Personality disorders Flashcards
1
Q
what is personality ?
A
- the collection of traits that we develop as we grow up which makes us individualized and governs how we think, feel and behave
- it influences how we develop opinions, relate to others, and respond to social situations
- not fully developed until adulthood
- personality traits tend to be stable across multiple domains of behavioural and psychological functioning
2
Q
diagnosing personality disorders ICD0-1
A
- does the individual display features of a personality disorder
- are they pathological, pervasive and persistent - identify the severity of the disorder
- are there traits in the personality makeup of this individual which contribute to the expression of the personality dysfunction
- domain traits are dimensional and correspond to the underlying structure of personality functioning. they are not diagnostic categories. they exist on a continuum with the normal personality - is there evidence of at least 5 borderline features requires for addition of the boderline pattern qualifier
3
Q
step 1 in diagnosing personality disorder - identify pathology
A
the pathology lies in:
1. cognition - experience and thoughts about self, world and others
- emotional management and expression
- behaviour - maladaptive patterns in interpersonal relationships and psychosocial function across a wide range of situations e.g occupational, familial, social and education
- generally manifests early, elements may first appear in childhood or adolescence and continue to manifest into adulthood. but they may have late onset e.g after loss of social supports which may have helped compensate for personality disturbance
- features may also be prominent in early adulthood but have largely disappeared by middle age
4
Q
step 2 in diagnosing personality disorders - identify severity
A
1) level of difficulty in interpersonal relationships
2) level of dysfunction in familial, social, occupational, and other roles
3) risk of harm posed to self and others
- mild, moderate and severe
5
Q
step 3 in diagnosing personality disorders - look for and identify domain traits
A
- negative affect
- emotional lability
- anxiousness
- depression
- anger
- self-loathing - Dissocial
- callousness
- grandiosity
- manipulative
- lacking empathy
- hostile
- aggressive - Anakastic
- rigid perfectionism
- rules and obligation
- perserveration
- narrow focus on control of behaviour of self and others - Detachment
- restricted affectivity
- withdrawl
- intimacy avoidance - Disinhibition
- impulsivity
- distractibility
- irresponsibility
- reckless
6
Q
step 4 diagnosing personality disorder - the borderline pattern qualifier
A
may be applied to individuals who meet 5 (or more) of the following criteria:
- a pervasive pattern of instability of interpersonal relationships and self-image
- frantic efforts to avoid real or imagined abandonment
- identity disturbance - unstable sense image and or sense of self
- A tendency to act rashly in states of high negative affect leading to potentially self- damaging behaviour
- recurrent episodes of self harm
- emotional instability due to marked reactivity in mood
- Chronic feellings of emptiness
- inappropriate intense anger or difficulty controlling anger
- transient dissociative symptoms or psychotic like symptoms in situations with high affective arousal
-* often associated with severe personality disorder
- associated with disinhibited, dissocial and negative affect domains but not detached or anakastic
7
Q
personality Difficulty
A
- subthreshold diagnosis i.e not a mental disorder per se
- characterized by some personality difficulties with emotion cognition and behaviour. these may be expressed intermittently or at a low level of intensity
- these difficulties are associated with problems in function but the latter are not sufficiently severe to cause notable disruption in social, occupational, and or interpersonal relationships
- may be coded with domain trait qualifiers
8
Q
epidemiology of personality disorders
A
- depends on diagnostic criteria used
- community prevalence rates around 2-14% (various studies
— up to 20% of primary care patients
— 40% of psychiatric patients (increases to 70% if you include personality difficulty) - 50% of psychiatric inpatients qualify for a diagnosis of PD
- amongst male prisoners-rates of about 60%
9
Q
etiology of personality disorders
A
- Biological
- serotonin transporter genes
- dopamine transporter genes
- heritability:
—- personality has 30% heritability, 80% of attachment style
- evidence for heritability of cluster B personality disorder
- familial relationship between: schizotypal and schizophrenia - Psychological: upbringing
- neglect/abuse-emotional, physical or sexual - Social: family situation-abuse, violence, drugs/alcohol
10
Q
diagnosis of personality disorder: clues in the psychiatric history
A
- psychiatric history
- self harm and suicide attempts - Family history
- relationships within the family
- family history of mental health problem/substance use/suicide - Personnel history
- childhood experiences within
– family - neglect/ abuse
— school – bullying/abuse
- relationships with teachers/ peers
- romantic relationships-history of difficulties
- occupation history - left / asked to leave multiple jobs. difficulties with employers/coworker
- premorbid personality
— history of mental difficutlies since childhood. unstable emotions
- substance use
- forensic history - evidence of lack of empathy, remorse, agression
11
Q
diagnostic dilemmas in personality disorders
A
- bipolar affective disorder is characterized by alternating mood states. Similar extreme moods may be also seen in some personality disorders e.g those with prominent negative affectivity or a borderline qualifier
- to diagnose BPAD the depression and hypomania/mania need to comply with the diagnostic criteria especially regarding the duration of symptoms
– depression > or equal to 2 weeks
– hypomania > or equal to 4 days
– mania > or equal to 1 weeks - however in Personality with a borderline qualifier mood states can change over hours
- impulsivity is a characteristic feature of some personality disorders especially those with prominent fearures of disinhibition or with a borderline qualifier. Impulsivity can lead to the same risky behaviours seen during hypomania/mania ie drug and alcohol use, overspending, shop lifting, gambling, indiscriminate sexual intercourse
- ADHD is associated with higher incidence of personality disorders. Impulsivity, anxiety, substance misuse, relationship difficulties may be features of both, making the diagnosis difficult
12
Q
Co-morbidities associated with personality disorders
A
- adjustment disorder
- depression
- anxiety/panic disorders
- eating disorders
- substance use
- bipolar disorder
- PTSD
**cannot diagnose a personality disorder together with a major psychiatric disorder at the same time
13
Q
what transference and countertransference problems do you think might arise while treating people with personality disorders
A
counterference (a therapist redirection of feelings towards a patient or becoming emotionally entangled with them)
- PD patients evoke strong reactions:
1. rejection
2. attraction/ wanting to help/ rescue
3. disgust
4. frustration
5. Anger
6. Helplessness
*Personality disorder patients are often undertreated
14
Q
treatment of personality disorders - biological
A
- main indication for use in comorbid mental illness
- off-label use in the absence of comorbidity;
1. antipsychotics (low dose) - some benefit emotional instability and paranoia
2. Antidepressants - efficacy is frequently low in personality disorders and prescription of antidepressants should not be routine - however in some they may help with negative affectivity, esp low mood and anxiety. Some SSRIs may help reduce impulsiveness and aggression
3. mood stabilizers - for affective instability or impulsivity especially those with borderline qualifier
15
Q
treatment of personality disorders - psychological
A
- individual therapy
- CBT
- Psychoanalysis
- schema-focused; cognitive therapy aiming to change collections of unhelpful beliefs
- psychodynamic; how past experiences affect
- cognitive analytical therapy; a way to recognise and change unhelpful patterns in relationships and behaviour
- group therapy: DBT in therapeutic community, psychodynamic group therapy
- DBT
— designed for patient with chronic suicidal ideation and self harm
—- aims to create a life worth living
— skills aquisition
— 1:1 psychotherapy
– group social skills
— mindfullness
– phone calls
