L6 NEUROCLIN II: Complex Emotional and Relational Needs (CERN/ Personality Disorders)

To understand the inherent limitations of trying to identify different personality disorders To understand the DSM-5 diagnoses and clusters To understand the high reported prevalence and comorbidity of personality disorders To understand factors that might cause personality disorders neurological, environmental To understand current evidence regarding effective treatment

why does experience of CERN matter?

• need to understand diversity of experience across individuals → beware of stereotypes

• need to get away from stigmatising representations, e.g.: dangerous, wilful, self-obsessed

• remember prevalence of PDs high

experience of a personality disorder- drawings from a former student + testimony

• emotional and interpersonal sensitivity

• small event know not big deal in rational mind → extremely emotional and dysregulated reaction

• interpersonal relationships and lack of trust → born out of past experiences, maintained by current behaviours

what can CERN diagnosis experience be like?

paradoxical

• being diagnosed can feel like 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 clarity about diagnosis and treatment can be frustrating too

how are personality disorders organised

clusters: a, b, c

cluster a

• paranoid personality disorder

• schizoid personality disorder

• schizotypal personality disorder

cluster b

• antisocial personality disorder

• histrionic personality disorder

• narcissistic personality disorder

• borderline personality disorder

cluster c

• avoidant personality disorder

• obsessive-compulsive personality disorder

• dependent personality disorder

conceptual issues

• defining personality

• personality problems in context

• sociopolitical perspectives

defining personality

our tendency towards patterns of behaviour, emotion, cognition, and interaction that show through regardless of the situation we are in

i.e.- trait rather than state

label if these are trait vs state:

1. Anxious before an exam

2. Anxious all the time

3. Wanting to do an important job well

4. Wanting to do everything perfectly

1. state

2. trait

3. state

4. trait

defining personality- positive and negative

personality can be smth that has pos implications if fits demands of world

negative influence if it does not fit the world around us

categories vs dimensions

• are pds just extremes on those dimensions?

• big five- openness, extraversion, etc- defined in dimensional way, high or low

• are PDs just extremes on those dimensions, if so how to establish cut off?

• are PDs distinct clumps at either extreme? introversion or extroversion

• or distinct clump at just one end of dimension? e.g. might see extreme neuroticism as a problem, but not extreme stability

→ efforts to define PDs use to assume simple categories (DSM-IV) → now more mixture of two approaches

DSM-IV definition of a PD

• 1994

• enduring pattern of inner experience and behaviour that deviates markedly from expectations of the individual’s culture

- very vague definition

- could encompass unusual belief systems e..g flat earthers, that might have been quite normal at some points in history

dsm 5 taskforce: changing definition of a PD

• lot more complex than dsm iv

• lots of plans for change, based on problems with dsm iv

• lots of debate

• still have same categories (clusters) somewhat

DSM-V definition of a PD

• 2013

• the essential features of a PD are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits

diagnosis of PD requires the following criteria (DSM5, 2013)

1. significant impairments in self (identity or self direction) and interpersonal (empathy or intimacy) functioning

2. one or more pathological personality trait domains or trait facets

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

4. 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

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

problems w dsm 5 definition

• subjective: significant, normative

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

• 
  

a semi difference between dsm iv and dsm v

• dsm iv had 10 PDs

• at end of long set of arguments, dsm v has same 10 diagnoses

• but, dsm-5 included research proposals to allow for future potential change in diagnosis

dsm-5 included research proposals to allow for future potential change in diagnosis, regarding…

• level of personality functioning

• personality trait domains and facets

• personality disorder types

summary of changes to dsm4→dsm5

• 5 maintains diagnostic criteria from 4

• 5 continues to define personality disorders on a categorical basis, like 4

• but it discusses a dimensional approach to the diagnosis of PDs and encourages further research on these

key issues in researching a diagnosis

• long term presentations

• independent of biological factors- e.g. drug use, starvation, actual threat

• diagnoses can not be made at a single clinical meeting

• → yet each of these gets ignored by clinicians, so cynicism reasonable

• do not usually diagnose in childhood/adolescence, but debate

cluster a- what

• odd/ eccentric

• personality disorders with some schizophrenia-like features

• lacking active symptoms like hallucinations

1. paranoid

2. schizoid

3. schizotypal

paranoid PD

• pattern of distrust and suspiciousness

• resistant to challenge by others

schizoid PD

• pattern of separation from social rls

• limited emotional expression and experience

schizotypal PD

• pattern of eccentric ideas, magical thinking

cluster b- what?

