Personality disorders: - Dissocial - emotionally unstable (EUPD) Flashcards
What are the different type of personality disorders? (clusters and types)
How does ICD-10 define dissocial personality disorder?
- Personality disorder characterized by disregard for social obligations, and callous unconcern for the feelings of others.
- There is gross disparity between behaviour and the prevailing social norms.
- Behaviour is not readily modifiable by adverse experience, including punishment.
- There is a low tolerance to frustration and a low threshold for discharge of aggression, including violence; there is a tendency to blame others, or to offer plausible rationalizations for the behaviour bringing the patient into conflict with society.
How does ICD-10 define Emotionally unstable personality disorder?
Personality disorder characterized by a definite tendency to act impulsively and without consideration of the consequences; the mood is unpredictable and capricious.
There is a liability to outbursts of emotion and an incapacity to control the behavioural explosions.
There is a tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or censored.
How does ICD -10 divide emotionally unstable personality disorder in order to distinguish them
Two types may be distinguished:
the impulsive type
* characterized predominantly by emotional instability and lack of impulse control
Borderline type
* characterized in addition by disturbances in self-image, aims, and internal preferences
* chronic feelings of emptiness,
* intense and unstable interpersonal relationships
* tendency to self-destructive behaviour, including suicide gestures and attempts.
What causes dissocial personality disorder?
Childhood has often involved:
* parental conflict
* harsh inconsistent parenting
* care from other agencies (i.e. been taken into care)
* truancy
* delinquency
* substance misuse
Criminal behaviour
* central but often preceeded by other difficulties e.g. socio-economic, educational, family, relationship
Comment on the epidemiology of dissocial personality disorder
General population
* 1-1.3% men
* 0-0.2% women
Prison
* <50%
What are disscial personality disorder symptoms?
- Unstable interpersonal relationships.
- Disregard for the consequences of their behaviour.
- A failure to learn from experience.
- Egocentricity.
- A disregard for the feelings of others.
- A wide range of interpersonal and social disturbance.
- Comorbid depression and anxiety.
- Comorbid alcohol and drug misuse.
When can you diagnose dissocial personality disorder ?
- Cannot diagnose <18
- but it often begins in childhood around age of 8
- in children conduct disorder is diagnosed and if symptoms persist past 18 diagnosis converts to dissocial
The ICD-10 wants what criteria to be met to diagnose dissocial personality disorder?
3 of:
* Callous unconcern for the feelings of others.
- Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations.
- Incapacity to maintain enduring relationships, (no difficulty in establishing)
- Very low tolerance to frustration / low threshold for discharge of aggression, including violence.
- Incapacity to experience guilt, or to profit from adverse experience, particularly punishment.
- Marked proneness to blame others, or to offer plausible rationalisations for the behaviour bringing the subject into conflict with society.
What are some differential diagnosis for dissocial personality disorder?
- Alcohol dependency.
- Mental disorders secondary to medical conditions (head injuries, seizure disorders)
- Anxiety disorders
- Other personality disorders
- General learning disability
- Brief psychotic disorder
- Post-traumatic stress disorder
- Depression
- Schizoaffective disorder
- Schizophrenia
What investigations / testing for a personality disorder?
- Toxicology screen (blood urine etc) for evidence of alcohol, illicit drugs as intoxication can lead patients to present with some features of personality disorders
- HIV/STI screen if approproate as poor impulse control or disregard of risk
Physcological testing to support clinical diagnosis, NICE cite:
* Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV).
* Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II).
* Structured Interview for DSM-IV Personality (SIDP-IV).
* International Personality Disorder Examination (IPDE).
* Personality Assessment Schedule (PAS).
* Standardised Assessment of Personality (SAP).
What are some associated diseases with dissocial personality disorder?
Anxiety.
Alcohol misuse.
Drug misuse.
Depression.
Attention deficit hyperactivity disorder (ADHD) in childhood.
What are complications of dissocial personality disorder?
Suicide
Substance abuse
Accidental injury
Depression
Homicide
Prognosis for personality disorders?
- poor - higher rates of morbidity and mortality than other groups
- worse outcomes in associated physical and mental illnessness
- Prevalence decreases with age but but may be that older adults are less impulsive / agressive or have got better at hiding them
What services may be involved in the management of a pt with dissocial personality disorder?
- mental health services
- substance misuse services
- social care
- criminal justice system and forensic mental health services
Management of dissocial personality disorder?
Bio:
* no drug treatment
* Dr M - more likely to blame behaviour on need for medication
Psych:
* Dr M: ciminal justice system - little can do to medically treat the antisocial behaviour
* Group psychotherapy - cognitive and behavioural interventions eg. ‘ reasoning and rehabiiltation’ or ‘stop and think’ groups to resolve behaioural violnce.
* Psychoeducation for pt and family
Social:
* Drug and alcohol misuse services if needed
https://www.nice.org.uk/guidance/cg77/chapter/Recommendations#treatment-and-management-of-antisocial-personality-disorder-and-related-and-comorbid-disorders
are men or women more likely to have personality disorders?
- overall personality disorders are distributed equally between males and females
- emotionally unstable personality disorder is more common amongst females.
How might someone with emotionally unstable personality disorder present?
- Relationship difficulties.
- Recurrent self-harm.
- Threats of suicide.
- Depression.
- Bouts of anger.
- Impulsivity.
- Social difficulties.
What are some differencial diagnoses for emotionally unstable personality disorder?
- Alcohol dependency.
- Mental disorders secondary to medical conditions (head injuries, seizure disorders).
- Other personality disorders.
- Anxiety disorders.
- General learning disability.
- Brief psychotic disorder.
- Post-traumatic stress disorder.
- Depression.
- Schizoaffective disorder.
- Schizophrenia.
What are conditons associated with emotionally instable personality disorder?
Mental health:
* Anxiety.
* Alcohol misuse.
* Drug misuse.
* Depression.
* Recurrent self-harm.
* Eating disorders.
* PTSD
Physical health:
* Arteriosclerosis
* Hypertension
* Hepatic disease
* Cardiovascular disease
* Gastrointestinal disease
* Arthritis
* Sexually transmitted infections
What is the management for emotionally unstable personality disorder?
Bio:
* treat any co-existing condition
* only use drugs for individual symptoms associated with disorder e.g. self harm, risk taking, transient psychotic symptoms, emotional instability (not for EUPD but for symptoms) or sedatives short term for crisis
Psych:
* Psychotherpay e.g. Dialectical Behavioural therapy (EUPD women risk of self harm - NICE says works well)
* should be 2x weekly sessions and not short (not <3 months)
* refer to CMHT or CAMHS if young
* Group therapy - community living for 6 weeks with other EUPD to normalise relationships - less common than DBT (DR M)
* Pyscoeducation for pt and family
Social
* develop a crisis plan which identifies triggers, self management strategies and how to acess services
Complications for EUPD?
Suicide
Substance abuse
Accidental injury
Depression
Homicide
Prognosis for EUPD?
- variable - some ppl recover / improve
- many still have social and interpersonal difficulties
