Personality Disorders

Question 1

DSM Classification

Answer 1

• enduring pattern of inner experience and behaviour that deviates from expectations of the culture
• inflexible and pervasive across situations
• leads to distress and impairment

Question 2

Group A

Mostly..

Answer 2

odd/ecentric:
- paranoid
- schizoid
- schizoptypal
Samuels et al. 02: mostly single men

Question 3

Group B

Mostly..

Answer 3

dramatic, emotional, erratic
- antisocial personality disorder
- historonic
- boarderline
Samuels et al. 02: mostly young men without a high school degree

Question 4

Group C

Mostly..

Answer 4

anxious, fearful - stable, no apparent trigger
- dependent
- avoidant
- OCD
Samuels et al. 02: mostly high school graduates never married

Question 5

Categorical vs. Continuum

Implication for treatment

Answer 5

Costa and McRae 90: maybe we are all on a continuum and identify with all personality disorders to some extent, they are extremes of normal personality traits

Treatment: moderate rather than remove (some may be adaptive eg. OCD and cleanliness)

Question 6

Cat. vs. Cont. SUPPORT

Trull et al. 98

Answer 6

Trull et al. 98: interviewed participants from clinical and non-clinical settings and found that high scores on the 5 factor personality models are highly associated with personality disorders

Question 7

Cat. vs. Cont. SUPPORT
Grilo et al. 02
BUT

Answer 7

personality disorders tend to overlap in characteristics and so there is a temptation to diagnose more than one disorder, particularly in men

BUT limited to patients responding to adverts

Question 8

Cat. vs. Cont. SUPPORT

Samuels et al. 02

Answer 8

historonic and dependent personality disorders are rare and may not represent useful categories

Question 9

Cat. vs. Cont. SUPPORT

Stablilty

Answer 9

personality disorders are not stable over time as the DSM implies, may be stable but vary in severity
Grilo et al. 04: 50% of those diagnosed did not recieve the same diagnosis 2 years later
BUT this could also reflect lack of agreement between diagnoses - reliability of diagnosis isn’t 100%

Question 10

Alternative model for diagnosis

Answer 10

provides ratings for personality disorders on a series of dimensions across 6 categories:
- antisocial
- boarderline
- avoidance
- narcissistic
- OCPD
- schizotypcal
and 5 personality trait domains and facets:
- negative affectivity
- detachment
- antagonism
- disinhibition
- psychotism
looks at severity of impairment, disturbances in self and interpersonal function to assess

Question 11

Characteristics of borderline personality disorder

Answer 11

erratic and self-interested to the detriment of others
emotionally liable and attention seeking
enduring pattern of instability, changes in mood and impulsive behaviour
significant fear of abandonment and rejection, so close relationships can turn sour
behaviour is unpredictable
- regular and unpredictable shifts in self imagine, changing personal goals and values etc.
- impulsive behaviour eg. drug use
- prolonged bouts of depression, self harm, suicide ideation and attempts

Question 12

Prevalance of BPD

Answer 12

2% of general and 19-95% of clinical populations

35% prison population

Question 13

Problems with prevalence rates

Gender

Answer 13

Widger and Trul: 75% of those with BPD are women, men are more likely to be diagnosed with antisocial

cross cultural variance: some gendered behaviour more acceptable in some cultures, BUT little evidence to suggest difference is a function of cultural differences – more studies needed

Question 14

Problems with prevalence rates

other

Answer 14

differences in rates may reflect differences in sampling procedures

McGulloway et al. 10: lower personality disorder rates in black than white, suggests neglect of diagnosis

Question 15

Problems with prevalance rates

Comorbidity

Answer 15

BPD has a behavioural style that may put you at risk of a wide range of psychopathologies
Zaranai 98: 50-57% of those with BPD also diagnosable with substance misuse, mostly men
Zaranai 98: women more likely to be comorbid with eating disorders (15%)
96.3% of those with BPD met criteria for depression, BUT also high for anxiety (40%)
with other personality disorders- 1.94 rate (less than 1/3 only had one PD)

Question 16

BPD a form of PTSD?

