Week 10 - personality disorders Flashcards
explain the controversy over personality disorder diagnosis
- Misunderstood and misdiagnosed by diagnosis, services and population, discriminated against in these settings and often used as exclusion criteria in MH diagnoses.
- Trauma often ignored especially for men and often misused as derision by services as attention seeking and manipulation.
- Gender, ethnicity (black females more diagnosed with psychosis instead and men antisocial disorder), age (‘too young’), neurotypical status (comorbidity with autism)
who are there risks for?
to others
to self
from others
risk to others
violence, sexual aggression/exploitation
risk to self
active behaviours like self-harm and neglect; passive behaviours such as non-engagement in behaviours promoting wellbeing
risk from others
violence, sexual aggression, exploitation, neglect/abandonment, discrimination
DSM-5 diagnostics
- Cluster A (odd, eccentric): paranoid, schizoid, and schizotypal personality disorder
- Cluster B (dramatic, emotional, erratic): borderline, antisocial, histrionic, and narcissistic personality disorder
- Cluster C (anxious, avoidant): avoidant, dependent, obsessive-compulsive personality disorder
common features across types of PD
- Problem of overlap and reliability as commonly have abnormal behavioural, emotional regulation, interpersonal relationships, intrapersonal conflict and shame and guilt.
ICD-11 changes
focus on severity not categories from mild to severe impairment
common comorbidities
- PTSD, cPTSD, mood disorders, substance misuse, ED, other personality disorders, dissociation, developmental disorders
role of early trauma: evidence
- Strong evidence between exposure to childhood trauma and all classes of personality disorder on a general level (not specific)
- Trauma may explain the neurobiological evidence supporting personality disorders and the epigenetic effect of trauma explains the high rates in families.
- Porter 2019: importance of considering childhood adversity when treating BPD.
prevalence of PD
NIH 8%
how are diagnoses made?
NICE guidelines
psychometric tools
key considerations of PD diagnoses
- Overlap between other personality disorders and also with other diagnoses
effects of Emotionally unstable personality disorder (EUPD)/borderline personality disorder (BPD):
○ 75% attempt suicide and 10% commit
○ Self-harm and hospitalisation
○ Impulsivity and aggression
○ Conflict in relationships
prevalence of Emotionally unstable personality disorder (EUPD)/borderline personality disorder (BPD):
○ 1-2% of population
○ Highest diagnosed
aetiology of Emotionally unstable personality disorder (EUPD)/borderline personality disorder (BPD):
○ Stress-diathesis model of environmental factors and biology
○ Biosocial model underpins dialectical behaviour therapy (DBT)
§ Emotional vulnerability, impulsivity, invalidating and ineffective environment
invalidating environments
being told your responses and emotions are not correct or important, misinterpretation of feelings, needs being ignoreds
sources of invalidation
home, school, MH and physical services, A&E, self and others
maintenance
- Escalating behaviours, unhelpful invalidation, help through harm and suicide, absence of therapy, exclusion from services, limited specialist services
theories of BPD
- Excessive aggression
- Emotional dysregulation
- Failed mentalisation
- Interpersonal hypersensitivity
are PD psychiatric or neurological?
- Genetic vulnerability
- Neurological changes following trauma: delayed brain maturation, smaller brain volume and dysfunctional neuroendocrine system.
- Dysregulated activity in the brain that is consistent with the emotional regulation, problem solving, and behavioural difficulties associated with BPD.
PD vs trauma response
- High incidence of trauma in childhood for women with BPD (are BPD and cPTSD the same?)
- 50% overlap of women with EUPD and cPTSD
issues with treatment
- Level of specialist skill, burnout, maintaining empathy whilst being genuine, reinforcement issues that invalidate person, managing risk and multiple treatments, lengthy treatments
Dialectical Behaviour Therapy (DBT)
§ Group, 1-1, coaching (validation towards change)
§ Learn skills in Emotional Regulation, Distress Tolerance, Interpersonal Effectiveness, Mindfulness
§ 5 components: individual therapy, group therapy, structuring environment, consultation
§ Behavioural change analysis to target behaviours and identify stages of treatment
§ Brings down self-harm wants but is manipulation wrong?
Schema-focused therapy (SFT)
§ Developed for entrenched, relational, and complex problems integrated approaches.
§ Cognitive, behavioural and experiential strategies conducted over 3 stages of assessment, emotional awareness and change stage.
