Personality and Personality Disorders D R T R I S H N U N E S

C O N S U L T A N T P S Y C H I A T R I S T

A D U L T N E U R O D E V E L O P M E N T A L S E R V I C E

N O R T H U M B E R L A N D , T Y N E & W E A R N H S F O U N D A T I O N T R U S T

Structure Personality & theories

Personality assessment

Personality disorders

Case presentation & some reflections

What is personality?

Personality Persona (Greek)= mask

Individual’s attitudes & ways of thinking, feeling and behaving

Personality profile allows one to be recognised by others & powerful regulator of social relationships

Biopsychosocial factors for survival of individual within their habitat

Personality “characteristic pattern of thinking, feeling & acting”

Five major perspectives on personality:

1. Psychoanalytical-unconscious motivation

2. Behavioural-learned dimension of personality

3. Cognitive-learning & organisation of info

4. Humanistic-inner capacity for growth

5. Trait theory-what traits we possess

Psychoanalytical perspective-first comprehensive theory of personality

Sigmund Freud (1856-1939)

Austrian neurologist

Some patients’ symptoms did not have physical cause

Collaboration w Breuer: Studies of hysteria (Anna O)

Use of hypnosis, concentration method & free association

Freud’s Topographical Model of the Mind Unconscious:

memories, ideas & affects that are repressed

Primary process thinking

Motivating principle: pleasure principle

Preconscious:

Develops during childhood, maintains repression& censorship

Secondary process thinking

Reality principle

Conscious: Attention sensory organ

Secondary process thinking

Reality principle

Freud’s Structural Model of Mind

ID- works on pleasure principle

(Biological)

EGO Works on reality

principle (Psychological)

SUPEREGO Works on moral/ ideal principle (Social)

Defense mechanisms Developed by Freud with daughter Anna

Unconscious distortion of reality to avoid anxiety

Multiple classification subsequently

E.g. denial, repression, projection, regression, etc.

Other psychoanalytical theorists Carl Jung

Melanie Klein

Donald Winnicott

Behavioural approach School of behaviourism evolved in 1910s, led by JB Watson

Other behaviourists: BF Skinner (operant conditioning), A Bandura, W Mischel

This approach claims that people, their problems and actions can be explained by observing their behaviour

Assumes that after birth, all humans are similar. Therefore, formation of personality is greatly related to the surrounding environment, which is to shape and bring up the future individual

Seligmann’s “Learned helplessness”

Cognitive approach Evolves from behaviourist theory/ social learning

Idea that people are who they are because of the way they think, including how information is attended to, perceived, analysed, interpreted, encoded and retrieved.

People tend to have habitual thinking patterns which are characterised as a personality. Your personality, then, would be your characteristic cognitive patterns

Humanistic approaches Focusses on qualities that differentiate humans from non-human animal species

Self-actualisation is core individual motivational force

“Man, as a man, supersedes the sum of is parts”

Rogers’ self theory, Maslow’s hierarchy of needs, Rollo May

Maslow’s Hierarchy of Needs-Theory of Human motivation

Trait theory

Gordon Allport (1937)

Traits are emotional, cognitive & behavioural tendencies on which individual varies

Most common approach is FIVE FACTOR MODEL of PERSONALITY (FFM) Consists of 5 broad dimensions of personality

personality profile –culmination of each of these 5 factors and a number of lower order sub-factors

PD reflects extreme versions of normal personality, so system can be used for normal & pathological personality

BIG FIVE

Measuring personality Projective personality tests:

◦ Rorschach inkblots

◦ Thematic Apperception Test (Henry Murray)

Measuring Personality/PD Personality inventories:

16PF (personality factors)-Cattell et al

Minnesota Multiphasic Personality Inventory (MMPI)

Wisconsin’s Personality Inventory (WISPI)

Structured Clinical Interview:

Structured clinical interview for DSMV personality disorder

Assessing personality in clinical interview Accurate assessment of person’s enduring & pervasive patterns of

◦ Emotional expression

◦ Interpersonal relationships

◦ Social functioning

◦ View of themselves & others

WHEN NOT SUFFERING FROM ANOTHER MENTAL DISORDER

◦ Information from other sources

◦ Information from psychiatric history

◦ Exploration of interests, attitudes, self-concept, coping w difficulties, specific traits

Personality as a Mental Disorder

A mental disorder characterized by lasting maladaptive patterns of behavior and inner experience, shown across many contexts and deviating markedly from those accepted by the individual's culture

Examples of difficulties: •Keeping relationships •Getting on with co-workers •Getting on well with friends and family •Not been able to keep out of trouble •Control feelings or behaviour •listen to other people