Answer 16

30% comorbid
Pagura et al. 10:
- higher prevalance of repeated childhood traumatic events than either alone
- high degree of lifetime cooccurance but not overlapping
Zanarini 98: PTSD is common but not universal in BPD

Question 17

Issues with comorbidity

Answer 17

more disturbed, need more intensive treatment

personality disorders come with ingrained styles that may trigger symptoms of other disorders

Question 18

Issues with treatment

Answer 18

37% undergoing therapy wont complete

may be likely to manipulate their therapist

Question 19

Problems with theories for BPD

Answer 19

can be traced back to childhood, but 75% don’t meet criteria for diagnosis after 10-15 years
Widiger and Corbitt: maybe antisocial and borderline manifest differently in males and females?

Question 20

Risk factors for BPD

Torgersen et al. 04

Answer 20

developmental andescents (eg. abuse and neglect)
paternal psychopathy
academic underachievement - low intelligence
low social economic status
inner-city life
divorced/separation
BUT are these cause or effect?

Question 21

Risk factors for BPD

Johnson 99

Answer 21

police records and self report
of those with BPD, 71% experienced sexual abuse, 38% physical abuse
BUT 20% no abuse

Question 22

Risk factors for BPD

Schwarze et al. 13

Answer 22

prenatal adversity

eg. maternal distress, drugs, tobacco

Question 23

Genetics
Torgerson
Loehlin 92
Baron (BUT)

Answer 23

75% and 35% MZ and DZ twins concordance rate

meta-analysis showed .30 gene effects

3-5x more likely for relatives to develop BUT student sample

Question 24

Genetics

Goldsmith and Nigg 94

Answer 24

common traits in BPD found to be heritable eg. neuroticism

Question 25

Genetics | Comorbid with bi-polar

Answer 25

44% BPD have bipolar disorder spectrum, which has a genetic basis so there's a potential genetic basis for BPD

