Personality Disorders

Question 1

General criteria for a personality disorder

Answer 1

Enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. The pattern is manifested in 2 or more of the following areas;

• cognition
• affectivity
• interpersonal functioning
• impulse control

Pattern is inflexible and pervasive
Leads to clinically significant distress or impairment in a range of important areas of functioning
The pattern is stable and can be traced back at least to early adulthood
It is not better explained by another diagnosis
It is not attributable to a physiological change

Question 2

What is personality?

Answer 2

Refers to individual differences in characteristic patterns of thinking, feeling and behaving

Question 3

What does the study of personality focus on?

Answer 3

Two broad areas

• understanding of individual differences in particular personality characteristics such as sociability or irritability
• understanding how the various part of a person come together as a whole

Question 4

What treatments do patients with personality disorder have more use of than patients with major depression?

Answer 4

Psychiatry outpatient
Psychiatry inpatient
Psychopharmalogic treatment

Question 5

DSM IV Cluster Classification - Cluster A

Answer 5

Including paranoid, schizoid and schizotypal personality disorders, which may manifest in cognitive distortion and an interpersonal style that is odd, eccentric or detached
“Odd Eccentric”

Question 6

DSM IV Cluster Classification - Cluster A, what are the prominent problems?

Answer 6

With the perceived safety of interpersonal relationships

Question 7

DSM IV Cluster Classification - Cluster A, features of paranoid personality disorder

Answer 7

Don’t usually come for treatment as too paranoid, ongoing and enduring pattern rather than a state that someone enters, doesn’t just happen with other active symptoms

Question 8

DSM IV Cluster Classification - Cluster A, features of schizoid personality disorder

Answer 8

Rarely come voluntarily for treatment, if they do, disorder is generally better controlled, appear to have absolute detachment from close relationships

Question 9

DSM IV Cluster Classification - Cluster A, features of schizotypical personality disorder

Answer 9

Social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behaviour, early adult onset

Question 10

DSM IV Cluster Classification - Cluster B

Answer 10

Consisting of antisocial, borderline, histrionic and narcissistic personality disorders, which often involve behaviour that appears dramatic, erratic, impulsive, aggressive or affectively dysregulated
“Dramatic Erratic”

Question 11

DSM IV Cluster Classification - Cluster B, features of antisocial personality disorder

Answer 11

Pervasive pattern of disregard for and violation of the rights of others, occurring since teens, as indicated by failure to conform to social norms, impulsivity etc.

Question 12

DSM IV Cluster Classification - Cluster B, features of narcissistic personality disorder

Answer 12

Pervasive pattern of grandiosity, need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by e.g. grandiose sense of self-importance, preoccupied by fantasies of unlimited success, requires excessive admiration, arrogance etc.

Question 13

DSM IV Cluster Classification - Cluster B, features of borderline personality disorder

Answer 13

Pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts e.g. frantic efforts to avoid real/imagined abandonment, unstable and intense interpersonal relationships, identity disturbance

Question 14

DSM IV Cluster Classification - Cluster B, features of histrionic personality disorder

Answer 14

Pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in contexts e.g. uncomfortable in situations where they are not the centre of attention, rapidly shifting and shallow expressions of emotions, interaction with others often characterised by inappropriate sexuality etc.

Question 15

DSM IV Cluster Classification - Cluster C

Answer 15

Includes avoidant, dependent and obsessive-compulsive personality disorders that tend to involve fear, anxiety, apprehension or perceived avoidance of harm
Prominent problems relate to anxiety and how it is managed
“Anxious Fearful”

Question 16

DSM IV Cluster Classification - Cluster C, features of obsessive compulsive personality disorder

Answer 16

Pervasive pattern of preoccupation with orderliness, perfectionism, and mental and inter-personal control, at the extent of flexibility, openness and efficiency beginning by early adulthood

Question 17

DSM IV Cluster Classification - Cluster C, features of avoidant personality disorder

Answer 17

Pattern of social inhibition, feelings of inadequacy

Question 18

DSM IV Cluster Classification - Cluster C, features of dependent personality disorder

Answer 18

Pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning by early adulthood and present in a variety of contexts e.g. difficulty making everyday decisions, needs others to assume responsibility for most major areas in life

Question 19

DSM V - types of personality disorder

Answer 19

Paranoid 
Schizoid 
Schizotypal
Antisocial
Borderline 
Histrionic
Narcissistic
Avoidant 
Dependent 
Obsessive-compulsive

Question 20

What does personality comprise?

Answer 20

The natural and acquired impulses and habits, interests and complexes, the sentiments and ideals, the opinions and beliefs

Question 21

What is the ICD Classification of Mental and Behavioural Disorders

Answer 21

1. Markedly disharmonious attitudes and behaviour, involving several areas of functioning
   - self-identity and worth
   - impulse control
   - fixed negative ways of perceiving and thinking
   - style of relating to others and relationships extreme
2. Abnormal behaviour is enduring, of long-standing nature and not limiting to episodes of illness
3. Abnormal behaviour is pervasive and maladaptive to a broad range of personal and social situations
4. The manifestations appear during childhood or adolescence and continue into adulthood
5. The disorder leads to considerable personal distress by not always evident
6. Often but not always associated with significant problems in social and occupational performance

Question 22

What is the approximate prevalence of personality disorder in;
Community
GP 
Psychiatric outpatients
Psychiatric inpatients 
Prison

Answer 22

Community 10%
GP 20% 
Psychiatric outpatients 30% 
Psychiatric inpatients 40% 
Prison up to 80%

Question 23

What percentage of people with a personality disorder meet the criteria for another PD?

