PSY2003 S2 W5 Personality Disorders

Question 1

Why does experience matter when understanding personality disorders?

Answer 1

Need to understand the diversity of experience across individuals (Beware of stereotypes).
Need to get away from stigmatising representations,( e.g.“Dangerous”, “Wilful”,“Self-obsessed”)
Remember that the prevalence of personality diagnoses is high, so I know I will be talking to some people with such issues today

Question 2

What are two experience of personality disorder?

Answer 2

Emotional and interpersonal sensitivity
Interpersonal relationships and lack of trust

Question 3

What is the experience of personality disorder with emotional and interpersonal sensitivity?

Answer 3

Distinction between their rational and emotional mind. Emotional mind much louder. Interpersonally sensitive – “A look is all it takes”

Question 4

What is the experience of personality disorder with interpersonal relationships and lack of trust?

Answer 4

is born out of past experience, maintained by current behaviours.

Question 5

What is the dignaosis of personality disorder like?

Answer 5

Can be paradoxical experience:
being diagnose can feel like you are being written off as: a problem person, having no prospect of change.
Being diagnosed can be an enormous relief: Recognition that there is a problem, access to therapy
But the lack of clarity about diagnosis and treatment can be frustrating too

Question 6

What is personality?

Answer 6

Personality is our tendance towards patterns of behaviour, emotion, cognition and interaction that show through regardless of situation we are in. (traits rather than state).

So, personality can be something that has positive implications if it fits the demands of the world. But it can be a negative influence if it does not fit the world around us or its rules.

Question 7

What is the difference between State and Trait?

Answer 7

Anxious before an exam – STATE
Anxious all the time – TRAIT
Wanting to do an important job well – STATE
Wanting to do everything perfectly - TRAIT

Question 8

Are personality disorder well defined?

Answer 8

no
and diagnosis are being refined

Question 9

What does the field focus on ?

Answer 9

borderline personality disorder: more common than all the others put together

Question 10

What causes personality disorders?

Answer 10

The causes of the personality disorders are much more consistently about common developmental experiences (trauma, emotional invalidation) than about neurological factors

Question 11

What treatments excited for BPD?

Answer 11

There are effective psychological treatments for BPD
But we still have only limited understanding of the factors that underpin the other personality disorders, and that lead to effective treatments

Question 12

Is there literature comparing theorapis/treatments head to head?

Schema Therapy vs DBT

Answer 12

Very few pieces of literature comparing therapies/treatments head to head.
BOOTs trial – comparing schema therapy and DBT

Question 13

What is dialectical behaviour therapy?

Linehan 1993

Answer 13

Behaviourally-based programme.
Managing impulsive behaviours and thought processes in BPD.
Elements of contingency management, operant conditioning, mindfulness, etc.
Very resource intensive.
Designed to manage symptoms effectively, but not to remove the cognitions But main outcome measure is suicidality

Question 14

What is the largest trial to date?

Answer 14

Arntz et al. 2022
Effectiveness of predominantly group schema therapy and combined individual and group schema therapy for BPD
N = 495
Treatments as usual
Predominantly group schema therapy
Combined individual and group schema therapy
Results: Combined individual and group schema therapy group had significantly reduced BPDSI score compared with the treatment as usual, predominantly group schema therapy. But Combined individual and group schema therapy group score did not significantly differ in the treatment as usual and predominantly group schema therapy groups.

Question 15

What is the schema therapy review ?

Taylor et al. 2017

Answer 15

Does schema therapy change schemas and symptoms?

Systematic review

Greatest evidence for Personality Disorder

Question 16

How do we conceptualise personality disorder with socio political perspective?

Answer 16

A way of saying ‘that person is weird’ - how good are we at agreeing on that?

A way of saying ‘that person is not acceptable’ - and we know people disagree on that…

A way of saying ‘that person is not within social bounds’ - e.g., detained in Soviet Gulags due to being defined as ‘antisocial’ for having non-fitting views

A way of saying ‘that person is not diagnosable, but is pretty close and probably will have a problem soon, so let’s something about it now’ - e.g., early definitions of borderline personality disorders were about being borderline of experiencing psychosis

Takes us into the medico-legal perspective - are we entitled to jail/detain people on the basis of what we believe they might do? what if we do not and they go on to offend? levels of caution and politics can still get in the way

Question 17

How do personality varies?

Answer 17

Varies along dimensions

Question 18

Are personality disorders distinct ‘clumps’ at extreme? Or a distinct clump at just one end of the dimension?

Answer 18

e.g., extreme introversion or extraversion could be seen as a problem.
e.g., we might see extreme neuroticism as a problem, but not extreme stability

Question 19

How is personality disorder define in the DSM-5?

Answer 19

Efforts to define personality disorders used to assume that it was simple categories (DSM-IV) but now are more of a mixture of the two approaches (DSM-5)

Question 20

What is the definition of personality disorder in the DSM-5 in 1994 ?

