Personality Disorders

Question 1

Definition of personality

Answer 1

Defined in terms of consistency in patterns of thinking, feeling and behaving that are pervasive across life domains and enduring over time.
The five factor model identified 5 personality traits: neuroticism, extroversion, openness to experience, conscientiousness and agreeableness.

Question 2

Personality disorder definition

Answer 2

Milton identified 3 core features that differentiate disordered personality from normal-range problematic behaviours.
Functional inflexibility.
Self-defeating behaviour patterns.
Tenuous stability under stress (marked instability in mood, thinking and behaviour).

Question 3

Diagnosis of personality disorder: DSM-5

Answer 3

Enduring patterns of perceiving, relating to and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.
These patterns must differ from the individual’s cultural group and cause significant personal distress and impairment in functioning.

Question 4

DSM-5 refers to 10 personality disorders that have been grouped into 3 clusters

Answer 4

Cluster 1: paranoid, schiziod and schizotypal personality disorders. Characterised by odd or eccentric trait and behaviours.
Cluster 2: antisocial, borderline, histrionic and narcissistic personality disorders. Defined by dramatic, emotional or erratic traits and behaviours.
Cluster 3: avoidant, dependent and obsessive-compulsive personality disorders. Anxious and fearful traits and behaviours.

Question 5

Schizotypal personality disorder

Answer 5

Characterised by marked discomfort with close relationships, as well as a range of perceptual and cognitive distortions and off behaviour.
Have a few close friends, being anxious around other due to paranoid fears.
Manifest a number of positive and negative psychotic symptoms, but tend to be more transient (lasting minutes to hours) so does not warrant diagnosis of a psychotic disorder.

Question 6

Paranoid personality disorder

Answer 6

Pervasive pattern of suspiciousness and distrust, and are hyper vigilant for signs of other trying to harm them in some way.
Perceive malevolence when it is not present.
Beliefs are chronic and persistent over time.

Question 7

Schiziod personality disorder

Answer 7

Exhibits a low desire for connection with other human being and no interest or pleasure in social activities, including sex.
Emotionally cold with a restricted range of emotional responses.

Question 8

Narcissistic personality disorder

Answer 8

Individuals who are arrogant and concerned with their own power and abilities. They show disdain and disregard for people, are interpersonally exploitive, manifest a sense of self-entitlement and are often envious of others or believe others are envious of them.

Question 9

Histrionic personality disorder

Answer 9

Pervasive pattern of excessive emotionality and an intense need for attention and approval, which is sought by means of overly dramatic behaviour and seductive behaviour.

Question 10

Borderline personality disorder

Answer 10

Instability in terms of emotions, sense of identity, and interpersonal relationships.
Changeable mood that lasts hours or days.
May engage impulsively in potentially self-destructive behaviours eg substance use, gambling, mutilation and suicidal acts.

Question 11

Antisocial personality disorder

Answer 11

Pervasive patterns of criminal, impulsive, callous and/or ruthless behaviour predicated upon disregard for the rights of others and an absence of respect for social norms.

Question 12

Dependent personality disorder

Answer 12

Pervasive need to be cared for and fear of rejection, which lead to total dependence on and submission to others.

Question 13

Avoidant personality disorder

Answer 13

Pervasive anxiety, sense of inadequacy and fear of being criticised that lead to the avoidance of most social interactions with others and to restraint and nervousness in social situations.

Question 14

Obsessive-compulsive personality disorder

Answer 14

Pervasive rigidity in one’s activities and interpersonal relationships; includes characteristics such as emotional construction, extreme perfectionism and anxiety resulting from even slight disruptions to one’s routine.

Question 15

Dimensional approach to personality dysfunction

Answer 15

This approach maintains that the various personality characteristics exist on a continuum from low to high. Those with a ‘disorder’ occupy the extreme end of the continuum.
There was difficulty reaching agreement when preparing the DSM-5 so the categorical model was retained.
There is a dimensional-categorical hybrid model in the DSM-5 section on ‘Emerging Measures and Models’.

Question 16

The role of culture in personality disorders

Answer 16

Certain personality styles, and disorders, fit certain cultures or occupations.
Eg higher rates of antisocial disorder in Korea than Japan and Taiwan because those cultures emphasise social cohesion rather than individualism.
‘When personality profiles correspond to social expectations, certain traits may not be considered pathological unless they seriously interfere with functioning’.

Question 17

Epidemiology of personality disorders

Answer 17

Prevalence for each of the disorders is around 1-2%.

Expect obsessive-compulsive personality disorder, at approx 2-4%.

Question 18

Factor approaches

Answer 18

Emphasise that personality is the degree to which an individual manifests certain traits and combination of traits. Eg big five (except openness) are related to disordered personality.
Traits are inherited and environment plays a role in the extent to which genetically based personality dispositions are expressed.

Question 19

Beck’s Cognitive Model

Answer 19

Each personality disorder is characterised by specific maladaptive core beliefs.
These beliefs influence the processing of social information in such a way as to maintain the person’s dysfunctional beliefs by filtering out inconsistent information and interpreting ambiguous information as consistent with the dysfunctional belief.

Question 20

Young’s schema therapy model

Answer 20

Emphasises the presence of early maladaptive schemes which may be rigid and resistant to change.
Therapy educated the person about their schemas and uses cognitive and behavioural techniques to modify them.

Question 21

Linehan’s Biological Model

Answer 21

Developed for borderline personality disorder, but has also been applied to antisocial behaviours.
Posit that borderline personality disorder develops due to the interaction of biologically based emotional vulnerability (poor emotion regulation) and invalidating environments (child experiences neglect and abuse and is not taught how to cope with negative emotions).

