mrcpsych general adult module personality disorders · 2018. 11. 28. · models of personality •...

MRCPsych General Adult Module

Personality Disorders

GA Module: Personality Disorders

Aims and Objectives

• Aims

– The overall aim is to give an overview of personality disorders

• Objectives:

– By the end of the sessions, trainees should have:

An understanding of personality disorders (aetiology, epidemiology,

diagnostic criteria, classification, psychopathology, clinical

presentation, assessment, course and prognosis) and their

management (pharmacological, psychological, social).


To achieve this

• Case Presentation

• Journal Club

• 555 Presentation

• Expert-Led Session

• MCQs

• Please sign the register and complete the feedback


Expert Led Session

Personality Disorders: an

overview

Contents• What is personality?

• What constitutes a personality disorder?

• Models of personality

• Aetiological theories

• Classification

• Epidemiology

• Features of personality disorders

• Assessment of personality disorders

• Management / Treatment

• Course & Prognosis

• Personality Disorder and the amended MHA

• References and Further reading

• MCQs

What is personality?

The ingrained patterns of thought, feeling and behaviour

characterizing an individual’s unique lifestyle and mode

of adaptation, and resulting from constitutional factors,

development and social experience.

WHO Lexicon of Psychiatric and Mental Health Terms

What constitutes a personality disorder?

ICD-10

‘…. comprise deeply ingrained and enduring behaviour patterns, manifesting

themselves as inflexible responses to a broad range of personal and social

situations. They represent either extreme or significant deviations from the way the

average individual in a given culture perceives, thinks, feels, and particularly relates

to others. Such behaviour patterns tend to be stable and to encompass multiple

domains of behaviour and psychological functioning. They are frequently, but not

always, associated with various degrees of subjective distress and problems in social

functioning and performance.’

DSM-IV

‘an enduring pattern of inner experience and behaviour that deviates markedly from

the expectations of the individual’s culture’. The pattern is inflexible and pervasive

across broad range of situations, has an early onset, is stable and leads to significant

distress or impairment.

Models of personality

• Categorical: ICD-10 and DSM-IV – personality disorders are

defined as discrete discontinuous categories.

• ‘Experimental’ approach: it looks for general laws on personality

and establishes causal relations between personality variables.

• Psychoanalytical approach: the psychology of the Ego and

description of defence mechanisms, both normal and

pathological.

• The correlational approach: it assumes that structure of

personality is common to all individuals but it differs in different

combinations of traits.

• Dimensional models: traits are distributed among dimensions

which make it possible to classify individuals according to their

personality e.g. the five-factor model.

Aetiological theories

Paranoid PD

o Deficits in cortical dopamine poor conceptual organization

suspiciousness and distorted interpretation.

o Deficits arising in early developmental stages mistrust and lack of

confidence

o Lack of protective care and affective support in childhood facilitates

development of paranoid features

Schizoid PD

o Familial association may exist between schizotypal PD and

Schizophrenia


Antisocial PD – complex and multi-factorial

o Twin, adoption and family studies have demonstrated that genetic

factors strongly contribute.

o Longitudinal studies – a ‘developmental’ relationship between antisocial

behaviour and childhood hyperactivity.

o Indices of reduced brain serotonin activity such as low levels of

serotonin metabolite 5-hydroxyindole-acetic acid in CSF and low platelet

MAO activity aggression

o Parental deprivation, inconsistent maternal care, family violence and

severe childhood physical abuse are strong predictors of development

of ASPD.

o Social disintegration and chronic criminality, reflect a normal adaptation

to an abnormal social environment.

o The multifactorial origin and its early onset and manifestations indicate

that it cannot be attributed to cultural conflicts and social determinants.