Answer 20

“An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture”
Vague definition, could encompass unusual belief systems, that might have been quite normal at some points in history.
Complex after DSM-5 task force met lots of plans for change, based on problems with DSM-5 but lots of debate, so we still have the same categories

Question 21

What is the definition of personality disorder in the DSM-5 in 2013 ?

Answer 21

“The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits”.

Question 22

What criteria is require for the diagnosis of personality disorders ?

Answer 22

Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning

1 or more” pathological” personality trait domains or trait facets

Impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and across situations

Diagnosis of a personality disorder requires the following criteria (cont):

Impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment

Impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)

Question 23

What re some problems with the diagnosis of personality disorders in the DSM-5 (2013)?

Answer 23

define ‘significant’ and ‘normative’

clinicians tend to use diagnosis regardless of substance use, nutrition issues, injury, etc.

Question 24

What are other difference in the diagnosis of personality disorders?

Answer 24

DSM-IV had 10 personality disorders.
At the end of a long set of arguments, DSM-5 came out with the same 10 diagnoses. But,
DSM-5 included research proposals to allow for future potential change in diagnosis.
Level of personality functioning
Personality trait domains and facets
Personality disorder types

Question 25

What are the changes to the DSM4 to DSM5?

Answer 25

DSM-5 maintains diagnostic criteria from DSM-4 and continues to define personality disorders on categorical basis. But it discusses a dimensional approach to the diagnosis of personality disorders and encourages further research on these.

Question 26

What are the key issues in reaching a diagnosis?

Answer 26

Long-term presentations Independent of biological factors (drug, starvation, actual threat) Diagnoses cannot eb made at a single clinical meeting Yet each of these gets ignored by clinicians..so please remember that an element of cynicism is pretty reasonable And remember that for a lot of people who have complex emotional needs, receiving a diagnosis can be a huge relief, so let’s make it accurate… Usually do not diagnose in childhood and adolescence (controversial)

Question 27

What are the different clusters for personality disorder?

Answer 27

Cluster A: Paranoid Personality Disorder, schizoid Personality Disorder, Schizotypal Personality Disorder Cluster B: Antisocial Personality Disorder, Histrionic personality, Narcissistic Personality Disorder, Borderline personality disorder Cluster C: Avoidant Perosnalty disorder, Obsessive compulsive personality disorder, Dependent Personality

Question 28

What are the personality disorder in cluster A?

Answer 28

Odd, eccentric Personality disorder Paranoid PD Schizoid PD Schizotypal PD

Question 29

What is schizotypal PD? | Cluster A

Answer 29

pattern of eccentric idea, magical thinking

Question 30

What is personality disorder ? | Cluster A

Answer 30

with some schizophrenia-like features: lacking active symptoms, such as hallucinations

Question 31

What is Paranoid PD? | Cluster A

Answer 31

pattern of distrust and suspiciousness, resistant to challenge by others

Question 32

What is schizoid PD? | Cluster A

Answer 32

pattern of separation from social relationships, limited emotional expression and experience

Question 33

What is cluster B personality disorders?

Answer 33

Dramatic and erratic PD characterised by impulsive/erratic and/or self-centred behaviours, emotions and thinking Antisocial PD Bordline PD Narcissistic PD Histrionic PD

Question 34

What is Antisocial PD? | Cluster B

Answer 34

Pattern of disreard of other's right, strong links to conduct disorders and criminality, selfishness and lack of empathy

Question 35

What is Borderline PD? | Cluster B

Answer 35

Emotionaly unstable PD-ICD Patterns of unstable relationships, mood, behaviour efforts to control emotion (self harm, drink) & avoid rejection

Question 36

What is Narcissistic PD? | Cluster B

Answer 36

Pattern of overestimation of own abilities and accomplishments Pervasive need for admiration, while not caring about others Anger when not recognised for their specialness Fragility of self-esteem

Question 37

What is Histrionic PD? | Cluster B

Answer 37

Attention-seeking, need to be the centre of attention Dramatic behaviour, undue emotional expression Exaggerated presentation

Question 38

What is personality disorders in CLuster C?

Answer 38

Anxious/Fearful Personality disorder characterised by anxiety that is lifelong, not related to any triggers Avoidant PD Dependet PD Obsessive-Compulsive PD

Question 39

What is Avoidant PB? | Cluster C

Answer 39

pattern of social avoidance inadequacy, and sensitivity to others’ views of them

Question 40

What is dependent PD? | Cluster C

Answer 40

pattern of dependence on others’ care submissive, clinging, seek others’ approval/support

Question 41

What is obsessive-compulsive PD? | Cluster C

Answer 41

excessive perfectionism (focus on doing the task: forget the goal) need for order, patterns and control

Question 42

What are the diagnostic clusters of personality disorders?

