Personality disorders - F60 Flashcards
What is some epidemiology of personality disorders?
About 1/20 people have some sort of personality disorder in the UK
The most common types are schizotypal (m>f), antisocial (m>f), borderline (f>m) and histrionic (f>m); less common are narcissistic (m>f) and avoidant (m>f)
Cluster A personalities are especially common in homeless people
Co-occurrence of PDs is common too
What is the aetiology of PD?
Mix of genetics/biology, psychological and environmental influence i.e. trauma - no clear cut answers
What are some environmental risk factors for PD?
Child abuse and neglect
i) Particularly sexual abuse but also aggressive or unloving households etc
Socioeconomic status
i) Lower status may correlate with higher incidence
Parental personality issues
i) Either by genetic transfer or modelling or both, issues can be picked up
ii) Poor parenting may also have an impact – i.e. lack of maternal bonding in borderline personality disorder, lack of breast feeding
What are the general criteria required for PD diagnosis?
Disharmonious attitudes and behaviour, usually involving several areas of functioning i.e. affectivity, impulse control, ways of thinking and perceiving, relating to others
These patterns are long standing and not limited to episodes of mental illness
Traits are pervasive i.e. expresses itself across varied situations
Manifestations always appear during childhood or adolescence and continue to adulthood
Disorder leads to considerable personal distress, may only be apparent late in its course
Usually but not always causes the individual marked difficulties in social/occupational/familial etc circumstances
Not attributable to another adult mental disorder or organic disease/injury/dysfunction
What are ‘cluster A’ PDs?
Odd or eccentric disorders
Paranoid PD, schizoid PD, schizotypal PD
Often associated with schizophrenia but those diagnosed often have a greater grasp on reality
Can be paranoid and have difficulty being understood – eccentric modes of speaking and unwillingness/inability to form and maintain close relationships
How do people with paranoid PD present?
Delusional type -
Pattern of irrational suspicion i.e. with the fidelity of a sexual partner
Mistrust of others, unforgiving of insults
Interpretation of others motivations as malevolent
Excessive sensitivity to setbacks
Combative and tenacious sense of personal rights
Possible excessive self-importance and often excessive self-reference
How do people with schizoid PD present?
Socially withdrawn type -
Lack of interest and detachment from social relationships
Apathy, limited capacity for pleasure
Restricted emotional expression
Preference for fantasy, solitary activities and introspection
How do people with schizotypal PD present?
Distorted reality type -
Pattern of extreme discomfort interacting socially
Distorted cognitions and perceptions – paranoid or bizarre but not true delusions
Cold or inappropriate affect
Anhedonia
Odd or eccentric behabiour
Obsessive ruminations
Occasional transient quasi-psychotic experiences w/intense hallucinations (auditory or other) and delusion-like ideas
What are cluster B disorders?
Dramatic, emotional or erratic disorders
Antisocial/dissocial PD, Borderline/emotionally unstable PD, Histrionic PD, Narcissistic PD
How do people with antisocial PD present?
Psycho/sociopathic type -
Pervasive pattern of disregard for and violation of rights of others; repeatedly breaking the law
Lack of empathy
Bloated self image
Manipulative
Impulsive behaviour
Gross disparity between behaviour and the prevailing norms that is not modifiable by adverse experience including punishment
Low tolerance to frustration
Low threshold for discharge of aggression, including violence
Tendency to blame others or offer plausible rationalisations for the behaviour bringing the patient into conflict with society
Incapacity for maintaining relationships
Use of substances 3-5x more likely
How do people with borderline PD present?
Pervasive pattern of abrupt mood swings
Instability and intensity in relationships, behaviour and affect
Impulsivity
Liability to outbursts of emotion and incapacity to control behavioural explosions
Tendency to quarrelsome behaviour, especially when impulsive acts are thwarted or censored
Disturbance in self image, aims and internal preferences
Chronic feelings of emptiness; tendency to self-destructive behaviour incl self harm and suicide attempts
What are some common comorbidities with BPD?
Depression, anxiety, ED, PTSD, substance misuse and bipolar disorder
How do people with histrionic PD present?
Pervasive pattern of attention seeking behaviour, self dramatisation, theatricality
Shallow and labile affectivity
Exaggerated expression of emotions
Suggestibility
Egocentricity
Self-indulgence
Lack of consideration for others
Easily hurt feelings
Continuous seeking for appreciation, excitement and attention
How do people with narcissistic PD present?
Grandiosity, with expectations of superior treatment from other people
Fixated on fantasies of power, success, intelligence and attractiveness etc
Self-perception of being unique, superior, associated with high status people and institutions
Needing continual admiration from others
Sense of entitlement to special treatment and to obedience from others
Exploitative of others to achieve personal gain
Unwilling to empathise with feeling, wishes, needs of others
Intensely envious of others and the belief that others are equally envious of them
Pompous and arrogant demeanour
What are cluster C disorders?
Anxious or fearful disorders
Anxious/avoidant PD, Dependent PD, Anakastic/obsessive-compulsive PD
How do people with avoidant PD present?
Persistent and pervasive feelings of tension and apprehension
Belief that one is socially inept, personally unappealing or inferior to others
Excessive preoccupation with being criticised or rejected in social situations
Unwillingness to become involved with people unless certain of being liked
Restrictions in lifestyle because of a need to gave physical security
Avoidance of social or occupational activities that involve interpersonal contact because of fear of criticism, rejection or disapproval
How do people with dependent PD present?
Encouraging or allowing others to make most of one’s important life decisions
Subordination of one’s own needs to those of others on whom one is dependent; undue compliance with their wishes
Unwillingness to make even reasonable demands on people one depends on
Feeling uncomfortable/helpless when alone because of exaggerated fears of inability to care for oneself
Preoccupation with fears of being abandoned by a person with whom one has a close relationship and being left to care for oneself
Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others
How do people with anakastic PD present?
Feelings of excessive doubt/caution
Preoccupation with details, rules, lists, order, organisation or schedule
Perfectionism that interferes with task completion
Excessive conscientiousness, scrupulousness and an undue preoccupation with productivity, to the exclusion of pleasure and interpersonal relationships
Excessive adherence to social conventions
Rigidity and stubbornness
Unreasonable insistence by the individual that others submit to their way of doings things
Intrusion of insistent and unwelcome thoughts/impulses
What are some other specific personality disorders?
Depressive - low mood and self esteem, guilty, worrying
Haltlose - selfish, irresponsible, hedonistic
Passive-aggressive - procrastination, inefficiency, stubbornness
Sadistic - cruel, aggressive, manipulative, violent
Self-defeating - rejecting of pleasurable experiences and help, pessimistic, drawn to things that will lead to their suffering
What is the general treatment for personality disorders?
Some drugs indicated for if other problems co-occur with PD ie SSRIs, antipsychotics etc
Mainstay of management is psychotherapy - various forms for various disorders, some more receptive than others - to help people understand themselves better and cope with difficulties
What is the treatment plan for those with borderline PD?
Review and care programme by CMHTs
Psychotherapy - DBT, Mentalisation-based therapy
Withdrawing, ending or changing treatment in those with BPD can evoke strong emotional reactions - changes need to be discussed before and are structured and phased + effective collaboration with other care providers during changeover, including crisis access
What is the treatment for those with antisocial DP?
CBT
Democratic Therapeutic Communities (also for other PDs)
What is the prognosis for PDs?
Are lifelong but rend to improve with age ie antisocial behaviour and impulsiveness seem to decrease in 30s-40s
Can also go the other way - schizotypal can develop into schizophrenia
