Week 4-Personality Disorders

Question 1

What influences on contemporary psychiatry occurred during the 18th-20th Century?

Answer 1

-Early attempts in European psychiatry to describe ‘maladaptive’ personalities

-Philippe Pinel’s “Manie sans delire” (Mania without delusion), refers to a group of male patients prone to impulsive violence without any other psychiatric symptoms (e.g., cognitive problems, delusions, hallucinations etc.,). Suggested it was a result of parenting practises and early experiences

-Kraepelin’s 7 types of psychopathic (more referred to as mentally ill with impairments) personalities resulting from an inborn defect: ‘excitable’, ‘irresolute’, ‘persons following their instincts’, ‘eccentrics’, ‘pathological liars and swindlers’, ‘enemies of society’ and ‘quarrelsome’

-Freud’s work connected childhood experiences to personality traits which led to various psychoanalytical descriptions of different personality types

-Pathological or maladaptive personalities that were longstanding, and in the absence of other psychiatric symptoms (abnormal in cultures and no hallucinations or delusions present)

Question 2

What is the 21st century understanding of contemporary psychiatry?

Answer 2

Personality disorders generally refer to a pattern of experiences and behaviours that affect cognition, emotions, relationships, and behaviour (these disorders are classified)

-It differs from what is expected within the dominant culture

-It typically emerges by late adolescence or early adulthood and is stable and long-standing

-It causes significant personal distress or problems in functioning and is generally considered maladaptive (if not these 2 then we cannot say it’s a personality disorder)

-It covers a wide range of experiences and behaviours that tend to be seen as relating to someone’s personality

Question 3

How does Diagnostic classification work?

Answer 3

-Categorical systems assume that there is an objective difference between mental health and illness

-Pathological and non-pathological (normal) personality traits are seen as separate categories (relating to personality disorders) to allow clinicians to diagnose the range and quality

-Most frequently used diagnostic manuals in Western practice are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD)

-Diagnostic categories have changed over time and therefore across versions of the DSM and ICD (personality disorder definitions differ from the 80s due to research and cultural norms)

Question 4

What 6 criteria is there in the DSM to be diagnosed with a general personality disorder?

Answer 4

1. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in 2 (or more) of the following areas: cognition, affectivity, interpersonal functioning, or impulse control.
2. Inflexible and pervasive (evident) across a broad range of personal and social situations.
3. Leads to clinically significant distress or impairment in social, occupational or other important areas of functioning.
4. Stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (e.g., not mid thirties).
5. Not better explained as a manifestation or consequence of another mental disorder. (other mental disorder shouldn’t be root essentially)
6. Not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., Phineas Gage)

Question 5

What is the Cluster A: Odd/eccentric cluster personality?

Answer 5

-Personality disorders with behaviours viewed as strange and odd

-Paranoid Personality Disorder (PPD): distrusting and suspicious interpretation of the motives of others (being cheated on, someones out for them etc.,)

-Schizotypal Personality Disorder (STPD): social discomfort, cognitive distortions, peculiar thoughts, unusual language, and behavioural eccentricities, but no psychotic episodes.

-Schizoid Personality Disorder (SPD): social detachment and restricted emotional expression, socially isolated (not enjoying the company of others, being indifferent to others opinions)

Question 6

What’s Cluster B: Dramatic/erratic cluster personality?

Answer 6

-Disorders where emotions may be intense or impulsive behaviour

-Antisocial Personality Disorder (ASPD): disregard for and violation of the rights of others, aggressive and impulsive behaviour, tendency to manipulate others. (might not be good at planning ahead or honouring commitments)

-Narcissistic Personality Disorder (NPD): grandiosity, need for admiration, tendency to exploit others lack of empathy.

-Histrionic Personality Disorder (HPD): excessive emotionality, flamboyant and attention seeking, use physical appearance to attract attention.