Question 26

``` Neurochemicals Norra 03 BUT Friedel 04 also BUT ```

Answer 26

low levels of serotonin led to impulsivity BUT just female participants dopamine dysfunction has a role in emotional information processing, impulse control and cognition drugs affecting these neurotransmitters also affect BPD BUT circumstantial evidence, not direct

Question 27

Neurochemicals | Cortisol

Answer 27

cortisol is elevated in those with BPD with a hyperactive HPA network meaning a greater biological stress response associated with an increased risk of suicidal behavioura may dispose those with BPD to experience past events as traumatic and current events more emotionally Walker et al. 02: cortisol baseline levels are heritable

Question 28

Neurochemicals | Estrogen

Answer 28

related to the expression of BPD in female patients, predicting changes in symptoms when controlled for by an increase in negative affect

Question 29

Neuroimaging | Prefrontal cortex - what does it do? how does it relate to BPD?

Answer 29

helps regulate emotions and is less active in those with BPD, especially in memories of abandonment

Question 30

Neuroimaging | Limbic system

Answer 30

excessive activation of limbic system in those with BPD hippocampus: spatial learning, contextualising memory amygdala: threat perception, coordinates and initiates response to fear

Question 31

amygdala | Herpertz et al. 01 and Krystal

Answer 31

Herpertz et al. 01: looked at prisoners with APD and BPD, BPD showed less frowning like (psychopaths) but more in response to negative stimuli, reflecting a restrictive, negatively biased communication of emotions their startles response patterns were similar to that of controls, demonstrating an intact capacity for adverse affective stages to prime aversion activations and a broader tendency to avoid situations of pain/danger Krystal: some show less activation in situations of increased negative emotions

Question 32

Psychodynamic approach | Object Relations Theory

Answer 32

- those with BPD receive inadequate love and support from important figures, leading to an insecure ego, leading to a fear of rejection and low self esteem and motivating those with BPD to want to respond to people in the way they've been treated in the past - tendency to see others as quarrelsome, which triggers a negative affect, which leads to more behaviour during interactions with others - defence mechanism: splitting, evaluating people in a black or white manner - tend to judge own emotions on dimensions of valency, not arousal, and so are likely to judge emotions of others in an all or nothing way with little intensity control = extreme swings in emotions

Question 33

Object relations theory | eg.

Answer 33

experiencing childhood abuse and expecting the same treatment from similar figures in adult life

Question 34

Limitation of ORT

Answer 34

abuse is common in many personality disorders, why would it lead to BPD and not another? this isn't taken into account

Question 35

Psychodynamic theories | Dysfunctional schemas

Answer 35

Young et al. 03: maladaptive schemas develop from early childhood schemas determine reactions to events trauma not being processed may result in stunted emotional cognitive development eg. schema of self as bad, emotion being dangerous, may lead to clinging to get support from others or keeping distance due to mistrust highly comorbid with APD and BPD may suggest common aiteology

Question 36

Lobbertael et al. 05

Answer 36

looked at patient and prisoners, with medical staff as controls those with APD and BPD score higher in measures of schema and have higher rates of experienced abuse compared to controls

Question 37

Lobbertael et al. 05

Answer 37

BUUT BPD scored higher than APD on detached protector, angry child, abandoned/abused child and punitive parent mode scales schema mode questonnaire -- self report

Question 38

Object relations psychotherapy aims to..

Answer 38

attempts to identify and block manipulative behaviours at an early stage, expose weak egos and fragile self-image that underlies BPD

Question 39

Object relations psychotherapy stages

Answer 39

clarification: ask P to elaborate on thoughts, actions and emotions of the self and others in problematic situations confrontation: point out the inconsistencies between patients' differing accounts of self and other interpretation: explanations for inconsistency - suggest links between use of defences to reduce anxiety associated, while attempting to integrate the all good/bad object relations

Question 40

SUPPORT for Object Relations Therapy BUT

Answer 40

Svartg et al. 04: clients with cluster C PD show improvements short term use is as beneficial as CBT Yeomans and Diamond: series of trials support effectiveness in functioning more able to reflect on the roles involved in emotionally intense increases better able to tolerate painful emotions without splitting self/others or acting emotionally intense BUT it is hard to assess effectiveness

Question 41

Diathesis Stress approach

Answer 41

genetically determined temporamental characteristics and stressful environmental factors in family / wider society

Question 42

Diathesis Stress eg.

Answer 42

Linehan Biosocial Theory 87 BPD have a vulnerability that compromises their capacity for emotion regulation when communication about ones inner challenging experiences are repeatedly and chronically exposed to invalidating environment moderate displays of emotion are punished, but extreme are reinforced by expressions of concern/medical care -- results in an ongoing, intense emotional inhibition and periodic, intense emotional displays

Question 43

