week 10

Personality disorder

• an enduring pattern of inner experience and behaviour that differs markedly from cultural expectations and affects:

• Cognition

• Emotions/affect

• Interpersonal functioning

• Impulse control

Why personality disorder matters

It is associated with:

• poorer general health

• Increased mortality

• Increased suicide attempts

• Difficulties in treatment relationships

• Can complicate treatment of other disorder

Stigma around personality disorders

Common harmful assumptions include:

• “attention seeking”

• “Manipulative”

• “Untreatable”

DSM-5 Personality disorder clusters

Cluster A: Odd/Eccentric

• paranoid PD

• Schizoid PD

• schizotypal PD

Cluster B: dramatic/emotional

• antisocial PD

• Borderline PD

• Histrionic PD

• Narcissistic PD

Cluster C: anxious/fearful

• avoidant PD

• Dependent PD

• Obsessive-compulsive PD

Cluster A

• cluster A disorder can resemble schizophrenia-spectrum symptoms

Eg: paranoia, detachment and ideas or references

Paranoid personality disorder (PDD)

• pervasive distrust and suspiciousness of others without sufficient evidence

features:

• believes others may harm or deceive them

• Suspects partners is cheating without evidence

• Interprets neutral comments as attacks

Schizoid personality disorder (ScPD)

• detachment from social relationships + real stricter emotional expression

Features:

• little desire for relationships

• few close friends

• Prefers activities alone

• Flat affect

Schizotypal personality disorder (SzPD)

• social/interpersonal difficulties plus odd beliefs, perceptions and behaviours

Features:

• discomfort with close relationships

• Suspiciousness

• Social anxiety

• Few close friends

• Unusual beliefs

• Odd/vague speech

Eg: thinking a TV presenter is speaking directly to you

Cluster B

• dramatic

• Emotional

• Erratic

Cluster B has:

• high public awareness

• High stigma

• Strong research base especially BPD

Antisocial personality disorder (ASPD)

• pervasive disregard for and violation of the rights of others

Features:

• Breaking social rules

• Lying/deceit

• Recklessness

• Anger/aggression

• Disregard for safety

• Lack of concern after hurting others

Important diagnostic points:

1. Person must be at least 18

2. Evidence of conduct disorder before age 15

3. Pattern occurs around age 15 onwards

Borderline personality disorder (BPD)

• someone with pervasive instability in identity, relationships, emotions and behaviour

Relationships:

• intense unstable relationships

• Fear of abandonment

• Splitting

Emotions:

• high emotional reactivity

• Chronic emptiness

• Intense emotional outbursts

Behaviour:

• impulsivity

• Self-harm

• Substance use

• Anger/violence

Splitting

• seeing another person in extremes, rather than holding a balanced view

Eg: “they are amazing” —> “they are terrible”

Also called

Idealisation—> devaluation

Histrionic personality disorder (HPD)

• excessive emotionality + attention seeking

Features:

• uncomfortable when not receiving attention

• May use appearance to gain attention

• Rapidly changing/shallow emotions

• Impressionistic speech

Narcissistic personality disorder (NPD)

• Is patterns involving grandiosity, entitlement, need for admiration and poor empathy

Features:

• fantasises or success

• Sees self as superior

• Exaggerated achievements

• Expects special treatments

Cluster C

• anxious

• Fearful

• Interpersonal anxiety

• Less research than cluster B

• Treatment generally used psychotherapy such as CBT

Avoidant personality disorder (AvPD)

• social inhibition due to feeling of inadequate and hypersensitivity to criticism and rejection

Features:

• extreme social withdrawal

• Feeling of inadequacy

• Very sensitive to criticism

• Reluctant to take risks

• Avoids situations because of embarrassment

Dependent personality disorder (DPD)

• excessive dependence on others

Features:

• difficulty making everyday decisions

• Needs others to take responsibility

• Uncomfortable alone

• Fears independence/separation

• Goes to great lengths to gain support

• Submissive

• Difficulty disabling due to fear of losing support

Obsessive-compulsive personality disorder (OCPD)

• patterns of maladaptive perfectionism, excessive orderliness, rigidity and very high standards

Features:

• workaholism

• Excessive focus on rules

• Inflexibility

• Emotional detachment

• Relationships may feel superficial

Problems with categorical DSM model

1. Diagnostic overlap

• people often meet criteria for multiple PDs

• Many historically received PDNOS

2. limited reliability

• clinicians may disagree about whether diagnosis is present

3. Arbitrary threshold

• diagnosis is present/absent

• poor description of severity

• One symptom can change diagnosis

• BPD can be diagnosed through 256 different combination or symptoms

4. Unstable over time

• diagnosis can change

• Significant change may occur over as little as 6 months

Categorical model

• asks does the person have the disorder: yes or no?

Dimensional model

• asks how sever is the personality dysfunction and what traits are present ?

DSM-5 Alternative model for personality disorders (AMPD)

• DSM-5 introduced the AMPD because of problems with the categorical system

AMPD has 2 main parts:

1. Level of personality functioning:

• looks at identity, self-direction, empathy and intimacy

severity: no impairments, some impairments, moderate, severe, extreme

2. Personality trait domains

   • has 5 main domains

Negative affectivity:

• tendency towards strong negative emotions eg: anxiety, emotional lability, hostility and depressively

Detachment:

• withdrawal from relationships/emotions

• Eg: social withdrawal, intimacy avoidance and Anhedonia

Antagonism:

• oppositional/interpersonally exploitative traits

• Eg: manipulation, deceit, grandiosity and hostility

Disinhibition:

• poor impulse control

• Eg: impulsivity, irresponsibility, distractibility and risk taking

Psychoticism:

• unusual thoughts/perceptions

• Eg: eccentricity, perceptual dysregulation and unusual beliefs

Biosocial theory

• Developed for BPD later applied more broadly to

• Main idea is personality pathology/emotion dysregulation develops through interactions between biological vulnerability and invalidating environments

Treatment of personality disorders

• Dialectical behaviour therapy

• Combines: CBT concepts, mindfulness, acceptance

Can include:

• individual therapy

• Group therapy

• Phone coaching

Goals:

• Improve distress tolerance

• Reduce suicidal behaviour

Schema therapy

Targets:

• long-standing

• Maladaptive beliefs

• Maladaptive thinking patterns

Metallisation- based therapy (MBT)

Mentalising

• Ability to understand your own thoughts/ feelings/ intentions

• Ability to understand other people’s thoughts/feelings/ intentions

Medication

• medication is not generally recommended as the main treatment for personality disorder itself