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Personality disorders

PD: INTRODUCTION

Principles

 Personality = characteristic behavioural, emotional, and cognitive attributes of individual. Often


stable and usually apparent mid-adolescence.
 At times of stress, they can decompensate.
 PD = a severe disturbance in characterological constitution and behavioural tendencies of the
individual, usually involving several areas of personality, and nearly always associated w
considerable personal and social disruption.
 These people come into contact with doctors because they are concerned about themselves, or
more commonly because others are affected/concerned by their actions.
 The interaction between personality (disorder) and psych disorder is important.
o Predisposing (PD)  psych disorders (e.g. anxious PD and anxiety disorder)
o PD can co-exist with psych disorders and this worsens prognosis (e.g. BPD and bipolar)
o PD can be mistaken (DDx) for another condition (e.g. paranoid PD vs. delusional
disorder; or BPD vs. bipolar)
o Personality can be affected dimensionally by psych conditions (e.g. personality
deterioration in chronic schizo)
o Pathoplastic effect: modify the clinical features even if no direct causal role (e.g.
anankastic traits = obsessive compulsive traits exaggerated by depression)
 Problems
o PD isn’t a “disease” – do not medicalise. Term is also pejorative.
o Dx is unreliable. No clear distinction between PD and psych disorders
o One man’s PD is another’s virtue.

Diagnosis

 Based on deviation of > 1 more aspects of personality. Common to all PD are:


o Personality attributes cause distress or dysfunction to patient (most PD, except
antisocial – they feel fine) or those around
o Dysfunction in ALL context (extreme deviation from norm)
o Pervasive, stable, and recognisable characteristic since late adolescence
 Important for corroborative history.
o Deviation cannot be explained by psych conditions or organic disease
 Specific conditions are Dx according to the domains most affected (most prominent)

Classification

 Dimensional  quantifies how much absolute Sx deviate from norm


 Categorical  overlap is common
 Dimensional + categorical approach to allow recording of traits above threshold…
 ICD-10 has 10 types, while DSM-5 have only 3 clusters (simpler).
 Personality traits are, in reality, dimensional (they exist on a continuum and merge into each
other) – consequently, any classification that limits presence/absence of a trait is problematic.

Epidemiology and aetiology

 2-15% (UK = 4.4%).


o Community: 10% (2-3% dissocial), GP: 20%, psych OPD = 30%, psych I/P = 40%
o Overall M> W
Personality disorders

 MC are: obsessive-compulsive, avoidant, schizoid, and borderline


 Often co-exist with other psych conditions poor lifestyle  ; psych pt: 50%; substance
misuse or eating disorder: 70%
 Prisoners: 50% men, 30% women
 Very little known about aetiology.
o Patterns of childhood behaviour predict personality and PD (weakly). There is early
origins and stability in personality.
o Upbringing have major impact. Adverse experiences are important RF e.g. NAI.
o Psychodynamic
 Freud hypothesis – failure to negotiate through stages of psychosexual
development (stuck)
 Objects relation theory = as infant grows older they can develop a spectrum on
their world view. If disrupted  dichotomous black/white, good/bad picture 
seen in BPD = splitting.
 Attachment theory = from birth, attached to maternal figure (clingy)  if this
attachment is disrupted e.g. usually in abused patient  PD
o Moderate genetic contribution (35-50% heritability for neuroticism and extraversion)
and to some PD (anankastic and dissocial types).
 MZ twins reared apart more alike on personality (v.s. reared together –
conflicting similar personality = try to be different)
 Sumi’s work on rhesus monkeys (genetic aggressiveness is restrained when
reared by gentle mothers)
o Aggressive behaviour in ch anomalies = supermales (XYY), and are more common in men
o Neurological – EEG: cortical immaturity; lower hippocampal volume in F w BPD
(?prolonged high cortisol level); loss of hemispheric integration in abused boys.