Answer 42

Three broad clusters with ten diagnoses: odd/eccentric, dramatic/erratic and anxious/fearful Big overlap across clusters and diagnoses – it is rare for people to only meet one personality disorder criteria If one meets the criteria for one PD, on average one meets the criteria for 4.5 Expected to identify which cluster a diagnosis belongs to but not the criteria for each personality disorder.

Question 43

What is the prevalence of personality disorders?

Answer 43

no clear onset, so focus on prevalence rather than incidence Rate found depends on how thorough the assessment is: many studies use weak measures and overestimate prevalence hugely. Gender bias in diagnosis (Women in CLuster C & B and men in cluster A) Most reliable studies suggest a rate of 10-15% for all personality disorder Most common: borderline, schizotypal, antisocial, obsessive compulsive. But figures really vary hugely.

Question 44

Are personality disorder comorbide?

Answer 44

High rate of co-occuring personality disorder (not so distinct after all) High rate of comorbidity with: depression, substance misuse, panic disorder, PTSD, social phobic, eating disorder, neurodiversity

Question 45

If someone is diagnosed with a personality disorder now, does that mean they will have this problem for the rest of their life?

Answer 45

Historically it used to be yes, but now it’s more so no.

Question 46

What is the old viewpoint on is personality disorder for life?

Answer 46

Yes but the symptoms tend to fade after 40Y, untreatable

Question 47

What is the current viewpoint on is personality disorder for life?

Answer 47

No, as a large number of cases are not diagnosable a few years later. - Zanarini et al. (2013) Treatment for some personality disorders is effective in some cases

Question 48

What is Sceham therapy ?

Answer 48

Integrative Therapy based on the Schema Model Three ways of changing schemas Doing - Behavioural Techniques Feeling - Experiential Techniques Thinking - Cognitive Techniques Greater focus on: Therapeutic relationship (rapport) Using mental imagery techniques Using Chairwork in therapy

Question 49

What are the three ways of chaning schemas? | Shema therapy

Answer 49

Doing - Behavioural Techniques Feeling - Experiential Techniques Thinking - Cognitive Techniques

Question 50

What is the best treatment?

Answer 50

Schema Therapy (Young et al. 1990; 2003) Integrative Model (cognitive, behavioural, gestalt, attachment theory, object relations) Three ways of changing schemas: * Behavioural (Doing) * Feeling (Experiential) * Thinking (Cognitive) Addresses the cognitions that underpin the behaviours and emotions: core beliefs/Schemas A lot of exploration of how those beliefs developed, and modification of the beliefs and emotions. very commonly related to long-term responses to trauma and experience of being parented inadequately

Question 51

What are some treatments for personality disorders?

Answer 51

Limited evidence A range of clinical suggestions about such treatment: all the evidence is for psychological interventions, rather than neurological. Beck et al. (2016): range of clinical guidance based on CBT. Evidence for other, more integrative therapies o Cognitive analytic therapy (Ryle) o Mentalization-based treatment (Bateman)

Question 52

What is Psychotherapy for BPD? | Cristeau et al. 2017

Answer 52

33 studies, N = 2256 PTT Review focused on therapy Most therapy had same levels of advocacy

Question 53

What did Oud et al. 2018 find for treatments?

Answer 53

20 studies, N = 1375 PTT Quality of trails was moderate Physiotherapy’s had modicum effect compared to community treatment.

Question 54

What are Biological/Neurological factors underpinning cluster A PDs?

Answer 54

General Genetics Enlarged ventricles Enhanced startle response Cognitive deficits Lack of link to specific PDs

Question 55

What are Biological/Neurological factors underpinning cluster B PDs?

Answer 55

Antisocial – childhood conduct disorder, Genetics, low anxiety & Weak fear conditioning Borderline – Genetics & Limbic system dysfunction

Question 56

What are Biological/Neurological factors underpinning cluster C PDs?

Answer 56

Avoidant - Genetics General –? Physiological predisposition to anxiety

Question 57

What are Environmental factors underpinning cluster C PDs?

Answer 57

Avoidant – childhood negative experience Dependent – fear of rejection General – experience driving schema development

Question 58

What are Environmental factors underpinning cluster B PDs?

Answer 58

Antisocial – modelling Borderline – trauma/emotional invalidation Narcissistic – doting/praising parents? General – Experience driving schema development

Question 59

What are Environmental factors underpinning cluster A PDs?

Answer 59

General PD: Parental relationships, Rejection & Abuse

Question 60

What did Gask et al. find? 2013 | Reading

Answer 60

Personality disorder is associated with high service use and excess medical morbidity and mortality. Diagnosis of personality disorder along a single dimension of severity is a major change from traditional categorical approaches. Most non-psychiatrists are aware of the diagnosis of personality disorder but rarely make it with confidence. Epidemiological studies show that 4-12% of the adult population have a formal diagnosis of personality disorder; if milder degrees of personality difficulty are taken into account this is much higher. People carry the label of personality disorder with them, and this can influence their care when they come into contact with services, including mental health providers