• dramatic/ erratic

• personality disorders characterised by impulsive/erratic and/or self-centred behaviours, emotions, and thinking

• antisocial PD

• borderline PD

• narcissistic PD

• histrionic PD

antisocial PD

• pattern of disregard of other’s rights

• strong links to conduct disorders and criminality

• selfishness and lack of empathy

borderline PD

• in ICD- EUPD

• pattern of unstable rls, mood, and behaviour

• efforts to control emotion (e.g. drink; self-harm) and avoid rejection

narcissistic PD

• pattern of overestimation of own abilities and accomplishments

• pervasive need for admiration, while not caring abt others

• anger when not recognised for their specialness

• fragility of self-esteem

histrionic PD

• attention-seeking, need to be the centre of attention

• dramatic behaviour, undue emotional expression

• exaggerated presentation

cluster c- what?

• anxious/fearful

• personality disorders characterised by anxiety that is lifelong

• → not related to any trigger

• avoidant PD

• dependent PD

• obsessive-compulsive PD

avoidant PD

• pattern of social avoidance

• inadequacy, and sensitivity to others’ views of them

dependent PD

• pattern of dependence on others’ care

• submissive, clinging, seek others’ approval/support

obsessive-compulsive PD

• excessive perfectionism (focus on doing the task: forget the goal)

• need for order, patterns, and control

summary of diagnostic clusters

• three broad clusters with ten diagnoses: odd/eccentric, dramatic/erratic, and anxious/fearful

• big overlap across clusters and diagnoses- it is rare for ppl to only meet one personality disorder criteria → if one meets criteria for one PD, on average one meets the criteria for 4.5

prevalence of PDs

• 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 cluster b+c; men cluster a)

• most reliable studies suggest a rate 10-15% for all PDs. most common: borderline, schizotypal, antisocial, obsessive-compulsive

• figures vary hugely- beware

comorbidity

• high rate of cooccurring PDs → not so distinct after all

• high rate of cooccurrance:

1. depression

2. substance misuse

3. panic disorder

4. PTSD

5. social phobia

6. eating disorders

• afraid of abandonment (BPD) → dependent PD

is a personality disorder for life?

old viewpoint:

• yes, but the symptoms tend to fade after 40 years of age

• untreatable

current evidence:

• no, as a large number of cases are not diagnosable a few years later

• see Zanarini et al., (2013) for an example of such evidence: Disturbed cognitions are common in patients with borderline personality disorder and are distinguishing for the disorder. They also decline substantially over time but remain a problem, particularly those of a nonpsychotic nature.

• treatment for some PDs effective in some cases

aetiology

study + causation of disease

framework for considering aetiology

1. biological/neurological factors

2. personality disorder → specific personality disorders

3. environmental factors

factors underpinning cluster A PDs- general

biological/neurological factors:

• genetics

• enlarged ventricles

• enhanced startle response

• cognitive deficits

→ lack of link to specific PDs

environmental factors:

• parental relationships

• rejection

• abuse

factors underpinning cluster B PD: antisocial

biological/neurological factors:

• childhood conduct disorder

• genetics

• low anxiety

• weak fear condition (fearful event- worse at learning to respond in fearful way)

environmental factors:

• modelling (schema- antisocial- angry and impulsive child)

factors underpinning cluster B PD: borderline

biological/neurological factors:

• genetics

• limbic system dysfunction

environmental factors:

• trauma/emotional invalidation

factors underpinning cluster B PD: narcissistic

environmental factors:

• doting parents ?

factors underpinning cluster B PDs- general

environmental factors:

• experience driving schema development

schema → antisocial → angry and impulsive child

evidence for for disorders - treatment

• limited evidence for most disorders

• a range of clinical suggestions about such treatment - all evidence is for psychological intervention, rather than neurological

• Beck et al (2016) provide a range of clinical guidance based on cognitive behaviour therapy

  Some evidence for other, more integrative therapies: Cognitive analytic therapy (Ryle); Mentalisation-based treatment (Bateman)

psychological therapies for PDs

• CBT for PDs- adapts Beck’s CBT approach for depression

• Schema Therapy (Young; Artntz)- schemas and schema modes- integrative Cognitive Analytic Therapy (Ryle) - reciprocal roles in formulation

• Mentalisation-based treatment (Bateman and Fonagy)- teaching to mentalise- putting youself in someone else’s shoes - improve awareness of self-states

• Generalist approach: structured clinical management (Bateman and Fonagy)

psychotherapy for BPD- Cristeau et al., (2017)

• 33 studies

• N = 2256 Ps

• efficacy of psychotherapies for borderline personality disorder

• a systematic review and meta analyses

• importance- BPD is a debilitating condition, but several psychotherapies are considered effective

• objective- conduct an updated systematic review and meta-analysis of randomised clinical trials to assess the effiacy of psychotherapies for BPD populations

• data sources - search teams were borderline personality and randomised trials in pubmed, psycinfo, etc