Answer 23

54%

Question 24

Features of paranoid personality disorder

Answer 24

Excessive sensitiveness to setbacks and rebuffs
Bears grudges persistently
Suspicious, misconstrues actions as hostile
Combative, tenacious sense of personal rights
Suspicious regarding fidelity of partner
Excessive self-importance
Conspiratorial explanations of events

Question 25

Features of schizoid personality disorder

Answer 25

Social detachment Emotional coldness, detachment or flattened affect Finds few activities pleasurable Limited capacity to express feelings Apparent indifference to praise or criticism Little interest in sexual experiences with another person Preoccupation with fantasy and introspection - eccentricity Lack of desire for close friends or confiding relationships

Question 26

Features of antisocial personality disorder

Answer 26

Callous unconcern for feelings of others Gross and persistent irresponsibility and disregard for social norms, rules and obligations Incapacity to maintain enduring relationships Low tolerance to frustration Low threshold for violence and aggression Incapacity to experience guilt or to profit from experience, especially punishment Blames others

Question 27

What is psychopathy?

Answer 27

Severe form of antisocial PD Characterised by antisocial behaviour, callous disregard and lack of empathy Generally diagnosed using the PCL-R

Question 28

Features of impulsive-type borderline PD

Answer 28

Emotional instability and lack of control | Outbursts of violence and threatening behaviour are common, especially in response to criticism

Question 29

Features of borderline-type borderline PD

Answer 29

Emotional instability Self-image, aims and internal preferences often unclear or disturbed Chronic feelings of emptiness Intense unstable relationships causing repeated emotional crises Associated excessive efforts to avoid abandonment Suicidal threats or self-harm

Question 30

Futures of histrionic PD

Answer 30

``` Self-dramatisation, theatricality Suggestibility Shallow and labile affect Seeks excitement, centre of attention Inappropriate seductiveness Over-Concern with physical attractiveness ```

Question 31

Features of obsessive compulsive PD

Answer 31

Preoccupation with details, rules, lists, order, organisation and schedule Perfectionism interferes with task completion Conscientiousness, scrupulousness, undue preoccupation with productivity to exclusion of pleasure and relationships Pedantic, rigid and stubborn Insists others submit to their way of doing things Reluctant to allow others to do things Intrusion of unwelcome, insistent thoughts or impulses

Question 32

Features of anxious/avoidant PD

Answer 32

Persistent, pervasive tensions and apprehension Believe they are socially inept, unappealing or inferior to others Preoccupation with being criticised or rejected in social situations Unwillingness to become involved unless certain of being liked Restriction in lifestyle because of need for security Avoidance of activities involving interpersonal contact because of fear of criticism, disapproval or rejection

Question 33

Features of dependent PD

Answer 33

Allows others to make important life decisions Subordination of own needs to those of others on whom they are dependent Unwillingness to make demand on people on whom they are dependent Fear of being abandoned Uncomfortable or helpless when alone Fear inability to care for themselves Unable to make decisions without excessive help from others

Question 34

Diagnosis of PD

Answer 34

Clinical Thorough history taking important Can use structure interviews e.g. international personality disorder examination (IPDE), personality disorder questionnaire (PQD)

Question 35

Aetiology of personality disorder

Answer 35

Early trauma - reported physical, sexual or verbal abuse and neglect in 60-80% of BPD patients Non-trauma - emotionality - negative affectivity - affective instability - emotional dysregulation - inherited tendencies towards anxiety, emotional instability, reactivity, sensitivity, self-consciousness and being easily upset

Question 36

Where might there be neuropsychological impairment in BPD?

Answer 36

Attention - vigilance Verbal learning Memory

Question 37

Principles of management of PD

Answer 37

Patients need to be motivated to change/get better Provide reliable and consistent therapeutic management Try get patients to think about what they are feeling and to recognise them as thoughts and feelings rather than impulses Therapy unlikely to be useful unless it lasts for at least 18 months

Question 38

Treatment methods for BPD

Answer 38

Dialectic behavioural therapy Mentalisation-based treatment Symptomatic prescribing Co-occurring mental illness

Question 39

Rationale for pharmacotherapy in PD

Answer 39

Pharmacotherapy directly influences PDs Exerts an effect over core or nuclear symptom clusters Exerts its therapeutic effect by treating comorbid axis I disorders

Question 40

Effective components of psychotherapy treatment

Answer 40

Be well structured Devote considerable effort to enhancing compliance Be theoretically highly coherent to both therapist and patient Be relatively-long term Encourage a powerful attachment relationship between therapist and patient Be well-integrated with other services available to the patient

Question 41

What is mentalising?

Answer 41

Process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and intentional varied mental processes