Personality Disorders

Question 1

What is personality?

Answer 1

Comes from Greek word for mask - “Persona”
Key pattern of inner experience. Manner of thinking/feeling etc
What is portrayed in interaction with others.

Consists of aspects of Nature (Innate temperament: Genetic, constitutional) and Nurture (Character: Acquired values and attitudes) –> particular traits –> Personality (as expressed in psychosocial context)

Question 2

What is a Personality Disorder, according to DSM-V?

Answer 2

Enduring pattern of inner experience/behaviour that:

• Deviates markedly from societal norms
• Pervasive, inflexible and stable over time
• Leads to distress or impairment

Pattern manifested in 2 or more areas:
- Cognition
- Affect
- Interpersonal functioning
- Impulse control
(not all areas of personality need to be affected in PDs)
Onset: very early (childhood) or adolescence for adults

Question 3

What are the core features of PDs? (4)

Answer 3

1. Functional Inflexibility: Failure to adapt to situations
   - Applying same rigid response to many diff situations, even when inappropriate
2. Self-defeating: Respond/cope in ways that worsen the situation or is highly damaging
3. Unstable in response to stress: Unstable mood, thoughts and behaviours during stressful life events

• Often accompanied by lack of insight: Failure to recognise dysfunctional aspect of personality. They just think it’s part of who they are

Question 4

History of PD development in the DSM

Answer 4

Just know that it’s variable and volatile.

Question 5

Classification systems: What are the differences between how DSM-V and ICD-10 have classified PDs?

Answer 5

DSM-V: 10 PDs categorised in 3 clusters
ICD-10: 9 PDs. Not clustered, and have slightly different labels
e.g. Antisocial = Dissocial, Obsessive-compulsive = Anankastic

Question 6

List all the PDs in their clusters as in DSM-V.

Answer 6

Cluster A (Odd/eccentric)
Paranoid
Schizotypal
Schizoid
Cluster B (Dramatic/emotional/erratic)
Borderline
Antisocial
Histrionic
Narcissistic
Cluster C (Anxious/fearful)
Avoidant
Dependent
OCPD

Question 7

What are the characteristics of the way the DSM-V PDs have been classified?

Answer 7

• PDs rarely appear in textbook form
• Highly comorbid - Lots of overlap, both within and between clusters (esp within clusters)
• Survey of clinicians: 60% of patients did not fit in these 10 categories

Categorical (Axis-I) vs Dimensional Approach (Axis-II)
DSM-V uses categorical approach
- Assumes that PDs represent distinct clinical syndromes
Adv: Clarity and ease of communicating info
Disadv: Hard to distinguish threshold from “normal” personality traits to meeting PD criteria
- Gradual move towards dimensional/spectrum approach for PD classification

Question 8

Differences between DSM-IV Axis I vs Axis II?

Answer 8

Axis I: Major clinical disorders with acute symptoms that need treatment
Axis 2: PDs (and intellectual disabilities)
- Early age of onset
- Enduring traits that are clinically significantly distressing/dysfunctional
- Involves self and identity - related to presumed poorer self-awareness (lack of insight)
- Generally poorer response to treatment - often prolonged
But: high degree of co-occurrence of symptoms (comorbid)
- heterogeneity within diagnoses
- diagnostically unreliable
- lack of robust scientific evidence

Question 9

A1. Paranoid PD: Symptom Description

Answer 9

Consistent/pervasive pattern of distrust, suspiciousness, and prolonged grudges held.
- Believes others intentionally exploit, harm or deceive them
- Severely sensitive to criticism & threat - hypervigilant for signs of others to harm them
- Misinterprets comments to indicate concealed, hidden or malevolent intent/motivation
- Hostile, aggressive and angry response to perceived insults
- Jealousy (distrust and misinterpretation)
2/3rds of them meet criteria for other PDs (Schizotypal, Narcissistic, Borderline, Avoidant)

