Lecture 3: Personality disorders

What topics are discussed?

Clusters
This topic has not been discussed in the lecture. However, it can be convenient to have a quick summary about the clusters and the different types of personality disorders. Therefore the other topics which were discussed in the lecture and literature are easier to understand.

Cluster A: strange behaviour
- Paranoid: not trusting others, extern attribution bias (blaming others for own failures), easily getting jealous, resulting in problems at work and in relationships, they often seem professional and efficient and are proud they can handle everything rationally/without emotions
- Schizoid: flat, superficial behaviour, not feeling pleasure, not feeling anything like mood swings (although they can experience depression), not understanding how/why they feel the way they feel
- Schizotypal: strange, eccentric, and creative behaviour, feeling like they cannot fit into society, often psychotic features, they want to be in contact with others, but they are very frightened to do so
General characteristics: social aversion, failure to form relationships, poor self-awareness and empathic ability, (relative) indifference to these abilities.

Cluster B: dramatic
- Antisocial: not caring about emotions and rights of others, rationalising own destructive behaviour, lying, often raised in an instable family with lack of parental care, sometimes referred to as sociopaths or psychopaths
- Borderline: instability with moods, relationships, impulsivity which leads to reckless behaviour, self-mutilation, suicide attempts, fear of being abandoned
- Histrionic: constantly seeking attention, paying attention to how others judge and perceive them, inappropriate, seductive or sexual provocative behaviour
- Narcissistic: not interested in others, strong desire to be admired by others, overestimation of their own qualities, easily jealous of others and having the idea that others are jealous of them, not good at taking criticism

Cluster C: anxious
- Avoidant: low self-esteem, extremely shy, sensitive to criticism, anxious and avoiding risks, caused by neglect, abuse, being bullied
- Dependent: extremely dependent on partner, parents or friends, makes others make important decisions, fear of being abandoned, often suicidal
- Obsessive-compulsive: strong desire to have everything neat and organised, perfectionist, often superficial relationships with others, strong comorbidity with Asperger and eating disorders
 

Stigma
There is a stigma around personality disorders. A personality disorder is difficult to treat and it is difficult to deal with in life. Some people think a personality disorder is just bad behaviour instead of a real disorder and that those people just have to change their behaviour. There’s especially a high stigma around those with borderline disorder. For patients themselves there is also a stigma. They often have a low self-esteem as they cannot maintain relationships with others and such. There is also a stigma around care givers, because of the patients’ symptoms they cannot have relationships and they have a hard time when it comes to work.

Reasons to pay more attention to PD
There are multiple reasons why there should be paid more attention to personality disorders. First of all, a personality is quite prevalent. The prevalence is up to 15%, and the highest prevalence is noted in people in contact with the criminal justice system, as 2/3 of the prisoners have a personality disorder. Second, a personality disorder is a predictor of (poor) treatment outcomes. Third, personality disorder comes with premature mortality. This is due to one’s lifestyle (e.g. smoking, other bad habits), suicidal behaviour, cardiovascular and respiratory diseases, and a much lower life expectancy. Fourth, personality disorders come with greater costs for society. Fifth, a personality disorder causes high distress for both patients and those around them. Sixth, people with a personality disorder are often unemployed or have a hard time getting and maintaining a job, resulting in a lower social economic status. Finally, personality disorders cause impairment in (social) functioning, resulting in fewer to no personal relationships.

Reasons undertreatment
Personality disorders are often undertreated. This is because there are difficulties in the interaction between patients and health professionals and also because it is very difficult to recognise a personality disorder. Training for psychotherapy is very expensive and the treatment is of long duration. 25% of the patients get the (right) treatment for personality disorder.
How can you recognise a personality disorder?
- Changes in relationships and difficulties maintaining relationships
- Behavioural patterns and changes in behaviour
- Emotional dysregulation
- Problems with social interaction
- Unable to benefit from treatment for another psychiatric disorder and/or difficulties in the therapeutic relationship

Screening for personality disorder: questions
- In general, do you have difficulty in making and keeping friends?
- Would you normally describe yourself as a loner?
- In general, do you trust other people?
- Do you normally lose your temper easily?
- Are you normally an impulsive sort of person?
- Are you normally a worrier?
- In general, do you depend a lot on others?
- Are you a perfectionist?

DSM V Personality disorder
A personality disorder is characterised by an enduring, stable pattern of inner experience and behaviour that deviates from expectations of the individual’s culture. This can be found within four dimensions:
- Cognition: how does one think about themselves? E.g.: patients can think others are threatening them and abusing them (e.g. paranoid PD), or they think they cannot deal with life alone and therefore need someone for stability (e.g. borderline PD)
- Affectivity: e.g. being very sensitive and having to deal with severe mood wings
- Impulse control: someone can be very quiet and withdrawn, someone else could be very impulsive and would start to scream and express anger when something small and inconvenient happens
- Interpersonal functioning: people can have problems maintaining and keeping friendships
Behaviours, cognitions and thoughts in these four dimensions can lead to distress or impairment in social, occupational or other important areas of functioning. Within personality disorder there is a lot of variety depending on the number of criteria and severity of symptoms shown. Personality disorders also often come with other personality disorders or psychiatric disorder (comorbidity).

