Personality Disorders

Question 1

Define personality?

Answer 1

Cluster of relatively predictable patterns of thinking, feeling and behaving that is generally consistent across time, space and context

i.e: we can all become irritable but we are not irritable in most situations

Question 2

5 components of personality structure?

Answer 2

1. Openness
2. Neuroticism
3. Agreeableness
4. Extraversion
5. Conscientiousness

Question 3

What is a personality disorder (ICD-10)?

Answer 3

An enduring pattern of inner experience and behaviour that deviates markedly from expectations of their culture; this pattern manifests in 2 or more of the following areas:

1. Cognition, i.e: ways of perceiving and interpreting self, other people and events
2. Affectivity, i.e: range, intensity, lability and appropriateness of emotional response
3. Interpersonal functioning
4. Impulse control

Question 4

Requirements that must be fulfilled to meet a diagnosis of personality disorder?

Answer 4

1. ENDURING pattern that is inflexible and PERVASIVE across a broad range of personal and social situations
2. Pattern has a long duration and is stable; onset in, at least, adolescence or early adulthood
3. Enduring pattern is not better explained as a manifestation / consequence of another mental disorder
4. Enduring pattern is not attributable to physiological effects of a substance, e.g: drug of abuse, medication, or another medical conditions, e.g: head trauma

NOTE - they are often, but not always, assoc. with various degrees of subjective distress and problems with social, occupational, etc, performance

Question 5

Difference between traits, disorder and episodes?

Answer 5

Traits of a condition are displayed by many people; these do not always cause problems

It is only a disorder if it is pervasive, not just related to specific situations, and causes distress and/or impairment of functioning in most areas

i.e: being shy does not indicate a personality disorder, nor does

Episodic behaviour is more likely due to another disorder, e.g: affective disorder

Question 6

Aetiology of personality disorder?

Answer 6

Unclear; most conditions are a result of the complex interaction between genes, the individual and their environment

There is a hereditary component

Different personality disorder may have different contributing factors

Question 7

Occurrence of personality disorders?

Answer 7

~10%; they are more common than T1DM and T2DM combined, IBD, MS, epilepsy, RA and asthma, i.e: many cases are undiagnosed

1/10 people in the general population have a personality disorder; this is higher in psychiatric patients, due to greater unmet needs and greater impairment

Question 8

Types of personality disorder and categorisation, according to ICD-10?

Answer 8

Paranoid

Schizoid

Dissocial

Emotionally unstable:
• Impulsive
• Borderline

Histrionic

Anankastic

Anxious (avoidant)

Question 9

Types of personality disorder and categorisation, according to DSM-5?

Answer 9

Cluster A - ‘odd and eccentric’:
• Paranoid
• Schizoid
• Schizotypical

Cluster B - 'dramatic, emotional and erratic':
• Antisocial
• Borderline
• Histrionic
• Narcissistic

Cluster C - ‘anxious and fearful’:
• Avoidant
• Dependent
• Obsession-compulsive

Question 10

What is paranoid PD?

Answer 10

Pervasive distrust and suspiciousness of others, such that their motives are interpreted as malevolent

Begins by early adulthood and presents in a variety of contexts

Question 11

Diagnostic criteria for paranoid PD?

Answer 11

4 OR MORE of the following:

1. Suspects, without sufficient basis, that others are exploiting, harming or deceiving him/her
2. Preoccupied with unjustified doubts about the loyalty or untrustworthiness of friends / associates
3. Reluctant to confide in others due to unwanted fear that the info will be used maliciously against him/her
4. Reads hidden demeaning or threatening meanings into benign remarks or events
5. Persistently bears grudges, i.e: unforgiving of insults, injuries or slights
6. Perceives attack on his/her character or reputation that are not apparent to others; quick to counterattack and react angrily
7. Recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner

Question 12

What is schizoid PD?

Answer 12

Pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings

Begins by early adulthood and presents in a variety of contexts

Question 13

Diagnostic criteria for schizoid PD?

Answer 13

4 OR MORE of the following:

1. Neither desires not enjoys close relationships, inc. being part of a family
2. Almost always chooses solitary activities
3. Has little, if any, interest in having sexual experiences with another person
4. Takes pleasure in few, if any, activities
5. Lacks close friends or confidants other than 1st degree relatives
6. Appears indifferent to the praise or criticism of others
7. Shows emotional coldness, detachment or flattened affectivity

Question 14

What is antisocial PD?