Question 10

A1. Paranoid PD: Underlying Assumptions and Thought processes

Answer 10

Assumptions: (very negative in nature)
People are malicious and out to get you –> Expectancy of hostility, Lack of trust, Guardedness –> Suspiciousness and guarded against closness, resentful, failure to trust others –> Tendency to elicit hostility & distrust from others

They will take advantage of you if they can –> Guardedness

You will be ok as long as you do not let your guard down –> Vigilance
(refer to diagram)

Question 11

A2: Schizoid PD: Symptom Description

Answer 11

Like talking through a glass wall. Cold, hard to connect
Detachment and disinterest in social relationships
- Withdrawal into internal world to avoid affect and maintain distance from others
See others as intrusive and controlling
Flatness of affect: coldness, aloofness, self-absorption, social ineptitude or conceit
Unresponsive to socially criticism:
- Sexually apathetic, reflecting incapacity to form interpersonal bonds
- Anhedonia
Comorbid with Schizotypal and avoidant PDs

Question 12

A3: Schizotypal PD: Symptom Description

Answer 12

Marked interpersonal deficits, behavioural eccentricities and distortions in perception and thinking (that do not meed criteria for schizophrenia)
(e.g. magical thinking, extreme superstition, etc)
- Odd thoughts and speech patterns: vague, abstract, but coherent
- Often seek treatment for anxiety, depression and affective dysphoria
Comorbid with borderline, avoidant, paranoid and schizoid PDs
- Tend to be at the fringe of eccentric groups - even more eccentric than them (e.g. vegans)

Question 13

B1: Antisocial PD: Symptom Description

Answer 13

Repeated reckless disregard for others/social norms
- Victimising/blaming others for inadequacies
- Shallow and manipulative interpersonal relationships
- Self-centered focus (related to histrionic/narcissistic) and failure to adhere to regulations
- Impulsive, aggressive, charismatic, deceitful
- Lack empathy, although they experience guilt and depression
- Antisocial behaviour: may/may not have crim history
Comorbid: Borderline, narcissistic, histrionic and schizotypal PDs

Question 14

B2: Borderline PD: Main Symptoms

Answer 14

1. Emotional instability/affective dysreg in reaction to envr/interpersonal problems
   - wide range of extreme emotions (anxiety, anger, dissociation)
2. Low impulse control: Self-harm, promiscuity, suicidal behaviour (10% suicide), spending, binge eating, poor limit setting
   - Suicide: stems from feelings of emptiness - makes them feel more real
   - Can be attn seeking
3. Identity/insecure attachments
   - Unstable self-concept, avoidance of real/imagined relationships
   - Inability to integrate positive and negative aspects of self –> sense of emptiness

Question 15

B2: Borderline: Prevalence, Comorbidity

Answer 15

Prevalence: most prev PD in clinical settings (due to self-harm)
- 10% of outpatients
- 15-20% of inpatients
Highly comorbid with mood disorders, substance-use disorders & anxiety disorders (PTSD)
(% of people with these disorders also have borderline)
15% MDD
10% Dysthymia
15% Bipolar I
20% Bulimia/Anorexia
10% Substance abuse
- Shared impulsivity/disinhibition and affective instability personality traits
Arguably causing greatest disability of all PDs

Question 16

B3: Histrionic PD: Symptoms

Answer 16

Attention-seeking behaviour - very dramatic
(Used to be called “Hysterical PD” in DSM-II, 1968)
- Excessive emotionality, attention seeking, egocentric, flirtatious, seductiveness (vain)
- Gregarious, manipulative
- Shallow and fickle displays of emotion - affects interpersonal relationships
Comorbid: Narcissistic, borderline, antisocial, psychoactive substance abuse

Question 17

B4: Narcissistic PD: Symptoms

Answer 17

Huge sense of self-entitlement
Pervasive pattern of grandiosity, sense of entitlement, exaggerated sense of self-importance, arrogant attitudes/behav
Have fragile self-esteem, envy, self=consciousness and vulnerability
- Compensate with self-righteousness, pride, contempt, vanity and superiority
Cold, disinterested, snobbish, patronising
Comorbid: Antisocial, Histrionic, borderline + Substance abuse

