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Flashcards in Personality Disorders Deck (23):
1

What is a personality disorder (according to the DSM)

An enduring pattern of inner experience and behaviour that,
- deviates markedly from culture,
- is pervasive, inflexible & stable over time,
- leads to distress or impairment

Manifests in 2 or more of;
- cognition,
- affect,
- interpersonal functioning
- impulse control

2

What are the core features of PDs

1. Functional inflexibility
2. Self defeating behaviours
3. Unstable response to stress
4. Lack of insight

Also, involve self identity and are enduring and pervasive in all areas of life

3

Which PDs are in Cluster A?

Cluster A; Odd/Eccentric
- paranoid
- schizoid
- schizotypal

4

Which PDs are in Cluster B?

Cluster B; Dramatic/emotional/erratic
- antisocial
- borderline
- histrionic
- narcissistic

5

Which PDs are in Cluster C?

Cluster C; Anxious/fearful
- avoidant
- dependent
- obsessive compulsive

6

How does the DSM categorise PDs?

A categorical approach like the DSM assumes that personality disorders represent distinct clinical
syndromes
- Advantages: clarity and ease of communicating information
- Disadvantages: difficult to distinguish the threshold between ‘normal’ personality traits and a personality disorder

Axis I vs Axis II disorders:
- AXIS I: Major clinical disorders with acute symptoms that need treatment
- AXIS II: Personality disorders (& intellectual disabilities): early onset, enduring, poorer treatment response, diagnostic unreliability

7

What are the features of Paranoid PD?

Consistent & pervasive pattern of distrust, suspiciousness and prolonged grudges held:
- Believes others intentionally exploit, harm or deceive them
- Reluctance to disclose personal information
- Severely sensitive to criticism & threat (hypervigilent)
- Misinterprets comments to indicate concealed, hidden or malevolent intent or motivation
- Hostility, aggression & anger to perceived insults
- Jealousy (distrust & misinterpretation)

2/3 comorbid with other PDs

Behaviour tends to illicit hostility which reinforces cognitions

8

What are the features of Schizoid PD?

- Detachment and disinterest in social relationships
- Sees others as intrusive and controlling
- Flatness of affect: coldness, aloofness, self-absorption, social ineptitude or conceit
- Unresponsive to social criticism: sexually apathetic
reflecting incapacity to form interpersonal bonds
- Anhedonia

Comorbid with schizotypal and avoidant PDs

9

What are the features of Schizotypal PD?

- Marked interpersonal deficits, behavioural eccentricities and distortions in perception & thinking
- Odd thoughts & speech patterns: vague, abstract but
retains coherence
- Often seek treatment for anxiety, depression & affective dysphoria

Comorbid with borderline, avoidant, paranoid and
schizoid PDs

10

What are the features of Antisocial PD?

- Repeated reckless disregard for others
- Victimizing & blaming others for inadequacies
- Shallow & manipulative interpersonal relationships
- Self-centered focus & failure to adhere to regulations
- Impulsive, aggressive, charismatic, deceitful
- Experience guilt & depression but lack capacity to
empathize
- Anti-social behaviour: criminal behaviours may or may not be present

Co-morbidity with borderline, narcissistic, histrionic &
schizotypal PDs

11

What are the features of Borderline PD?

- Emotional instability/affective dysregulation in
reaction to environmental & interpersonal situations
- Impulse control (promiscuity, suicidal behaviour, spending, binge eating, poor limit setting)
- Identity/insecure attachments (Unstable self-concept, avoidance of relationships, Inability to integrate +ve and -ve aspects of self leading to sense of emptiness)

Most prevalent PD in clinical settings (10% of outpatients, 15-20% of inpatients)

comorbid with mood disorders, substance-use disorders & anxiety disorders (PTSD)
- patients with these disorders often meet BPD diagnosis

Arguably associated with the greatest levels of
disability of all the PDs

12

What are the features of Histrionic PD?

- Excessive emotionality, attention-seeking, ego-centric,
flirtatious, seductiveness (focus on grooming),
- Denial of anger and hostility
- Gregarious, manipulative, low frustration tolerance,
suggestibility, somatization
- Displays of emotions: shallow and fickle in interpersonal relationships

Comorbid: narcissistic, borderline, anti-social PDs &
psychoactive substance abuse

13

What are the features of Narcissistic PD?

- Personalities organised around maintenance of self-esteem by eliciting external adulation
- Pervasive pattern of grandiosity, sense of entitlement,
privilege, or expectation of preferential treatment,
exaggerated sense of self-importance, arrogant behavior & attitude
- Fragile self-esteem, envy, self-consciousness, & vulnerability: “image replaces substance”
- Self-righteousness, pride, contempt, vanity & superiority
- Insensitivity or impatience to problem of others: cold, disinterested, snobbish, patronizing

Comorbid with: anti-social, histrionic, borderline PDs &
substance abuse

14

What are the features of Avoidant PD?

- Pervasive social inhibition, discomfort in social
situations, feelings of inadequacy, low self esteem,
hypersensitivity to criticism, disapproval, shame,
ridicule & rejection
- Avoidance of activities involving personal contact
& groups
- Socially inept/incompetent, personally unappealing, inferior to others

Comorbid with dependent PD & Axis I mood, anxiety, & eating disorders

15

What are the features of Dependent PD?

