Personality Disorders & Substance Misuse Flashcards
What is personality and what factors shape it?
Personality refers to individual differences in characteristic patterns in thinking feeling and behaving
Factors shaping personality
- *Biological**: Genes - temperament, physical appearance/characteristics, IQ, disability
- *Psychological**: Early attachment and environment, siblings, peer relationships, schooling, traumas
- *Social**: Socialeconomic status, war/peace, social media, culture, climate, immigration
What are personality disorders?
- Personality disorders are conditions in which an individual differs significantly from an average person, in terms of how they think, perceive, feel or relate to others.
- Personality disorders are a class of mental disorders characterized by enduring maladaptive patterns of behaviour, cognition, and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual’s culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.
Remember the 3P’s.
Persistant
Problematic
Pervasive - across different contexts
Describe the different abnormal personality types.
- 10 different types of personality disorder are identified which are usually grouped around 3 clusters: A, B, C
- It is common for people to have more than one type of personality disorder
- People may also present with traits of one type rather than the full disorder
- Scoring high on severity and across different types is a sign of increasing complexity.
Type A : Paranoid, Schizoid, Schizotypal
Type B: Borderline, Naricissistic, Antisocial, Histrionic
Type C: Obsessive Compulsive, Dependent, Anxious - Avoidant
Describe the Cluster A personality types
- Paranoid: Present as suspicious and mistrustful, misinterpreting events as persecutory, bearing grudges, strong sense of personal rights. Not true psychosis though. Difficult to engange and treat.
- Schizoid: Present as detached, solitary, aloof, little interest in people and sex, indifferent, lacking close friends.
- Schizotypal: Present as eccentric, odd behaviour and thinking, unconventional beliefs. May go on to develop schizophrenia.
Describe the Cluster B personality Disorders
- Borderline aka Emotionally unstable: Present with emotional instability, impulsivity, parasuicidal acts, chronic feelings of emptiness, intense & unstable relationships, fear of abandonment.
- Narcissistic: Present as grandiose, self-important, degrading others. Don’t usually ask for help unless failed.
- Antisocial: Present with unconcern for the feelings of others, disregard for rules, impulsivity, low tolerance to frustration, failure to take responsibility. Often criminal.
- Histrionic: Present as theatrical, dramatic, exhibit superficial emotionality, seductiveness, suggestibility
Over time cluster B tend to become cluster C. As they mature they get a feeling of emptyness.
Describe the Cluster C Personality Disorders
- Obsessive Compulsive aka Anankastic : Present as rigid, stubborn, perfectionistic, preoccupied with rules, order and routine, have a higher sense of morality. But do not have the intrusive thoughts and rituals.
- Dependent: Present as needing others to make decisions for them, fear abandonment, unable to cope alone, need for reassurance. Difficult to maintain adequite distance.
- Anxious- Avoidant: Present with persistent anxiety, sensitive to rejection, tend to avoid relationships unless acceptance is guaranteed.
Describe attachment theory
What is the Hamilton Boundary Seesaw Model
• According to ‘attachment theory’, the emotional bond between
parent and childis crucially important for the child’s survival. Experience of a consistent and responsive caregiver in childhood gives a person the sense thatthe world is safe and they are lovable.
- There is growing evidence from neuroscience that secure attachment helps the brain develop and enables the necessary wiring and chemical connections that help babies regulate their feelings.
- Repeated experiences of care and affection help the babies interact with the world in a trusting and flexible way, gives them a model of relating, increases their confidence and their capacity to tolerate and resolve conflict
- When babies have an experience of the world as unsafe and abusive, they might grow up to become adults who cannot trust others, expect others to be hostile and neglectful. They do not have the necessary chemicals and connections to help them manage their feelings which tent to overwhelm them.
- When considering attachment in adults, it is easy to see that when patients are in crisis or in need of help, people who are in the caring role (professionals) represent attachment figures
Hamilton Boundary Seesaw Model
Pacifier: We are overinvolved, and the patient feels that they can rescue them
Controller: Underinvolved and / or too controlling
Negotiatior : Boundries with care, compassionate but firm. Explicit limits and flexible balance.
Explain self harm in personality disorder
People with personality disorder, (especially bordeline) tend to self harm as a response to overwhelming states of mind.
Self-harm is a coping strategy. However it should be taken seriosuly as as it might lead to serious harm or death
Self harming by cutting releases endorphins in the body, which temporarily gives a sesnse of well-being thus creating the potential for addiction
Replacing self-harm with less damaging strategies is recommended i.e. elastic bands on the wrist, holding ice cube.
Staff’s response to self harm should prioritise safety and well being but not be critical to punishing
What are the treatment principles of personality disorders?
- Recognise and treat co-morbid substance abuse and psychiatric illness
- Understanding the importance of attachment and therapeutic relationship that allows them to see the same person and build trust
- Understanding together crisis indicators and acting before crisis happens. Risk assessment is crucial.
- Appropriate boundaries and contract to keep safe. Should incorporate the person taking the responsibility for getting help for self-harm. Confusing boundaries in childhood may have been internalised so need to be realisting and clear in what is available.
- Good communication between different clinicians
- Well-coordinated , shared and coherent treatment. Reflective practice groups, MDT meetings to understand splits
- Psychotropic medication (mood stabilisers) only to treat comorbidities.
