Personality Disorders

Question 1

what is a personality disorder?

Answer 1

this exists when the patient or others experiences suffering (distress or disability) as a result of the patient’s personality. It interferes negatively with how we live our lives.

Question 2

personality disorder classification?

Answer 2

Cluster A: odd and eccentric (prev. sensitive and suspicious?):
paranoid-suspicious, hold grudges, misinterpret interactions as hostile
schizoid-cold, solitary, rich fantasy life, not keen on relationships/praise or criticism
schizotypal (ICD-10:classified with schizophrenia)

Cluster B: dramatic, emotional and erratic:
histrionic-appear sociable and outgoing, but also self-centered and prone to short-lived enthusiasms, person recovers quickly from extreme displays of emotion. Sexual provocative behaviour without tender feelings. Self-deception and persist with elaborate lies long after others know truth.
borderline (emotionally unstable-impulsive)
narcissistic-not included in ICD-10. morbid self-admiration
antisocial (dissocial-ICD-10)

Cluster C:anxious and fearful:
avoidant (anxious)
obsessive-compulsive (anankastic)
dependent

Question 3

why are pts with dependent personalities at risk of developing depression?

Answer 3

dependent personlity= people are passive and unduly compliant with the wishes of others. If left to themselves, they have difficulty dealing with the demands and responsibilities of everyday life, which may lead to low mood and feelings of hopelessness which may be experienced as part of depression.

Question 4

what is cyclothymia?

Answer 4

this is now classified among mood disorders in both ICD-10 and DSM-IV
formerly cyclothymic personality disorder. Person’s mood alternates between gloomy and elated over periods of days to weeks. This instability can be part. disruptive to work and social relationships.

Question 5

what are the symptoms of a paranoid personality disorder (part of sensitive and suspicious personalities)?

Answer 5

people are sensitive and suspicious, they mistrust others and suspect their motives, and are prone to jealously.
they are touchy, irritable, argumentative, and stubborn.
some have a strong sense of self-importance and special ability, although they may feel their potential has been lessened by others letting them down or deceiving them.

Question 6

characteristics of emotionally unstable PD?

Answer 6

centered around impulsivity and poor self-control
intense but unstable relationships-tend to make them quickly but easily lose them
persistent feelings of boredom and emptiness, with uncertainty about personal identity and a fear of abandonment
unstable moods, unwarranted anger and emotional outbursts, low tolerance of stress-may hear voices or noises when stressed, difficult controlling emotions
transient psychotic symptoms
impulsive, engage in self-damaging behaviours e.g. reckless spending or gambling, reckless sex, chaotic eating, and substance abuse.
can feel paranoid or depressed
feel bad about yourself, may precipitate self-harm
can be recurrent threats or acts of self-harm
strong assoc. with self-harm and suicidal thinking

Question 7

characteristics of antisocial personalities e.g. dissocial personality disorder (ICD-10)?

Answer 7

tendency to violence
lack of guilt
lengthy forensic history, may begin with petty delinquent acts but escalate to callous, violent crime
disregard of feelings of others
can’t sustain close relationships, includ. intimate
family problems e.g. violence towards partner and children, or neglect of them, frequent separation and divorce
don’t learn from experience so persist with behaviours or behave worse despite negative social consequencies and legal penalties
callous acts, cruelty, inflict pain
impulsive behaviour, low tolerance of frustration, lack of consistent striving towards goals-may cause unstable work record.

assoc. with alcohol and substance misuse

Question 8

overall aetiology of personality disorders?

Answer 8

interaction of genetic factors and upbringing-exposure to abuse, family violence or parents who drink too much
MAINLY PSYCHOLOGICAL FACTORS e.g. relating to childhood abuse

Question 9

5 suggested causes of antisocial personality disorder?

Answer 9

genetic factors
childhood experience-separation from parents-parental disharmony before separation, separation itself or consequence of sep. e.g. upbringing in care, may be assoc. also physical or sexual abuse in childhood, violence in the family or alcoholism
injury to brain at birth
abnormal brain development
5-HT-low levels in brain assoc. with aggressive behaviour

Question 10

what should be assessed when managing a pt with a personality disorder?

Answer 10

identify positive features- can try to encourage and develop these
identify any co-morbid psychiatric disorder e.g. depression
assess any substance misuse
identify provoking factors
assess effects on family
assess risk, both to self and others

Question 11

drug tment of personality disorders?

Answer 11

antipsychotics at times of increased stress, may reduce depression and hostility in borderline personalities
lithium and other anticonvulsants may be used if affective instability or impulsivity e.g. borderline PD, and cyclothymia and dysthymia
SSRI fluoxetine may benefit mood in borderline PDs
anxiolytics e.g. BZDs should generally be avoided as although improve ST well-being, cause dependence and disinhibition.

Question 12

general aspects of PD management?

Answer 12

pt should take responsibility for their own actions, be willing to solve their own problems, agree modest aims to work to achieve over time, gain confidence and learn from mistakes.
build therapeutic relationship
agree a care plan
build on strengths
deal with/avoid provoking factors
reduce alcohol/illicit drug use
help family
drug therapy, not recommended by NICE, often co-morbid mental illness requiring drug tment
psychological tment e.g. self-help, CBT and therapeutic community methods of psychotherapy-espec. in antisocial PDs.

Mostly time and attachment

Question 13

how common are personality disorders?

Answer 13

at any given time, about 1 in 20 people (5%) will have a PD

Question 14

characteristics of a histrionic PD?

Answer 14

worry a lot about own appearance
self-centered
experience strong emotions which change quickly and don't last long
can be seductive
suggestible
crave new things and excitement
over-dramatise events

Question 15

characteristics of narcissistic PD?

