Personality Disorders

Question 1

Personality

Answer 1

Personality refers to Enduring Patterns of Thoughts, Attitudes, Moods and Behaviours which
help to define individuals; Common features =Traits, observed in variable degrees in different
people, useful as structure to describe personality

Question 2

Personality Disorders

Answer 2

Causes either disability or distress; May react in unusual ways
to illness or to treatment, and stressful events; Behave in unusual ways when
mentally ill; Behave in ways that are stressful or dangerous to themselves or others;
or develop psychiatric disorders more often than others

Question 3

How to distinguish between normal personality from personality disorder

Answer 3

Difficult to distinguish normal personality from Personality Disorder; No valid and reliable
measures; Practically, can be identified based on functional disability to self or others
o Develop gradually in early years through adolescence, without clear onset
• Personality is defined as enduring and stable; Small changes may occur gradually over many
years; Personality change refers to abrupt, step-like changes which can result from – Organic
Causes within the Brain, Residual Effects of Severe Mental Illnesses (e.g. Schizophrenia), or
exceptionally severe stressful situations

Question 4

Assessment of Personality

Answer 4

• Information can be derived from Corroborative source (Typically best source if collateral
history from observant), Patient’s own account of past behaviour in variety of circumstances,
Patient’s own account of personality and Patient’s behaviour in interview (although that is
often unreliable as it reflects current mood)
• Describing normal personality can be done without technical terms; Short descriptions which
might include Favourable and Unfavourable characteristics

Question 5

Assessment of Personality: general question

Answer 5

• General Questions – How do you think your friends and family would describe your
personality, or you as a person
• Relationships – Occupational, Social, Intimate; Ease, Quantity, Quality, Longevity; Comfort in
company and nature of Romantic relationships
• Usual Mood – General Character of Mood, Stability, Spontaneity/Reactive, Expression
• Other traits – E.g. Reactions to Disagreement, Decision Making, etc
• Attitudes, Beliefs and Standards – E.g. To illness, Religion, Personal beliefs
• Habits – Typical Daily Routine, Social history, etc

Question 6

Anxious, moody or worry prone

Answer 6

• In common: Worries about day-to-day problems or health; Inflexible, Obstinate, Indecisive;
Mood might be persistently gloomy/pessimistic, or unstable

Question 7

Anxious

Answer 7

=Avoidant Personality Disorder – Persistently anxious, ill at east, fearful of
disapproval or criticism; Feel inadequate or timid

Question 8

Anankastic

Answer 8

=Obsessive Compulsive Personality Disorder – Inflexible, Obstinate and Rigid in
their opinions and focus on unimportant detail
o Indecisive, and having made decisions worry about consequences
o Humourless, Judgmental while worrying about opinion of others
o Perfectionism, Rigidity and Indecisiveness; Might appear outwardly controlled but can
be irritated by disturbance to routine and may have violent feelings of anger

Question 9

Dependent Personality Disorder

Answer 9

Passive, unduly compliant with wishes of others; Lack
vigour, self-reliance and avoid responsibility; Achieve aims by persuading others to assist
them while protesting their own helplessness
o Some supported by more self-reliant partners; Left to themselves, have difficulty
dealing with demands and responsibilities

Question 10

Affective Personalities

Answer 10

– Lifelong tendency to persistent gloom, elation or varied mood;
Abnormal but not severe enough to be classed as Affective Disorders
o NB: Not recognised as Personality Disorder by ICD-10 or DSM

Question 11

Paranoid Personality Disorder

Answer 11

Sensitive, Suspicious; Mistrust others and suspect their
motives and are prone to jealousy; Touchy, Irritable, Argumentative and Stubborn
o Strong sense of self-important and special abilities, and might feel potential being
stymied by others letting them down or deceiving them

Question 12

Schizoid Personality Disorder

Answer 12

Emotionally cold, Self-sufficient and Detached
o Introspective, might have complex fantasy life
o Little concern for the opinion of others, and may pursue solitary source through life

Question 13

Schizotypal Personality Disorder

Answer 13

Eccentric; Unusual ideas, or Ideas of Reference
o Abstract and Vague speech, with inappropriate affect;
o NB: ICD-10 classifies as Schizophrenia rather than Personality Disorder

Question 14

Emotional Unstable

Answer 14

=Borderline Personality Disorder – Combination of Histrionic and
Antisocial Features, centred around Impulsivity and poor Self-control;
o Initially believed to be borderline Schizophrenia; Presents frequently to healthcare
o Intense but unstable relationships; Persistent feelings of Boredom and Emptiness
with uncertainty about Personal Identity and fear of Abandonment
o Mood often unstable – Outbursts of Anger, Low Tolerance of Stress
o Impulsive, Engage in Self-Damaging Behaviours (E.g. Spending, Gambling, Sex, Eating,
Substance Abuse)
o Threats or acts of Deliberate Self-Harm might be recurrent

Question 15

Histrionic Personality Disorder

Answer 15

Sociable, Outgoing and Entertaining
o Self-centred, Prone to Short-lived Enthusiasms, and lack Persistence
o Extreme displays of emotion with quick recovery and without remorse
o Sexually provocative behaviour is common, but without tender feelings
o Self-Deception, Ability to persist with Elaborate lies

Question 16

Narcissistic Personality Disorder

Answer 16

Morbid Self-Admiration; Grandiose sense of Self-
importance and Pre-occupied with Fantasies of Success, Power and Intellectual Brilliance
o Crave attention, exploit others and Seek favours but do not return them
o NB: ICD-10 does not recognise Narcissistic PD

