Personality Disorders Flashcards
ICD classification of personality disorders
- Emotionally unstable (inc borderline)
- Dissocial
- Histrionic
- Anxious (avoidant)
- Dependent
- Schizoid (schizotypal recognised as spectrum of schizophrenia)
- Paranoid
- Anankastic
Implications of personality disorder
- Higher morbidity and mortality (suicide and homicide)
- Shorter life expectancy
- Difficulties in interpersonal relationships –> poor quality care
- Smoking, alcohol and drug misuse
Assessment of personality disorders
- Standardised assessment of personality - abbreviated scale
- Iowa Personality disorder screen
Key symptoms of borderline personality disorder - emotional
Emotional:
* Heightened emotional sensitivity
* Impaired emotional regulation
* Slow return to baseline from emotionally heightened status
* Chronic feelings emptiness
* Difficulty to control angry feelings
Key symptoms of BPD - interpersonal
- Abandonement fears
- Relational instability
Key symptoms of BPD - behavioural
- Impulsive behaviours (eg binge eating, reckless spending)
- Self harming
- Suicidal behaviours
Cognitive symptoms of BPD
- Identity disturbance
- Transient psychotic symptoms
- Dissociative experiences
Factors influencing development of BPD
- Genetic factors
- HPA axis - when activated in response to chronic stress eg childhood abuse, function can be compromised
- Neurotransmitters and endogenous opioids - altered oxytocin, opioids and vasopressin. Serotonoergic function in impulsive aggressive
- Structureal and functional brain changes - amygdala, hippocampal. Frontolimbic dysfunction.
- Developmental theories
- Attachment theory
- Adverse events
What is developmental theory?
- Children exposed to emotionally invalidating environment can develop BPD
- Need attachment, containment, communication, inclusion and agency for healthy personality formation
- Disruption to these in form of abuse, neglect, deprivation or loss can result in BPD
What is mentalising theory?
- Capacity to make sense of ourselves and of others in terms of mental states
- If parents emotionally under involved with children this impairs social cognitive capacity and undermines experience in own mind - misread own mind and minds of others.
Adverse events and BPD
- History of sexual abuse is common in BPD
- Neglect by caregivers
- Parental responsiveness following reports of abuse (believing, protecting and not expressing high levels of anger)
Screening for BPD
- McLean screening instrument for BPD
Management of paracetamol overdose
IV n-acetyl cysteine
Features of overdose of paracetamol which dictate whether can treat with medication or not
- Amount taken - paracetamol level blood tst
- Staggered overdose or taken at once (if staggered, need NAC)
Questions to ask to assess intention of overdose? What can indicate level of suicidality?
- What did you want to happen after you took the tablets?
- Had you planned this in advance?
- Preperations in place for attempt - eg stockpiling meds
- Final acts - Had you written a note? Made a will? Said goodbyes? Arranging care of children/pets?
- Help seeking
- Attempts for overdose to be concealed
- How do you feel now you are awake? Do you feel regret?
- Had you been drinking alcohol or doing illicit drugs at the time?
- Do you want to try and do that again?
