Youth Personality and Somatic Symptom Disorders (Final)

Question 1

What are Personality Disorders? DSM-5-TR

Answer 1

An enduring pattern of inner experience and behaviour that deviates markedly from the norms and expectations of the individual’s culture. Pervasive and inflexible. Stable over time. Onset in adolescence or early adulthood.

Question 2

What are personality disorders - Cluster A (Odd/Eccentric)

Answer 2

Paranoid, Schizoid, Schizotypal.

Question 3

What are personality disorders - Cluster B (Dramatic/Emotional/Erratic)

Answer 3

Antisocial, Borderline, Histrionic, Narcississtic

Question 4

What are personality disorders - Cluster C (Anxious/Fearful)

Answer 4

Avoidant, Dependent, Obsessive-Compulsive

Question 5

PDs in Youth Prevalence

Answer 5

Prevalent = ~11% and moderately stable. PD symptoms peak in early adolescence. Bidirectionally related to severe behavioural and developmental consequences.

Question 6

To diagnose PD in youth under 18, symptoms must be:

Answer 6

Pervasive, persistent (more than 1 year), not limited to a developmental period, not attributable to another mental disorder.

Question 7

PD Assessment in Youth: Structured Interviews

Answer 7

E.g. Childhood interview for Borderline Personality Disorder (CI-BPD).

Question 8

PD Assessment in Youth: Self-report measures

Answer 8

E.g. Borderline Personality Features Scale for Children (BPFSC).

Question 9

PD Assessment in Youth: Multi-informant

Answer 9

Teen may not see PD symptoms as problematic. Pervasiveness across contexts. Discrepancies are important.

Question 10

PD Assessment in Youth: Longitudinal

Answer 10

Assess stability of symptoms across time

Question 11

PD Diagnosis: Categorical

Answer 11

DSM-5 Section II. PDs as distinct syndromes. Most often used system. Most people don’t fit cleanly into one category, so you end up with a lot of “specified” or “unspecified diagnosis”.

Question 12

PD Diagnosis: Categorical -Problems

Answer 12

1. Inter-category comorbidity: End up with a mix of a bunch of PDs
2. Intra-category heterogeneity: The symptoms don’t line up within one category (hundreds of combinations of symptoms and still meet criteria).
3. Stigma of rigid categories

Question 13

PD Diagnosis: Dimensional

Answer 13

Seeing personality traits on a spectrum from maladaptive to adaptive. Importance in Youth: Psychopathology manifests differently in youth. Normative behaviour at one age could be pathological at another. Discrepancies caused by multi-informant report.

Question 14

PD Diagnosis: Dimensional - Advantages

Answer 14

Emphasizes multi-dimensionality of PDs. Reduces stigma. Eases goal-setting in treatment.

Question 15

PD Diagnosis: DSM Section III - Alternative Model (AMPD)

Answer 15

Dimensional-Categorical. Criteria A: Level of Personality Functioning. Criteria B: Pathological Personality Traits

Question 16

Borderline Personality Disorder

Answer 16

Instability of interpersonal relationships, self-image, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts.”

Question 17

Borderline Personality Disorder: DSM-Categorical

Answer 17

Fear of abandonment. Unstable and intense interpersonal relationships. Identity disturbance. Impulsivity. Recurrent suicidal behaviour or self-mutilating behaviour. Affective instability. Chronic feelings of emptiness. Inappropriate, intense anger. Transient, stress-related paranoid ideation or dissociative symptoms.

Question 18

Borderline Personality Disorder: DSM-AMPD

Answer 18

Two or more of: Identity, self-direction, empathy, intimacy. Four or more of: Emotional lability, anxiousness, separation insecurity, depressivity, risk taking, hostility.

Question 19

Borderline PD: Considerations for Youth

Answer 19

Evidence in favour of reliability and validity of BPD diagnosis in youth, just as in adults. Main markers of adolescent BPD: Self-harm, Risk-taking. Poorer impulse control in adolescence in general (there is a certain extent that is norma) - Need for age-specific norms. Unstable sense of identity in adolescence.

Question 20

BPD Etiology: Genetics/Biological Factors

Answer 20

General genetic psychopathology propensity: Substance use, anxiety, antisocial personality, mood disorders in family all risk factors. BPD features in 12-year-old twins: 66% of variance genetic.