-Borderline Personality Disorder (BPD): unstable relationships (being obsessed but devaluing partner), self-image, difficulties in emotion regulation, and impulsivity. Difficulty controlling anger, self-harm behaviours, and chronic feelings of emptiness (also dissociation)

Question 7

What is Cluster C: Anxious/fearful personality?

Answer 7

-Personality disorders characterised by feelings of anxiety

-Avoidant Personality Disorder (APD): socially inhibited (reluctant to interact with strangers), feelings of inadequacy, hypersensitivity to negative evaluation.

-Dependent Personality Disorder (DPD): submissive behaviour (others make decisions for them), need to be taken care of, fear separation (may do things they don’t want to do to achieve that).

-Obsessive-Compulsive Personality Disorder (OCPD): preoccupation with orderliness, perfectionism, and control (to the point it’s ineffective).

Question 8

How does the International Classification of Diseases (ICD-11) describe and assess Personality Disorders?

Answer 8

-The 11th version of the ICD only retained a general description of Personality Disorder

-PD’s are defined as “a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption.”

-A first assessment evaluates whether symptoms meet the threshold for a Personality Disorder. The service user must present with significant problems in self and interpersonal functioning for a minimum of 2 years and across different contexts e.g., low-self worth, issues in self-identity, difficulty maintaining healthy relationships etc.,

-If the threshold is met, the PD is categorised as ‘mild’, ‘moderate’ (most areas of life affected), or ‘severe’ (all areas of life affected) based on factors such as the degree of dysfunction, the level of distress, and risk by looking at 5 different personality traits

Question 9

How common are personality disorders?

Answer 9

-Around 1 in 16 people worldwide are being given a PD diagnosis at some point (Huang et al., 2009)

-Around 1 in 20 to 25 are diagnosed with a personality disorder in the UK (Coid et al., 2006; Singleton et al., 2001)

-Prevalence rates vary across socio-demographic factors (more common in men, those who are separated or unemployed, and urban areas but could mean those factors are more to diagnostic bias)

-Prevalence rates are far higher in healthcare and forensic settings compared to the general community

-Prevalence estimates in psychiatric inpatient settings range from 36% to 67% and in prison settings between 60 and 70%

-Prevalence rates vary cross-culturally and tend to be lowest in Western Europe (Huang et al., 2009)

Question 10

Are personality disorders categorical or dimensional?

Answer 10

-PDs are diagnosed according to a categorical perspective: an individual either has a ‘disordered personality’ or not.

-But, personality consists of personality traits that range on a dimension and vary in degree and not in kind (not just introvert or extrovert)

-PDs therefore might be extreme variants of normal personality traits that lead to mental distress

-Widiger & Simonsen (2005) found that diagnostic criteria for DSM PD’s overlap well with high or low traits on common personality dimensions

-Dimensional approach incorporated in the DSM-5 as an ‘Alternative Model of Personality Disorders’ (AMPD) (ICD does it to a certain extent but still categorical as determining whether a personality disorder or not) where if you show a moderate degree then you can be diagnosed with PD

Disadvantages:
-Still not fully dimensional as clinician has to determine whether a PD is present or not
-It only applies to certain personality disorders (borderline, narcissistic, antisocial and obsessive compulsive so can’t diagnose every PD)

Question 11

What’s inter-rater reliability in relation to PD?

Answer 11

-IRR assesses whether different clinicians give the same diagnosis to a given individual

-Perfect reliability (1) means that different clinicians always arrive at the same diagnosis for a given individual. Important for any diagnostic tool.

-IRR for DSM PD diagnoses vary considerably, and can be poor for some PD’s (e.g., Zanarini et al., 2000)

-DSM-5 Field Trials suggest that IRR is still poor for the DSM-5

-The Alternative Model performs better (e.g., Christensen et al., 2018; Garcia et al., 2018)

-This means different clinicians or instruments can determine whether someone is diagnosed with a PD or not and which one.

Question 12

What are the limitations of saying PDs are stable over time?

Answer 12

-The key assumption that PD’s are long-standing and stable patterns of experiences.

