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iBSC Abnormal Psychology > Session Twelve (Personality Disorders) > Flashcards

Session Twelve (Personality Disorders) Flashcards

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1
Q

Define personality?

A
  • An individual’s characteristic patterns of thoughts, emotions and behaviours, as well as the psychological mechanisms (hidden or otherwise) which dictate them.
  • Relatively consistent traits and unique characteristics that give a sense of consistency to a person’s identity
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2
Q

What is a personality disorder?

A
  • An enduring pattern of inner experiences or behaviours that is markedly different from the cultural norms.
  • Affecting the way a person relates to others and themselves.
  • Causing significant differences in Cognition/ Affectivity/ Interpersonal functioning/ Impulse control
  • Behaviour patterns are normally pervasive over time and inflexible.
  • Individuals are normally highly stubborn.
  • And normally have significantly reduced emotional range with which to cope with life stress.
  • Must be distressing to the individual or others to count as as PD.
  • Leads to clinically significant impairment in social life, occupation, relationships…
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3
Q

What aspects of a person are influenced by having a personality disorder?

A
  • Cognition
  • Affect
  • Interpersonal functioning
  • Impulse control

(this then usually leads to other issues, such as isolation, depression, addiction).

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4
Q

Who is most likely to experience a personality disorder?

A
  • Most likely age of diagnosis is early adolescence
  • 70% of those diagnosed are women
  • It is believed men with the condition are more likely to enter the criminal justice system or spiral into addiction than receive a formal diagnosis
  • (prison population prevalence of ASD might be as high as 60%)
  • Although affects 1% of population so generally common
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5
Q

What common co-morbidities exist in Personality Disorder patients?

A
  • Dissociation and self-harm are immensely common
  • Suicidal ideation
  • Depression, dysthymia, bipolarism, psychotic phenomena are all pretty common
  • Link to PTSD, a very high percentage of PD sufferers were victims of some form of abuse
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6
Q

What health inequalities are experienced by PD patients?

A

Morel likely to…

  • Suffer from depression or anxiety
  • Have issue with drugs or alcohol
  • Suffer from CVD or obesity
  • Live a shorter life (average is roughly 20 years shorter)
  • Die an unnatural death (high suicide rate, but also high homicide and accident rates)

For this reason there has been significant impact on improving accessibility and care for these patients.

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7
Q

Broadly, what are the 3 clusters of Personality Disorders (according to ICD-10 and DSM-IV)?

A

Cluster A = Paranoid, Schizoid, Schizotypal

Cluster B = Antisocial, Borderline, Narcissistic, Histrionic

Cluster C = Avoidant, Dependent, Obsessive compulsive

N.B: Some differences between DSM and ICD, ICD doesn’t recognise Schizotypal or Narcissistic.

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8
Q

What are the ‘3 main areas of difficulty’ which therapists look to address in these patients?

A
  • Affect Regulation (difficulties and variations in emotions)
  • Relationships (how people relate to themselves and others)
  • Identity (fragile self-esteem, poor sense of identity)
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9
Q

What are the 3 Ps of PD diagnosis, all of which must be present for a diagnosis to be considered?

A

PROBLEMATIC: Outside the norm for the society in which they live, source of unhappiness for the patient or those around them, sever limitations in their ability to live their lives.

PERSISTENT: Problematic characteristics continue over time, normally emerging in adolescence but remain relatively stable into later life.

PERVASIVE: Affects most if not all aspects of the person’s life; their intimate, family and social relationships as well as the world around them, their work life etc…

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10
Q

What is distinct about the ICD-11 treatment of Personality Disorders compared to ICD-10 or DSM-IV?

A

One diagnosis; ‘Personality Disorder’.

  • Based on the logic that you cannot reliably distinguish PD diagnoses from one another in clinical practice.
  • Instead terms people as mild, moderate or severe. Reflects psychologies move towards viewing conditions on a spectrum with normal conditions.
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11
Q

What are the arguments for and against diagnosing people with a personality disorder?

A

Cons:

  • Immensely stigmatising
  • Disempowering to the patient
  • Insulting and unhelpful
  • Since so many are caused by events in their past, is it fair to describe a person reacting to trauma as a disorder rather than just an understandable response to immense stress>

Pros:

  • Many people like the label, gives a name to thoughts and feelings they’ve been living with for years
  • Allows them to explain themselves to friends and family easier, more forgiving
  • Access to support groups
  • Can normalise it
  • Often need diagnosis to access services
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12
Q

Define Borderline Personality Disorder.

A

“Pervasive pattern of instability of interpersonal relationships, self-image and affects combined with marked impulsivity which begins in early adulthood and is present in a variety of contexts”.

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13
Q

What are the diagnostic criteria for BPD?

A

5 out of 9 of…

  • Frantic efforts to avoid real or imaginary abandonment
  • A pattern of unstable and intense interpersonal relationships characterised by jumping between extremes of liking and hating the person
  • Identity disturbance (persistent distortion of self-image or perceived self)
  • Impulsiveness
  • Recurrent suicidal threats or behaviours
  • Affective instability (marked reactivity of mood)
  • Chronic feelings of emptiness
  • Inappropriate, intense anger
  • Transient stress-related dissociative symptoms or paranoid ideation
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14
Q

What are the issues with the 5/9 diagnostic criteria for BPD?