Answer 14

Pervasive pattern of disregard for and violation of the rights of others

Occurs since the age of 15 years

Question 15

Diagnostic criteria for antisocial PD?

Answer 15

3 OR MORE of the following:

1. Failure to conform to social norms with respect to lawful behaviours, as indicated by repeatedly performing acts that are grounds for arrest
2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit/pleasure
3. Impulsivity or failure to plan ahead
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults
5. Reckless disregard for safety of self or others
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or to honor financial obligations
7. Lack of remorse, as indicated by indifference to or rationalisation of hurting, mistreating or stealing from another

Question 16

What is borderline PD?

Answer 16

Pervasive pattern of instability of interpersonal relationships, self-image, and affects and marked impulsivity

Begins by early adulthood and presents in a variety of contexts

Question 17

Diagnostic criteria for borderline PD?

Answer 17

5 OR MORE of the following:

1. Frantic efforts to avoid real or imagined abandonment
2. Pattern of unstable and intense interpersonal relationships, characterized by alternating between extremes of idealization and devaluation
3. Identity disturbance -
   markedly and persistently unstable self-image or sense of self
4. Impulsivity in at least two areas that are potentially self-damaging, e.g: spending, sex,
   substance abuse, reckless driving, binge eating
5. Recurrent suicidal behavior, gestures, or threats or self-mutilating behavior
6. Affective instability due to a marked reactivity of mood, e.g: intense episodic dysphoria, irritability, or anxiety; these episodes usually last a few hours and only rarely more than a few days
7. Chronic feelings of emptiness
8. Inappropriate, intense anger or difficulty controlling anger, e.g: frequent displays of temper, constant anger, recurrent physical fights
9. Transient, stress-related paranoid ideation or severe dissociative symptoms

NOTE - many people display these traits

Question 18

What is histrionic PD?

Answer 18

Evasive pattern of excessive emotionality and attention seeking

Begins by early adulthood and presents in a variety of contexts

Question 19

Diagnostic criteria for histrionic PD?

Answer 19

5 OR MORE of the following:

1. Uncomfortable in situations in which he/she is not the center of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior
3. Displays rapidly shifting and shallow expression of emotions
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self-dramatization, theatricality and exaggerated expression of emotion
7. Suggestible, i.e: easily influenced by others or circumstances
8. Considers relationships to be more intimate than they actually are

Question 20

What is avoidant PD?

Answer 20

Pervasive pattern of social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation

Begins by early adulthood and presents in a variety of contexts

Question 21

Diagnostic criteria for avoidant PD?

Answer 21

4 OR MORE of the following:

1. Avoids occupational activities that involve significant interpersonal contact, due to fears of criticism, disapproval, or rejection
2. Unwilling to get inv. with people unless certain of being liked
3. Shows restraint within intimate relationships, due to fear of being shamed or ridiculed
4. Preoccupied with being criticized or rejected in social situations
5. Inhibited in new interpersonal situations because of feelings of inadequacy
6. Views self as socially inept, personally unappealing or inferior to others
7. Unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing

Question 22

What is dependent PD?

Answer 22

Pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour

Begins by early adulthood and presents in a variety of contexts

Question 23

Diagnostic criteria for dependent PD?

Answer 23

5 OR MORE of the following:

1. Difficulty making everyday decisions without an excessive amount of advice and reassurance from others
2. Needs others to assume responsibility for most major areas of his or her life
3. Difficulty expressing disagreement with others because of fear of loss of support or approval (NOTE - does not inc. realistic fears of retribution)
4. Difficulty initiating projects or doing things on his/her own, due to lack of self-confidence in judgment or abilities (not a lack of motivation or energy)
5. Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant
6. Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself
7. Urgently seeks another relationship as a source of care and support when a close relationship ends
8. Is unrealistically preoccupied with fears of being left to take care of himself or herself

Question 24

What is obsessive-compulsive PD?

Answer 24

AKA Anankastic PD

Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control; this is at the expense of flexibility, openness, and efficiency

Begins by early adulthood and presents in a variety of contexts, as indicated

Question 25

Diagnostic criteria for obsessive-compulsive PD?

