Personality Disorders Flashcards
In the general diagnosis of personality disorder according to ICD-10, which of the
following is not necessary for a diagnosis?
A. The behaviour must affect the ability to control impulses
B. The behaviour or way of interacting must be pervasive across different
situations
C. The patterns of behaviour are associated with considerable distress
D. The patterns of behaviour arise in late childhood or adolescence
E. There must be no evidence of organic brain disease or injury as a cause
of the disorder
A. The behaviour must affect the ability to control impulses
While many people with personality disorder do have difficulty with
impulse control (A), it is not necessary for a diagnosis. ICD-10 specifies
that the individual’s inner experiences or behaviour must be manifest in
more than one of the following areas (but not necessarily all).
- Cognition
- Affectivity
- Control over impulses
- Manner of relating to others.
This behaviour cannot be limited to one situation or stimulus, but must
pervade across the individual’s inner and social worlds and must be
inflexible, maladaptive and dysfunctional (B). There must be distress,
either to the individual themselves, their social environment, or usually
both (C). The disorder must have arisen during late childhood or
adolescence (D), and should be ‘stable’ and of long duration. Changes
occurring within adulthood themselves do not qualify as personality
disorders, but may represent personality change, usually as the result
of severe and enduring stress. An organic cause cannot be responsible
for the disorder (E) – there is a separate diagnostic category for ‘organic
personality disorder’ – an example would be frontal lobe injury
Regarding personality and its development, which of the following statements is
false?
A. Body build is not a reliable way to assess personality type
B. Freudian theory states that normal personality development involves
successfully passing through various stages of development
C. Idiographic personality theories state that every individual is unique
D. It is now generally accepted that personality can be described by three
factors
E. The environment plays a large part in personality development
D. It is now generally accepted that personality can be described by three
factors
There are a bewildering number of personality theories and constructs.
However, it is becoming increasingly accepted that five (not three) factors
can adequately describe personality. These can be remembered with
the mnemonic ‘OCEAN’ - Openness to experience, Conscientiousness,
Extraverson/intraversion, Agreeableness and Neuroticism (D). Kretschmer
originally described three body-types that he believed were associated with
specific personality types (A). However, empirical research has not shown
any reliable link between the two. Freud hypothesized that for normal
personality development, an individual must successfully pass through
various developmental stages of ‘the libido’, namely oral, anal and genital
(B). Failure at one, e.g. anal, would result in personality difficulties in
later life (in this case, obsessional traits). Idiographic personality theories
are concerned with the uniqueness of every individual (C), compared
to nomothetic theories in which personality is thought to be made up
of differing degrees of stable factors, and individuals differ only in the
amount of each of these factors that they possess. The environment
as well as our genetic makeup of course are responsible for how our
personality develops (E) – this has been backed up by numerous twin and
other studies.
Which of the following is least likely to predict dangerous behaviour?
A. Co-morbid mental disorder
B. Co-morbid substance abuse disorder
C. Juvenile delinquency
D. Pathological lying
E. Superficial charm
A. Co-morbid mental disorder
While there are specific examples when co-morbid mental disorder
(which excludes personality disorder) would increase dangerousness
(e.g. the presence of violent command hallucinations, high levels of
perceived threat in paranoid states), overall, very little violence is directly
attributable to mental illness (A). People with mental illness are more
likely to be the victims of violence than perpetrators of it. Co-morbid
substance misuse is positively correlated with dangerousness (B). The
aetiology of this relationship, however, is extremely complex. Juvenile
delinquency (C) may predict a tendency towards psychopathy (which
itself is related to dangerousness). This forms part of one of the most
commonly used assessment tools for psychopathy, the Hare Psychopathy
Checklist – Revised (PCL-R), as part of Factor 2 – ‘Socially Deviant
Lifestyle’. (D) and (E) are also part of the PCL-R for psychopathy, but fall
into Factor 1 of the checklist – ‘Aggressive Narcissism’.
A 22-year-old woman with a diagnosis of borderline personality disorder
attends accident and emergency after saying she has taken an overdose of
paracetamol following an argument with her mother. She is an outpatient at the
local personality disorder service where she has a key worker. This is her fourth
attendance in accident and emergency for similar reasons in the last 6 weeks. A
full assessment reveals no evidence of depression. Her blood results reveal low
levels of paracetamol. She does not want to die but cannot say she will not try and
harm herself again. What would the most appropriate management be?