Borderline PD (EUPD) – complex and multi-factorial

o Family studies – parents with BPD have greater incidence of mood disorders but not

schizophrenia; high family incidence of ASPD and alcoholism.

o Reduced levels of serotonin metabolite 5-hydroxyindole-acetic acid in CSF and

blunted prolactin response to serotonin agonists association with impulsive

aggression.

o HPA axis dysfunction suggesting increased feedback inhibition and increased

sensitivity of some areas of amygdala have been reported.

o BPD may be associated with abnormal emotional reactivity in the limbic areas and

insufficient regulatory function at the cingulate and prefrontal areas of the brain.

o Childhood trauma could play a crucial role – higher incidence of sexual/physical

abuse and neglect.

o Deficiencies in self and identity development linked to attachment failures with

parental figures in early developmental phases.

o Onset of BPD needs the interaction of predisposing factors, both biological and

developmental, and environmental precipitants.


Avoidant PD

o Children who are belittled, criticized or rejected by parents have

decreased self-esteem resulting in social avoidance.

o Biological mechanisms of anxiety disorders and social phobias have a

role.

o Hypersensitivity of brain areas involved in the separation-anxiety

response and overactivity of serotonin limbic neuronal circuits may

underlie these traits.

Genetic Networks

Environment

[Parents, Education,

Economic, Siblings]

BRAIN

Temperamental traits

[Fearfulness, Novelty-seeking, aggressiveness, empathy, altruism,

extraversion, persistence, conservatism, religiosity, resilience, etc.]

Genes, Environment & Personality

Harner D, Science, 2004

Classification

• DSM-III divided 11 PDs in three clusters:

Cluster A ‘Odd’ or ‘eccentric’

Paranoid

Schizoid

Schizotypal

Cluster B ‘Dramatic’ or ‘erratic’

Histrionic

Narcissistic

Antisocial

Borderline

Cluster C ‘Anxious’

Avoidant

Dependent

Obsessive-compulsive

Passive-aggressive

Classification

ICD-10 DSM – IV

Paranoid Paranoid

Schizoid Schizoid

Dissocial Antisocial

Emotionally Unstable

- Impulsive

- Borderline

Borderline

Histrionic Histrionic

Anankastic Obsessive-compulsive

Anxious avoidant Avoidant

Dependent Dependent

Other Schizotypal

Narcissistic

Other

NB- Both have low Discriminant validity

i.e. it is the rule,

rather than the exception,

that multiple personality diagnoses

will be made.

Epidemiology

• Personality disorders are common conditions (Coid 2006a) that, by definition, run a prolonged course and

are often associated with poor outcome (Stone 1993; Skodol 2005) and increased mortality (Harris 1998).

• In a general population study of British households, Coid et al (2006a) found a weighted prevalence of 4.4%

for a diagnosis of any personality disorder.

• In a non-clinical sample, all personality disorders, except schizotypal, were more prevalent in men than

women (Coid 2006a); however, in clinical samples, women with borderline personality disorder may be more

likely to seek treatment (Tyrer 2000). There is an increased prevalence of personality disorder in people who

are unemployed, divorced or separated, living in urban areas and from lower socioeconomic groups (Coid

2006a).

• There are strong associations between cluster B personality disorders and psychotic, affective and anxiety

disorders. There is also a strong association between cluster C personality disorders and affective and

anxiety disorders (Coid 2006a). Both psychiatric in- and out-patients have a high prevalence of personality

disorder – estimated to be of the order of 50%.

• It is important that where personality disorder occurs in conjunction with mental illness this is recognized, as

it may require adaptation of either the treatment, or the way in which this is delivered (Tyrer 2003; Dowsett

2007).