A

Since you only need 5 of 9 two people with wildly different clinical pictures can receive the same diagnosis, is this internally valid?

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15
Q

What are the 5 types of problems caused by BPD, that clinicians tend to focus on?

A
  • Behaviour problems (impulsivity, self-harming, suicide, violence)
  • Emotion problems (emotions change quickly, very strong emotions such as anger or anxiety)
  • Thinking problems (rigid thinking, black and white, suspicion or paranoia, dissociative experiences when stressed out)
  • Identity problems (not knowing who you are, feelings of emptiness)
  • Relationship problems (unstable relationships, fears of abandonment)
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16
Q

What are the 5 domains affected by BPD?

A

BITER

Behaviour, Identity, Thinking, Emotion, Relationship

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17
Q

What is the diagnostic criteria for Antisocial Personality Disorder?

A

Pervasive pattern of disregard for (and violation of) the rights of others + occurring since the age of 15 + in a person over the age of 18 + 3 of….

  • Failure to conform to social norms (normally means the law)
  • Deceitfulness (e.g. lying or coning)
  • Impulsivity
  • Irritability and aggressiveness
  • Disregard for safety
  • Irresponsibility (e.g. with money, with work)
  • Lack of remorse after hurting or otherwise mistreating another

(can’t be explained by Sz or mania)

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18
Q

What do you call the under 15 y/o equivalent of ASPD?

A

Conduct Disorder

19
Q

Why can’t you diagnose someone below the age of 18 with a personality disorder?

A
  • Personalities aren’t fully formed yet so high risk of misdiagnosis
  • Many symptoms of PDs can kinda be explained by normal teenage behaviour
20
Q

What are the unifying factors between BPD and ASPD?

A
  • Impulsivity
  • Doing things outside of social norms
  • (sort of cognitive and emotional deficits)
21
Q

Who gets ASPD more often?

A

Men, whereas women are more likely to get BPD.

Suggested reasoning = men more prone to externalise emotion, women to internalise.

22
Q

What assessment techniques are commonly used in the diagnosis of PDs?

A
  • Semi-structured interviews
  • Psychometrics
  • Self-reports
  • Observations
  • Collateral histories

Gold standard = using triangulation through multiple sources to make a DIAGNOSIS OF EXCLUSION

23
Q

What did Moran et al (2003) aim to achieve?

A

Produce a simple, 8 question survey for determining whether a person has a PD.

Questions:

  • Do you have difficulty making friends?
  • Do you trust others?
  • Would you describe yourself as a loner?
  • Are you perfectionist?
  • Are you impulsive?
  • Do you depend on others?
  • Are you a worrier?
  • Do you lose your temper easily?

If yes to most questions, consider PD

24
Q

What is psychological formulation?

A
  • An alternative to diagnosis based on constructing an individual understanding of someone and their difficulties done in collaboration with the patient.
  • Aims to reflect the person’s story and puts them at the centre, rather than trying to fit them into a diagnosis
  • Incorporates early trauma, developmental impact of environment, biological predispositions
25
Q

What is the 5 Ps approach to psych formulation?

A 
PROBLEM (what is going on?)
PREDISPOSING (why me?)
PRECIPITATING (why now?)
PERPETUATING (why still?)
PROTECTIVE (what works?)
26
Q

Outline the Attachment Theory approach to psych formulation (or to PD in general? slide unclear. how does Attachment theory relate to PD)?

A

Fonagy et al:
- Lack of contingency in early attachments disables emotional regulation as baby must internalise how emotions are expressed, managed, inhibited.

  • Children who are treated well learn: what they feel, that they are protected and safe, how to soothe themselves when frightened, that others have different and changing thoughts, feelings and intentions
  • Children who are abused or neglected learn: to expect to be treated badly by others, can’t understand or regulate feelings, become anxious, lose the ability to think or read other people, try to manage and contain anxiety through action
27
Q

Outline the reasoning behind the Power Threat Meaning Framework (PTMF) of Psych Formulation?

A

Works on understanding:

  • the adversities a person faces
  • the meaning they derive from them
  • how the problematic behaviours they display now are likely just coping mechanisms developed early in life that were adaptive at the time for surviving the threat

Essentially threat leads to a normal personality response, now that the threat has passed and the patient is an adult the response manifests as PD. Offers trauma informed narrative on distress

28
Q

According to PTMF, what are the impacts of trauma, Adverse Childhood Events (ACEs) and interpersonal threats?

A

Impacts on:

  • How we learn to relate and understand others from early on in life
  • Our ability to self-regulate over time
  • Development and consolidation of core views about self, others, world
29
Q

What is the central question behind PTMF?

A

Is PD a pathology or a predictable outcome to repeated and severe adversity.

30
Q

Outline the framework of PTMF? What questions do you ask the patients?