Management

 Depends on the patient’s readiness to engage (c.f. dependent) and resources available.
 Help person avoid situations that cause problems e.g. intoxication or confrontations
 MHA now  just need to state “appropriate treatment is available” to Section.
 Help them find lifestyles that maximises strength, minimises personality difficulties
 Be consistent w managing crisis pt. Admissions RARELY helpful and reinforce behaviour.
Consistent, community-based approach BETTER.
 Inpatient – where?
o General psych wards (acute wards) – risk of dependence, risk of behaviour regression
o Therapeutic communities (Henderson and Cassel Hospitals)
o Specialist secure services
 Careful DDx from mood disorders and psychosis. Bear in mind onset and course
 Written care plan; ensure good communication w agencies to avoid “splitting” (disagreements
between staff induced by patient – people w these personality traits induce range of strong
feelings)
 Respond to threats consistently and do not reinforce manipulative behaviours (e.g. splitting)
 Transparency and clear boundaries agreed about unacceptable behaviour and nature of care
provided. Be clear of what you think, must use label/Dx, risk, Tx, admission etc. Important for
such patients who do not learn clear boundaries (e.g. sexually abused by parents – don’t know
right from wrong R/S)
 Reliability = if you make an appointment, you must keep your word.
Personality disorders

 Non-judgemental person-cantered care + promote choice + develop optimistic trusting R/S +


manage endings and transitions (NICE 2008)
 Psychotherapeutic assessment considered
 Tx co-existing psych disorders and substance misuse.
 Psychotherapy is main-stay Tx
o For borderline personality disorder  intensive and specific psychotherapy called DBT
(dialectical behaviour therapy) is effective. This usually involves a group + mix of IPT,
addiction therapy, CBT etc. to try to address issues that stop them from functioning.
o CBT – challenge behaviour to break cycle
o Supportive psychotherapy – an ear to listen (attachment theory); try to develop capacity
for +ve attachement
o Group (e.g. therapeutic communities) – very powerful: since someone from the group
who can challenge them and tell their behaviour is BS, rather than coming from
psychologist. Therapeutic communities = learn to respect each other.
o Family therapy – if pt have dysfunctional family + usually for i/p to discharge (they have
to work out RS with disordered family, accept it, so as to minimise harm.
o Individual psychoanalytic therapy (rarely used, Freud theory)
 No licensed medications (often in practice, trial off-license to reduce distress and help w Sx).
o AD – only if co-existent depression
o Anti-Q – low-dose clozapine may help w BPD by reducing arousal and impulsivity
o Mood stabilisers e.g. carba – can help w mood swings, impulsivity, anger control (meh)
o BZDs: avoid (can paradoxically cause disinhibition, rage reaction, and risk of
dependence); only if ST use.
o Person w BPD often have > 2 drug charts, usually meds for physical health

Prognosis

 Lifelong condition and stable = bad prognosis. High M+M.


 But fluctuations do occur esp. middle age. (“Matures with age”).
 PD associated with increased mortality rate and worsens outcome of comorbid psych
conditions. Increased risk of violence if comorbid with psychosis.
 Increased suicide rates – mood instability/ impulsive/ alienation/ aggression/ co-morbid
substance misuse.
 Response to Axis I treatment worse if co-morbid PD.
 Distinguish: mature PD (= cluster A) which are first recognised in late adolescence that remain
stable or worsen w age, and immature PD (= clusters B and C) which have onset in childhood and
mellows with age.
o LT prognosis for BPD rather ok  75% no longer meet criteria over 15 years. Good
prognostic factor = stable environment, low impulsivity, psychological attitude, good
motivation.

SPECIFIC CONDITIONS

Cluster A (eccentric) personality disorder (“mad”)

 Aloof, suspicious, solitary  they by nature tend to avoid services due to their suspiciousness
and persecutory belief.
Personality disorders

 Key issues are (1) to distinguish them from psychosis esp. chronic delusional disorder; (2) to
decide if significant harm to themselves or others; (3) to decide if Tx should be given such as
low-dose antipsychotics (w consent and compliance may be poor) or social interventions (but
isolation rarely perceived by them as problem)
o Psychotherapy is C/I because harmful and ineffective…
 Paranoid
o Suspicion and distrust of others w conspiracy
o Sensitivity of criticism + setbacks, defensive and combative, bear grudges
o Self-importance
o Paranoid PD is a RF for psychosis.
 Schizoid
o Looks very similar to autism
o Emotionally cold and detached, introspective, social isolation (lack close friends)
o Lack joie de vivre (little enjoyment of activities, little interest in sex, prefer solitary
activities), preoccupation w fantasy, insensitive to norms and conventions
 Schizotypal
o

Cluster B (dramatic) personality disorder (“Bad”)

 Overlap between individual disorders in this cluster.