• Therapeutic approaches include:
Group treatment / therapeutic community
Dialectical Behavioural therapy - emphasis placed on developing coping strategies to improve impulse control
Mentalisation Based Therapy - bringing together aspects of psychodynamic, cognitive-behavioral, systemic and ecological approaches.
Transference Focused Therapy - highly structured, twice-weekly modified psychodynamic treatment
Social
- Support groups
- Substance Misuse services
- Assistance with social problems
- Help to access education and work
How do you assess substance misuse?
- What drug(s)
- How long - when did you first try it, when did it become a problem
- How much
- Money
- How often - daily or in binges, as in coce
- Withdrawal
- Previous treatment episodes
- complications
- overdose - hospital
- BBV (tests and vaccinations)
Past medical Hx
Social Hx esp housing and support
What psychiatric conditions are commonly assoicated with alcoholism
Alcoholic Dementia
Wernicke-Korsakoff’s
Independent Major Depression
Affecting upwards of 80% as:
- Consequence of alcohol’s depressant effects on the brain - can enable suicide in at risk patient
- A syndrome reflecting an alcohol–induced mood disorder with depressive features
- An independent major depressive disorder coexisting with or even predating alcoholism.
? precise cause–and–effect as depressive episodes frequently predate the onset of alcoholism
Bipolar Disorder
Among manic patients, 50–60 percent abuse or become dependent on alcohol or other drugs
Diagnosing bipolar is difficult with the complex effects of alcohol on mood states, and common features shared by both illnesses (e.g., excessive involvement in pleasurable activities with high potential for painful consequences)
Again 60% started abusing alcohol or drugs before their first affective symptoms
Anxiety Disorders
Overall, anxiety disorders do not occur at higher rate but specific anxiety disorders, such as panic disorder, social phobia, and PTSD, however, appear to have an increased co–occurrence with alcoholism
Thus, symptoms and signs of alcohol–induced anxiety disorders typically last for days to several weeks, tend to occur secondary to alcohol withdrawal, and typically resolve relatively quickly with abstinence and supportive treatments
ASPD and ADHD
15 to 20 percent of alcoholic men and 10 percent of alcoholic women have comorbid ASPD.
They are likely to develop alcohol dependence at an earlier age
In the case of alcohol abuse, what are the worrying symptoms?
What does withdrawal present like?
Men and women should not drink more than 14 units of alcohol each week
- Head Injury
- Confusion
- Shaking / Seizures
- Hallucinations (esp visual)
- Vomit blood or coffee grinds
- Severe abdo pain
- Sudden yellow
Alcohol withdrawal: Early
Brain trying to re-excite itself
Tremor
Sweating
Nausea
Anxiety
Tachcardia
Alcohol withdrawal: Late
Delirium Tremens (global confusion and autonomic hyperactivity that can cause CVS collapse) - give benzos as a clamp to excitation instead of alcohol
Disorientation
Hallucination
Tremor
BP, pulse, fever, motor incoordination
Describe the recognition and management of Wernicke’s and Korsakoff’s
- Alcoholic malnutrition leads to VIT B1 DEFICIENCY
- Brain lesions – haemorraging in midbrain (Hyp/Mam. bodies)
- Thiamine stores last approx 1 month but features (including tendon reflexes and p.neuropathy) can occur in a week or so of reduced intake
- 10% chronic alcoholics will develop W-K. If untreated mortality is 15-20%
- Treatment is with parenteral Thiamine (pabrinex)
Wernicke’s Encephalopathy
* **Triad: Ataxia**, **Nystagmus** (usually horizontal) **Ophthalmoplegia** (VI nerve palsy) * Other features are vomiting, altered level of consciousness, fever or hypothermia, ptosis and abnormal pupillary reflexes (non reacting miotic pupil)
Korsakoff’s
- Is the result of repeated Wernicke’s because of the haemorrages
- Prominent impairment of recent and remote memory
- Yet immediate recall is usually preserved
- Disordering of “time sense” and ordering of events. Impaired ability to learn new things
- Confabulation is marked, but not always present
- Other function largely normal
What are the signs of opiate overdose and withdrawal?
Overdose - very few signs
Pin point pupils
Decreasing consciousness
Slow breathing
Death after 90min-2hrs
Naloxone IM!
Recognising Opiate Withdrawal
Early peroid: first 12 hours
- Sweaty clammy skin
- Dilated pupils
- Persistent yawning
- Lacrimation
- Rhinorrhoea
- Goosebumps
- Tachycardia
- Restlessness
LATE DAY 2-3
- Nausea and vomiting
- Diarrhoea
- Abdominal cramps
- Insomnia
- Muscle pains
Don’t tend to die from opiate withdrawal - 7 to 9 days
How do you manage opiate addiction?
Naloxone and artifical respiration in overdose!
Methadone
- Less addictive - has a longer half life, not much or a high, or a low
- Allows people to move on
- Gets people support and therapy
- 40mg fatal in non tolerant
- So start 30mg titrate from 10mg with symptoms
Buprenorphine
- Tablet under tongue
- 1 x day
- Partial Agonist: Blockade.
- More tightly bound so won’t feel heroin. But means they will go into withdrawal.
- 8 then 16mg
- Diff to overdose
