Week 4-Personality Disorders Flashcards
What influences on contemporary psychiatry occurred during the 18th-20th Century?
-Early attempts in European psychiatry to describe ‘maladaptive’ personalities
-Philippe Pinel’s “Manie sans delire” (Mania without delusion), refers to a group of male patients prone to impulsive violence without any other psychiatric symptoms (e.g., cognitive problems, delusions, hallucinations etc.,). Suggested it was a result of parenting practises and early experiences
-Kraepelin’s 7 types of psychopathic (more referred to as mentally ill with impairments) personalities resulting from an inborn defect: ‘excitable’, ‘irresolute’, ‘persons following their instincts’, ‘eccentrics’, ‘pathological liars and swindlers’, ‘enemies of society’ and ‘quarrelsome’
-Freud’s work connected childhood experiences to personality traits which led to various psychoanalytical descriptions of different personality types
-Pathological or maladaptive personalities that were longstanding, and in the absence of other psychiatric symptoms (abnormal in cultures and no hallucinations or delusions present)
What is the 21st century understanding of contemporary psychiatry?
Personality disorders generally refer to a pattern of experiences and behaviours that affect cognition, emotions, relationships, and behaviour (these disorders are classified)
-It differs from what is expected within the dominant culture
-It typically emerges by late adolescence or early adulthood and is stable and long-standing
-It causes significant personal distress or problems in functioning and is generally considered maladaptive (if not these 2 then we cannot say it’s a personality disorder)
-It covers a wide range of experiences and behaviours that tend to be seen as relating to someone’s personality
How does Diagnostic classification work?
-Categorical systems assume that there is an objective difference between mental health and illness
-Pathological and non-pathological (normal) personality traits are seen as separate categories (relating to personality disorders) to allow clinicians to diagnose the range and quality
-Most frequently used diagnostic manuals in Western practice are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Diseases (ICD)
-Diagnostic categories have changed over time and therefore across versions of the DSM and ICD (personality disorder definitions differ from the 80s due to research and cultural norms)
What 6 criteria is there in the DSM to be diagnosed with a general personality disorder?
- An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in 2 (or more) of the following areas: cognition, affectivity, interpersonal functioning, or impulse control.
- Inflexible and pervasive (evident) across a broad range of personal and social situations.
- Leads to clinically significant distress or impairment in social, occupational or other important areas of functioning.
- Stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood (e.g., not mid thirties).
- Not better explained as a manifestation or consequence of another mental disorder. (other mental disorder shouldn’t be root essentially)
- Not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., Phineas Gage)
What is the Cluster A: Odd/eccentric cluster personality?
-Personality disorders with behaviours viewed as strange and odd
-Paranoid Personality Disorder (PPD): distrusting and suspicious interpretation of the motives of others (being cheated on, someones out for them etc.,)
-Schizotypal Personality Disorder (STPD): social discomfort, cognitive distortions, peculiar thoughts, unusual language, and behavioural eccentricities, but no psychotic episodes.
-Schizoid Personality Disorder (SPD): social detachment and restricted emotional expression, socially isolated (not enjoying the company of others, being indifferent to others opinions)
What’s Cluster B: Dramatic/erratic cluster personality?
-Disorders where emotions may be intense or impulsive behaviour
-Antisocial Personality Disorder (ASPD): disregard for and violation of the rights of others, aggressive and impulsive behaviour, tendency to manipulate others. (might not be good at planning ahead or honouring commitments)
-Narcissistic Personality Disorder (NPD): grandiosity, need for admiration, tendency to exploit others lack of empathy.
-Histrionic Personality Disorder (HPD): excessive emotionality, flamboyant and attention seeking, use physical appearance to attract attention.
-Borderline Personality Disorder (BPD): unstable relationships (being obsessed but devaluing partner), self-image, difficulties in emotion regulation, and impulsivity. Difficulty controlling anger, self-harm behaviours, and chronic feelings of emptiness (also dissociation)
What is Cluster C: Anxious/fearful personality?
-Personality disorders characterised by feelings of anxiety
-Avoidant Personality Disorder (APD): socially inhibited (reluctant to interact with strangers), feelings of inadequacy, hypersensitivity to negative evaluation.
-Dependent Personality Disorder (DPD): submissive behaviour (others make decisions for them), need to be taken care of, fear separation (may do things they don’t want to do to achieve that).
-Obsessive-Compulsive Personality Disorder (OCPD): preoccupation with orderliness, perfectionism, and control (to the point it’s ineffective).
How does the International Classification of Diseases (ICD-11) describe and assess Personality Disorders?