ICD 10 vs DSM 5 ICD 10 DSM V

Paranoid Paranoid

Schizoid Schizoid

Schizotypal

Dissocial Antisocial

Emotionally unstable PD-

a) Impulsive b) borderline type

Borderline

Histrionic Histrionic

Narcissistic

Anankastic Obsessive-compulsive

Dependent Dependent

Anxious (avoidant)

Avoidant

Torgerson, S.2009 The nature and nurture of personality disorders. Scan J psychol 50:624-632

Prevalence (DSM V)

• OCPD 2%

• Paranoid 2%

• Antisocial 1-4%

• Schizoid 1%?

• Schizotypal 1%

• Avoidant 1-2%

• Histrionic 2%

• Borderline 2-3%

• Dependent 0.5%

• Narcissistic 0.5-1%

Reichborn-Kjennerud T. 2010 Dialogues Clin Neurosci 12(1):103-114

Genetic origin

Genes linked to neurotransmitter systems:

Serotonin

Dopamine systems are involved

Heritability of normal personality traits is approximately 0.5

AETIOLOGY

Multi-factorial

• Genetic: Norwegian twins study

• Environmental factors:

Difficult childhood

Physical and sexual abuse

• Structural brain problems

ICD 10 (F60) “These are severe disturbances in the personality and behavioural tendencies of the individual;

not directly resulting from “disease, damage or other psychiatric disorder……..”

“………usually manifest since childhood or adolescence and continuing throughout adulthood”

Cluster A: Odd and eccentric

Paranoid

Schizoid

Schizotypal

F60.0 Paranoid personality disorder

•At least 4 of the following: •(1) Excessive sensitivity •(2) Tendency to bear grudges •(3) Suspiciousness and a pervasive tendency to distort experience by misconstruing the neutral or friendly actions of others as hostile or contemptuous

•(4) A combative and tenacious sense of personal rights out of keeping with the actual situation

•(5) Recurrent suspicions, without justification, regarding sexual fidelity of spouse or sexual partner

•(6) Persistent self-referential attitude, associated particularly with excessive self-importance

•(7) Preoccupation with unsubstantiated "conspiratorial" explanations of events around the subject or in the world at large

F60.1 Schizoid personality disorder

At least four of the following : •(1) Few, if any, activities provide pleasure. •(2) Displays emotional coldness, detachment, or flattened affectivity •(3) Limited capacity to express warm, tender feelings for others as well as anger. •(4) Appears indifferent to either praise or criticism of others. •(5) Little interest in having sexual experiences with another person (taking into account age). •(6) Almost always chooses solitary activities. •(7) Excessive preoccupation with fantasy and introspection. •(8) Neither desires, nor has, any close friends or confiding relationships (or only one) •(9) Marked insensitivity to prevailing social norms and conventions

Cluster B: Dramatic, Emotional,Erratic • Antisocial or Dissocial • Borderline or Emotionally Unstable • Histrionic • Narcissistic

F60.2 Dissocial personality disorder

• At least three of the following : •(1) Callous unconcern for the feelings of others •(2) Gross and persistent attitude of irresponsibility and disregard for social norms, rules and obligations

•(3) Incapacity to maintain enduring relationships, though having no difficulty to establish them

•(4) Very low tolerance to frustration and a low threshold for discharge of aggression, including violence

•(5) Incapacity to experience guilt, or to profit from adverse experience, particularly punishment

•(6) Marked proneness to blame others

F60.3 Emotionally unstable PD

•F60.30 Impulsive type • At least three of the following must be present, one of which is (2): •(1) A marked tendency to act impulsively and without consideration of the consequences.

•(2) A marked tendency to quarrelsome behaviour and to conflicts with others, especially when impulsive acts are thwarted or criticized. •(3) Liability to outbursts of anger or violence, with inability to control the resulting behavioural explosions.

•(4) Difficulty in maintaining any course of action that offers no immediate reward.

•(5) Unstable and capricious mood.

F60.31 Borderline type

•At least three of the symptoms mentioned above in criterion B (F60.30) must be present, and in addition at •least two of the following: •(6) Disturbances in and uncertainty about self-image, aims and internal preferences (including sexual). •(7) Liability to become involved in intense and unstable relationships, often leading to emotional crises. •(8) Excessive efforts to avoid abandonment. •(9) Recurrent threats or acts of self-harm. •(10) Chronic feelings of emptiness.

