Personality Disorders

Question 1

What are the five big personality traits (five factor model)

Answer 1

Use the Mnemonic OCEAN
O - Openness to experience
C - Conscientiousness
E - Extroversion
A - Agreeableness
N - Neuroticism (this is the tendency to experience negative emotions over positive ones)

But bear in mind that the DSM does not base its diagnosis of personality disorders on any particular personality framework.

Question 2

Simply put, when do personality disorders emerge?

Answer 2

When certain personality traits become inflexible, disabling or extreme (TIDE).

Most personality traits are flexible - in contrast, problems can emerge when these traits are rigid and inflexible.

Question 3

What are the three PD Clusters?

Answer 3

Cluster A (“weird” “mad”)
Paranoid
Schizoid
Schizotypal

Cluster B (“wild” “bad”)
Borderline
Antisocial
Narcissistic
Histrionic

Cluster C (“worried” “sad”)
Dependent
Obsessive compulsive
Avoidant

Remember the Party Mnemonic
Cluster A will PaSS on the invite
Cluster B run the risk of being BANHed from future parties
Cluster C the party will be DOA

Question 4

What is the Mnemonic for Borderline Personality Disorder

Answer 4

I DESPAIR

I - identity disturbance
D - dysphoria or chronic feelings of emptiness
E - emotional instability
S - self harming/suicidal tendencies
P - psychotic or dissociative symptoms
A - anger/hostility
I - impulsivity
R - unstable relationships

Question 5

Define personality

Answer 5

An individuals totality of innate, enduring and recognizable patterns of perceiving, relating to and thinking about themselves, others and the environment

Question 6

What is a personality disorder?

Answer 6

(A) An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, manifested in two or more of the following areas:

• cognition
• affectivity
• interpersonal functioning
• impulse control

(B) is pervasive and inflexible across a broad range of personal and social situations.

(C) leads to clinically significant distress or impairment in social, occupational and other important areas of functioning

(D) The pattern is stable and of long duration, and its onset can be traced back at least to at least adolescence or early adulthood

(E) The enduring pattern is not better explained as a manifestation or consequence of another mental disorder

(F) Not attributable to the physiological effects of a substance or medical condition

Question 7

What are the requirements and limits of diagnosing personality disorders before the age of 18?

Answer 7

Antisocial personality disorder cannot be diagnosed before the age of 18

The features must have been present for at least a year

Question 8

What are the DSM5 criteria for Paranoid Personality Disorder

Answer 8

A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving
   him or her.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends
   or associates.
3. Is reluctant to confide in others because of unwarranted fear that the information
   will be used maliciously against him or her.
4. Reads hidden demeaning or threatening meanings into benign remarks or events.
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
   partner

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, or another psychotic disorder and is not
attributable to the physiological effects of another medical condition.

Question 9

What are the DSM 5 criteria for schizoid personality disorder?

Answer 9

A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood and
present in a variety of contexts, as indicated by four (or more) of the following:

1. Neither desires nor enjoys close relationships, including being part of a family.
2. Almost always chooses solitary activities.
3. Has little, if any, interest in having sexual experiences with another person.
4. Tal<es pleasure in few, if any, activities.
5. Lacks close friends or confidants other than first-degree relatives.
6. Appears indifferent to the praise or criticism of others.
7. Shows emotional coldness, detachment, or flattened affectivity.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, another psychotic disorder, or autism
spectrum disorder and is not attributable to the physiological effects of another medical
condition.

Question 10

What are the DSM 5 criteria for schizotypal personality disorder?