Question 17

Dissocial =Antisocial Personality Disorder

Answer 17

Often Co-morbid with Substance Abuse

o Impulsive Behaviour, Low Tolerance, Callous or Violent acts, Lack of guilt, Forensic Hx

Question 18

Epidemiology of Personality Disorder

Answer 18

• Overall 5-10%; M>F, decreases with age
• Antisocial more common in men; Histrionic and Emotionally-Unstable more common in
women; Often Co-morb with other mental disorders

Question 19

Aetiology of Personality Disorder

Answer 19

• Results from interaction of Genetic Factors and Childhood/Upbringing; Unknown relative
contributions due to difficulty with accurate measurement
• Most research mainly around Antisocial Personality Disorder
o Genetic Factors, Childhood Experience, Birth Injury (Poor evidence), Abnormal Brain
Development (Circumstantial Evidence), Serotonin Hypothesis

Question 20

Management of Personality Disorders

Answer 20

• Assess Risk; Aim to identify and treat co-morbid disorders such as DSH and Substance Abuse
• Help deal with/avoid situations which provoke problem behaviours, General support to
reduce tension and increase self-esteem and Supporting families
• Management should be realistic, focussing onto specific problems and not attempting to
change personality; Patients encouraged to take responsibility for their actions and be willing
to problem-solve, agree to modest aims and work to achieve over time, gain confidence and
learn from mistakes as opportunities

Question 21

Management of Personality Disorders: Therapeutic relationship

Answer 21

• Therapeutic Relationship – Patient should feel Valued as a person; Trust and Confidence
o Should not be allowed to be too intense, dependent or demanding
o If multiple people involved in care, roles defined and made clear to patient
• Build on strengths – Recognise and develop talent and skills
• Dealing with, or avoiding Provoking factors, Reducing Substance Abuse

Question 22

Management of Personality Disorders: Pharmacotherapy

Answer 22

Mainly to manage Co-morb; Antipsychotics, Lithium and Anticonvulsants,
and Antidepressants have specific roles; Benzodiazepines should be avoided where possible
• Psychotherapy – Self-help in the first instance; CBT more appropriate than Dynamic Therapy
o Schizoid, Paranoid and Dissocial seldom benefit from psychotherapy

Question 23

Management of Personality Disorders: Therapeutic Community

Answer 23

E.g. Complex Needs Service comprising Assessment, Intensive

Group Therapy, Intensive Day Programmes and Post-therapy programme

Question 24

Specific Management of Emotionally-Unstable PD

Answer 24

Consider if person presents to primary care recurrent DSH or persistent risk-taking behaviour; If in crisis in primary care perform Risk Assessment, Manage Anxiety and Encourage
manageable changes and Coping Skills
o CMHT to assess Psychosocial and Occupational Functioning, Coping Strategies,
Strengths and Vulnerabilities
o Management of Comorbid mental disorders and Social issues

Question 25

Specific Management of Emotionally-Unstable PD: Treatment planning

Answer 25

Consider Choice and Preference, Degree of Impairment and Severity,
Willingness and Motivation, Ability to remain within boundaries of therapeutic relationship

Question 26

Specific Management of Emotionally-Unstable PD: Psychotherapy

Answer 26

Comprehensive Dialectical Behavioural Therapy if reducing recurrent self-
harm is main priority; >3/12 of treatment

Question 27

Specific Management of Emotionally-Unstable PD: Pharmacotherapy

Answer 27

Antipsychotics not for medium or long-term treatment; May be

considered for co-morb; Sedative medication might be useful in crisis but no more than 1/52

Question 28

ICD-10 Criteria for Emotionally Unstable Personality Disorder

Answer 28

General Criteria (F60) – Characteristic and Enduring Patterns of Inner Experience and
Behaviour as a whole deviate from culturally expected and accepted range, in more than one
of the following areas – Cognitive, Affectivity, Impulse Control, Interpersonal Manner
o Deviation must manifest itself pervasively as Inflexible, Maladaptive and
Dysfunctional; Personal Distress or impact on social environment
o Stable, long duration with onset in Late Childhood or Adolescence
o Not a manifestation of other adult mental disorders with organic causes ruled out

Question 29

F60.30 (EUPD Impulsive Type)

Answer 29

Marked tendency to quarrelsome behaviour and conflicts with others when impulsive acts are thwarted/criticised,
o plus 2 of either – Marked tendency to act unexpectedly without considering
consequences, Liability to outbursts of Anger/Violence with inability to control,
Difficulty maintaining any course of action without immediate reward, and
Unstable/Capricious Mood

Question 30

F60.31 (EUPD Borderline Type)

Answer 30

Addition of at least two of – Uncertainty about Self-image,
Aims and Internal Preferences (including Sexual), Liability to be involved in Intense and
Unstable Relationships often leading to emotional crisis, Excessive Efforts to avoid
Abandonment, Recurrent Threats/Acts of Self-harm, and Chronic Feelings and Emptiness

Question 31

DSM-V Criteria for Borderline Personality Disorder

Answer 31

• Significant Impairment to Self-Functioning (Identity or Self-Direction)
• Impairment to Interpersonal Functioning (Empathy or Intimacy)
• Negative Affectivity – Emotional Liability, Anxiousness, Separation Insecurity, Depressivity
• Disinhibition – Impulsivity and Risk Taking
• Antagonism – Persistent or Frequent Angry Feelings
• Impairments are relatively stable over time and consistent over situations; Not due to
substance influence or general medical condition