Banerjee et al (2009) APT

http://apt.rcpsych.org/content/15/5/389#ref-10











Prevalence( from epidemiological surveys)

PD Category No. of

Studies

Median prevalence rate (%)

Paranoid 13 1.6

Schizoid 13 0.8

Schizotypal 13 0.7

Antisocial 24 1.5

Borderline 15 1.6

Histrionic 12 1.8

Narcissistic 10 0.2

Obsessive-compulsive 13 2.0

Anxious –avoidant 13 1.3

Dependent 12 0.9

Passive-aggressive 8 1.7

New Oxford Textbook of Psychiatry, 2nd Ed

Features of Personality Disorders

Paranoid PD Schizoid PD

Suspicious Emotionally cold

Mistrustful Detached

Jealous Aloof

Sensitive Lacking enjoyment

Resentful Introspective

Bears grudges

Self-importance

Shorter Oxford Textbook of Psychiatry, 6th Ed


Emotionally Unstable PD, borderline type (ICD-

10)

Borderline PD (DSM-IV)

Disturbed /uncertain self-image Identity disturbance

Intense and unstable relationships Intense and unstable relationships

Efforts to avoid abandonment Efforts to avoid abandonment

Recurrent threats or acts of self-harm Recurrent suicidal behaviour

Chronic feelings of emptiness Chronic feelings of emptiness

- Transient stress-related paranoid ideation

Impulsive type -

Impulsive Impulsive

Liability to anger and violence Difficulty controlling anger

Unstable capricious mood Affective instability

Quarrelsome, Difficulty maintaining a course of

action

-



Dissocial PD Histrionic PD Narcissistic PD`

Callous Self-dramatization Grandiose sense of self-

importance

Arrogant and haughty

Transient relationship Suggestibility Fantasizes about unlimited

success, power, etc

Irresponsible Shallow labile affect Believes himself/herself to be

special

Impulsive and irritable Seeks attention and excitement Requires excessive admiration

Lacking guilt and remorse Inappropriately seductive Sense of entitlement to favours

and compliance

Failure to accept responsibility Additionally in DSM –IV:

Speech excessively

impressionistic

Considers relationships to be

more intimate than they are

Exploits others

Lacks empathy

Envious of others, and believes

that others envy him/her



Anxious Avoidant PD Dependent PD Anankastic PD

Feelings of tension (not DSM) Allows other to take responsibility Preoccupied with details, rules

Feels socially inferior Unduly compliant Inhibited by perfectionism

Preoccupied with rejection Unwilling to make reasonable

demands

Over-conscientious and

scrupulous

Avoids risk Feels unable to care for self Excessively concerned with

productivity

Avoids social activity Fear of being left to care for self Rigid and stubborn

Restraint in intimate

relationships, due to fear of

being shamed or ridiculed

Needs excessive help to made

decisions

Expects other to submit to their

views

Inhibited in new personal

situations, due to feelings of

inadequacy

Experiences difficulty in initiating

projects, goes to excessive

lengths to obtain support,

urgently seeks a supportive

relationship (DSM)

Excessively pedantic and bound

by convention

Excessively doubtful and

cautions (not in DSM)

Cannot discard worthless objects,

miserly, hoards money (DSM)


Assessment of personality – General Points

• Self-description of personality is difficult and may be distorted by a mental disorder.

• The doctor or ward staff rarely know the patient long enough and in ‘normal’

circumstances to be sure of personality type.

• An informant (someone who has known the patient when they were free of

symptoms for a number of years and preferably in more than one circumstance), is

desirable.

• It is important to be sure that the informant or patient understands that the interview

concerns a time of life when the patient was well (i.e. for premorbid personality).

• Begin by asking an open-ended question to describe in his/her own, how the patient

was at the time. Then ask subsidiary questions that concern features of that

category.

• Ask to indicate whether the features were generally present and whether the

personality seemed responsible for personal suffering or handicap in social or

occupational life.

• It is important to avoid using the term ‘personality disorder’ to explain

disagreeable behaviour unless you have adequate evidence.

Goldberg, 1998

Assessment of personality – General Points 2

• Assessment conducted in line with the principles of the National Health Service’s

care programme approach places an emphasis on the following areas :

o risk of harm to self and others

o the presence of other mental health difficulties

o the complexity of a person’s personality difficulties

o the level of burden and/or distress placed on other family members or agencies.