Answer 10

A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort
with, and reduced capacity for, close relationships as well as by cognitive or perceptual
distortions and eccentricities of behavior, beginning by early adulthood and present in
a variety of contexts, as indicated by five (or more) of the following:

1. Ideas of reference (excluding delusions of reference).
2. Odd beliefs or magical thinking that influences behavior and is inconsistent with
   subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or
   “sixth sense”: in children and adolescents, bizarre fantasies or preoccupations).
3. Unusual perceptual experiences, including bodily illusions.
4. Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate,
   or stereotyped).
5. Suspiciousness or paranoid ideation.6. Inappropriate or constricted affect.
6. Behavior or appearance that is odd, eccentric, or peculiar.
7. Lack of close friends or confidants other than first-degree relatives.
8. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or
depressive disorder with psychotic features, another psychotic disorder, or autism
spectrum disorder.

Question 11

What are the DSM 5 criteria for antisocial personality disorder?

Answer 11

A. A pervasive pattern of disregard for and violation of the rights of others, occurring since
age 15 years, as indicated by three (or more) of the following:

1. Failure to conform to social norms with respect to lawful behaviors, as indicated by
   repeatedly performing acts that are grounds for arrest.
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
   personal profit or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
5. Reckless disregard for safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent
   work behavior or honor financial obligations.
7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
   mistreated, or stolen from another.

B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or bipolar disorder.

Question 12

What are the DSM5 criteria for borderline personality disorder?

Answer 12

A pervasive pattern of instability of interpersonal relationships, self-image, and affects,
and marked impulsivity, beginning by early adulthood and present in a variety of contexts,
as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal
   or self-mutilating behavior covered in Criterion 5.)
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
   substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
   irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
   temper, constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

Question 13

What are the DSM 5 criteria for histrionic personality disorder?

Answer 13

A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Is uncomfortable in situations in which he or she is not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or
   provocative behavior.
3. Displays rapidly shifting and shallow expression of emotions.
4. Consistently uses physical appearance to draw attention to self.
5. Has a style of speech that is excessively impressionistic and lacking in detail.
6. Shows self-dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances).
8. Considers relationships to be more intimate than they actually are.

Question 14

What are the DSM 5 criteria of narcissistic personality disorder?

Answer 14

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack
of empathy, beginning by early adulthood and present in a variety of contexts, as indicated
by five (or more) of the following

1. Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents,
   expects to be recognized as superior without commensurate achievements).
2. Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal
   love.
3. Believes that he or she is “special” and unique and can only be understood by, or
   should associate with, other special or high-status people (or institutions).
4. Requires excessive admiration.
5. Has a sense of entitlement (i.e., unreasonable expectations of especially favorable
   treatment or automatic compliance with his or her expectations).6. Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own
   ends).
6. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
7. Is often envious of others or believes that others are envious of him or her.
8. Shows arrogant, haughty behaviors or attitudes.

Question 15

What are the DSM 5 criteria for avoidant personality disorder?

Answer 15

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following

1. Avoids occupational activities that involve significant interpersonal contact because of
   fears of criticism, disapproval, or rejection.2. Is unwilling to get involved with people unless certain of being liked.
2. Shows restraint within intimate relationships because of the fear of being shamed or
   ridiculed. ‘
3. Is preoccupied with being criticized or rejected in social situations.
4. Is inhibited in new interpersonal situations because of feelings of inadequacy.
5. Views self as socially inept, personally unappealing, or inferior to others.
6. Is unusually reluctant to take personal risks or to engage in any new activities because
   they may prove embarrassing.

Question 16

What are the DSM 5 criteria for dependent personality disorder?

Answer 16

A pervasive and excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation, beginning by early adulthood and present in a variety of
contexts, as indicated by five (or more) of the following:

1. Has difficulty making everyday decisions without an excessive amount of advice and
   reassurance from others.
2. Needs others to assume responsibility for most major areas of his or her life.
3. Has difficulty expressing disagreement with others because of fear of loss of support
   or approval. (Note: Do not include realistic fears of retribution.)
4. Has difficulty initiating projects or doing things on his or her own (because of a lack of
   self-confidence in judgment or abilities rather than a lack of motivation or energy).
5. Goes to excessive lengths to obtain nurturance and support from others, to the point
   of volunteering to do things that are unpleasant.
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being
   unable to care for himself or herself.
7. Urgently seeks another relationship as a source of care and support when a close relationship ends.
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Question 17

What are the DSM 5 criteria for obsessive-compulsive personality disorder?