 “Emotionally unstable” PD
o Impulsive PD
 Tendency to act impulsively w/o consideration of consequences
 Tends to quarrel w others esp when impulsive acts thwarted or criticised
 Liable to outbursts of anger w inability to control behavioural explosions
 Difficult to maintain any course of action that offer no immediate reward
 Unstable and capricious mood
o Borderline (BPD) = tends to be young WOMEN
 Impulsivity (NEED at least 3 of the impulsive criteria) PLUS
 Disturbance about self-image, aims, and internal preferences
 Liable to be involve in intense/unstable transient R/S  emotional crises
that is recurrent OD/cutting
 Recurrent threats or acts of DSH to get admitted or medicated (dramatic
plea for help)
 Excessive efforts to avoid abandonment
 Chronic feeling of emptiness
 Also: variable, intense mood + stress-related psychotic-like Sx (“quasi-psychotic”
or depressive or suicidal ideation).
 Seems to be OOP to objective impression.
 Associations (not strong or specific): childhood sexual abuse, PTSD, bulimia
nervosa.
 ?Aetiology: DA and 5-HT frontal lobe dysregulation
 Dissocial (=psychopathic, antisocial) = tends to be young MEN (w untreated CD)
o Callous disregard for others feelings, cannot maintain/unstable + transient R/S
o Low frustration threshold, irritable + impulsive
o Failure to learn from experience, failure to accept responsibility, lack guilt. Blames
others and rationalises instead.
Personality disorders

o Grossly irresponsible for social norms, low threshold for violence


o Worsened by drugs and EtOH.
o ?Aetiology: temporal lobe EEG abnormalities, minimal brain dysfunction from minor
brain injury or delayed maturation, and other genetic, psych, social factors. Thought to
involve dysregulation of frontal lobe activity by DA and 5-HT (just like BPD).
o In practice, most rarely treat as no intervention shown to be effective. Avoid admission
(disrupts other patients). Main goal is to R/O other Dx that can be Tx.
 Forensic psych have some expertise in assessing and managing disorder.
o Mental Health Act sometimes use to admit patient w DPD if they commit serious crime.
Effectiveness of Tx is poor (antipsychotics or psychotherapy) still… instead offer
programmes within criminal justice system.
 Histrionic
o Exaggerated, theatrical display of emotion (attention-seeking)
o Vain, suggestible, crushes + fads; inapt seductiveness
o Shallow, labile mood
o Continually seek to be centre of attention; egocentric and self-indulgent – long for
appreciation by manipulation and easily hurt if not achieved.
 Narcissistic
o Grandiose self-importance, arrogant, expects praise and respect
o Exaggerates achievements and abilities
o Exploits others

Cluster C (anxious) personality disorder (“sad”)

 This cluster rarely pt clinically (so very little knowledge on management). If it does, set realistic
goals, enhance self-esteem, and avoid escalating contact that simply fosters dependency.
 Dx is made by someone who presents with DD or anxiety disorder. Cluster C is RF for both.
 Anankastic (= obsessional)
o Excessive orderliness, preoccupation with detail, perfectionism
o Excess doubt and caution
o Obsessions here are egosyntonic (= not intrusive; e.g. cleanliness is Godliness, everyone
else is filthy)
 V.s. OCD = egodystonic (= intrusive; I have to wash my hands 20X or I will die)
o Excessive productivity to the point that it affects social RS
o Inflexible, pedantic, dogmatic, stubborn, humourless
 Anxious (= avoidant)
o Persistent tense and apprehensive feelings; believe they are socially inept or inferior
o Avoid personal contact, unwilling to get involve w people they like
o Restriction of lifestyle and social or occupational activities
o Excessive fear of criticism and rejection
 Dependent
o Encourages others to make decisions, excessive need to be taken care of
o Subordinate one’s own needs to comply w others; unwilling to negotiate reasonably
o Feels uncomfortable or exaggerated anxiety if left alone; preoccupied w fears of being
left alone
o Limited capacity to make day-to-day decisions
o May overlap w BPD.
o S/E of admitting them = they become dependent on you and the institutin

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