Personality disorders

Question	Answer
What is a personality?	A set of consistent thoughts, feelings and behaviours shown across time in a variety of settings. Made up of characteristics (or personality traits). Each trait has different strengths and weakness in different situations.
When does personality become disorders?	When it is Pervasive – occurs in all/most areas of life Persistent – evidence from adolescence and continues through adulthood Pathological – causes distress to self or others; impairs function (occupation/social/relationship).
How do we assess personality clinically?	Personal History. Asked directly “Before all these happened, what kind of person were you? ” “How would your friends describe you?” Religious belief/moral views. How to deal with stress/pressure? Hobbies/Interest/favourite books or films. Check with other informants. Good to ask how they used to get on with teachers at school. Any abuse? Excluded? Truancy? Self-harm?
What are the ICD-10 classifications of personality disorders?	Paranoid. Schizoid. Dissocial (antisocial). Emotionally Unstable (Impulsive and Borderline subtype). Histrionic. Anankastic. Anxious (avoidant). Dependent.
Describe the features of a Paranoid PD	SUSPECT: Sensitive, Unforgiving, Suspicious, Possessive and jealous of partners, Excessive self-importance. Conspiracy theories. Tenacious sense of rights. These consultations can go on for a long time so try to keep it brief. They have many perceived wrongs and are often involved in numerous litigations.
Describe the features of a Schizoid PD	ALL ALONE: Anhedonic, Limited emotional range, Little sexual interest, Apparent indifference to praise/criticism, Lacks close relationships, One-player activities, Normal social conventions ignored, Excessive fantasy world. Must not confuse with ASD - those with ASD usually cannot understand how others might be feeling but those with Schizoid PD usually can.
Describe the features of a Histrionic PD	ACTORS: Attention seeking, Concerned with own appearance, Theatrical, Open to suggestion, Racy and seductive, Shallow affect. Can often switch very quickly from being quite distressed to fairly upbeat - also you may find yourself not reacting to the things they tell you - because we pick up on the shallow affect.
Describe the features of an Emotionally Unstable PD	Two types (ICD-10): Borderline and Impulsive. Common features for both types (AEIOU): Affective instability, Explosive behaviours, Impulsive, Outburts of anger, Unable to plan or consider other consequences.
Describe the features of Borderline type Emotionally Unstable PD	SCARS. Self image unclear (may be distorted gender identity, often linked to abuse), Chronic 'empty' feeling, Abandonment fears (will often sabotage their discharges), Relationships are intense and unstable, Suicide attempts and self-harm. They occasionally experience fleeting psychotic features.
Describe the features of an Impulsive type Emotionally Unstable PD	LOSE IT: Lacks impulse control, Outbursts of threats of violence, Sensitivity to being criticised or let down, Emotional instability, Thoughtless of consequences.
Describe the features of a Dissocial PD (psychopath/sociopath).	FIGHTS: Forms but cannot maintain relationships, Irresponsible, Guiltless, Heartless, Temper easily lost, Someone else's fault. Could also add in charm, which they often have. They display very little emotional reaction to pain and fear. They also derive no corrective benefit from punishment.
Describe the features of an Anankastic PD	DETAILED: Doubtful, Excessive detail, Tasks not completed (working too long trying to get them perfect), Adheres to rules, Inflexible, Likes own way, Excludes pleasure and relationships, Dominated by intrusive thoughts. NOT the same as OCD - OCD is more focused on a few areas - cleaning, washing, checking, symmetry, whereas anankastic personality disorder is more overarching.
Describe the features of an Anxious/Avoidant PD	AFRAID: Avoids social contact, Fears rejection/criticism, Restricted lifestyle, Apprehensive, Inferiority, Doesn't get involved unless sure of acceptance.
Describe the features of a Dependent PD	SUFFER: Subordinate, Undemanding, Feels helpless when alone, Fears abandonment, Encourages others to make decisions, Reassurance needed.
How are PDs diagnosed?	SCID questionnaire. Can have "mixed personality disorder" if they meet criteria for more than one category. Some patients are sub-threshold, they are often thought of as having abnormal personality traits, rather than a full PD.
What is the epidemiology of PDs?	10% prevalence overall. 30% of psychiatric outpatients. 40% of psychiatric inpatients. 50% of prison population.