-The 11th version of the ICD only retained a general description of Personality Disorder
-PD’s are defined as “a marked disturbance in personality functioning, which is nearly always associated with considerable personal and social disruption.”
-A first assessment evaluates whether symptoms meet the threshold for a Personality Disorder. The service user must present with significant problems in self and interpersonal functioning for a minimum of 2 years and across different contexts e.g., low-self worth, issues in self-identity, difficulty maintaining healthy relationships etc.,
-If the threshold is met, the PD is categorised as ‘mild’, ‘moderate’ (most areas of life affected), or ‘severe’ (all areas of life affected) based on factors such as the degree of dysfunction, the level of distress, and risk by looking at 5 different personality traits
How common are personality disorders?
-Around 1 in 16 people worldwide are being given a PD diagnosis at some point (Huang et al., 2009)
-Around 1 in 20 to 25 are diagnosed with a personality disorder in the UK (Coid et al., 2006; Singleton et al., 2001)
-Prevalence rates vary across socio-demographic factors (more common in men, those who are separated or unemployed, and urban areas but could mean those factors are more to diagnostic bias)
-Prevalence rates are far higher in healthcare and forensic settings compared to the general community
-Prevalence estimates in psychiatric inpatient settings range from 36% to 67% and in prison settings between 60 and 70%
-Prevalence rates vary cross-culturally and tend to be lowest in Western Europe (Huang et al., 2009)
Are personality disorders categorical or dimensional?
-PDs are diagnosed according to a categorical perspective: an individual either has a ‘disordered personality’ or not.
-But, personality consists of personality traits that range on a dimension and vary in degree and not in kind (not just introvert or extrovert)
-PDs therefore might be extreme variants of normal personality traits that lead to mental distress
-Widiger & Simonsen (2005) found that diagnostic criteria for DSM PD’s overlap well with high or low traits on common personality dimensions
-Dimensional approach incorporated in the DSM-5 as an ‘Alternative Model of Personality Disorders’ (AMPD) (ICD does it to a certain extent but still categorical as determining whether a personality disorder or not) where if you show a moderate degree then you can be diagnosed with PD
Disadvantages:
-Still not fully dimensional as clinician has to determine whether a PD is present or not
-It only applies to certain personality disorders (borderline, narcissistic, antisocial and obsessive compulsive so can’t diagnose every PD)
What’s inter-rater reliability in relation to PD?
-IRR assesses whether different clinicians give the same diagnosis to a given individual
-Perfect reliability (1) means that different clinicians always arrive at the same diagnosis for a given individual. Important for any diagnostic tool.
-IRR for DSM PD diagnoses vary considerably, and can be poor for some PD’s (e.g., Zanarini et al., 2000)
-DSM-5 Field Trials suggest that IRR is still poor for the DSM-5
-The Alternative Model performs better (e.g., Christensen et al., 2018; Garcia et al., 2018)
-This means different clinicians or instruments can determine whether someone is diagnosed with a PD or not and which one.
What are the limitations of saying PDs are stable over time?
-The key assumption that PD’s are long-standing and stable patterns of experiences.
-But, most PD symptoms decrease over time (D’Huart et al., 2003) and decrease generally with age
-PD diagnoses appear less stable over time compared to other DSM diagnoses (Morey & Hopwood, 2013)
-Test-retest reliabilities of PD diagnoses can be poor
-“…the longstanding characterisation of PDs are enduring, stable, beginning in adolescence lacks nuance” (Morey & Hopwood, 2013, p.520)
What did Baca-Garcia et al (2007) find after analysing data from > 10,000 patients in a Spanish hospital?
-34.1% of P’s who received a PD diagnosis in their first evaluation retained the same diagnosis in their last evaluation 10 years later
-26.3% of P’s who received a specific PD diagnosis in the last evaluation received the same diagnosis in their first evaluation
-Used ICD (10)
What’s the Comorbidity with other Personality Disorders?
-Many studies find a high rate of comorbidity (co-occurrence) between PDs
Coid et al (2006) found that:
-Many P’s with a cluster A PD were also diagnosed with a cluster C (48%) or B (32%) PD
-27% of P’s with a cluster C also had a cluster B PD diagnosis
-Could be due to the overlap in diagnostic criteria between PDs and poor discriminant validity of measures
-It might also mean that some PDs are actually variants of the same underlying construct (Farmer, 2000)
What does the Alternative Model in DSM-5-TR (AMPD) base a PD diagnosis on?
- Moderate or greater impairment in personality functioning
- Pathological personality traits
It consists of an assessment of (i) Self and interpersonal functioning and (ii) Five domains of pathological personality traits: negative affectivity, detachment, antagonism, disinhibition, and psychotism
How do PD diagnoses intertwine?