Question 21

BPD Etiology: Environment

Answer 21

More likely to have experienced childhood abuse/neglect (ACEs). Childhood sexual abuse is a risk factor for both BPD and severity of BPD.

Question 22

BPD Etiology - Major Theoretical Stances: Linehan’s biosocial theory

Answer 22

BPD results from the interaction between biological emotional vulnerability and an invalidating environment (real or perceived). Belief that one’s feelings/thoughts do not matter. Reduced ability to recognize and label emotions. Dysfunction in the experience and regulation of emotions.

Question 23

BPD Etiology - Major Theoretical Stances: Fonagy’s metalization model

Answer 23

BPD arises from deficits in mentalization, or the ability to understand one’s own and others’ behaviors in terms of mental states (thoughts, feelings, intentions).
These deficits are often rooted in early attachment disruptions. Deficits in mentalizing –> poor development of the self. If I’m hyper-mentalizing: You take one tiny instance of me making all of these attributions, which damages your self-esteem and leads to a poor development of the self.

Question 24

BPD Course

Answer 24

1. Starts in childhood: Childhood extremes in temperament (e.g., novelty-seeking and harm-avoidance) + negative affectivity or other personality traits.
2. These temperament traits can eventually become early internalizing / externalizing problems.
3. Maturation principle (or lack thereof): There is a normative amount of temperamental difficulties that begin to tapper off into early adulthood and mature.
4. Normative developmental toll of individuation: acting out in ways that are maladaptive in order to see the developmental goals that you feel like you are misinterpreting gout on.
5. Early-onset BPD, or BPD traits in adolescence.
6. Some remission… or is it?

Question 25

BPD Course: Some remission... or is it

Answer 25

There is a decent amount of remission. But there is a theory that it isn't actually remission, but a conversion of remission into something like MDD or an anxiety disorder or an externalizing disorder, and as you change development stages and your environment changes so much, sometimes the presentation of an underlying pathology can change so much that it seems like you're in remission.

Question 26

BPD Treatment

Answer 26

Early intervention. Evidence-based treatments: 1. The main treatment is Dialectical Behavioural Therapy (DBT): Combine traditional talk therapy approaches (validation and affirmation) with the change focus of CBT. Targets emotion dysregulation, distress tolerance, and interpersonal difficulties. 2. MBT: Greater reductions in self-harm and depression than TAU I adolescence. Improves metallization. Reduces attachment avoidance. 3. Transference-focused psychotherapy, etc.

Question 27

Addressing Inaccessibility of BPD Treatment

Answer 27

Showed that it's difficult to treat BPD. Limited availability. Possible solution - stepped care approach: Clinical staging (Targeting "Adolescent Risky Behaviour Pathway" and Targeting "Psychopathological Pathway").

Question 28

The Controversy of PDs in Youth

Answer 28

Are youth's personality too unstable to justify diagnosis of a PD? Is diagnosis of PD in youth endorsed by psychiatric nomenclature? Certain features of personality pathology are normative in adolescence? Symptoms of PDs or internalizing and externalizing disorders?

Question 29

Response to PD Controversy: Just Trauma?

Answer 29

Multifinality of mental health outcomes associated with trauma. Distinguishing between Complex PTSD and Borderline Personality Disorder. Conceptualization must always have face validity to adolescent: what you present you your patient has to be valid to them .

Question 30

Response to PD Controversy: Diagnosis Guides Treatment

Answer 30

All other medical disciplines diagnose before treating. Need to be able to detect early PD to administer appropriate early intervention for PD. Some PD treatment programs require PD diagnosis. Remember AMPD! And stopped care/clinical staging - Doesn't have to be all or nothing.

Question 31

Somatic Symptom Disorder Criteria

Answer 31

A. Distressing or disrupting somatic symptoms. B. One of: 1. Disproportionate and persistent thoughts about the seriousness of one's symptoms. 2. Persistently high level of anxiety about health or symptoms. 3. Excessive time and energy devoted to these symptoms or health concerns. C. Persistence of somatic symptoms.

Question 32

Somatic Symptoms in Youth

Answer 32

Commonly includes headaches, stomachaches, fatigue, nausea, musculoskeletal pain. More commonly a single prominent symptom in children. Headache and abdominal pain most common combination. Associated with severe physical and mental consequences. Linked with depression and anxiety under internalizing umbrella. Comorbidity as the rule, not the exception.