• study selection - included RCT clinical trials of adults w diagnosed BPD randomised to psychotherapy exclusively or to control intervention. study selection differentiated stand-alone design

→ some evidence for CBT for psychotherapy and for mentalisation based treatment

Oud et al., (2019)

• austrailian and new zea journal of psych

• 20 studies

• 1375 Ps

• some evidence trials were moderate quality

• some evidence for BPD and DBT and schematherapy

• the actual no of trials- Ps quite low, biggest one was DBT trial

• Linehan trials that influence the analysis guidelines are relatively small

best treatment evidence

• best evidence-based treatment seems to be re numbers + schema therapy (Young et al., 1990;2003)

• integrated model → cognitive techniques, gestalt, behavioural techniques, attachment theory, object relations

• treatment involves three ways of changing schemas: cog techniques, behavioural techniques, and experimental techniques incl imagery work and imagery rescripting to work with past negative events and and w the therapist to try to generate a new script and try and change the meaning of the negative experience

• three ways of changing schemas:

1. behavioural- doing

2. feeling - experimental

3. thinking - cognitive

focus on:

• therapeutic rls (rapport)

• using mental imagery techniques

• using Chairwork in therapy

→ first trial 2006, Geson, AJP

→ adapted approach, trial by Bali, 2014- for cluster C

→ combined group and individual therapy trial, using approach

schema therapy review taylor et al., (2017)

• question- does schema therapy change schemas and symptoms? a systematic review across mh disorders

• does it change beliefs, mechanism trying to target, and symptoms

• 40ish studies

• most said wld measure both, only abt 12 reported results for schemas and symptoms

• strongest evidence was for BPD w a few trials in EDs, PTSD lower areas

Arntz et al., (2022)

• largest trial in CERN/PD

• JAMA psych

• RCT: Effectiveness of predominantly group schema therapy and combined individual and group schema therapy for BPD

• 495 ppl, 15 mh centres in 5 countries

• 495 Ps randomised

• 246- treatment as usual (TAU)

• 125- predominantly group schema therapy (PGST)

• 124- combined individual and group schema therapy (IGST)

findings:

• the IGST group had signifcantly reduced BPDSI score compared with TAU and PGST groups

• BPDSI score did not signficantly differ in PGST and TAU groups

primary outcome:

• change in BPDSI (borderline personality disorder severity index) score at 3 y from baseline

• score range 0-90, >20 clear bpd, <15 as recovery criterion

predominantly group schema therapy, ppl come together in a group 2x a week and the schema therapy and approach is taught + idea is group offers peer support

→ power to try to catalyse change so as ppl get better they see others improve too and sharing experiences can be powerfu

other thing they tested was 1-1 sessions + group sessions

• 1.5 treatment each

compared to best practice- DBT, mentalisation based therapy, etc

findings- best for combined group, individual and group had biggest reduction on BPDSI measure

Crawford et al., (2016)

• Brief Psychological Support

• brief individual psychological intervention for ppl with probable intervention for ppl w probable pd: a multicentre, researcher-masked, randomised, controlled superiority trial in england

• N = 336

• brief 10 session approach

• no effect on social functioning, no cost effectiveness

• too short- discharge was like “falling off a cliff edge”

what can be taken from Crawford et al., (2016)

• problems r longer term bc it can take ppl a while to develop a rapport and to trust

• shoet brief therapies- not much value testing more of them bc not much impact and they wld like to talk

where else is there good treatment evidence?

• DBT (Linehan, 1993)- Cognitive behavioural treatment of BPD (but little attention to thoughts in manual)

• trials good evidence, numbers quite small

• it is a behavioural based programme

• managing impulsive behaviours and thought processes in BPD

• elements of contingency management, operant conditioning, mindfulness, etc

• v resource intensive

• designed to manage symptoms effectively, but not to remove cognitions, main outcome measure suicidality

• elements of contingency management, what to do if situations come up, mindfulness as a strategy, resource intensive as well - involves group and individual , out of hours options to phone call if distressed etc

• 2009- no difference adding telephone support or not so dont use now unless ppl really want to

DBT + BPD

• reduces suicide risk in individuals w BPD

• one study- after one year of treatment, 75% no longer met criteria

• emotional dysregulation, DBT employs opposite action skill

• takes practice

• 
  

which has better outcomes- ST or DBT? study

current ongoing netherlands study- Bufus trial

comparing DBT to ST

• towards optional treatment selection for BPD patients (BOOTS): a study protocol for a mutlicenter randomised clinical trial comparing ST and DBT

conclusions

•Personality disorders are still not well defined overall

•The diagnoses themselves are still being refined

•There is more a movement within services to be less diagnostically focused and use CERN language, as less stigmatising

•The field is very much focused on borderline personality disorder

–more common than all the others put together

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

•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