Answer 25

4 OR MORE of the following: 1. Feeling of excessive doubt and caution 2. Preoccupation with details, rules, lists, order, organisation, schedule 3. Perfectionism that INTERFERES with task completion, e.g: to a degree that they end up late 4. Excessive conscientiousness and scrupulousness 5. Undue preoccupation with productivity, to the exclusion of pleasure and interpersonal relationships 6. Excessive pedantry and adherence to social conventions. 7. Rigidity and stubbornness. 8. Unreasonable insistence that others submit to exactly his/her way of doing things, or unreasonable reluctance to allow others to do things

Question 26

Difference between OCD and obsessive-compulsive PD?

Answer 26

Those with obsessive-compulsive PD agree with themselves/their actions, whereas those with OCD know that it is excessive (as in all anxiety disorders) and become frustrated with themselves, i.e: OCD is egodystonic and obsessive-compulsive PD is egosyntonic Usually, OCD is more focused, i.e: obsessions and compulsions are around a specific thing, like cleanliness, whereas obsessive-compulsive PD is pervasive OCD is very treatable, whereas obsessive-compulsive PD is difficult to treat

Question 27

Are anti-social PD and psychopathy the same thing?

Answer 27

They are not; antisocial PD is largely based on behaviour but psychopathy describes deficits in emotional and cognitive functioning

Question 28

Features of psychopathy?

Answer 28

``` Factor 1 (interpersonal / affective): • Facet 1 (interpersonal) - glibness (superficial charm), grandiose self-worth, pathological lying, conning / manipulative • Facet 2 (affective) - lack of remorse, shallow affect, lack of empathy/callous, failure to accept responsibility for actions ``` ``` Factor 2 (social deviance): • Facet 3 (lifestyle) - need for stimulation (prone to boredom), parasitic lifestyle, lack of realistic long-term goals, impulsivity, irresponsibility • Facet 4 (antisocial) - poor behavioural controls, early behavioural problems, juvenile delinquency, revocation of condition/release, criminal versatility ```

Question 29

Occurrence of psychopaths?

Answer 29

Not all psychopaths are imprisoned; many are successful in corporations

Question 30

Prognosis of PD?

Answer 30

Fairly stable over time but this does not mean that change is impossible; patients's symptoms/behaviour can improve over time

Question 31

General basis for treatment of PD?

Answer 31

Not much evidence but TREATMENT OF CO-MORBIDITY is effective and is the focus, e.g: depression, anxiety

Question 32

Which types of PD are considered non-responders?

Answer 32

Little guidance on the treatment of the following Cluster A: • Schizoid PD • Paranoid PD Cluster B: • Histrionic PD • Dissocial PD Cluster C: • Anankastic (Obsessive- Compulsive) PD • Avoidant PD

Question 33

Treatment of avoidant PD?

Answer 33

Social skills training helpful for some patients, by helping to increase self-efficacy and functioning Anti-depressants NOTE - again, not much evidence

Question 34

Treatment of boderline PD?

Answer 34

Main psychological treatment is Dialectical Behavioural Therapy (DBT) 'Mentalisation' is popular but there is less evidence for it Drug treatment primarily for co-morbid conditions (no drug has a license for borderline PD): • MAOIs may be effective for co-morbid depression and borderline PD • Anti-psychotics may have a role, mainly Olanzapine (weight gain) and haloperidol have evidence • Topiramate for anger and aggression

Question 35

What is DBT?

Answer 35

Complex package of groups, firm boundaries and management of interpersonal issues, mainly affecting suicidal behaviour; it attempts to combine behavioural approaches with concept such as acceptance and mindfulness It is hard work and has a high drop-out rate

Question 36

What is mentalisation?

Answer 36

Process by which we interpret out own actions as being meaningful, based on our own internal mental states; impaired ability to mentalise apparently affects our ability to regulate our emotions and maintain interpersonal relationships NOTE - using this as a treatment is not supported by as much evidence as DBT

Question 37

Treatment of antisocial PD?

Answer 37

Psychological interventions - group-based cognitive and behavioural interventions, in order to address problems such as impulsivity, interpersonal difficulties and antisocial behaviour Pharmacological interventions - not routinely used