Question 18

C1: Avoidant PD: Symptoms

Answer 18

Social inhibition, discomfort in social situations, feelings of inadequacy, low self esteem, hypersensitivity to criticism/rejection/ridicule
Avoidance of social activities
Socially inept/incompetent, personally unappealing, inferior to others
Low self-esteem
Comorbid: Dependent and Mood, anxiety, eating disorders

Question 19

C2: Dependent PD: Symptoms

Answer 19

Exaggerated sense of not being able to take care of themselves - reliance on others
Lack in self-confidence, feel incompetent, constantly needing reassurance

Question 20

C2: Dependent PD: Key characteristics

Answer 20

Self view: Needy, weak, helpless and incompetent
View of others: Strong caretaker. Function well when idealised figure is accessible
Threats: Rejection/abandonment
Strategy: Cultivate a dependent relationship by subordinating
Affect: Heightened anxiety. Depression if strong figure is removed, euphoria/gratification when dependent wishes are granted

Question 21

C3: OCPD: Symptoms

Answer 21

Extreme and pervasive pattern of perfectionism and orderliness (really high standards) - seen as “workaholics”
- very rigid lives run by rules and schedules
Rigidity, inflexibility and stubbornness
Preoccupation with rules, minor details and structure - attn to detail interferes with ability to complete tasks
Unrealistic standards of morality, ethics or values
Excessive need for control - interferes with ability to maintain interpersonal relationships or employment
- Reluctance to delegate tasks
(No sig r/ship between OCD and OCPD)

Question 22

C3: OCPD: Key characteristics

Answer 22

Self view: Responsible for themselves vs others. Driven by “shoulds”.
View of others: Too casual, irresponsible, self indulgent and incompetent
Threats: Any flaws, errors, disorganisation. Catastrophic thinking: Things will be out of control
Strategy: System of rules, standards and “shoulds”. Overly directing, punishing and disapproving.
Affect: Regrets, disappointment, and anger towards self/others because of perfectionistic standards

Some characteristics are quite useful /positive - but can get really dysfunctional

Question 23

EPIDEMIOLOGY:

What is the prevalence of PDs, in Australia and abroad?

Answer 23

Aus: 6.5% adults have 1+ lifetime prevalence
- Younger unmarried males: higher presence of anxiety, affective, or substance use disorder, and greater disability than those without PD
- Females: more prevalent in borderline/histrionic
International: 6-13%, average 9.7%

Question 24

What is the epidemiology of Antisocial PD?

Answer 24

0.2-3.3% general population
Gender diff: 3% males vs 1% females
3-30% of psychiatric outpatients
47% of male prisoners and 21% of female prisoners

Question 25

What is the epidemiology of Borderline PD?

Answer 25

Aus: 1-5%, USA: 1-2%, Norway: 0.7% Diagnosis: - 4-6% in primary care (GPs) - 25-40% in clinical population with mental illness - Females 3x higher than in males (diagnosed as antisocial) - Suicide rate of 10%

Question 26

What are some problems in the diagnosis of Borderline PD?

Answer 26

High prevalence, yet underrecognised and underdiagnosed - Symptoms co-occur with other mental disorders - Concerned that diagnosis is stigmatising and may interfere with clinician's ability to be empathetic

Question 27

What is an assumption of Antisocial PD? And what are some behaviours in PDs that break this assumption?

Answer 27

People act in a rational manner guided by logic, rules and social convention - Behaviours carried out with little regard for consequences - Inability to delay gratification - Self-defeating behaviours (cause aversive outcomes to themselves/others) - Irrational behaviours - aversive outcomes outweigh reward

Question 28

Antisocial PD Etiology: How are constitutional factors implicated in the etiology of Antisocial PD?

Answer 28

Constitutional factors = neurobio correlates: Envr/familial influences on predisposition of expression of antisocial variant - External vulnerabilities: Heritable broad trait-dispositional factor reflect disinhibitory personality and risk taking found in childhood CDs, adult antisocial behaviour and substance-use disorders

Question 29

What are the associated biological factors in the etiology of Antisocial PD?