- Pervasive need to be taken care of
- Exaggerated fear of being incapable of doing things
or taking care of things on their own – reliance on
others
- Lacking in self confidence & requiring constant
reassurance
- Often find themselves exploited and in abusive
relationships fearing abandonment
- Self view: needy, weak, helpless & incompetent View of Others: Strong caretaker idealized.

Threats: Rejection or abandonment
Strategy: Cultivate a dependent relationship by
subordinating

Affect: Anxiety heightened – disruption to the
relationship. Depression if their strong figure is
removed, euphoria/ gratification when dependent
wishes granted

16

What are the features of Obsessive Compulsive PD?

- Pervasive pattern of perfectionism and orderliness
- Rigidity, inflexibility & stubbornness
- Excessive need for control interfering with ability to
maintain interpersonal relationships or employment
- Preoccupied with rules, minor details, structure
- Attention to detail interferes with ability to complete tasks
- Unrealistic standards of morality, ethics or values
- Reluctance to delegate tasks

Comorbid: borderline, narcissistic, histrionic, paranoid,
schizotypal PDs
- No significant relationship between OCD & OCPD

Selfview: heightened responsibility, 'shoulds', Others; irresponsible and incompetent,

Affect: Regrets, disappointment, and anger toward self
and others because of perfectionistic standards

17

What is the epidemiology of PDs?

Prevalence
- 6.5% adult Australians have 1+ lifetime prevalence
- International data: 6.1 - 13.4%; average: 9.7%
- male PDs have higher levels of affective or substance disorders
- females more prone to borderline & histrionic

Antisocial
- 0.2-3.3% general population, 3% males vs. 1% females
- 3%-30% of psychiatric outpatients
- 47% of male prisoners & 21% of female prisoners

Borderline
- 4-6% in primary care (GPs)
- 25-40% in clinical population with mental illness
- Females 3x males (diagnosed as antisocial)
- still underrecognised and underdiagnosed

18

What is the aetiology of Antisocial PD?

Causes of APD not fully understood

Constitutional factors:
- predisposition determined by environmental & familial influences
- Externalizing vulnerabilities: heritable broad trait factor for disinhibitory personality & risk taking

Biological factors
- Reduced levels of serotonin (impulsive behaviours)
- Low resting heart rate --> physiological hypo-arousal --> sensation seeking
- Neuropsychological deficits on frontal lobe executive functioning

Psychosocial factors
- Shaped by environment & learned coping skills to deal with stress
- childhood dysfunctional role modeling & interactions
with family
- Peer group interactions: deviant sub-cultures - ?cause or effect

19

What are the treatment options for Antisocial PD?

Literature reviews indicate inherent difficulties and ineffectiveness of psychological interventions

Pharmacological agents to reduce aggressive
impulsivity

Multifaceted interventions targeting impulsivity,
aggression, addictive urges, and narcissistic traits
required BUT outcomes not positive

20

What is the aetiology of borderline PD?

Complex, uncertain, no integrated model available, Presumed contributory factors:

Genetic/biological factors:
- Twin & familial data suggestive of heritability factor
- Distinct genetic contribution to individual traits + clustering of traits
- Dysfunctional emotional regulation & stress (Low levels of serotonin, amygdala dysfunction)

Childhood complex traumas/ attachment theory
- Emotional/sexual/physical childhood abuse can cause developmental arrest BUT abuse alone neither necessary/sufficient
- parent/carer relationship style --> emotional dysregulation, security and self worth

psychosocial factors
- self-fulfilling prophecy
- individuals invalidate their own emotional experiences & depend on others

21

What is the IMPULSIVE treatment model for borderline PD?

Target IMPULSIVE factors:
- Impulsive,
- Moodiness,
- Paranoia under stress,
- Unstable self-image
- Labile & intense relationships
- Suicidality
- Inappropriate anger
- Vulnerability to abandonment
- Emptiness (sense of identity)

22

What is the Dialectical Behaviour Therapy (DBT) model for borderline PD?

CBT-based intervention for chronically suicidal behaviours. (moderate effect size)

Dialectic - a synthesis or integration of opposites/contradictions (acceptance and change)
- CHANGING behaviours causing suffering whilst simultaneously
- ACCEPTING oneself and current situation/life circumstances

Four Modules
- Mindfulness (Observing/attending to events, emotions & behavioural responses even if distressing)
- Distress Tolerance (Ability to tolerate and accept distress, observe and accept without approval)
- Interpersonal Effectiveness (Skills in specific interpersonal problem-solving, social & assertiveness)
- Emotional Regulation (Skills in identifying and labelling affect; triggers, experience and behaviours)

23

What is the Schema model of treatment for borderline PD?

Three stages:
1. Assessment: schemas are identified (use of questionnaires)
2. Emotional awareness & experiential phase: identifying how schemas operate in day-to-day living
3. Behavioral change: replacement of negative, habitual
thoughts & behaviors with new, healthy cognitive and
behavioral options

Schemas
- identify schemas (of the 18)
- identify coping style (surrender/ avoidance/ overcompensation)
- identify mode (innate child/ maladaptive parent/ healthy adult)

Complete recovery: 50%, Significant improvement: 66%
Outcomes strongly related to duration & intensity of treatment