• Consider the following factors during assessment :

o Demographic factors, Current social situation, Current presentation, Psychosocial

stressors, Previous history of violence and self-harm, Previous response to

treatment/supervision, Level of social support, Anger, Impulsivity, Substance misuse,

Presence or absence of mental illness

Banerjee et al (2009) APT

Assessment methods

• Methods with some evidence of good test-retest reliability:

Instrument Authors Method No. of

questions

Personality

Assessment

Schedule (PAS)

Tyrer et al Semi-structured interview with

informant can derive ICD-10 and

DSM-IV diagnoses.

24

International

Personality

Disorder

Examination (IPDE)

Loranger et al Semi-structured interview with

patients using ICD-10 and DSM-IV

criteria.

537

Structured Clinical

Interview for

Personalities

Disorders (SCID-II)

First & Gibbon Semi-structured interview with

patients DSM-IV criteria.

303

Zanarini Rating

Scale for Borderline

Personallity

Disorder

Zanarini Semi structured interview with

patients using DSM-IV BPD criteria

9

Treatment / Management*

* Psychological approaches to management are covered in detail in Psychotherapy module.

Overview of Treatment/management of EUPD is the main focus of this presentation.

Treatment approaches

Dividing personality disorder by

dimensions

• “The most prominent algorithm was proposed by Siever and

Davis(1991) and developed further by Soloff. They suggested

that the four dimensions (affective instability, anxiety-inhibition,

cognitive-perceptual disturbances, and impulsivity aggression)

that cut across all personality disorder categories should be

studied rather than individual symptom clusters or diagnoses.”

Bateman 2015

Borderline PD- Drug Treatment

• The available evidence indicates some beneficial effects with second-

generation antipsychotics, mood stabilisers, and dietary supplementation by

omega-3 fatty acids. However, these are mostly based on single study effect

estimates.

• Antidepressants are not widely supported for BPD treatment, but may be

helpful in comorbid conditions.

• Total BPD severity was not significantly influenced by any drug.

• No promising results are available for the core BPD symptoms of chronic

feeling of emptiness, identity disturbance and abandonment.

• Conclusions have to be drawn carefully in the light of several limitations of

RCT evidence that constrain applicability to everyday clinical settings

(among others, patients’ characteristics and duration of interventions and

observation periods).

Conclusion of Cochrane Review, June 2010

Borderline PD- Drug Treatment: NICE

• Do not use:

• Drug treatment specifically for borderline personality disorder or for the

individual symptoms or behaviour associated with the disorder (for

example, repeated self-harm, marked emotional instability, risk-taking

behaviour and transient psychotic symptoms)

• Antipsychotic drugs for the medium- and long-term treatment of borderline

personality disorder (NB: different to APA guidance who recommend use

of medication for different dimensions of BPD)

• Consider drug treatment in the overall treatment of comorbid conditions.

• Consider cautiously short-term use of sedative medication as part of the overall

treatment plan for people with borderline personality disorder in a crisis. Agree

the duration of treatment with them, but it should be no longer than 1 week.

• Review the treatment of those who do not have a diagnosed comorbid mental or

physical illness and who are currently being prescribed drugs. Aim to reduce and

stop unnecessary drug treatment.

Borderline PD- Psychological Therapy

• There are indicators of beneficial effects for various therapies for core

pathology and associated general psychopathology – Dialectical Behavioural

Therapy, Mentalization Based Therapy, Transference Focused Therapy,

Schema Focused Therapy, Systems Training for Emotional Predictability and

Problem Solving for Borderline Personality Disorder (STEPPS).

• But none of the treatments has a very robust evidence base, and there are

some concerns regarding the quality of individual studies.

• Overall, the findings support a substantial role for psychotherapy in the

treatment of people with BPD but clearly indicate a need for replicatory

studies.

Conclusion of Cochrane Review, August 2012

Borderline PD- Psychological Therapy : NICE

• 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.

