Youth Personality and Somatic Symptom Disorders Flashcards
Problem with PD diagnosis in adolesence (4)
(1) DSM focuses on adulthood
(2) “enduring criteria”: doesn’t applies to youth (there’s only so much time it can be)
(3) “Deviates from norms” - typical in adolescence
(4) “Onset in adolescence or early adulthood”: Confusing, cuz it’s also extremely rare in adolescence (but the onset is in adolescence?)
PD symptoms in adolescence are bidirectionally related to …
severe behavioural and developmental consequences
=> E.g. Trauma → Insecure child → act out with friends and family → kicked out of home again → stop going to school (…) bidirectional
Problems with seeing PD diagnosis as categorical (4)
- Inter-category comorbidity
- Intra-category heterogeneity: Hundreds of diff presentations of BPD
- Arbitrary diagnostic thresholds
- Stigma of rigid categories
PD Diagnosis: Dimensional
Spectrum from maladaptive to adaptive
Advantages of dimensional approach to PDs (6)
(1) Emphasizes multi-dimensionality of PDs
(2) Reduces stigma
(3) Eases goal-setting in treatment
=> e.g. You can see which specific traits are causing the problem
(4) Psychopathology manifests differently in youth
(5) Normative behaviour at one age could be pathological at another
(6) Discrepancies caused by multi-informant report
Alternative Model of Personality Disorders (AMPD)
- HYBRID model of Dimensional and Categories. Not used clinically.
- Diagnoses: ASPD, AvPD, BPD, NPD, OCPD, StPD, PD-TS (Still retains 6 categories)
Alternative Model of Personality Disorders (AMPD): Criteria A (see image)
Criteria A: Level of personality Functioning
- 2 domains: Self and Interpersonal Functioning
- Self-functioning:
=> Identity = How you think of yourself, Self-direction = your goals, what motivates you
- Interpersonal functioning:
=> Intimacy = closeness to others, how you’re able to interact in close relationships; Empathy
Alternative Model of Personality Disorders (AMPD): Criteria B (see image)
- Criteria B: Pathological Personality Traits
- Negative Affectivity (i.e. Neuroticism): how much negative affect you feel at baseline
- Detachment (i.e. Low extraversion)
- Disinhibition (i.e. low Consciousness)
- Dissociality (i.e. low Agreeableness)
- Anankastia (i.e. low Openness)
-> Sets up treatment goals in a nice way
Diagnosis of BPD in youth: reliability and validity
Evidence in favour of reliability and validity of BPD diagnosis in youth, just as in adults
Main markers of adolescent BPD (bit diff from adulthood) (2)
- Self-harm
- Risk-taking
=> BUT… Poorer impulse control in adolescence in general, need for age-specific norms
How young to have a diagnosis?
No lower limit. Can be as low as 12-13yo
BPD Etiology (2)
- Genes/Biology:
=> Family history of: Substance use, anxiety, antisocial personality, mood disorders + heritability - Environment
=> More likely to have experienced childhood abuse/neglect (ACEs)
=> Childhood sexual abuse a risk factor for both BPD and SEVERITY of BPD
BPD Etiology: Major Theoretical Stances – Linehan’s biosocial theory (4)
(1) Invalidating environment (real or perceived)
=> E.g. sensitive child (combination of family dynamic + sensitivity + responsibilities) → cannot be herself, cannot do ‘wrong’
=> When emotions don’t matter, you push them away → this causes dysfunction in regulation of emotion → over time: BPD
(2) Belief that one’s feelings/thoughts do not matter
(3) Reduced ability to recognize and label emotions
(4) Dysfunction in the experience and regulation of emotions
BPD Etiology: Major Theoretical Stances – Fonagy’s mentalization model (3)
(1) Vulnerability to emotional distress
(2) Hyper-responsiveness of attachment systems
(3) Deficits in mentalizing → poor development of the self
E.g. Sensitive children put through a lot of emotional stress… → hyper responsiveness in attachment system (very attuned to relationships and what could go wrong) → deficits of mentalizing (i.e. think of what other pple think) → hypermentalizing (”he thinks he hates me…”) → kills self-esteem and poor development of the self
BPD Course (3)
(1) Starts in childhood: Extremes in temperament
=> Novelty seeking & Harm avoidance: highly correlated with later BPD
(2) As temperament starts to grow → Personality: Can turn into e.g. negative affectivity
=> If high on extremes, can eventually become early internalizing/externalizing problems (often comorbid with BPD)
(3) While you’re still up here (temperamental difficulties), everybody else is maturing
-> Conflict look different, maladaptive behavior
-> Can develop into more solidified early onset of BPD in adolescence (or BPD traits)
Theory: People grow out of BPD (2)
(1) Decent amount of remission
(2) BUT: Because there’s so much overlap between BPD and other internalizing/externalizing symptoms, theory that it’s not actual remission but a conversion of remission into e.g. MDD, GAD (…)
=> Presentation of underlying pathology can change so much that it seems like remission
BPD Evidence-based Treatment (2)
(1) Dialectical Behavioural Therapy (DBT)
(2) Mentalization-based Treatment (MBT)
DBT (Dialectical Behavioural Therapy)
(1) Synthesis of change and acceptance
(2) Targets emotion dysregulation, distress tolerance, and interpersonal difficulties
=> Greater reductions in NSSI, depression, and BPD symptoms than TAU in adolescence
-> Combined therapy approach of affirmation, unconditional regard… with CBT
DBT: Main features of stress tolerance (3) components
- Emotion regulation: lot of understanding and self-validating - catch yourself before you go to distress (10/10)
- Reduce body temperature, intense exercise
- Paced breathing and progressive muscle relaxation
DBT: Interpersonal difficulties
Teaching in a very clear way how to interact with others
Mentalization-based Treatment (MBT)
(1) Focus on hyper mentalizing
(2) Improves mentalization
(3) Reduces attachment avoidance
=> Greater reductions in self-harm and depression than TAU in adolescence
DBT works rly well BUT: (2)
(1) Really intensive
(2) Limited availability
Possible solution answering the inaccessibility of DBT (2) - study
Stepped care approach:
1- CDP
- Targeting “Adolescent Risky Behaviour Pathway”
- Targets self-harming behaviours (for everyone)
2- DBT-A
- Targeting “Psychopathological Pathway”
- Reserved for pple meeting a certain threshold of BPD symptoms
=> CDP was ONLY good in addressing non-suicidal self-injury (not good by itself)
=> No sig. differences between CDP + no DBT-A and CDP + DBT-A groups
-> Highlights difficulty treating adolescent BPD
Is PD just trauma?
No.
(1) About 30% of adults diagnosed with BPD with no ACEs (=adverse childhood experiences)
(2) Multifinality of mental health outcomes associated with trauma