Question 33

Somatic symptom prevalence in youth

Answer 33

Most common in adolescence, gradual increase in prevalence during that time. Greater rates in girls than boys. Greater rates in non-intact/dysfunctional families.

Question 34

Somatic Symptom Disorder Assessment in Youth

Answer 34

Multi-informant. Caregiver assessment (parental concern and preoccupation with the child's symptoms, parental health anxieties). Important to assess the presence of other internalizing disorders and PTSD. Medical evaluation unnecessary (but important).

Question 35

Somatic Symptom Disorder in Youth: Biopsychosocial Etiology

Answer 35

Main theory - Reciprocal Maintenance Theory: When you experience something traumatic in your life, the nervous system becomes hyper-aroused. When this is excessive or chronic, it leaves psychological aspects of somatic symptoms (pain, distress). Your body is so hyper-aroused, and is signalling that something is wrong. Moderate genetic heritability. Autonomic nervous dysregulation linked to both PTSD and somatic symptoms. Somatic symptoms associated with heightened sensitivity to internal and external sensations, somatic hyper vigilance, selective attention to threat.

Question 36

SSD Course & Maintenance

Answer 36

Onset often in childhood/adolescence, associated with baseline anxiety or depressive disorder - persistence associated with history of depression. Youth with unexplained somatic symptoms more likely to have later anxiety disorders and depressive disorders. Temperamental/personality characteristics (e.g. negative affectivity, behavioural inhibition. anxiety sensitivity). Secondary gain.

Question 37

SSD Treatment

Answer 37

Things that work for anxiety and depression tend to work for somatic symptoms. Cognitive-behavioural therapies. Mindfulness-based therapies. Antidepressant medications. Family- and system-informed. Treating comorbid disorders.

Question 38

SSD, Anxiety, Depression: One Disorder?

Answer 38

High comorbidity and associations across lifespan. Conceptually linked. Overlap in heritability. Treatment for one, treatment for all. Dimensions of internalizing disorder. Impact on medical care.

Question 39

SSDs in the Medical Sphere

Answer 39

Dualistic approach. Physician as "cultural arbiter" of legitimate illness. Lack of medical explanation taken as "nothing wrong". Can increase stigma from medical staff.

Question 40

SSDs and CDs: More Similar Than They Seem

Answer 40

Somatization symptoms as predictor of adolescent BPD traits. Comorbid PD and SSD: 41-63% of adult SSD patients with at least one PD. Could somatization be a personality trait? Could it be a personality disorder?

Question 41

The Need for "Novel" Treatments

Answer 41

Treatment-resistant conditions: Partial but not full remission, Full remission but not recovery. "Gold-standard" of psychotherapy + psychotropics: Pros: Complementary and interdisciplinary. Evidence of efficacy + effectiveness. Transdiagnostic approach. Cons: Limited accessibility of therapy. Does not work for everybody. Delayed onset of psychotropics. Side effects of psychotropics.

Question 42

Hypnosis in Youth

Answer 42

Safe intervention. Long history of use in paediatric settings. Consists of: Induction of hypnotic state. Suggestions of sensory, cognitive-perceptual, or behavioural alterations, De-induction. Can be clinician or self-directed. Children may be particularly hypnotizable.

Question 43

Hypnosis Potential Applications in Youth

Answer 43

Reframe problems as solvable, conditions as manageable, build positive expectations. Change behavioural patterns. Control exaggerated reactivity to internal and external stimuli. Manage anxiety. Help process recent drama or traumatic memories.

Question 44

Hypnosis Caveats

Answer 44

A tool that must be practiced. May be more of an adjunct than the main therapeutic focus. Must be developmentally appropriate. Hypnotizability of people with PDs unclear.

Question 45

Psychedelic-Assisted Therapy

Answer 45

Use things like serotonergic hallucinogens (shrooms, led, ketamine...etc). Good evidence for adults with treatment-resistant disorders. Very little risk of overdose, long-term side effects, or addiction. On a personality level, it alters your self-perception and reduces your focus on your narrative self. Increased introspection and psychological insight, positive mood and sense of unity, improvements in openness and empathy.

Question 46

Psychedelic-Assisted Therapy: Evidence in Youth

Answer 46

Naturalistic study found that for adolescents without genetic vulnerability, lower psychotic and manic symptoms. Taking ayahuasca in religious setting associated with fewer psychiatric symptoms in adolescence. Only cross-sectional, non-clinical situations.