What are the DSM clusters of PDs?	Cluster A - 'odd and eccentric' = Schizoid, Paranoid, Schizotypal. Cluster B - 'dramatic and emotional' = Antisocial, Histrionic, Borderline, Narcissistic. Cluster C - 'anxious and fearful' = Obsessive compulsive, Anxious, Dependent.
What is the aetiology of PDs?	Genetics. Childhood temperament - early attachment difficulties, 'difficult temperament'. Childhood experience - traumatic upbringing, neglect or abuse. Neurochemical imbalance - e.g. impulsive behaviour/aggression and serotonin. Maladaptive psychological defence mechanisms.
DEFENCE MECHANISMS - what is meant by the term denial?	Refusal to admit certain unacceptable aspects of external reality.
DEFENCE MECHANISMS - what is meant by the term repression?	"Forgetting" of unacceptable ideas, emotions, memories and drives.
DEFENCE MECHANISMS - what is meant by the term distortion?	Reshaping of external reality to suit inner needs.
DEFENCE MECHANISMS - what is meant by the term splitting?	Division of ideas, objects and persons into good and bad by selectively focusing on positive or negative aspects - One of the DSM IV-TR criteria for borderline PD is a description of splitting: "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealisation and devaluation"
DEFENCE MECHANISMS - what is meant by the term idealisation?	Overestimation of positive attributes and underestimation of negative attributes of an idea, object or person.
DEFENCE MECHANISMS - what is meant by the term displacement?	Redirection of feelings for a person or thing to another, less important person or thing.
DEFENCE MECHANISMS - what is meant by the term reaction formation?	Adoption of ideas and behaviours that are diametrically opposed to one's own.
DEFENCE MECHANISMS - what is meant by the term projection?	Attribution of one's own unacceptable ideas or behaviours to others.
DEFENCE MECHANISMS - what is meant by the term rationalisation?	Use of feeble but seemingly plausible arguments either to justify one's shortcomings or make them seem 'not so bad after all'.
DEFENCE MECHANISMS - what is meant by the term intellectualisation?	Use of abstract terms that are devoid of feeling to think about one's instinctual drives.
DEFENCE MECHANISMS - what is meant by the term sublimation?	Channelling of instinctual drives into constructive activities such as work, art or sport.
DEFENCE MECHANISMS - what is meant by the term altruism?	A form of sublimation in which a person diffuses their anxiety by stepping outside themselves to help others.
DEFENCE MECHANISMS - what is meant by the term humour?	By seeing the absurd or ridiculous aspect of an emotion, event or situation, a person is able to put it in a less threatening context and thereby to diffuse the anxiety that it provokes in him or her.
What makes a defence mechanism maladaptive?	If the mechanism is not appropriate for the life stage of the person. E.g. Splitting is a defence mechanism of infancy.
What are the common co-morbidities of PDs?	Anxiety disorder (especially in Cluster C PDs). Depression. Substance misuse and alcoholism. Adjustment disorder/stress reaction.
What concerns are there about the management of a patient with PD?	Importance of boundaries (“draw the line”). Know your limits – seek help from seniors or other colleagues. Remember splitting – “you are the best doctor!...(next day) you are the worst doctor!” Demonstrate you are reliable and consistent rather than promising something you cannot deliver. Beware transference (how patient feel about you – don’t take it personally) and counter-transference (how you feel about them – don’t let it affect your professionalism). Patient may need to take responsibility of their action. Beware the “admission trap”- sometimes admission may be counter-productive, fostering dependence and disempowering individuals from adopting safer coping strategies.
What are some psychological interventions that could be used for personality disorders?	Cognitive Behavioural Therapy (CBT) Dialectical Behavioural Therapy (DBT) Cognitive Analytical Therapy (CAT - where a patient is encouraged to draw out repetitive cycles of thinking and behaviour they go through and how to get out of them). Therapeutic communities. Specialist service/unit for Personality Disorder.
Describe the pharmacological interventions used in PDs	Mainly symptom control and treating comorbid mental illness. Antipsychotics: for transient psychotic experience, reduction of impulsivity and agitation (e.g. quetiapine is particularly good for impulse control, risperidone good for conduct disorder). Antidepressants for comorbid illness such as anxiety and depression. Mood stabilisers. There is a place for medication in PDs but they can't cure them. NICE does not recommend any medication for borderline or dissocial PD.

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	Created by Anna Walker over 9 years ago