Concerns DSM V
Just as mentioned in the previous lectures, the DSM V is a source to be relied on, not to be valid. The DSM V is a classification, it does not include strong psychometric properties. Also, severity is not included and there is an overlap between diagnoses in personality disorders. An alternative model for DSM V is not yet ready for general use.

Epidemiology personality disorders 
The point prevalence of personality disorders is 4-15%. In clinical practice there are more women diagnosed with PD than men. This is possibly because women are more likely to seek treatment and a number of men could be diagnosed with other disorders or they could be in jail. There is a higher prevalence among ethnic minorities and there is a higher prevalence in urban areas than in rural areas.

PD lifespan
It is important to note than personality disorders can change over time and that patients can definitely learn how to deal with it. For example, 50-61% of the patients report no borderline personality disorder (anymore) two years after the diagnosis. Personality continues to stabilise until at least the age of 60. PD in children and adolescents is the strongest predictor for PD in adulthood.
Trauma, especially during childhood, e.g. abuse (sexual, emotional, physical) and neglect, and genetics (approximately 50%) play a major role in the development of personality disorders.

Of those with borderline PD, 97% has at least one childhood trauma.

Personality disorders can difficult to recognise in clinical practice. Patients often don’t seek help for their PD. There is an absence of reliable and quick instruments, and many patients are classified as unspecified PD. It is important to not diagnose PD in case of presence of severe other psychiatric disorders, like psychotic disorders, major depression, bipolar disorder, and autism spectrum disorder, even though personality disorders have a high comorbidity with other disorders.

(Slotema, 2020)

Treatment
Psychotherapy is the main treatment for PD. It has its focus on emotional dysregulation and social relationships and structured partnerships. Patients are encouraged to assume control over themselves. Psychotherapy is offered in both group settings and individual settings and possibilities are being an outpatients, doing a day clinic or being an inpatient. However, evidence is limited. There is no reliable placebo condition, studies are expensive for their long duration and intensity of treatment, and the majority of studies include only patients with borderline PD. Besides, PD symptoms reduce, but vocational and social adaption remain impaired. Acute severe symptoms do reduce though, like suicidal behaviour, aggressive outbursts, and hospitalisation. Specialised psychotherapy is no better than good control conditions. Finally, extensive and expensive training is needed.

There is no medication to treat PD. However, it can control anger attacks and mood swings and it can affect instability, cognitive-perceptual symptoms and impulsivity/anger.

Other inventions are crisis management, family therapy, nonverbal therapy, and treatment of comorbid disorders.

DSM V borderline personality disorder 
At least 5 criteria have to be present to get a diagnosis.

• Frantic efforts to avoid real or imagined abandonment
• Unstable and intense interpersonal relationships
• Identity disturbance
• Impulsivity in at least two areas
• Recurrent suicidal behaviour, gestures, threats, or self-mutilation behaviour
• Affective instability
• Chronic feelings of emptiness
• Inappropriate, intense anger or difficulty controlling anger
• Transient, stress-related paranoid ideation or severe dissociative symptoms

Dissociative symptoms 
- Amnesia: e.g. not being able to remember childhood before the age of 10
- Depersonalisation: when your body and feelings don’t feel like they belong to you or are you
- Derealisation: not feeling connected with your surroundings, can also happen in panic attacks or when you don’t sleep properly
- Hallucinations: experienced by 43% of those with PD. These can be auditory, olfactory, tactile, visual, or gustatory.

Suicide
40 to 50% of the patients who commit suicide have a personality disorder, often in combination with another disorder. One’s emotions are so extreme that the patient does not know what to do. However, there must be a reason, so as a clinician you have to explore what has happened and you have to acquire information. You have to help the patient be able to think adequately and help them gain control over their situation again.

What topics are discussed which aren’t discussed in the literature?
Dissociative symptoms, stigma, and reasons for undertreatment are topics which aren’t really discussed in the literature. All the other topics discussed in this lecture have also been covered in the literature. These topics are discussed in more detail, so definitely take a look at the articles by Tyrer, Reed, & Crawford (2015), Newton-Howes, Clark, & Chanen (2015), and Bateman, Gunderson, & Mulder (2015). These also cover topics which have not been discussed in the lecture.

How has this topic developed over the past few years?
As noted in the other lectures, the DSM has made a transition from DSM IV to DSM V, in which behavioural disorders and their criteria may have changed, been added or removed. It is important to use the DSM V and not the DSM IV, as some criteria or behavioural disorders can have made a major difference.

What comments are made with regard to the exam?

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What questions are being asked which could be asked on the exam? What is the answer?

People with borderline PD often exhibit which of the following characteristics?
A. Unpredictable and impulsive
B. Uninhibited and promiscuous
C. Demanding and angry
D. All of above

Monica has a difficult time maintaining friendships. She is generally suspicious of the motives of others, often misinterpreting the behaviour of her friends. Based on this information, the most likely PD diagnosis for Monica would be:
A. Dependent personality disorder
B. Avoidant personality disorder
C. Paranoid personality disorder
D. Histrionic personality disorder
 

With which disorder does PD have the highest comorbidity?
Anxiety disorders (70%).