Some meanings and functions of Self Harm A way of surviving a relationship

A form of communication

An expression of rage

A form of punishment for self or others

A way of dissociating and avoiding emotional pain

A way of feeling real

Self Harm Management

Risk minimisation rather then controlling risk

Promote patient responsibility

Acute versus chronic suicidal risk

Patient benefits from stability of ongoing therapeutic relationships and might not be well served by conventional crisis set up

Admission does not ensure absence of risk but might increase risk in the longer term in patients with chronic risk

Positive risk taking, Care Planning and Communication

Possible reasons for admission:

To minimise the risk of imminent suicide/homicide

At times of increased risk for example caused by psychosocial crisis

To treat comorbid psychiatric disorders such as severe depression, short psychotic episodes, severe Anorexia Nervosa

Psychotherapy for borderline PD

DBT therapy including components like prioritising hierarchy of target behaviours,telephone coaching, group skills training, behavioural skills training, contingency management, cognitive modification, reflection, empathy and acceptance

Psychodynamic Psychotherapy

CAT Cognitive Analytic Psychotherapy

CBT Cognitive Behavioural Psychotherapy

MBT Mentalisation-based therapy

Narcissistic Personality Disorder

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, lack of empathy as indicated by >5 of the following: ◦ Grandiose sense of self-importance

◦ preoccupied with fantasies of unlimited success, power, brilliance or beauty

◦ Believes he is special and can only be understood or should associate with other special or high status people

◦ Requires excessive admiration

◦ Has a sense of entitlement

◦ Is interpersonally exploitive

◦ Lacks empathy

◦ Is often envious of others and believes others are envious of him

◦ Shows arrogant, haughty behaviors or attitudes

F60.4 Histrionic personality disorder

•At least four of the following must be present: •(1) Self-dramatization, theatricality, or exaggerated expression of emotions. •(2) Suggestibility, easily influenced by others or by circumstances. •(3) Shallow and labile affectivity. •(4) Continually seeks excitement and activities in which the subject is the centre of attention. •(5) Inappropriately seductive in appearance or behaviour. •(6) Overly concerned with physical attractiveness.

Cluster C: Anxious and Fearful •Obsessive-Compulsive •Avoidant (Anxious/Avoidant) •Dependent

F60.5 OBSESSIVE COMPULSIVE (ANANKASTIC) PD

•At least four of the following must be present: •(1) Feelings of excessive doubt and caution. •(2) Preoccupation with details, rules, lists, order, organization or schedule. •(3) Perfectionism that interferes with task completion. •(4) Excessive conscientiousness and scrupulousness. •(5) Undue preoccupation with productivity to the exclusion of pleasure and interpersonal relationships. •(6) Excessive pedantry and adherence to social conventions. •(7) Rigidity and stubbornness. •(8) Unreasonable insistence that others submit to exactly his or her way of doing things, or unreasonable •reluctance to allow others to do things.

F60.6 Anxious [avoidant] personality disorder

At least four of the following must be present:

(1) Persistent and pervasive feelings of tension and apprehension.

(2) Belief that oneself is socially inept, personally unappealing, or inferior to others.

(3) Excessive preoccupation about being criticized or rejected in social situations.

(4) Unwillingness to get involved with people unless certain of being liked.

(5) Restrictions in lifestyle because of need of security.

(6) Avoidance of social or occupational activities that involve significant interpersonal contact, because of fear of criticism, disapproval or rejection

F60.7 Dependent personality disorder

• At least four of the following must be present: •(1) Encouraging or allowing others to make most of one's important life decisions. •(2) Subordination of one's own needs to those of others •(3) Unwillingness to make even reasonable demands on the people one depends on. •(4) Feeling uncomfortable or helpless when alone, because of exaggerated fears of inability to care for oneself. •(5) Preoccupation with fears of being left to take care of oneself. •(6) Limited capacity to make everyday decisions without an excessive amount of advice and reassurance from others.

Take home points:

•Personality disorders are common and frequently encountered in general and mental health settings •Identifying personality disordered patients informs how best to approach them • Don’t forget to screen for comorbid diagnoses • Looking after a patient with personality disorder is at times difficult and supervision can be important •Personality disorders run a chronic course, but psychological treatment approaches can lead to improvements and better adjustment

Case presentation 23 year old student

Referred to psychological services for individual therapy by Consultant Psychiatrist

Case presentation Referred to CMHT by GP due to more recent dip in her mood associated with thoughts of self-harm and suicide

Letter also alludes to interpersonal difficulties

Referred in 09/2016

Offered 3 assessment appointments as DNAs first 2

Case presentation Seen for assessment in 01/2017

History of presenting complaint:

Feeling low since September 2016 with no improvement in mood on an increasing dose of Citalopram

Triggered by ending of a relationship with an ex-boyfriend, who was very controlling

Re-emergence of DSH

No diurnal variation of mood

initial insomnia and no refreshing sleep

Chronically low libido

Intentional weight loss of 10 pounds

Difficulties with relationships

Case presentation ctd Few hypnogogic visual hallucinations

No other psychotic symptoms

Poor body image

Past medical history Closed fracture of distal humerus

Fracture of clavicle

Past psychiatric history Anorexia nervosa, aged 13

“Her family tried to help her to cope with it. She did not receive formal treatment. “

Subsequent depression, referral to CAMHS

Citalopram 20mg

CBT-acc to sister: was able to run rings around service providers

10 individual sessions w consultant psychiatrist-helpful

Past Psychiatric History Depression at 18

DSH-cutting

2 paracetamol ODs

Family history Father: anxiety

Mother depression & post-natal depression

Mother had breast ca, hyperthyroidism, Meniere’s disease

Forensic hx Nil

Drug & Alcohol hx Tried ketamine-felt ill afterwards

Alcohol binges on weekends-mood worse day after

Nil else

Personal history Mother works for the National Trust PT-reported tendency to overdo things.

Her father is a salesman and works around the country- very anxious

Twenty-four year old, older sister & identical twin sister.

Described her childhood was tough

Told as a child to that she was ‘mean and grumpy’ and ‘needed to change her attitude’

Loved primary school but hated secondary school-bullying

Despite her difficulties, she did very well in her exams

4 A’s at A Levels. Didn’t get into uni course of choice

Gap year and worked in a GP practice for experience

Studies now at Newcastle University

Countless abusive relationships

Hobbies: reading

Mental State Examination A&B: Presented as a tall, slim women. She made limited eye contact. Her affect was reactive and she was an articulate historian. She became tearful at points during interview.

Speech: no abnormality in the volume, rate or tone of her speech

Mood is dysthymic rather than depressed

Thoughts: No formal thought disorder. Low self-esteem and worries that she is not worthy or good enough. She worries about her size and shape. There was no suicidal intent at interview and she does have hope for the future.

No evidence of perceptual abnormality.

Insight: she thinks she was depressed, and when we talked about her difficulties, she was able to reflect on her situation and how her core beliefs about herself might be driving feelings of low mood and anxiety and other difficulties she has at an interpersonal level.

Impression Dysthymia

Emotionally unstable PD traits

Plan: Suggestions?

Plan: Consider changing antidepressant

Ivy college

Cognitive analytical therapy

Plan: CAT cannot be provided-referral to regional psychotherapy department

Assessment: Assessed over several sessions

Took place before and during end of year exams

Fear of not being liked and being not good enough

Recognised that this affects relationships

Struggles with being apart from family

Different relationship described with sisters

Assessment Impression:

X presented initially in a slightly detached manner which made it difficult to engage with her. She described marked anxieties and insecurities which often left her feeling fragile and overwhelmed. Over the course of the assessment sessions her slightly detached narrative gave way to a more human presentation of someone who struggled with interpersonal relationships in part because they stirred up strong feelings including (when faced with limitations) her feelings of frustration and anger

Recommendations: Although I suspect that X is essentially looking for a supportive environment in which she can be understood, she does have some capacity to engage with a reflective process, to be curious and to understand. She is aware that her insecurities and anxieties result in difficulties in her interpersonal relationships.

I wonder about her capacity to tolerate difference given her closest relationship has been with her twin who is “her other half”.

I think at this point a brief individual psychotherapy will provide X with an opportunity to reflect on her relational difficulties and understand more about her own internal and external dynamics.

First appointment Boundaries explained and agreed

Appeared able to speak freely

Summer holiday not what she expected

Talks extensively about having failed end of year exam and having to resit

Describes suicide attempt to me

Describes effect on current boyfriend

Reflection on session Arrived slightly late

More fluent than expected

Relationship with others-sibling rivalry

What is it like to be only half

Sense of pushing rage/ anxiety into other people

1st treatment session

Thoughts?

Reflections Showing narcissistic traits

Left me feeling annoyed as was keen to transgress boundaries

Projections of neglectful object

Boundaries Victims of abuse usually come from families with inconsistent nurturing & grossly distorted family roles

External boundaries-same place and time, same length of time

No additional contact

In psychoanalytical terms, analyst should be confined to interpretations

Language-first name or not?

No self-disclosure

No physical contact

Questions