Question 22

Dialectic behaviour therapy (DBT)

Answer 22

Type of psychological treatment developed by Linehan for borderline personality disorder.
Combines cognitive-behavioural and Zen techniques in four modules: mindfulness, interpersonal effectiveness, distress tolerance and emotion regulation.

Question 23

Cognitive analytic theory

Answer 23

Links aspects of cognitive psychology with object relations approach (psychoanalytic theory).
Personality disturbances develop from reciprocal roles.
Children who are abused internalise experiences of being a victim and an abuser. Then continue these behaviours and thinking patterns in later life, as a personality disorder.
Therapy focuses on working with the person to develop an understanding of these reciprocal role procedures.

Question 24

Mentalisation-based treatment

Answer 24

Mentalisation is the capacity to think about one’s own mental state and the mental states of others.
If a child is abused, they internalise the carers mental state (angry, hatred etc) and develop an image of themselves reflected in that. To achieve a bearable sense of self, they externalise the painful image as an ‘alien self’.
So aggression towards others as seen in BPD are efforts to destroy the ‘alien self’.
Therapy tries to stabilise the person’s sense of self and enhance their capacity to know their own mind and that of others.

Question 25

Early-intervention programs for personality disorders

Answer 25

Clinicians are often reluctant to make a diagnosis before 18 years to avoid stigma.
However, symptoms often begin during adolescence and early adulthood Eg BPD.
Early intervention can promote more adaptive developmental pathways, reduce psychopathology and improve general functioning.

Question 26

Aetiology of Cluster A disorders

Answer 26

Genetically based neurological abnormalities combined with certain environmental inputs (Eg low birth weight, childhood socioeconomic status) predispose an individual to developing odd, eccentric or psychotic features.

Question 27

Treatment of Cluster A disorders

Answer 27

Intimacy and trust issues make treatment difficult.
CBT: enhance self-awareness, teach social skills and improve quality of life. Exposure therapy to social situations can be helpful.
Pharmacotherapy: low doses of antipsychotic medications to treat psychotic symptoms.

Question 28

Aetiology of Cluster B disorders: antisocial personality disorder

Answer 28

Genetic component.
Biological risk factors: low levels of physiological arousal. Fearlessness.
Interaction between genetic and adverse environmental factors.

Question 29

Treatment of cluster B disorders: antisocial personality disorder

Answer 29

The majority of treatment focuses on comorbid disorders eg substance use, and on risk management.
Mentalisation-based treatment is being trialled.
Lithium and antipsychotic medication have been used to manage impulsive and aggressive behaviours.

Question 30

Aetiology of Cluster B disorders: borderline personality disorder

Answer 30

Importance of genetics is unclear.
Core elements like impulsivity and aggression are linked to neurobiological impairments.
Psychosocial factors like childhood trauma are stronger associated with BPD.
Interaction between biological and psychosocial factors.

Question 31

Treatment of cluster B disorders: borderline personality disorder

Answer 31

People with BPD often seek help.
Psychological intervention is recognised as the first line treatment.
Psychodynamic treatments, CBT, DBT, schema therapy, and cognitive analytic therapy.

Question 32

Aetiology of Cluster B disorders: narcissistic personality disorder

Answer 32

Little is known about the origins.
Most theories state it being a consequence of non-empathetic, invalidating and/or inconsistent early childhood experiences.
Child’s needs for attention are not met.

Question 33

Treatment of cluster B disorders: narcissistic personality disorder

Answer 33

Individuals unlikely to seek treatment unless depressed or experiencing high levels of distress related to relationship difficulties.
Limited research base on treatment for NPD.

Question 34

Aetiology for Cluster B disorders: histrionic personality disorder

Answer 34

Inconsistent, intense and non-empathetic parent-child interactions.
Unmet needs for care and attention result in overly dramatic behaviour to be noticed.

Question 35

Treatment of Cluster B disorders: histrionic personality disorder

Answer 35

Lack of empirical findings.

Cognitive therapy may be helpful to address identifying and challenging assumptions about dependency on others.

Question 36

Aetiology of Cluster C personality disorders: avoidant personality disorder

Answer 36

Modest genetic contribution.
May manifest in the very early developmental period, and be associated with childhood neglect and early rejection experiences.

Question 37

Treatment of Cluster C personality disorders: avoidant personality disorder

Answer 37

Often seek treatment for comorbid disorders like depression and anxiety.
CBT, social skills training and psychodynamic therapies may be helpful.
Behavioural techniques aimed at countering social avoidance are effective.

Question 38

Aetiology of Cluster C personality disorders: dependent personality disorder

Answer 38

Common for family members to have the disorder.
So, potential genetic predisposition or vulnerability.
Early physical abuse may lead to DPD.

Question 39

Treatment of Cluster C personality disorders: dependent personality disorder

Answer 39

Promising results from trials of schema therapy and DBT.

Behavioural strategies for anxiety management are also useful.

Question 40

Aetiology of Cluster C personality disorders: obsessive-compulsive personality disorder

Answer 40

Moderate genetic contribution.
Childhood experiences of verbal and emotional abuse.
Eg learn to avoid punishment by doing approves behavioural routines eg excessive tidiness.

Question 41

Treatment of Cluster C personality disorders: obsessive-compulsive personality disorder

Answer 41

Individuals typically seek help for comorbid anxiety or depression.
Cognitive-behavioural approaches: challenging dysfunctional beliefs, in vivo exposure to feared situations, graded exposure eg gradually altering overly rigid routines.