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Perspectives on Clinical Psychology > Personality Disorders > Flashcards

Personality Disorders Flashcards

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1
Q

DSM Classification

A
  • enduring pattern of inner experience and behaviour that deviates from expectations of the culture
  • inflexible and pervasive across situations
  • leads to distress and impairment
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2
Q

Group A

Mostly..

A 
odd/ecentric:
- paranoid
- schizoid
- schizoptypal
Samuels et al. 02: mostly single men
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3
Q

Group B

Mostly..

A 
dramatic, emotional, erratic
- antisocial personality disorder
- historonic
- boarderline
Samuels et al. 02: mostly young men without a high school degree
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4
Q

Group C

Mostly..

A

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

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5
Q

Categorical vs. Continuum

Implication for treatment

A

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)

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6
Q

Cat. vs. Cont. SUPPORT

Trull et al. 98

A

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

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7
Q

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

A

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

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8
Q

Cat. vs. Cont. SUPPORT

Samuels et al. 02

A

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

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9
Q

Cat. vs. Cont. SUPPORT

Stablilty

A

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%

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10
Q

Alternative model for diagnosis

A 
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
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11
Q

Characteristics of borderline personality disorder

A

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

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12
Q

Prevalance of BPD

A

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

35% prison population

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13
Q

Problems with prevalence rates

Gender

A

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

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14
Q

Problems with prevalence rates

other

A

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

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15
Q

Problems with prevalance rates

Comorbidity

A

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)

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16
Q

BPD a form of PTSD?

A

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

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17
Q

Issues with comorbidity

A

more disturbed, need more intensive treatment

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

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18
Q

Issues with treatment

A

37% undergoing therapy wont complete

may be likely to manipulate their therapist

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19
Q

Problems with theories for BPD

A

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?

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20
Q

Risk factors for BPD

Torgersen et al. 04

A

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?

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21
Q

Risk factors for BPD

Johnson 99

A

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

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22
Q

Risk factors for BPD

Schwarze et al. 13

A

prenatal adversity

eg. maternal distress, drugs, tobacco

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23
Q

Genetics
Torgerson
Loehlin 92
Baron (BUT)

A

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

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24
Q

Genetics

Goldsmith and Nigg 94

A

common traits in BPD found to be heritable eg. neuroticism

25
Q

Genetics

Comorbid with bi-polar

A

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

26
Q 
Neurochemicals
Norra 03 BUT
Friedel 04
also
BUT
A

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

27
Q

Neurochemicals

Cortisol

A

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

28
Q

Neurochemicals

Estrogen

A

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

29
Q

Neuroimaging

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

A

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

30
Q

Neuroimaging

Limbic system

A

excessive activation of limbic system in those with BPD

hippocampus: spatial learning, contextualising memory
amygdala: threat perception, coordinates and initiates response to fear

31
Q

amygdala

Herpertz et al. 01 and Krystal

A

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

32
Q

Psychodynamic approach

Object Relations Theory

A
  • 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
33
Q

Object relations theory

eg.

A

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

34
Q

Limitation of ORT

A

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

35
Q

Psychodynamic theories

Dysfunctional schemas

A

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

36
Q

Lobbertael et al. 05

A

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

37
Q

Lobbertael et al. 05

A

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

38
Q

Object relations psychotherapy aims to..

A

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

39
Q

Object relations psychotherapy stages

A

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

40
Q

SUPPORT for Object Relations Therapy

BUT

A

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

41
Q

Diathesis Stress approach

A

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

42
Q

Diathesis Stress eg.

A

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

43
Q

Linehan 87 Dialectical Behavioural Therapy (a form of CBT)

A

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

44
Q

DBT Modules

A

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

45
Q

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

A

Bloom et al. 12: successful

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

46
Q

DBT support
McMain 12
BUT

A

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!

47
Q

DBT support
Clarkin et al. 07
BUT

A

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??

48
Q

DBT support

Soler et al. 05

A

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

49
Q

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

A

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)

50
Q

CBT

A

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

51
Q

CBT Beck and Freedman 90

A

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

52
Q

CBT support

Linehan et al. 94

A

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

53
Q

CBT support

Davidson et al. 14

A

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

54
Q

Schema focussed therapy

3 stages

A

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

55
Q

PROs and CONs of schema focussed therapy

A

+ modest evidence
+ cost effective
- small number of studies

56
Q

NICE guidelines for treatment

A

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

57
Q

Issues with treatment (in the past)

A

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

58
Q

So in therapy..

A

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

Perspectives on Clinical Psychology (2 decks)

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