-But, most PD symptoms decrease over time (D’Huart et al., 2003) and decrease generally with age

-PD diagnoses appear less stable over time compared to other DSM diagnoses (Morey & Hopwood, 2013)

-Test-retest reliabilities of PD diagnoses can be poor

-“…the longstanding characterisation of PDs are enduring, stable, beginning in adolescence lacks nuance” (Morey & Hopwood, 2013, p.520)

Question 13

What did Baca-Garcia et al (2007) find after analysing data from > 10,000 patients in a Spanish hospital?

Answer 13

-34.1% of P’s who received a PD diagnosis in their first evaluation retained the same diagnosis in their last evaluation 10 years later

-26.3% of P’s who received a specific PD diagnosis in the last evaluation received the same diagnosis in their first evaluation

-Used ICD (10)

Question 14

What’s the Comorbidity with other Personality Disorders?

Answer 14

-Many studies find a high rate of comorbidity (co-occurrence) between PDs

Coid et al (2006) found that:
-Many P’s with a cluster A PD were also diagnosed with a cluster C (48%) or B (32%) PD
-27% of P’s with a cluster C also had a cluster B PD diagnosis

-Could be due to the overlap in diagnostic criteria between PDs and poor discriminant validity of measures

-It might also mean that some PDs are actually variants of the same underlying construct (Farmer, 2000)

Question 15

What does the Alternative Model in DSM-5-TR (AMPD) base a PD diagnosis on?

Answer 15

1. Moderate or greater impairment in personality functioning
2. Pathological personality traits

It consists of an assessment of (i) Self and interpersonal functioning and (ii) Five domains of pathological personality traits: negative affectivity, detachment, antagonism, disinhibition, and psychotism

Question 16

How do PD diagnoses intertwine?

Answer 16

-Those with a PD diagnosis are more likely to have 3 or more ‘Axis I) diagnoses (Huang et al., 2009)

-Conceptual overlap between diagnostic criteria of PDs and other mental disorders in the DSM

-For example, auditory hallucinations are a diagnostic criteria for both schizophrenia and schizotypal personality disorder

-Diagnostic criteria of PDs might represent sub-clinical levels of other forms of mental distress

-Personality disorder classifications do not seem to adequately describe individuals’ experiences of mental distress

Question 17

Are Personality Disorders relational problems?

Answer 17

Individualism:
-The DSM is based on an individualistic model which attributes mental distress to factors within the person
-Pathologises normal responses

Collectivism:
-Many of the diagnostic criteria for PDs refer to things that happen between people e.g., disregard for others, lack of empathy
-PD’s might be a response to things that are happening between people, rather than a ‘disorder’ within the individual e.g., sensitive to criticism

Question 18

How do Adverse or traumatic childhood life experiences relate to Personality Disorders?

Answer 18

-Childhood trauma includes a variety of traumatic experiences in childhood (<18 years) including emotional and physical abuse and neglect, and sexual abuse

-The majority of people using mental health services have been exposed to adverse or traumatic life experiences

-The experiences associated with the term ‘personality disorders’ are VERY closely associated with childhood abuse (dissociation, lack of empathy etc., very linked to this)

-Those who experienced childhood abuse are 4 to 6 times more likely to develop a PD (Back et al., 2021; Battle et al., 2004; Johnson et al., 1999)

-Different forms of abuse linked to different PDs e.g., physical abuse linked to antisocial PD, emotional or sexual abuse linked to BPD or histrionic PD)

Question 19

How is childhood trauma associated with maladaptive personality traits? (Beck et al., 2021)

Answer 19

Beck et al (2021): Review of studies between 2017 and 2021 using the dimensional AMPD:
-Detachment and psychoticism are clearly associated with childhood trauma, particularly emotional abuse and neglect

-Negative affectivity and antagonism are also associated with having experienced childhood trauma

-These responses are similar to trauma-associated avoidance and trauma-reactive dissociation (disconnection from thoughts, feelings, memories, identity, behaviour)

Question 20

What is the link between Childhood trauma and BPD?