Answer 17

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and inteφersonal control, at the expense of flexibility, openness, and efficiency, beginning by
early adulthood and present in a variety of contexts, as indicated by four (or more) of the
following:

1. Is preoccupied with details, rules, lists, order, organization, or schedules to the extent
   that the major point of the activity is lost.
2. Shows perfectionism that interferes with task completion (e.g., is unable to complete a
   project because his or her own overly strict standards are not met).
3. Is excessively devoted to work and productivity to the exclusion of leisure activities and
   friendships (not accounted for by obvious economic necessity).
4. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or
   values (not accounted for by cultural or religious identification).5. Is unable to discard worn-out or worthless objects even when they have no sentimental
   value.
5. Is reluctant to delegate tasks or to work with others unless they submit to exactly his
   or her way of doing things.
6. Adopts a miserly spending style toward both self and others; money is viewed as
   something to be hoarded for future catastrophes.
7. Shows rigidity and stubbornness.

Question 18

Discuss the biopsychosocial management of personality disorders

Answer 18

BIOLOGICAL
- short term therapy recommended
- some PDs are shown to be worsened by pharmacological treatment (BPD)

• antidepressants - can reduce impulsivity and aggression, or be used in the co-morbid treatment of psychiatric disorders
• mood stabilizers - reduce anger, impulsivity, hostility and affect dysregulation
• antipsychotics - help affect dysregulation, impulsivity, cognitive-perceptual symptoms, aggression, impulsivity
• sedative hypnotics - for acute crisis management

PSYCHOLOGICAL
- CBT
- DBT - a type of CBT that is tailored to meet the needs of those with BPD. Balanced acceptance techniques with change techniques. Teaches mindfulness, distress tolerance and emotional regulation.
- Insight-orientated therapy - awareness of the connection between past events and the individuals maladaptive coping styles is encouraged
- supportive therapy - uses reassurance, direction, suggestion and persuasion to relieve symptoms

SOCIAL
- family counselling and support groups
- leaving abusive environments
- child access and custody
- community based resources
- substance use support

Question 19

What is an alternative approach to BPD where dialectical behavioral therapy is unable to be offered?

Answer 19

Based on a newer model of treatment called GPM - good psychiatric management, new focus on treatment strategies that any clinician can follow.

Treatment strategies can be summed up in mnemonic DELAPSE

D - diagnose - and tell the patient about the diagnosis
E - educate - important to explain the interpersonal sensitivity, risk factors and heritability for the disorder and the overall good prognosis
L - life outside of treatment - try to enhance social functioning by encouraging them to pursue activities that they find meaningful as well as develop healthy interpersonal relationships.
A - avoid medications
P - prioritize - most people have many other disorders as well
S - safety plan
E - expect change from them

Question 20

What is the mnemonic that describes the DSM 5 criteria of antisocial personality disorder?

Answer 20

ACID LIAR (3 of the 7)
A - Adult - entry level requirement
C - criminality
I - impulsivity
D - disregard for safety

L - lying
I - irresponsibility
A - aggression
R - remorselessness

Question 21

What are the two clusters of ASPD?

Answer 21

• Cluster B ASPD
• Psychopathy

Question 22

What are the key features of Cluster B ASPD

Answer 22

Those whose bad behavior is due to them externalizing negative emotions
Emotional instability
Sensitivity to rejection, strong reactions to interpersonal triggers
Impulsivity that causes people to lash out

“reactive violence”
Often say that their impulsive or violent acts are related to intense feelings of sadness, anger or irritability that they cannot cope with and need to do something - externalize

The aggressive act is associated with a feeling of power or emotional thrill that numbs the negative feelings that the patient was wanting to deal with

Chronic feelings of emptiness, alienation, feelings of boredom
Also often have poor social skills and grasp of social structures. They feel lonely and isolated.