Linehan 87 Dialectical Behavioural Therapy (a form of CBT)

Answer 43

a multimodal programme with group based skills training, individual psychotherapy, telephone consultation, therapist consultation meetings and anciliary treatments such as medication and acute inpatient a client centred view of acceptance but also provides insight of dysfunctional ways of thinking and provides skills to overcome this -- helps clients moderate extremes of emotionality -- improves self esteem and helps individual to cope with relationships -- promotes positive emotions must be done with caution as those with BPD are sensitive to criticism

Question 44

DBT Modules

Answer 44

1) Distress tolerance - how to deal with crises in effective ways 2) Interpersonal effectiveness - how to ask for things and say no to others while maintaining self respect and important relationships 3) emotion regulation - set of skills to understand, be more aware and more in control 4) mindfulness - set of stills to focus attention and live life in the present

Question 45

DBT support Bloom et al. 12 Stoffer et al. 12

Answer 45

Bloom et al. 12: successful | Stoffer et al. 12: decreases inappropriate anger, reduction in self harm and leads to improvement in general functioning

Question 46

DBT support McMain 12 BUT

Answer 46

2 year followup on post treatment outcomes DBT and general psychiatric management had similar and signficant improvements for the majority of outcomes BUT 53% werent employed or in school, 39% were on disability support -- will the benefits hold up in everyday life? BUT no more effective than general!

Question 47

DBT support Clarkin et al. 07 BUT

Answer 47

compared DBT, transference focussed therapy and supportive counselling all improved in depression, anxiety, global functioning and social adjustement DBT and transference = improved suicidality transference and counselling = improved anger transference was the only predictor of change in irritability, verbal and direct assault -- so it's good but not as good as transference??

Question 48

DBT support | Soler et al. 05

Answer 48

60 BPD patients effective over long term when combined with appropriate medication (olanzapine) BUT 43-68% didn't complete, maybe only those determined to get better continued

Question 49

Drug treatment of BPD Cochrane 10 Oalbu and Hall 10 Pelissolo and Jost 11

Answer 49

Cochrane 10: drugs for the comorbid issue but no medications show promise for the actual BPD Olabu and Hall 10: few RCTs have looked at the medication treatment of BPD, often experiements have small, poorly controlled samples, so there's little evidence to back it up BUT seems to be effective for particular parts of the disorder Pelissolo and Jost 11: drugs for aggression and impulsivity reduce symptoms in those with BPD (eg. beta-blockers)

Question 50

CBT

Answer 50

initially not used for PD, treatment depends on BPD and cognitive functions relative to the patient -- still an active process to develop it to BPD so a bit early to say if its effective

Question 51

CBT Beck and Freedman 90

Answer 51

therapist deals with coexisting problems first, then teaches patient to identify and evaluate key automatic thoughts sessions are structured to build trusting relationship with patient therapist employs guided imaging to unravel meaning of earlier experiences that contribute to dysfunctional behavioural patterns homework assignments to issues apply cognitive and emotional focussed schema restricting techniques to dispute core beliefs and develop more adaptive behaviour and beliefs

Question 52

CBT support | Linehan et al. 94

Answer 52

Linehan et al. 94 equally as effective as psychodynamic and superior to non-therapy control conditions -- specifically DBT which is a form of CBT

Question 53

CBT support | Davidson et al. 14

Answer 53

RCT including CBT 27 sessions over 12 months - patients attended 16 on average CBT showed high efficacy in real clinical settings showed gradual, sustained improvement in suicidal behaviour, attendance at A+E and number of inpatient psych days improved positive symptom index at 1 year and state anxiety, dysfunctional beliefs and quantity of suicidal acts at 2 year followup

Question 54

Schema focussed therapy | 3 stages

Answer 54

1) client needs to be convinced that their problems are not evidence for their schemas, their schemas are the cause of their problems -- self knowledge is important for understanding schemas related to childhood circumstances rather than representing truths about the way a person is 2) identify and prevent schema avoidance responses so client can experience the emotional states that ensue after prevention of schema 3) client examines the life events that give rise to schema experiences

Question 55

PROs and CONs of schema focussed therapy

Answer 55

+ modest evidence + cost effective - small number of studies

Question 56

NICE guidelines for treatment

Answer 56

DBT for self-harming (and beyond) women mentalisation based therapy and CBT use of pharmacology with caution -- but ultimately it is the patients choice, no one go-to

Question 57

Issues with treatment (in the past)

Answer 57

used to be a lot of blame (which NICE 04 considers unacceptable for those who self harm) on those with the PD rather than blaming the disorder, diagnosis wasn't seen as an excuse as it is in schizophrenia, problems with control and restraint, missing medications when in-patient BUT now theres a rescue approach -- patients dont have control or conscious knowledge over behaviour and arent responsible for it

Question 58

So in therapy..

Answer 58

it's important to be empathetic and compassionate - patients are responsible for their behaviour but not to blame