Answer 15

have a strong sense of your own self-importance
dream of unlimited success, power and intellectual brilliance
crave attention from other people, but show few warm feelings in return
take advantage of other people
ask for favours that you do not then return

Question 16

what is treatment in a therapeutic community?

Answer 16

this is a place where people with long-standing emotional problems can go to (or sometimes stay) for several weeks or months. Most of the work is done in groups. People learn from getting on – or not getting on - with other people in the treatment group. It differs from ‘real life’ in that any disagreements or upsets happen in a safe place. People in treatment often have a lot of say over how the community runs. In the UK, it is more common now for this intensive treatment to be offered as a day programme, 5 days a week.

Question 17

when should CPA-the care programme approach, be used in patients with borderline PD?

Answer 17

people routinely or frequently in contact with more than 1 secondary care service. Of part. importance if difficulties in communication between the service user and healthcare professionals, or between healthcare professionals.

Question 18

characteristics of a schizotypal personality (classified with schizophrenia rather than PD in ICD-10)?

Answer 18

eccentric behaviour
odd ideas
difficulties with thinking
lack of emotion, or inappropriate emotional reactions
see or hear strange things
sometimes related to schizophrenia, the mental illness

Question 19

characteristics of anankastic PD?

Answer 19

worry and doubt a lot
perfectionist - always check things
rigid in what you do, stick to routines
cautious, preoccupied with detail
worry about doing the wrong thing
find it hard to adapt to new situations
often have high moral standards
judgemental
sensitive to criticism
can have obsessional thoughts and images (although these are not as bad as those in obsessive-compulsive disorder

Question 20

characteristics of anxious PD?

Answer 20

very anxious and tense
worry a lot
feel insecure and inferior
have to be liked and accepted
extremely sensitive to criticism

Question 21

characteristics of dependent PD?

Answer 21

passive
rely on others to make decisions for you
do what other people want you to do
find it hard to cope with daily chores
feel hopeless and incompetent
easily feel abandoned by others

Question 22

triggers in PD?

Answer 22

using a lot of drugs or alcohol
problems getting on with your family or partner
money problems
anxiety, depression or other mental health problems
important events
stressful situations
loss, such as death of a loved one

Question 23

what is mentalisation based therapy? (MBT)

Answer 23

combines group and individual therapy. form of psychodynamic psychotherapy. It aims to help you better understand yourself and others by being more aware of what’s going on in your own head and in the minds of others. It is helpful in borderline personality disorder-* pts lack theory of mind whereby they can work out what others are thinking and therefore predict what their behaviour is going to be. lacking this, if they feel -ve about themselves, they presume others think -vly of them, and can’t understand that their actions may cause upset or concern for others for that pt.

Question 24

use of psychological therapy in the treatment of emotionally unstable PD?

Answer 24

Consider twice-weekly psychotherapy sessions, although the frequency should be adapted to the
person’s needs and context of living.
Do not use brief psychological interventions (of less than 3 months’ duration) specifically for borderline personality disorder or for the individual symptoms of the disorder outside a service that has the characteristics outlined above.
For women with borderline personality disorder for whom reducing recurrent self-harm is a priority, consider a comprehensive dialectical behaviour therapy programme (DBT)-this uses a combination of cognitive and behavioural therapies, with some techniques from Zen Buddhism. It involves individual therapy and group therapy.
Use the CPA to clarify the roles of different services, professionals providing psychological treatment
and other healthcare professionals when providing psychological treatment as a specific intervention
in a person’s overall treatment and care.
Monitor the effect of treatment on a broad range of outcomes, including personal functioning,
drug and alcohol use, self-harm, depression and the symptoms of borderline personality disorder.

Question 25

role of drug tment in emotionally unstable PD?

Answer 25

often patients prescribed an array of medication despite NICE not recommending any drug treatment specifically for emotionally unstable PD. Query as to whether medication has any medically significant role in stabilising a pt.
NICE only recommends drug tment in overall tment of comorbid conditions and that can consider cautiously short-term use of sedative medication as part of the overall treatment plan in a crisis. Agree the duration of treatment with them, but it should be no longer than 1 week.
r/v drug tment in those with no diagnosed comorbid physcial or mental health conditions and aim to reduce and stop unnecessary drug tment.

Question 26

Key qns in history when talking to a pt with suspected PD?

Answer 26

How do you view yourself now? How would you describe yourself? How do you view yourself when you are well?
How would other people describe you?
Risk assessment- do you ever feel life is not worth living. Any thoughts about ending you life. Any plans? Any acts? Protective factors?
Any thoughts about confronting others/harming others?
Past psych history-self harm and suicide attempts, eating disorders, OCD
Personal history-childhood abuse-sorry I have to ask this next qn but sometimes people who share your experiences have suffered some physical, emotional or sexual abuse, has this happened to you?

Question 27

Aetiology of borderline PD

Answer 27

Biological vulnerability- impulsiveness and affective instability
Psychological-trauma, early sep from or loss of parents, or abnormal parenting
Social- anything stopping the buffering of psychological problems by extra familial influences. Rapid social change and loss of social structures. Changes in social structures with rapid change in society may be responsible for increasing prevalence.

Question 28

role of a therapeutic community in the treatment of PD?

Answer 28

aim for patients to form attachments with other group members, and to then use these attachments to manage their emotions, rather than resorting to self-harm.
should explore previous trauma and -ve experiences which they may have not shared before. listening to others share similar experiences helps the pt to aknowledge that this experience was extremely difficult and damaging so helps with the pt’s understanding as to why they feel the way that they do.