Week 10 - personality disorders

Question 1

explain the controversy over personality disorder diagnosis

Answer 1

• 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)

Question 2

who are there risks for?

Answer 2

to others
to self
from others

Question 3

risk to others

Answer 3

violence, sexual aggression/exploitation

Question 4

risk to self

Answer 4

active behaviours like self-harm and neglect; passive behaviours such as non-engagement in behaviours promoting wellbeing

Question 5

risk from others

Answer 5

violence, sexual aggression, exploitation, neglect/abandonment, discrimination

Question 6

DSM-5 diagnostics

Answer 6

• 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

Question 7

common features across types of PD

Answer 7

• Problem of overlap and reliability as commonly have abnormal behavioural, emotional regulation, interpersonal relationships, intrapersonal conflict and shame and guilt.

Question 8

ICD-11 changes

Answer 8

focus on severity not categories from mild to severe impairment

Question 9

common comorbidities

Answer 9

• PTSD, cPTSD, mood disorders, substance misuse, ED, other personality disorders, dissociation, developmental disorders

Question 10

role of early trauma: evidence

Answer 10

• 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.

Question 11

prevalence of PD

Answer 11

NIH 8%

Question 12

how are diagnoses made?

Answer 12

NICE guidelines
psychometric tools

Question 13

key considerations of PD diagnoses

Answer 13

• Overlap between other personality disorders and also with other diagnoses

Question 14

effects of Emotionally unstable personality disorder (EUPD)/borderline personality disorder (BPD):

Answer 14

○ 75% attempt suicide and 10% commit
○ Self-harm and hospitalisation
○ Impulsivity and aggression
○ Conflict in relationships

Question 15

prevalence of Emotionally unstable personality disorder (EUPD)/borderline personality disorder (BPD):

Answer 15

○ 1-2% of population
○ Highest diagnosed

Question 16

aetiology of Emotionally unstable personality disorder (EUPD)/borderline personality disorder (BPD):

Answer 16

○ Stress-diathesis model of environmental factors and biology
○ Biosocial model underpins dialectical behaviour therapy (DBT)
§ Emotional vulnerability, impulsivity, invalidating and ineffective environment

Question 17

invalidating environments

Answer 17

being told your responses and emotions are not correct or important, misinterpretation of feelings, needs being ignoreds

Question 18

sources of invalidation

Answer 18

home, school, MH and physical services, A&E, self and others

Question 19

maintenance

Answer 19

• Escalating behaviours, unhelpful invalidation, help through harm and suicide, absence of therapy, exclusion from services, limited specialist services

Question 20

theories of BPD

Answer 20

• Excessive aggression
  
  • Emotional dysregulation
  • Failed mentalisation
  • Interpersonal hypersensitivity

Question 21

are PD psychiatric or neurological?

Answer 21

• 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.

Question 22

PD vs trauma response

Answer 22

• High incidence of trauma in childhood for women with BPD (are BPD and cPTSD the same?)
  
  • 50% overlap of women with EUPD and cPTSD

Question 23

issues with treatment

Answer 23

• Level of specialist skill, burnout, maintaining empathy whilst being genuine, reinforcement issues that invalidate person, managing risk and multiple treatments, lengthy treatments

Question 24

Dialectical Behaviour Therapy (DBT)

Answer 24

§ 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?

Question 25

Schema-focused therapy (SFT)

Answer 25

§ 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.