A. Admit to inpatient unit
B. Call for urgent Mental Health Act assessment
C. Detain under Section 5(2) of the Mental Health Act
(MHA) in the
accident and emergency department
D. Discharge from accident and emergency with follow-up
from her key
worker
E. Remove patient and ban from further accident and emergency
attendances
D. Discharge from accident and emergency with follow-up
from her key
worker
The most appropriate option is to discharge her with follow-up from her
key worker (D). She is currently in a service designed specifically to cope
with the difficulties people with personality disorder face. There is little
evidence here that an inpatient admission would be helpful (A). People
with borderline personality disorder often feel chronically abandoned and
not listened to, so while admission may make both the clinician and patient
feel safer, it is seldom useful in the long term. People with personality
disorder often use admissions as justification for their behaviours. Firm
boundaries coupled with thoughtful empathy are necessary to help these
individuals. Again, like their being no justification for admission, there
is no evidence for using the MHA (and indeed it is unlikely she would be
detainable). Therefore (B) and (C) would not be appropriate – and in fact
one could not use Section 5(2) in any case as this is only applicable to
current inpatients, not to patients in accident and emergency. Banning
the patient from accident and emergency (E) will only serve to confirm
the woman’s feelings of abandonment – the behaviour is likely to escalate
rather than stop, and will just occur in another department where she is
not known, which is potentially much more dangerous.
A 29-year-old man is arrested for aggravated assault on a former girlfriend. It is
his ninth offence of a similar nature. The court asks for a psychiatric opinion. He
is noted to be emotionally cold with an extremely reduced tolerance to frustration.
He feels no remorse for his actions, blaming his girlfriend for ‘putting it about’.
What is the most likely diagnosis?
A. Anankastic personality disorder
B. Antisocial personality disorder
C. Emotionally unstable personality disorder
D. Histrionic personality disorder
E. Schizoid personality disorder
B. Antisocial personality disorder
Antisocial personality disorder (B), also known as dissocial, psychopathic
or sociopathic personality disorder, is commonly seen in forensic
settings, and tends to affect men more than women. Aside from the
features listed above, these individuals show gross disregard for social
norms, cannot maintain meaningful relationships and usually have
disordered development in childhood, often with diagnoses such as
conduct disorder. This disorder is classified in Cluster ‘B’, a system
adopted by DSM-IV (but not ICD-10). Cluster B disorders include those
that are overly dramatic, emotional or with impulse control problems.
Note that the other options are not explained further here as they are
used in subsequent questions.
A 68-year-old woman attends her GP following the death of her husband. She
is tearful but ‘doesn’t want to bother the doctor’. The GP notices that she says
yes to every suggestion and she says she does not know how to cope as her
husband did everything for her except the cooking. The GP feels very helpless
and somewhat irritated by the end of the conversation. What is the most likely
diagnosis?
A. Anankastic personality disorder
B. Dependent personality disorder
C. Emotionally unstable personality disorder
D. Histrionic personality disorder
E. Schizoid personality disorder
B. Dependent personality disorder
Dependent personality disorder is described here (B). These people often
only come to attention when their spouses leave or die. They tend to
allow others to take responsibility for them and will find it extremely
hard to make decisions. They tend to not ask things of others but require
large amounts of help and advice. This disorder falls into the DSM-IV
Cluster ‘C’ category, which includes disorders characterized by anxiety
or fear.
A 19-year-old man is referred to the local psychiatric community team as his
new GP is worried he is schizophrenic. The letter states that he is ‘extremely odd,
and does not seem to have an emotional response to anything’. On assessment,
he states he has only come to understand the ‘psychiatric care pathway’ a little
more but does not feel he has any problems. He seems aloof and disdainful of
the psychiatrist. He appears to have few hobbies except for inventing his own
mathematical equations. What is the most likely diagnosis?
A. Anankastic personality disorder
B. Emotionally unstable personality disorder
C. Histrionic personality disorder
D. Schizoid personality disorder
E. Schizotypal personality disorder
D. Schizoid personality disorder
The vignette is describing someone with likely schizoid personality
disorder (D). The name is possibly confusing, although it is thought by
some to be connected to schizophrenia. However, these people do not
have the psychotic symptoms that are the hallmark. Instead, they tend to
be isolative, aloof and emotionally detached (although not in the violent
way of antisocial personality disorder). They gain little pleasure from
things except perhaps unusual intellectual activities, and usually have
few friends or relationships. This is a Cluster ‘A’ disorder (characterized
by odd or eccentric patterns of behaviour). Schizoid personality disorder
should not be confused with schizotypal personality disorder (E). The
latter has actually been taken out of the personality disorder section
in ICD-10 and placed within the schizophrenia and related disorders
category. These individuals present with symptoms of social anxiety as
well as odd cognitive and perceptual experiences and beliefs that do not
amount to delusions or hallucinations. They may have unusual speech
patterns. This disorder is definitely felt to be related to schizophrenia.
