Personality disorders Flashcards
A personality disorder is defined as
An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture and is manifested in 2 or more of the following areas:
- COGNITION (ways of thinking and interpreting self, others, events)
- AFFECTIVITY (range, intensity, lability and appropriateness of emotional response.)
- INTERPERSONAL functioning
- IMPULSE control
What are the four ways/places that the PERSONALITY DISORDER (PD) must manifest to meet criteria
Must be two of the following:
- COGNITION (ways of thinking and interpreting self, others, events)
- AFFECTIVITY (range, intensity, lability and appropriateness of emotional response.)
- INTERPERSONAL functioning
- IMPULSE control
Name the three core features of PERSONALITY DISORDERS (PD)
- Functional inflexibility
- Self defeating behaviour patterns
- Tenuous stability under stress
Back in the days of DSM IV, what axis were PERSONALITY DISORDERS (PD) in?
Axis 2
What is the key aspects of the general PERSONALITY DISORDER (PD) diagnostic characteristics?
STABLE and long duration (traced at least to early adulthood or adolescence)
What are the five things mentioned as posing challenges to diagnosing PERSONALITY DISORDERS (PD)?
- Establishing prevalence over time
- Age requirements
- Role of genes norms
- Impact of cultural background
- Diagnosis process
When were PERSONALITY DISORDERS (PD) introduced into the DSM
1980
What are the Cluuuuusters
Mad, Bad, Sad
What’s the bottom age limit for diagnosing PDs?
18
What is in Cluster A (mad)
PARANOID
SCHIZOID
SCHIZOTYPAL
What’s the key thing about diagnosis PARANOID PD (Cluster A)
The paranoia needs to not occur exclusively during an episode of SCZ or other disorders w/ Psychotic features
Aetiology of PARANOID PD
Research is sparse
- More common in relatives of those with schizophrenia (genetic loading?)
- Low self-esteem
- Deficits in emotional and social processing
- Can find ecological niche where PD works in favour
What are the three key things about diagnosis SCHIZOID PD (Cluster A)
- Loner, detachment - think the Hermit
- Restricted emotional expression
- Needs to not occur exclusively ding an epos of SCZ or there order w/ Psychotic features
What is the aetiology of SCHIZOID PD
Very little research – some calls for it to be removed from DSM-5 pre publication
- Speculation that linked to Aspergers
- Barren upbringing, underpowered limbic system
Not associated with schizophrenia spectrum disorders
High level of dysfunction
Which is the PD that is associated with having an ‘underpowered limbic system’ following a barren upbringing?
SCHIZOID PD
What are the two key things about diagnosis SCHIZOTYPAL PD (Cluster A)
- Loner and can’t be close to people - lack of lose friends
- Distortions of perception and cognition (like psychosis)
What’s the difference between SCHIZOID PD and SCHIZOTYPAL PD?
The former includes perceptual/cognitive distortions
Whats the difference between SCHIZOTYPAL PD and SCZ
State vs trait
What is the aetiology of SCHIZOTYPAL PD
- Link with schizophrenia - milder form of schizophrenia
- Cognitive abnormalities - attention, memory deficits;
- Higher levels of dopamine neurotransmitter (Siever and Davis, 2004).
- Crossover to schizophrenia-spectrum disorders
What are the four key things about diagnosis ANTISOCIAL PD (Cluster B)
- Focused on behaviours
- Disregard for others
- Failure to conform to social norms
- Must be conduct disorder before 15 years
What is the aetiology of ANTISOCIAL PD?
- High sensation-seeking; childhood conduct disorder, low psycho-physiological arousal
- Elevated in family members, as is higher levels of criminality, high levels of impulsivity (genetic contribution)
- Low levels of serotonin; Frontal problems
- High levels of childhood aggression and associated with physical abuse, harsh and neglectful parenting
- Link with psychopathy (but not the same)
What should be the implications for sentencing?
What’s the key difference between Psychopathy and ANTISOCIAL PD?
Psychopathy is more about a lack of emotions, whereas antisocial PD is more about behaviour
What’s the key thing about diagnosis BORDERLINE PD (Cluster B)?
Instability of interpersonal relationships
What is the aetiology of BORDERLINE PD?
- Torgersen et al. (2000) found genetic contribution
- Associated with sexual, physical abuse and neglectful and invalidating environments
- Low serotonin
- Increased hippocampal volumes and heightened activation in amygdala
- Have insecure attachment and fearful of abandonment, desire intimacy but anxious about dependency on others
What are the key differences between BPD and complex PTSD, symptomatically?
In BPD but not PTSD:
- frantic effort to avoid abandonment
- unstable sense of self
- unstable and intense interpersonal relationships
- impulsiveness
What are the key psychopharmacological differences between BPD and complex PTSD?
BPD does not respond to mood stabilising medication
What’s the one key thing about diagnosis HISTRIONIC PD (Cluster B)
Attention seeking
Aetiology of HISTRIONIC PD (Cluster B)
Don’t know much
Family studies show other Cluster B Personality Disorders in the family.
What are the key four things about diagnosis NARCISSISTIC PD (Cluster B)
- Grandiosity
- Lack of empathy
- Exploitative
- Not aligned with objective reality
Aetiology of NARCISSISTIC PD
TWO THEORIES
- Barren/aggressive upbringing (Kernberg), which can lead to compensatory falsies (Stone, 1993)
OR
- Too much praise - inflated ego
Livelsey et al. (1993) say this PD has the highest genetic loading
Factor analysis reveals two types of NARCISSISTIC, what are they?