Key features or symptoms of EUPD
- Intense unstable relationships
- Unclear sense identity
- Impulsivity
- Unpredictable affect
- Thoughts, threats or acts of self harm
- Unpredictability
Aetiologies of personality disorders
- Childhood development - insecure attachments, trauma, inconsistent parenting
- Genetic
- Psychodynamic theories - maladaptive or primintive defence mechanisms
- Cognitive behavioural theories - development of maladapative schemata/core belieds derived from early experiences
Management recommendations for EUPD
Psychoeducation
Psychotherapy mainly:
* Dialectical behavioural therapy
* Therapeutic community
* Cognitive analytic therapy
* Psychodynamic therapy
Cluster A personality disorders
- Paranoid
- Schizoid
- Schizotypal
Cluster B personality disorders
- Antisocial
- Histrionic
- Narcisstic
- Borderline (EUPD)
Cluster C personality disorders
- Avoidant
- Dependent
- Obsessive compulsive/Anankastic
Cluster A - paranoid personality type
- Hypersensitivity and unforgiving attitude when insulted
- Unwarranted tendency to question the loyalty of friends
- Reluctant to confide in others
- Preoccupation with conspirational beliefs and hidden meaning
- Unwarranted tendency to perceive attacks on character
Schizoid Cluster A personality traits
- Indifference to praise and criticisim
- Preference solitary actvities
- Lack interest in sexual relationships
- Lack desire companion
- Emotionally cold
- Few interests
- Few friends/confidants other than family
Schizotypal Cluster A traits
- Ideas of reference (differ from delusions in that some insight)
- Odd beliefs and magical thinking
- Unusual perceptual disturbances
- Paranoid ideation/suspiciousness
- Odd/eccentric behaviour
- Lack close friends other than family
- Inappropriate affect
- Odd speech without being incoherent
Antisocial cluster B personality
- Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest
- More common in men
- Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure
- Impulsiveness or failure to plan ahead;
- Irritability and aggressiveness, as indicated by repeated physical fights or assaults
- Reckless disregard for the safety of self or others
- Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations
- Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Histrionic personality traits Cluster B
- Inappropriate sexual seductiveness
- Need to be the centre of attention
- Rapidly shifting and shallow expression of emotions
- Suggestibility
- Physical appearance used for attention seeking purposes
- Impressionistic speech lacking detail
- Self dramatization
- Relationships considered to be more intimate than they are
Narcissistic personality disorder cluster B
- Grandiose sense importance
- Preoccupation with fantasies of unlimited success power or beauty
- Sense of entitlement
- Advantage of others to achieve own needs
- Lack empathy
- Excessive need for admiration
- Chronic envy
- Arrogant
Cluster C - obessive compulsive
- Occupied with rules, lsist, order
- Perfectionism - hampers completing tasks
- Rigid about morality, ethics and values
- Unwilling to pass work/tasks on to others unless surrender to their way of doing things
- Stingy spending style
Avoidant cluster C traits
- Avoidance of occupational activities that involve interpersonal contact - fear criticism or rejection
- Unwillingness to be involved unless certain of being liked
- Pre-occupied with ideas of being criticised or judged in social situations
- Restraint in intimate relationships
- Reluctant to take personal risks due to fear embaressment
- Views self as inept and inferior to to others
- Social isolation but crave social contact
Dependent personality type cluster C
- Difficulty making everyday decisions without excessive reassurance from others
- Need for others to assume responsibility for major areas of their life
- Difficulty in expressing disagreement with others due to fears of losing support
- Lack of initiative
- Unrealistic fears of being left to care for themselves
- Urgent search for another relationship as a source of care and support when a close relationship ends
- Extensive efforts to obtain support from others
- Unrealistic feelings that they cannot care for themselves
Differentials for irritability
- Mania
- Antisocial personality disorder
- EUPD
Agencies involved when ?child abuse
- Local safeguarding
- Childrens social services
- The police
Professionals complete DASH (domestic abuse, stalking and honour based violence risk assessment model. Which may lead to referral to MARAC (multi agenecy risk assessment conference)
Support leicester for domestic violence and sexual abuse
- Sexual assault referral centre - if happened recently and want to complete forensic examination
- Freeva
- Jasmine House
What is conduct disorder?
- a mental health condition in children and teens
- characterized by a persistent pattern of antisocial, aggressive, or defiant behaviors
- that violate social norms and the rights of others
Management of antisocial (dissocial) personality disorder
- Avoid pharmacological
- Be aware of misuse of prescription medication
- Manage comorbid problems with drugs and alcohol eg Turning point referral
- Avoid inpatient admissions - only use if crisis and avoid MHA - if needed get advice from forensic/specialist personality disorder services
Psychological:
* Group CBT
Differential for personality change that occurs later in life
Frontotemporal dementia
what is transference? - example
- The patient begins to describe feelings that the therapist is too controlling.
- When this is explored in therapy the patient realises that this feeling is a repetition of reactions and feelings that she has towards her mother, which she has had since childhood.
- The patient was not consciously aware that she was doing this until it was explored in therapy
eg phenomenon within psychotherapy in which repetitions of old feelings, attitudes, desires, or fantasies that someone displaces are subconsciously projected onto a here-and-now person
Paracetamol overdose and graph interpretation
If the paracetamol concentration lies on or above the treatment line, NAC should be administered.