-Those with a PD diagnosis are more likely to have 3 or more ‘Axis I) diagnoses (Huang et al., 2009)
-Conceptual overlap between diagnostic criteria of PDs and other mental disorders in the DSM
-For example, auditory hallucinations are a diagnostic criteria for both schizophrenia and schizotypal personality disorder
-Diagnostic criteria of PDs might represent sub-clinical levels of other forms of mental distress
-Personality disorder classifications do not seem to adequately describe individuals’ experiences of mental distress
Are Personality Disorders relational problems?
Individualism:
-The DSM is based on an individualistic model which attributes mental distress to factors within the person
-Pathologises normal responses
Collectivism:
-Many of the diagnostic criteria for PDs refer to things that happen between people e.g., disregard for others, lack of empathy
-PD’s might be a response to things that are happening between people, rather than a ‘disorder’ within the individual e.g., sensitive to criticism
How do Adverse or traumatic childhood life experiences relate to Personality Disorders?
-Childhood trauma includes a variety of traumatic experiences in childhood (<18 years) including emotional and physical abuse and neglect, and sexual abuse
-The majority of people using mental health services have been exposed to adverse or traumatic life experiences
-The experiences associated with the term ‘personality disorders’ are VERY closely associated with childhood abuse (dissociation, lack of empathy etc., very linked to this)
-Those who experienced childhood abuse are 4 to 6 times more likely to develop a PD (Back et al., 2021; Battle et al., 2004; Johnson et al., 1999)
-Different forms of abuse linked to different PDs e.g., physical abuse linked to antisocial PD, emotional or sexual abuse linked to BPD or histrionic PD)
How is childhood trauma associated with maladaptive personality traits? (Beck et al., 2021)
Beck et al (2021): Review of studies between 2017 and 2021 using the dimensional AMPD:
-Detachment and psychoticism are clearly associated with childhood trauma, particularly emotional abuse and neglect
-Negative affectivity and antagonism are also associated with having experienced childhood trauma
-These responses are similar to trauma-associated avoidance and trauma-reactive dissociation (disconnection from thoughts, feelings, memories, identity, behaviour)
What is the link between Childhood trauma and BPD?
-Those with BPD are 13 times more likely to report adverse childhood experiences compared to other clinical groups (Porter et al., 2020)
-97% of individuals with BPD report at least one type of childhood trauma (Slotema et al., 2018)
-Particularly emotional (Porter et al., 2020) and sexual trauma (Ball & Links, 2009) seem to play a role in the development of BPD
-Comorbidity with (complex) Post Traumatic Stress Disorder (c/PTSD; Moller et al., 2020)
What is the effect of childhood trauma on biological processes?
-Childhood trauma can influence biological processes which can eventually lead to mental distress (Teicher et al., 2016; Read er al., 2014)
-Key mechanism is the effect of childhood trauma on the functioning of the HPA axis dysregulation of stress and threat response
-It influences brain development in areas such as the frontal lobe and hippocampus
-Environment can have a buffering (or exacerbating) impact on this interaction
-Does not mean that trauma-based forms of mental distress should be considered as a ‘brain disorder’
What are the limitations of the current evidence base in childhood trauma and PDs?
-Variablility across studies in definitions and measurement of ‘childhood trauma’ important forms of childhood trauma might be missed
-Trauma is not always included as a measure in biomedical studies
-Studies largely rely on self-report, with the risk of biases
-Studies based on DSM categories might be unable to identify more fine-grained effects and differences due to the categorical system
-Findings are largely based on Western samples, whilst there are cross-cultural differences (and biases) in the development and diagnosis of PDs
-Difficult to disentangle the effect of different types of trauma on different types of personality traits
What is the Power Threat Meaning Framework? (Johnston & Boyle, 2018)
-Developed as an alternative to traditional diagnostic models
-It is a structure for identifying patterns in emotional distress, unusual experiences and troubling behaviour
-Links people’s life experiences to mental distress to help make sense of distress
-Considers the role that power and trauma play in mental distress
What is the impact with being labelled with ‘Personality Disorder’?
-Personality Disorder diagnoses are common
-PD diagnosis can provide access to services and provide an explanation for individuals (Perkins et al., 2018)
-PDs are one of the most stigmatised diagnostic categories, even among mental health professionals
-Service users seen as ‘time-wasters, difficult, manipulative, bed-wasters, or attention seeking’ (NIMHE, 2003, p.20)
-Lack of specialised services dedicated to PD treatment