Answer 20

-Those with BPD are 13 times more likely to report adverse childhood experiences compared to other clinical groups (Porter et al., 2020)

-97% of individuals with BPD report at least one type of childhood trauma (Slotema et al., 2018)

-Particularly emotional (Porter et al., 2020) and sexual trauma (Ball & Links, 2009) seem to play a role in the development of BPD

-Comorbidity with (complex) Post Traumatic Stress Disorder (c/PTSD; Moller et al., 2020)

Question 21

What is the effect of childhood trauma on biological processes?

Answer 21

-Childhood trauma can influence biological processes which can eventually lead to mental distress (Teicher et al., 2016; Read er al., 2014)

-Key mechanism is the effect of childhood trauma on the functioning of the HPA axis dysregulation of stress and threat response

-It influences brain development in areas such as the frontal lobe and hippocampus

-Environment can have a buffering (or exacerbating) impact on this interaction

-Does not mean that trauma-based forms of mental distress should be considered as a ‘brain disorder’

Question 22

What are the limitations of the current evidence base in childhood trauma and PDs?

Answer 22

-Variablility across studies in definitions and measurement of ‘childhood trauma’ important forms of childhood trauma might be missed

-Trauma is not always included as a measure in biomedical studies

-Studies largely rely on self-report, with the risk of biases

-Studies based on DSM categories might be unable to identify more fine-grained effects and differences due to the categorical system

-Findings are largely based on Western samples, whilst there are cross-cultural differences (and biases) in the development and diagnosis of PDs

-Difficult to disentangle the effect of different types of trauma on different types of personality traits

Question 23

What is the Power Threat Meaning Framework? (Johnston & Boyle, 2018)

Answer 23

-Developed as an alternative to traditional diagnostic models

-It is a structure for identifying patterns in emotional distress, unusual experiences and troubling behaviour

-Links people’s life experiences to mental distress to help make sense of distress

-Considers the role that power and trauma play in mental distress

Question 24

What is the impact with being labelled with ‘Personality Disorder’?

Answer 24

-Personality Disorder diagnoses are common

-PD diagnosis can provide access to services and provide an explanation for individuals (Perkins et al., 2018)

-PDs are one of the most stigmatised diagnostic categories, even among mental health professionals

-Service users seen as ‘time-wasters, difficult, manipulative, bed-wasters, or attention seeking’ (NIMHE, 2003, p.20)

-Lack of specialised services dedicated to PD treatment

Question 25

What are some Barriers to accessing care?

Answer 25

“Safer Care for Patients with Personality Disorder” - Report by the University of Manchester (2018)
-No clear care pathway for individuals diagnosed with a PD, especially those who did not meet the criteria for specialist PD services

-Lack of understanding, training and knowledge in staff

-Often involved short-term interventions in crisis moments

-Difficult to access specialised services recommended by NICE

-Prescription of medication which could result in overdose

Question 26

How is ethnicity bias present in Diagnostic criteria?

Answer 26

-DSM and ICD classifications are based on Western ideas about personality dysfunction

-McGilloway et al (2010) reported that White service users are more likely to be given a PD diagnosis

-Ethnic minorities underrepresented in referrals to PD services (Garrett et al., 2011)

-Ethnic minorities are less considered for PDs, therefore seem to be overlooked in diagnosis and treatment (McGilloway et al., 2010)

-Should also be considered that diagnostic criteria for PD might represent adaptive responses to environmental factors experienced by ethnic minorities

Question 27

How is gender bias present in Diagnostic criteria?

Answer 27

-Gender bias in over- and under diagnosing men and women for specific PDs

-Gender stereotypes are embedded within PDs

-For example, HPD and ASPD represent extreme versions of what is traditionally perceived as feminine and masculine in Western society (Nuckolls, 1992)

-Gender differences in prevalence could be the result of role expectations of what men and women should (and shouldn’t) be

-Some diagnostic criteria are more valid for men or women. For example, women might be more dependent on men due to power imbalances

Question 28

What ‘consensus statement’ have mental health organisations in the UK published in regard to PDs?

