way to manage difficult emotions.
*Narcissism– not really caring about the impact on others.
*Paranoid- suspicious on others
what 2 personality disorders are associated with increased risk of violence? what are some features of borderline PD?
antisocial and borderline
borderline features:
*unstable relationships
*impulsivity
*difficulty controlling anger
*recurrent self harm/suicidal behaviour
How outcomes can be measured to ensure that treatment is working and what are some of the methodological problems associated with this?
-measure symptoms , quality of life, social functioning, check if they still meet the criteria
problems:
*lengthy period of research and getting funding is hard
*some may reject treatment
*what symptoms should be measured as there are multiple associated with a single PD (there are so many symptoms so a comprehensive analysis of which symptoms is causing greatest disability should be measured)
*some symptoms may improve, while others get worse
What is the evidence for treatment outcomes (what works and mental health literature), what are the two manualised treatments models from mental health literature and their outcomes?
-What works literature:
to do with criminal legal system
*only looks at prisoner population- Criminal justice literature around offending behaviour programmes, majority of people who engage in offending behaviour have PD
*evidence shows that CBT helps to prevent relapse, however, some individuals may drop out of treatment
*Democratic therapeutic community -> community with therapeutic focus, more responsibility for prisoners, community meetings, smaller group therapies’.
-mental health literature
*looks at non-offenders and usually those with borderline PD
2 models:
*Mentalization-based treatment (MBT)
is a type of therapy designed to help people understand the thoughts, feelings, and intentions behind their own and others’ actions. It’s especially helpful for those with personality disorders, such as Borderline Personality Disorder (BPD), where interpreting mental states can be challenging.
mentalization is about understanding the mental states drives behaviours thus
MBT helps individuals improve their ability to mentalize, particularly in the context of relationships. People with personality disorders might find it hard to understand their own emotions or predict how others feel, leading to misunderstandings and conflicts.
Therapy provides a safe and supportive environment where individuals can explore their thoughts and feelings without judgment.
Through conversations and specific exercises, individuals are guided to reflect on their own mental states and those of others. This process helps them understand the links between thoughts, feelings, and behaviors, reducing impulsivity, and better emotional regulation,
Randomised controlled trial looked at MBT vs normal treatment and after 5 years they found:
reduction in suicide attempts, reduced inpatient admission, reduced need for medication, fewer people meet the criteria; and most of the improvements are persistent
*Dialectical behaviour therapy (DBT):
Dialectical behavioural therapy works on managing intense emotions and is particularly effective for treating borderline personality disorder.
DBT emphasises being present and fully aware in the moment without judgement. This helps individuals recognise and accept their thoughts and feelings, fostering a deeper understanding of themselves and their surroundings.
DBT teaches strategies to identify, understand, and manage intense emotions more effectively. This includes increasing positive emotional experiences. Interpersonal Effectiveness: This aspect of DBT helps individuals develop healthier ways to interact and communicate with others.
Randomised Control Trial of DBT vs expert treatment found after a one year follow up:
-they were half as likely to make a suicide attempt
-reduced A&E attendance and hospitalisation
-half as likely to drop out of treatment
what are some of the common factors (similarities between them) of these treatment models
Consistent approach- who sees the patient, individual or group, what time.
Transparent – patient knows what to expect they know the model; they know the length of treatment and what they expect to change and their responsibility in terms of engaging with treatment.
Treatment alliance -> it helps the individual think you have an interest, and are not judgmental. You need to maintain it throughout.
Consistency -> these models are re-manualized to make clear what the approach is, what needs to be done, and techniques, important to stick to the model.
Validation -> recognising that the patient’s experience is valid.
Motivation -> you need to build motivation.
Metacognition -> most evident in MBT, building a culture where it is okay to not know the answer and reflect.
Some studies have shown that 10% of people can get worse, may not be ready, may not be motivated, can be destabilised, and may reactivate trauma.
You need to show them you have a shared understanding of what the problem is. They may pseudo-engage.
Matching treatment to individual is very important- do they have the time; do they want to?
what is risk need responsivity?
You need to match the treatment to the individual.
Risk principle -> if someone is very risky, more intense treatment may be needed.
Need principle -> treatment must target needs linked to violence risk based on their specific trait.
Responsivity principle -> must accommodate to their characteristics. Individual factors that may make the treatment difficult or easy e.g., look at their cognitive abilities and levels of motivation
when is treatment best
-Best evidence suggests that the best treatment that works most effectively is when treatment is very intense in the beginning and then there is less intense
-Sometimes people need individual work to get them ready to be in a group. Or vice versa they may need group work and the individual work to address certain things.
should treatment be used for PD and give examples of medications that can be used for management?
There is no evidence based for drug treatment.
In prison: individuals with PD are on medication for psychiatric conditions.
They’ll see a GP in prison, but cannot provide resources to provide psychological treatment, so they prescribe mood stabilisers and antipsychotics; none of them work.
BPD -> mood stabilisers may work as it is a bit like bipolar.
Paranoia -> a bit like schizophrenia so antipsychotics can work. CLUSTER A (schizoid)
But there is lack of treatment
There is some utility in prescribing short-term antihistamines or antipsychotics but only short term, don’t add things before stopping things that are ineffective
what is etiology of PD
- Genetic Factors
Heritability: Research suggests that personality disorders, like many other mental health conditions, can run in families, indicating a genetic component. For example, studies of twins have shown that there is a significant heritable component to disorders such as borderline personality disorder (BPD).
Specific Genes: While no single gene is responsible for personality disorders, variations in multiple genes, especially those involved in neurotransmitter systems, may increase susceptibility.
2.neuroanatomy differences
* Frontal Lobes
Function and Structure: The frontal lobes, particularly the prefrontal cortex, play a crucial role in decision-making, impulse control, and moderating social behavior. Individuals with certain personality disorders, such as borderline personality disorder (BPD), often show reduced volume and activity in this area, which may contribute to difficulties in controlling impulses and regulating emotions.
*Amygdala
Emotion Processing: The amygdala is central to processing emotions, especially fear and aggression. Studies have shown that individuals with personality disorders, especially BPD, may have an overly reactive amygdala, leading to heightened emotional responses to perceived threats or negative stimuli.
3.psychological factors
Trauma and Stress: Early life trauma, such as abuse, neglect, or loss, is a significant risk factor for the development of personality disorders. Chronic stress or traumatic experiences can impact personality development and coping mechanisms.
describe characteristics of different PD (borderline, antisocial and narcissistic)
*Antisocial Personality Disorder
-failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest
-irritability and aggressiveness, as indicated by repeated physical fights or assaults
-lack of remorse, as indicated by being indifferent to or rationalising having hurt, mistreated, or stolen from another
*Borderline Personality Disorder
-unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation
-chronic feelings of emptiness
-inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
*Narcissistic Personality Disorder
-has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognised as superior without commensurate achievements)
-lacks empathy: is unwilling to recognise or identify with the feelings and needs of others
-shows arrogant, behaviours or attitudes