• For women with borderline personality disorder for whom reducing recurrent self-

harm is a priority, consider a comprehensive dialectical behaviour therapy

programme.

• When providing psychological treatment to people with borderline personality

disorder as a specific intervention in their overall treatment and care, use the

CPA to clarify the roles of different services, professionals providing

psychological treatment and other healthcare professionals.

• 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.

Dissocial PD

• Insufficient trial evidence to justify using any psychological intervention for adults

with Dissocial PD.

• Significant improvements were mainly confined to outcomes related to substance

misuse.

• No study reported significant change in any specific antisocial behaviour.

• Further research is urgently needed for this prevalent and costly condition

Conclusion of Cochrane Review, June 2010

Generalist treatment

Structured Clinical Management (SCM)

• Emerged as a control to PD specific psychological treatments

• Showed that there were some core elements in the specialist

treatment that could be provided in the general psychiatric

setting that helped.

• Large focus on structure and organisation of services as this is

almost as important as service itself.

• NB: other generalist approaches are “general psychiatric

management,” “good clinical care,” and “supportive

psychotherapy.”

SCM: General treatment

strategies. (from BPD. An evidence-based

guide for generalist mental health professionals.

Chap. 3).

• Careful assessment

• Giving diagnosis

• Information about BPD

• Crisis planning

• Risk assessment and management.

• Development of hierarchy of therapeutic areas.

• Agreement of clinician and patient responsibilities.

Cont.

• Development of motivation and establishment of

therapeutic alliance

• Stabilization of drug misuse and alcohol use.

• Development and agreement of comprehensive

formulation.

• Involvement of families, relatives, partners and others.

Course & Prognosis

• Personality disorders are considered as life long conditions, so little

change would be expected with time.

• There is little reliable evidence about their outcome other than for

borderline personality disorder.

Borderline PD

• The outcome is vary varied.

• Zanarini et al (2006) – 290 BPD patients were interviewed using SCID-II

every 2 years for 10 years. A total of 88% achieved ‘remission’ over this

time period, 39% by 2 yrs, a further 22% by 4 yrs, a further 22% by 6

years, and so on. Those who still showed BPD more often had comorbid

substance abuse or history of childhood sexual abuse.


Personality Disorders & the amended MHA (2007)

• The new definition of mental disorder in the amended Act: any disorder or

disability of the mind (so personality disorders are included)

• The classification of ‘psychopathic disorder’ was abolished.

• ‘Treatability’ is replaced by ‘appropriate medical treatment [‘includes nursing,

psychological intervention and specialist mental health habilitation, rehabilitation

and care…the purpose of which is to alleviate, or prevent a worsening of, the

disorder or one or more of its symptoms or manifestations’].

• Change in provision of Nearest Relative – the patient may now be able to replace

the NR to someone of their choice (which have a particular relevance in

personality disorders as a large proportion of PD patients have difficult

relationship with their family members).

References & Further Reading

• Bateman, A. W., Gunderson, J., & Mulder, R. (2015). Treatment of personality disorder. The

Lancet, 385(9969), 735-743. doi:http://dx.doi.org/10.1016/S0140-6736(14)61394-5

• Cowen P, Harrison P and Burns T (2012). Shorter Oxford Textbook of Psychiatry, Ed. 6th ,

OUP, Oxford.

• Gelder et al (2012) New Oxford Textbook of Psychiatry, Ed 2nd, OUP, Oxford.

• Goldberg D (Ed) ( 1998) The Maudsley Handbook of Practical Psychiatry. OUP, London.

• Zanarini MC et al (2006) Prediction of the 10-year course of Borderline Personality Disorder,

American Journal of Psychiatry, 163, 827-832.

• Zanarini, Mary C. (2003). Zanarini rating scale for borderline personality disorder (ZAN –

BPD): A continuus Meaure of DSM-IV Borderline psychopathology. Journal of Personality

Disorder, 17 (3), 233-242.

• Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K (2010) Pharmacological

interventions for borderline personality disorder, The Cochrane Library,

DOI: 10.1002/14651858.CD005653.pub2

References & Further Reading

• Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K (2010) Psychological therapies

for people with borderline personality disorder, The Cochrane Library,

DOI: 10.1002/14651858.CD005652.pub2

• NICE guideline CG78: Borderline Personality disorder: treatment and management.

• Harner, D (2004) Rethinking behaviour genetics, Science, 298, 71-72.

• Banerjee P, Gibbon S, Huband N (2009) Assessment of personality disorder. APT, 15 (5)

389-397.

• Coid J, Yang M, Tyrer P, et al (2006a) Prevalence and correlates of personality disorder in

Great Britain. British Journal of Psychiatry; 188: 423–31.

• Coid J, Yang M, Roberts A, et al (2006b) Violence and psychiatric morbidity in the national

household population of Britain: public health implications. British Journal of Psychiatry; 189:

12–9

• Tyrer P, Seivewright H (2000) Outcome of personality disorder. In Personality Disorders:

Diagnosis, Management, and Course (2nd edn) (ed P Tyrer): 105–25: Butterworth-

Heinemann.

• Soloff PH (1998) Algorithms for pharmacological treatment of personality dimensions:

symptom-specific treatments for cognitive-perceptual, affective, and impulsive-behavioral

dysregulation, Bull Menninger Clin, Vol. 62,195-214

• Siever, LJ, Davis, KL (1991) A psychobiological perspective on the personality disorders, Am

J Psychiatry, Vol. 148, 1647-1658

• Skodol AE, Gunderson JG, Shea TM, et al (2005) The collaborative longitudinal personality

disorders study (CLPS): overview and implications. Journal of Personality Disorders; 19:

487–504.

• Stone MH (1993) Long-term outcome in personality disorders. British Journal of Psychiatry;

162: 299–313.

• A useful paper on diagnosis is: Kernberg, O and Yeomans, F. (2013) Borderline personality

disorder, bipolar disorder, depression, attention deficit/hyperactivity disorder, and narcissistic

personality disorder: Practical differential diagnosis. Bulletin of the Menninger Clinic, Vol. 77,

No. 1 (Winter 2013)


Any Questions?

Thank you


MCQ

1. Which of the following is NOT a personality disorder

in ICD-10?

A. Schizoid personality

B. Paranoid personality

C. Emotionally unstable personality

D. Schizotypal personality

E. Anankastic personality


MCQ

2. Which of the following is not part of the Big Five

personality traits?

A. Agreeableness

B. Carefulness

C. Neuroticism

D. Openness

E. Extraversion


MCQ

3. A 36 year old man is visited at home by his GP. There is very little

furniture, no television, no ornaments or pictures on the wall. He is

indifferent to these observations, stating he has no need of those things.

He has limited contact with his family and does not have any friends. He

is clear he does not feel lonely or depressed. Which of the following

personality disorders could he have?

A. Histrionic

B. Antisocial

C. Paranoid

D. Schizotypal

E. Schizoid


MCQ

4. A 29 year old woman is seen in clinic for assessment of anxiety. She

describes longstanding fears of being left alone and cannot bear to make

decisions without others providing reassurance she is doing the right thing.

She lives with her parents. Her mother cooks all her meals and shops for

her clothes. Which of the following personality disorders could she have?

A. Histrionic

B. Anankastic

C. Paranoid

D. Dependent

E. Borderline


MCQ

5. Which of the following is not a generalist approach to people with

borderline personality disorder?

A. Good Clinical Care

B. Dialectical Behavioural Therapy

C. Structured Clinical Management

D. General Psychiatric Management

E. Supportive Psychotherapy


Any Questions?

Thank you.

mrcpsych general adult module personality disorders · 2018. 11. 28. · models of personality •...

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