- Gradiosity / Overt Narcissism - like you’d expect
2. Covert Narcissism - Grandiose behaviour is mask for sense of inadequacy
What’s the key things about diagnosis AVOIDANT PD (Cluster C)
Social inhibition
How do you differentiate AVOIDANT PD from from SOCIAL ANXIETY DISORDER (SAD)?
Persistence across time and contexts
What is the aetiology of AVOIDANT PD?
- High in restraint as children, high neuroticism, low extroversion, shyness in childhood; higher incidence of avoidant PD in first-degree relatives
- Punished for adventure as children, cold distant and neglectful parenting.
- Jovev and Jackson (2004) found schemas related to defectiveness and abandonment.
What are the two key things about diagnosis DEPENDENT PD (Cluster C)
Need to be taken care of
Fear of separation
Which is the lowest prevalence Personality Disorder?
Dependent D
What is the aetiology of DEPENDENT PD
- Separation anxiety disorder and agoraphobia more elevated in family members
- high neuroticism and low extroversion.
- Speculation that overprotected attachment (the world is a dangerous place and that they are incompetent to be able to deal with it alone)
What are FIVE key things about diagnosis OBSESSIVE COMPULSIVE PD (Cluster C)
Ordilness
Expense of efficiency and flexibility
Over consciienstuosu
Some hoarding
Don’t like delegating
What is the aetiology of OBSESSIVE COMPULSIVE PD
- High perfectionism
Millon and Davis (1996) – the child learned to suppress feelings and perform approved behavioral routines in order to avoid punishment or disapproval by parental figures
What % of people have PERSONALITY DISORDERS
6.5% in Aust
Maybe 12% in OECD
20-40% of people in clinical settings
What did Beck find with PERSONALITY DISORDERS
CBT not as effective
What was Beck and Young’s bright idea when CBT didn’t work for PDs?
Schemas
Each PD is characterised by a schema
Schemas are resistant to change
What is Young’s theory of schema?
Early maladaptive schema result from mixture of biological disposition and repeated failure to meet child’s core emotional needs:
(i) secure attachments to others;
(ii) develop a sense of identity, competence and independence;
(iii) to express one’s desires and emotions;
(iv) to have realistic limits set by others so as to learn self-control;
(v) spontaneity and play.
Schema mapping - What are the Disconnection/rejection ones?
Abandonment/Instability Mistrust/Abuse Emotional Deprivation Defectiveness/Unlovability Social Isolation
Schema mapping - What are the Impaired autonomy ones?
Dependence/Incompetence
Vulnerability to harm or illness
Enmeshment/undeveloped self
Failure to achieve
Schema mapping - What are the Impaired limits ones?
Entitlement/superiority
Insufficient self-control/self-discipline
Schema mapping - What are the Overvigilance/inhibition ones?
Negativity/Pessimism
Self-punitiveness
Emotional inhibition
Unrelenting standards
Schema mapping - What are the Other-directedness ones?
Subjugation
Self-sacrifice
Approval seeking/Recognition seeking
What are the three ways people perpetuate their schema
- Schema surrender (just go right into it)
- Schema Avoidance - block out, avoiding
- Schema overcompensation - opposite extreme (abandons before others can abandon them)
Dialectic Behaviour Therapy (DBT) model - three components
Linehan
- Emotional dysregulation - partly biological/ part experiential (emotionally restricted environment)
- Temperament - (ie for BPD - high in neuroticism, heightened baseline arousal, increased intensity of responses to emotional stimuli;
- Child is subjected to drastically invalidating environments, e.g., deprivation, neglect, and physical and emotional abuse.
becoming increasingly relevant
What are some issues with the DSM approach to diagnosis of PERSONALITY DISORDERS?
- Some DSM PD criteria are behaviours, e.g., criminal acts, others are traits, e.g., emptiness
- Some DSM PD criteria are harder to assess (identity disturbance) than others, e.g., impulsivity.
- Diagnostic criteria determined by consensus
- Some features of PDs are found in other disorders and also in people without PDs
What are the options for dimensional PERSONALITY DISORDER models?
NEO big five
Temperament and character inventory (Robert Cloninger) (not that informative for treatment apparently)
ICD-11 model
What is the ICD model for PERSONALITY DISORDERS?
Focus on impairment of self and interpersonal functioning, global assessment
Classified according to severity (Mild, Moderate, Severe)
One or more prominent trait qualifiers:
- Negative affectivity
- Detachment
- Dissociality
- Disinhibition
- Anankastia
Includes Borderline Patterns qualifier
What treatments work for PERSONALITY DISORDERS?
DBT or variants (Young Schema theory, DBT, CAT)
Group vs individual? (Jury out)
Nothing promising from drugs
What are the treatment outcomes per cluster for PERSONALITY DISORDERS?
Cluster A – Adaptive failures and least treatable
Cluster B - Major social problems – variable treatment success (some progress with CBT
Cluster C – Least severe adaptive failures best outlook
What are the issues with treatment of PERSONALITY DISORDERS?
Comorbidity
No consensus on how to measure improvement
Social/interpersonal function often remain impaired
Major lack of evidence-based treatment
What is in Cluster B (bad)
- ANTISOCIAL
- BORDERLINE
- HISTRIONIC
- NARCISSISTIC
What is in Cluster C (sad)
- AVOIDANT
- DEPENDENT
- OBSESSIVE COMPULSIVE