Answer 28

“…. We would like to abandon the term ‘personality disorder’ entirely. The label is controversial for good reasons: it is misleading, stigmatizing and masks the nature of the problem it is supposed to address, adding to the challenges which people experience. However, it has its advocates, not least among those for whom it has been the only passport to effective help. Currently, the label is used to allocate services and resources within the health and care system, so until an agreed alternative emerges we continue to advocate for an alternative way of defining this group of people…”

Question 29

What are some Interventions for Personality Disorders?

Answer 29

-Psychotherapy as the treatment of choice for PDs and sometimes, medication (Bateman et al., 2015)

-Current evidence supports a handful of interventions, including Dialectical Behavioural Therapy and Mentalisation based treatment

-Long-term treatments and a combination of individual and group sessions are generally more effective

-There are no licensed medications for PDs

-Anti-depressants, mood stabilisers, and antipsychotics have been used to reduce specific symptoms associated with some PDs

Question 30

What is Dialectical Behaviour Therapy?

Answer 30

An acceptance-based form of Cognitive Behavioural Therapy (CBT)

-Developed in the 1970s for parasuicidal women with BPD

-Since then, adapted to other populations

-Consists of individual therapy sessions, weekly group sessions, and coaching sessions

-Four key components: Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation

Question 31

What are some Pros for DBT?

Answer 31

-Most studied intervention for BPD

-Meta-analyses suggest that it is effective in reducing mental distress associated with BPD (Chen et al., 2021; Jones et al., 2023; Kliem et al., 2010; Panos et al., 2014; Rameckers et al., 2021; Stoffers et al., 2012)

-For example, reduces self-harm behaviours and depression

Question 32

What are some limitations for DBT?

Answer 32

-DBT can be overly complex, which can be overwhelming

-It is not a trauma-informed treatment - trauma is not explicitly addressed and behaviours are seen as ‘problem behaviours’, not adaptive responses

-Strict boundaries can affect therapeutic alliance

-Can be considered as not inclusive in terms of religious practises

-“Despite the majority of the individuals being sent to DBT having histories of severe childhood trauma, little about DBT treatment is “trauma-informed.” Rather, clinicians are trained to label feelings like suicidality, restricting food, self-injury, crying, and feeling sad as “problem behaviours” and are taught to engage in irreverent responses to clients who exhibit them. Talking about trauma is often shunned, and any of the aforementioned “behaviours” are commonly viewed as attention-seeking.”

Question 33

What are some Trauma-Informed Approaches?

Answer 33

-A broad term to describe interventions that recognise the effects of trauma

-Typical psychological therapies are not as effective for people with traumatic life experiences

-Move from “What is wrong with you?” to “What has happened to you?”

-Focuses on the recognition of trauma throughout and considers behaviours as an adaptive response to trauma

-It is increasingly recognised that PD interventions require a trauma-informed approach

Question 34

What are the key principles of trauma informed treatment according to Sweeney et al (2018)?

Answer 34

-Seeing through a trauma lens

-Appreciation of invisible trauma and intersectionality

-Sensitive discussion about trauma

-Trauma-specific support

-Preventing trauma in the mental health system

-Trustworthiness and transparency

-Collaboration and mutuality

-Empowerment, choice and control

-Safety

-Survivor partnerships

Question 35

What are some Trauma-informed approaches for Personality Disorders?

Answer 35

-It’s starting to be adopted in practice

-South West Yorkshire Partnership NHS Foundation Trust (SWYT) developed a Personality Disorder Pathway Strategy

-Components of trauma-informed approaches in the Offender Personality Disorder Pathway Strategy (NOMS, 2015)

-Power-Threat-Meaning Framework can be used as a meta-framework for these treatments