A 52-year-old woman comes in to her GP with a swollen knee which appears to be
osteoarthritic. During the assessment, however, she quizzes the GP on every little
detail of what he is doing. She began the interview by saying how disappointed
she was that the GP was running twelve and a half minutes late and that her
schedule had been ruined as a result. She asked several times about minute details
concerning the referral process. What is the most likely diagnosis?
A. Anankastic personality disorder
B. Anxious-avoidant personality disorder
C. Emotionally unstable personality disorder
D. Histrionic personality disorder
E. Paranoid personality disorder
A. Anankastic personality disorder
This represents an anankastic personality type (A), also known as
obsessive–compulsive personality disorder in DSM-IV. This is not the
same as obsessive–compulsive disorder, although the two may give rise to
some diagnostic difficulties. However, those with anankastic personality
disorders tend to be preoccupied with rules and schedules. They are
perfectionists and overly pedantic. They are usually quite rigid and may
be stubborn and difficult to get along with as they can come across as
extremely judgemental. This is also a Cluster ‘C’ disorder.
A 23-year-old woman is referred to the pastoral services at her college because
of concerns over her behaviour. She is reported to have episodic outbursts of
rage towards her classmates, although she acts in a flirtatious and fawning way
towards her male tutors. She has been admitted twice with impulsive self-harming
attempts. She has become obsessed with one of the more popular girls in the class,
adopting a similar dress sense and texting her often. When she was told by the
girl to leave her alone, she became enraged. What is the most likely diagnosis?
A. Anxious-avoidant personality disorder
B. Emotionally unstable personality disorder
C. Histrionic personality disorder
D. Narcissistic personality disorder
E. Paranoid personality disorder
C. Histrionic personality disorder
This is a difficult question, as this may get confused with narcissistic traits
(D) or with emotionally unstable traits (B). However, this description is
very suggestive of histrionic personality disorder (C), in which individuals
are prone to overly dramatic displays and occasional self-harm. They
are faddish and attention seeking, often sexually. They have a shallow
affect and cannot maintain relationships easily. They also tend to
be obsessed with their physical appearance. In contrast, emotionally
unstable personality disorder (B) does not present quite like this, although
obviously self-harming behaviour is prevalent here also. There is also often
considerable overlap between them, but emotionally unstable individuals
tend to have intense but unstable relationships and go to great lengths to
avoid being abandoned, while at the same time pushing people away. They
feel chronically empty. Likewise, narcissistic individuals may share some
of these characteristics, but the core of narcissistic personality disorder is
an inflated sense of self-worth, often being pretentious and boastful. They
crave attention as well as celebrity and believe they are above others. They
are usually callous and show little regard for the feelings of others.
Which of the following statements regarding management of personality disorder
is correct?
A. Antidepressant medications have no role in the management of
personality disorder
B. Antipsychotic medications have shown evidence of effectiveness in
management of personality disorder
C. Dynamic psychotherapy is contraindicated in emotionally unstable
personality disorder
D. Benzodiazepines are the drug of choice in borderline personality
disorder
E. Group psychotherapy is ineffective in managing personality disorder
B. Antipsychotic medications have shown evidence of effectiveness in
management of personality disorder
There are some small studies showing benefits of antipsychotic medication
(B) over a wide range of symptoms in personality disorder. However, there
is no consensus about who will benefit from these drugs, in what way, and
for how long. Individuals with personality disorder may sometimes end
up on a vast array of medications which is more likely to be symptomatic
of the treating clinician’s feelings of therapeutic impotence than any
observable benefit to the individual. Antidepressants (A) similarly may
have a role, particularly in terms of helping with impulse control. However,
as with antipsychotics, the use of psychotropic medication alone is almost
certain to be a failure without consistent and long-term psychological
interventions. Dynamic psychotherapy (C) is certainly used for the
management of many types of personality disorder, including emotionally
unstable. Benzodiazepines (D) should be used with extreme caution in
people with borderline personality disorder because of their potential for
dependence. Group psychotherapy (E) has been used for many years in the
management of individuals with personality disorder. One advantage of
this method is that issues of transference are not limited to the therapist,
but spread out amongst the group. The evidence suggests that on the whole
cognitive behavioural therapy (CBT) is more effective than medication for
generalized anxiety disorder (C). The effects of both are probably additive,
with the most success being for a combined approach of CBT and SSRIs.
While CBT is commonly conducted with just one client and therapist (E),
there is no reason that family members may not be invited to sessions and
in fact may even act as co-therapists in certain situations
