Personality Disorders

Question 1

What are personality traits?

Answer 1

enduring patterns of perception, thinking and relating to self and environment

Question 2

What is a personality disorder?

Answer 2

persistently inflexible, maladaptive traits which are stable over time and cause significant personal distress or functional impairment

Question 3

How do PD patients present?

Answer 3

a range of problems - self harm, depression, anxiety, violence, disorderly conduct, PTSD

may be concurrent with psychiatric illness - schizophrenia

diagnosis requires consistent features over time, which make it hard at time at crisis

concrete diagnosis is hard to achieve despite definitions

Question 4

What should the assessment of PD focus on?

Answer 4

sources of distress
comorbid mental illness 
specific impairments of functioning - work home social?
education and work 
criminality 
relationships 
sexual behaviour 

reliable collateral history is essential

Question 5

What are the different categories of PD?

Answer 5

Acquired
Specific
Dimensional approach
Categorical approach (cluster A, B, C)

Question 6

What is acquired PD?

Answer 6

Organic: insult e.g. brain damage or disease
i.e. frontal lobe lesion social disinhibition, behavioural changes
Or following a catastrophic event or the development of severe psych illnesses

Question 7

What is specific PD?

Answer 7

Difficult to find any links between an insult and the PD, causation is possibly down to genetic and environmental factors.
Usually start in adolescence or early adulthood

Question 8

What is the ‘dimensional approach’ classification of PD?

Answer 8

PD is part of a spectrum of behaviour that merges with normality – measured by personality inventories e.g. MMPI

Question 9

What is the ‘categorical approach’ to classifying PD?

Answer 9

ICD-10, DSM-IV assume that there are distinct types of PD

Cluster A, B, C

Question 10

What is the Cluster A PD?

Answer 10

“odd, eccentric”

Paranoid, schizoid or schizotypal

Question 11

What is the Cluster B PD?

Answer 11

“dramatic, emotional, erratic”

Borderline (emotionally unstable), antisocial, histrionic, narcissistic

Question 12

What is Cluster C PD?

Answer 12

“anxious, fearful”

Dependent, avoidant, obsessive-compulsive

Question 13

How does PD effect people and their lives?

Answer 13

• Significantly increased mortality and physical/psychiatric morbidity
• Affects relationships
• Strong association between some types and healthcare and criminal justice service involvement
• M/F relatively equal, higher prevalence in 25-44 y/o.
• Prevalence in prison sample groups is 50-80%
• Cluster A is more common in relatives of schizotypal patients
• Adverse social circumstances are associated with cluster B

Question 14

What is the general management for a PD patient?

Answer 14

• Gain an open trusting relationship with patient
• Take care to minis distress
• Crisis Mx Plan with patient, family, emergency care etc.
• short term meds or crisis or symptoms that can be medically treated
• psychological therapy to address and modify maladaptive traits

Question 15

What psychological therapies can be used in PD?

Answer 15

o	Dialectical behaviour therapy (DBT)
o	Mentalisation-based therapy (MBT)
o	CBT 
o	Cognitive Analytical Therpay (CAT) for borderline PD
o	Therapeutic communities

Question 16

What are the hallmarks of a problem caused by dysfunctional PD?

Answer 16

• Pervasive - occurs in all/most areas of life
• Persistent - evidence from adolescence and continues into adulthood
• Pathological - causes distress to self or others; impairs function (occupation/social/relationships)

Question 17

Describe the aetiology of a PD?

Answer 17

Genetics
Childhood temperament - emotional difficulties in childhood may impact PD
Childhood experience - link between neglect, trauma and abuse in childhood and PD
Neurochemical imbalance - links between impulsive behaviour and serotonin have been noted

Question 18

How is PD assessed in clinic?

Answer 18

History, MSE, physical exam, differential diagnosis, risk assessment, management plan
Ask questions about how long it has been a problem/how it affects relationships etc.
Screen for comorbidities - anxiety/depression/PTSD/sybstance misuse

Question 19

How can you find out more about the type of PD?

Answer 19

Ask about:
o Religious belief/morals
o How do you deal with stress/pressure
o Hobbies/interest/favourite books/films

Question 20

What is the short term management for a PD patient?

Answer 20

• Think about ongoing risks suicidal? Self harm? Overdose? Drugs/drink?
• Take history and consider comorbidity
• Risk assessment, the assess whether care is to be delivered as an outpatient/Inpatient

Question 21

What is the long term management?

Answer 21

• Strategies CBT, Dialectical Behavioural Therapy (DBT), Cognitive Analytical Therapy (CAT), therapeutic communities
• Good engagement from patient is vital
• Social interventions may also be appropriate stigma, social inclusion activites, finance, housing

Question 22

What should you be aware of when managing a PD patient?

Answer 22

• PD patients are challenging to manage and can provoke negative reactions in health care professionals
• Set clear boundaries
• Know your limits
• Beware of transference and counter transference
• Patients may need to take responsibility for their actions
• Beware of the admission trap can be counter productive, foster dependence and disempower indivduals from adopting safer coping strategies

Question 23

What is the prognosis of PD?

Answer 23

• PD, particularly cluster B, are linked to a higher rate of suicide, as a result of impulsivity and emotional instability
• Cluster B tends to be less common with increasing age

Question 24

How should medications be used in PD?

Answer 24

NICE do not recommend pharmacological treatment for PD
• Antipsychotics can be used to treat psychotic experiences, reduce impulsivity and agitiation
• Antidepressants for comorbid illnesses such as anxiety and depression
• Mood stabilisers for mood instability