Answer 29

- Reduced levels of serotonin (impulsive behaviour) - Low resting heart rate --> physiological hypo-arousal --> sensation seeking - Neuropsych deficits on frontal lobe exec functioning - -- Weak behavioural inhib and emotional reactivity - less responsive to threat and punishment - -- Evolutionary advantage?

Question 30

What are the associated psychosocial factors in the etiology of Antisocial PD?

Answer 30

- Personality and temperament, shaped by envr and learned coping skills to deal with stress - Social factors: childhood dysfunctional role modelling and interactions with family - Peer group interactions: Deviant sub-cultures - cause or effect?

Question 31

What are the key assumptions in the thought processes of someone with Antisocial PD?

Answer 31

(refer to diagram in notes) - Everyone is out to get what they can for themselves - Rules don't apply to me: I can bend them - If you're smart, you can beat the system

Question 32

What treatments are there for Antisocial PDs? And how successful are the treatments?

Answer 32

Inherent difficulties and ineffectiveness of psychological interventions (e.g. CBT, psychotherapy) Pharmacological agents - reduce impulsivity (lithium, SSRIs) - not very effective on its own Multifacted interventions needed to target impulsivity, aggression, addictive urges, and narcissistic traits - BUT: Outcomes not positive, particularly for severe end of spectrum (psychopathy)

Question 33

BORDERLINE PD: What are the key assumptions behind Borderline PD?

Answer 33

[refer to diagram in notes] - The world is dangerous and malevolent - I am weak and vulnerable - My feelings are unacceptable and dangerous

Question 34

What are presumed genetic etiological factors of Borderline PD?

Answer 34

Twin studies and familial data: suggests heritability factor - Traits: impulsive aggression and mood dysregulation transmitted, rather than direct hereditary genes linked to BPD - Envr factors influence genetic expression (intensity) of behaviours

Question 35

What are the presumed biological etiological factors of Borderline PD?

Answer 35

Neurophysiological/biological Dysfunctional emotional regulation and stress - Affect regulation (Amygdala/ACC), attention, self-control and executive functions (pFC): Implicated in processing, amplifying and attenuating of emotions generated by internal and/or envr stimuli - This is impaired in borderline? Threatening/aversive stimuli --> activated amygdala --> ACC --> pFC ACC: cog eval/processing of mood and affect regulation pFC: Inhibition of impulsive aggression by regulating amygdala

Question 36

How is serotonin implicated in the etiology of Borderline PD?

Answer 36

Serotonin: Regulates impulses, aggression and affect - Links to emotional instability, suicidal behaviours, and impulsivity behaviours - Low levels of serotonin impairs control of destructive urges

Question 37

How are childhood complex traumas implicated in the etiology of Borderline PD, especially from attachment theory?

Answer 37

Emotional/sexual/physical child abuse --> Developmental arrest - BUT abuse alone neither necessary/sufficient Child-parent relationship mediating factors (unstable, non-nurturing, lack of parental empathy and invalidation of experiences) hinders/distorts development of secure attachments --> Emotional dysreg Exacerbated if family member is perpetrator Attachment theory: Infants construct internalised concepts of self and others based on experiences - Sense of security and self-worth, enhanced by family members, shapes personality traits - Not attached --> Unstable personality traits?

Question 38

How are psychosocial factors implicated in the etiology of Borderline PD?

Answer 38

Personality traits/functioning - Parental failure to teach child to label and regulate emotional arousal, tolerate emotional distress, and when to trust own emotional responses during distress - Adulthood - individuals validate their own emotional experiences and depend on others for accurate reflections of external reality

Question 39

What are the three primary characteristic manifestations of psychopathology?

Answer 39

Emotional, behavioural and interpersonal dysfunction

Question 40

What are the targets of treatment intervention in Borderline PD?