A

PTMF replaces “what is wrong with you?” with:

  • What has happened to you?
  • How did this affect you
  • What sense did you make of it
  • What did you have to do to survive
  • What are your strengths
  • What is your story
31
Q

According to the PTMF model, what are the key life ‘threats’ a person with a personality disorder faces?

A
  • Relational (e.g. disrupted attachments, betrayal, isolation)
  • Emotional (e.g. feeling emotionally overwhelmed)
  • Social/Communal (e.g. isolation, exclusion)
  • Economic/Material (e.g. poverty, inability to meet basic physical needs, lack of access to services)
  • Environmental (e.g. feeling unsafe or threatened)
  • Bodily (e.g. ill health, chronic pain, disability, injury)
  • Identity (e.g. lack of ability to form a social, cultural, spiritual or personal identity)

Aim of PTMF therapy is to delve into the particulars of a patient’s history and current state to provide them with safety from these threats

32
Q

Briefly describe the treatment options available for PDs?

A
  • Limited. Not a massive evidence base to date.
  • Focus is on psych treatment
  • Most research is into BPD and ASPD
  • Medication only to reduce specific symptoms
  • Essentially you can’t treat a person’s disordered personality, but you can treat certain elements caused by this for instance self-harm
33
Q

What is the NICE guideline for people with BPD who self-harm

A

Dialectical Behaviour Therapy (DBT). Harm reduction is the priority.

Currently gold standard, as there is limited evidence in favour of other therapies (however, research into things such as MBT, CAT or STEPP is ongoing)

34
Q

What therapies exist for aiding BPD?

A
  • Dialectical Behavioural Therapy (DBT)
  • Mentalisation Based Treatment (MBT)
  • STEPP
  • Cognitive Analytic Therapy
  • STEPP
35
Q

How effective are BPD therapies?

A
  • Unclear
  • As of right now, only clear evidence is benefit of DBT in women who self harm (men still unclear)
  • However some evidence has suggested reductions in self-harm and hospitalisation, coupled with secondary benefits in terms of mood, engagement, functioning and attachment.
  • Movement in the field is towards a trans-theoretical approach that attempts to use multiple theories/therapies.
36
Q

What are the current NICE guidelines for managing ASPD?

A

Group based cognitive and behavioural interventions aimed at addressing:

  • Impulsivity
  • Interpersonal difficulties
  • Offending (illegal activity)
  • Other antisocial behaviours

Pharm interventions can be good for symptom management, or the management of common co-morbidities (e.g. depression)

37
Q

What is the evidence base for ASPD therapies

A

CBT:

  • Dawson et al, 2009
  • Showed reduced levels of verbal and physical aggression and improved social functioning

DBT:

  • McCann et al, 2000
  • Emerging evidence for the use of DBT in forensic settings
  • Able to reduce violence and aggression
38
Q

What are the NICE guidelines for Conduct Disorders?

A

CD = Antisocial behaviour in kids and young adults

Guidelines:

  • Require comprehensive assessment, including assessing parents and carers
  • Key worker to oversee care and facilitate engagement with services
  • Parents/carers offered referral for group or individual parent training programmes
  • 3-7 years: classroom based emotional literacy and problem solving programme
  • 11-17 years: referral for multimodal interventions + involvement of parents/carers
39
Q

What is the evidence base for CD treatment?

A

Cochrane review by Furlong et al (2013):
- Behavioural and CBT group-based parenting interventions effective and cost-effective for improving child conduct problems, parent mental health and parenting skills

40
Q

What forms of therapy are used in the management of CD?

A

Multi-systemic Therapy:

  • Focussed on the family and wider resources of school, community, criminal justice system
  • Uses intensive individual case work
  • Effectiveness has been demonstrated in RCTs

Functional Family Therapy:
- Focus on the immediate family environment and uses the family resources to change the patterns of antisocial behaviour

41
Q

What is the most important determinant of CD treatment effectiveness and how can you boost it?

A

Engagement by the child.

  • Prepare for challenges early on
  • Think what core needs this child has not had in their past, how can you provide that (e.g. secure foundation, consistency)
  • Planning, targeting
  • Timing and consistency
  • Balancing motivation and not assuming its fixed
42
Q

What is Dialectical Behaviour Therapy?

A
  • BPD as emotion regulation problem + skills deficits
  • Highly structured and behavioural
  • Based on a combination of accepting the patient is the way they are due to circumstances out of their control, and understanding there is a need to change
  • Targets reducing suicidal ideation and self-harming behaviours by increasing skills for emotion regulation and distress tolerance
  • Aim = to stabilise life threatening behaviours first, improve QoL next
  • Emphasis on developing capacity for mindfulness
  • Weekly; individual therapy, group skills training
  • 24/7 telephone contact to help cope with emergencies
43
Q

What are the 5 central tenants of DBT?

A
  • Interpersonal Effectiveness (keeping relationships steady, getting what you need socially while maintaining self-respect)
  • Emotional Regulation (reducing emotional intensity)
  • Distress Tolerance (reducing impulsivity, crisis management)
  • Mindfulness (focusing the mind, directing attention, understanding how you feel)
  • Walking the middle path (helping patients understand everything is not lack and white)

iBSC Abnormal Psychology (19 decks)

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