Answer 40

``` Think IMPULSIVE: Impulsive Moodiness Paranoia under stress Unstable self-image Labile (pliable) and intense relationships Suicidality Inappropriate anger Vulnerability to abandonment Emptiness (sense of identity) ```

Question 41

Dialectical Behaviour Therapy (DBT): Goals and key modules

Answer 41

Dialectic = A synthesis/integration of opposites/contradictions - Central dialectics of DBT: Acceptance AND Change Goals of DBT: - Changing behaviours causing suffering, while simultaneously - Accepting oneself and current situation/life circumstances - To enhance behavioural, emotional thinking and interpersonal interactions 4 modules: Acceptance skills: - Mindfulness - Distress Tolerance Change skills: - Interpersonal Effectiveness - Emotion Regulation

Question 42

DBT core skill module: 1. Mindfulness

Answer 42

Observing/attending to events, emotions and behavioural responses even if distressing - Step back and allow experience with awareness, rather than leave or terminate emotions Learning to apply verbal labels to behaviours and environmental events - Overcome tendency for literal reflection - "I feel unloved" interpreted literally as "I am unloved" Participating with attention, as opposed to mindlessly engage in an activity

Question 43

DBT core skill module: 2. Distress tolerance

Answer 43

Assumes that mental health requires ability to tolerate and accept distress Skill: Accept the current situation in a non-judgemental fashion - Experience current emotional state without attempting to change it - Observe own thoughts and actions without controlling or stopping these - Acceptance of reality does not mean approval of reality - distress is accepted, but doesn't make it any less painful

Question 44

DBT core skill module: 3. Emotion regulation skills

Answer 44

Difficulties in regulating pain emotions: core to behavioural reactions Assumes: emotional distress is a secondary response to intense shame, anxiety or rage Skills: Identifying and labelling affect. Observe and describe: a. Event triggering emotion b. Interpretation of event c. Phenomenological experience (phys/emotional feelings) d. Behav associated with emotions e. After effects on functioning

Question 45

DBT core skill module: 4. Interpersonal effectiveness

Answer 45

Skill: Specific Interpersonal problem-solving, social and assertiveness skills, to modify aversive environments and develop effective relationships - How to ask for things and say "no" to other people, while maintaining self-respect and important relationships - Limit setting on demanding behaviours --> Need for reassurance and acceptance

Question 46

What is the efficacy of DBT on treating Borderline PD?

Answer 46

16 studies, 8 RCTs - Moderate global effect size - Moderate effect size for suicidal and self-injurious behaviours - Drop out rate: 27% (high)

Question 47

What is the schema-focused therapy for BPD?

Answer 47

Integrates CB, experimental, interpersonal and psychoanalytic therapies into one model - Schemas = Long-standing self-defeating patterns/themes in thinking, feeling and behaving/coping (e.g. "I'm unlovable" "I'm a failure" - Broad, pervasive dysfunctional themes developed during childhood development persist into adulthood composed of memories/emotions/cog defining perspective of self and relationship with others --> sig degrees of impaired functioning

Question 48

What are the three stages of Schema-focused BPD Therapy?

Answer 48

1. Assessment: Identification of schemas (via questionnaires) 2. Emotional awareness and experiential phase: Identify how schemas operate in day-to-day living 3. Behavioural change: Replacement of negative, habitual thoughts and behaviours with new, healthy cognitive and behavioural options

Question 49

Examples of some schemas addressed in Schema-focused BPD therapy?

Answer 49

- Abandonment, - Entitlement - Mistrust - Dependence - Social isolation - Approval seeking - Negativism etc.

Question 50

Schema therapy: Coping styles and modes:

Answer 50

Schema/coping style = trait Maladaptive coping styles: Schema surrender, avoidance, overcompensation Mode = Current mood state/behav/cog - Innate child modes: Vulnerable/Angry/Impulsive/Contented child

Question 51

Outcomes of schema therapy

Answer 51

Complete recovery: 50% Sig improvement: 66% Outcomes related to duration and intensity of treatment (2 sessions/wk for 3 years) Therapy --> Full recovery!