Personality Disorder

Dr Ray Haddock

Consultant Psychiatrist in Psychotherapy

Sheffield Care Trust

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What is personality that it gets disordered?

How do we decide if it is disordered?

When is it disordered?

Where is it disordered?

When is a disordered personality not disordered?

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Objectives of Lecture1. To briefly consider how personality is

defined.

2. To describe and compare main diagnostic systems

3. How to diagnose personality disorder

4. What does NICE say

5. Treatment and Management evidence and the lack of it.

6. The future - some speculation

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What is personality?http://dictionary.reference.com/browse/personality

The visible aspect of one's character as it impresses others: He has a pleasing personality.

A person as an embodiment of a collection of qualities: He is a curious personality. Psychology . a. the sum total of the physical, mental, emotional, and social characteristics of an individual. b. the organized pattern of behavioral characteristics of the individual.

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The quality of being a person; existence as a self-conscious human being; personal identity.

The essential character of a person.

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Genes

Birth

Gene pool

CommunityWorkIntimateReproductionPersonal preference and choice

AdolescenceEarly

adulthood

Family, school peersChildhood

CaregiverDevelopment

NeurobiologicalPhysicalNutritionalEducationalEmotional

ModelsAttachment

Social learningPsychoanalysis

PiagetMaslow

EtcEtcEtc

Adulthood

Personality

Adaptability to context

Transition Home to

community

Adaptation Context

Life StageOf

Personality

Personality from first principles

Definitions of Personality Disorder ICD 10 “….clinically significant conditions and behaviour which

tend to be persistent and are the expression of an individual’s characteristic lifestyle and mode of relating to others…….as a result of both constitutional factors and social experience…..”

DSM IV “…. is an enduring pattern of inner experience and behaviour

that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.”

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DSM-5(No Longer Axis II)

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose personality disorder, the following criteria must be met.

• Significant Impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning

• One or more pathological personality trait domains or trait facets

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General diagnostic criteria for a personality disorder (derived from ICD 10 and DSM IV From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann

A. An enduring pattern of inner experience that deviates markedly from the expectations of the individual’s culture.This pattern is manifested in two (or more) of the following areas:1) Cognition, i.e. Ways of perceiving and interpreting self, other people and events2) Affectivity, i.e. The range, intensity, lability and appropriateness of emotional response3) Interpersonal functioning4) Impulse control

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General diagnostic criteria for a personality disorder (derived from ICD 10 and DSM IV From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann

A. An enduring pattern of inner experience that deviates markedly from the expectations of the individual’s culture.This pattern is manifested in two (or more) of the following areas:1) Cognition, i.e. Ways of perceiving and interpreting self, other people and events2) Affectivity, i.e. The range, intensity, lability and appropriateness of emotional response3) Interpersonal functioning4) Impulse control

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Comparison of DSM and ICDDSM-IV-TR DSM-IV-TR/DSM 5 ICD-10

Cluster A Schizoid/Removed Schizoid

Paranoid/Removed Paranoid

Schizotypal

Cluster B Borderline Emotionally Unstable-Impulsive-Borderline

Antisocial Dissocial

Narcissistic

Histrionic/Removed Histrionic

Cluster C Avoidant Anxious (avoidant)

Dependent/Removed Dependent

Obsessive-Compulsive Anankastic

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Differences between mental state and personality disorders

From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann

Mental State Disorders Personality Disorders

Temporary (Usually) Permanent (or at least long standing)

Reactive Generative

Dominated more by symptoms than behaviour

Dominated more by behaviour and relationships with others

Diagnosed mainly on mental state

Diagnosed on basis of long term function

May develop into other mental states

Tends to remain stable

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DSM-5

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose personality disorder, the following criteria must be met.

• Significant Impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning

• One or more pathological personality trait domains or trait facets

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General diagnostic criteria for a personality disorder - DSM 5

C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations

D. The impairments in personality functioning and the individual’s personality trait expressions are not better understood as normative for the individual’s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual’s trait expression are not solely due to the direct physiological effects of a substance (e.g., A drug of abuse, medication) or a general medical condition (e.g., severe head trauma

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DSM-5 IN

AntisocialAvoidantNarcissisticObsessive CompulsiveSchizotypalPD Trait specific

Negative affectivityDetachmentAntagonismDisinhibition vs CmpulsivityPsychotisism

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DSM-5

Out Paranoid

SchizoidHistrionicDependant

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DSM 5 specific criteria for each PD

A. Significant Impairments in personality functioning 1. Impairments in self functioning (a or b)

a. Identityb. Self-direction

2. Impairments in interpersonal functioning(a or b)

B. a. Empathyb. Intimacy

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DSM 5 specific criteria for each PD

B. Pathological Personality traits in the following domains: (e.g. for Antisocial)

1 Antagonism etc2 Disinhibition

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Prevalence General Population - lifetime 2-18% !! Primary Care 5-9% ?? great variation Psychiatric population 30-40% Inpatient populations 40-50% Prison 70% +

Conclusion?

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Making the Diagnosis - 1 History, History History! Recurring patterns of difficulty/symptoms Wide range of previous diagnoses Developmental history Problems at school Abuse/neglect (repeated and recurrent) Family

patterns/relationships/breakdowns/violence The internal world of the child Changes in context

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Making the Diagnosis 2 “Childhood was normal and all

developmental milestones were normal” !

Most developmental, milestones are genetically and biologically driven. Therefore it takes very substantial environmental factors to change them enough to notice as for most the range is variable in any case.

There is however an experience of childhood and development in the developmental context

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Making the Diagnosis Symptoms All symptoms are possible Interpersonal relationships – child and adult Behaviour reflects perception of reality- go

beyond the explanation Move from open to specific questioning

NICE GUIDELINES -Borderline PDTreatment and Management

CMHT management CPA Consistent approach to treatment

and management No stand alone short term

psychological treatments Pharmacological treatments? - only

for treatment of co-morbidity

NICE GUIDELINES -Borderline PDPsychological Treatment

No overwhelming evidence for any treatment

Dialectical Behaviour Therapy (Linehan) - certain groups - female -self harm, impulsivity

Psychodynamic therapies - evidence but not gold standard

Therapeutic community - for severe No particular role for inpatient

treatment

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Make the diagnosis Discuss and put in context – “normalise” Long term treatment and management plan Psycho-education Risk management Impulse management and control Specific interventions (short term to long term) Symptom targeted medication At every step it is important to attend to

engagement and collaboration

Treatment and management - Summary

NICE GUIDELINES - Antisocial Personality Disorder

Mostly Tier 4 management No specific treatments Forensic - low/high secure Mental Health services -

management of mental illnesses Intervention focussed more on

prevention - intervention with children and families

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Long term outcomes Some evidence that severity of disorder

diminishes with age Exacerbation and reduced recovery rates from

neurotic disorders The more severe/co morbidity the smaller the

response to interventions Impact of therapy? Mortality?

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The Future? Models of personality disorder that relate to

aetiology - increased understandingGeneticDevelopmentalNeurobiology of social functioning

Treatment and management approaches that are based on sound evidence and theoretical models

E.G.

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Genes

Birth

Gene pool

CommunityWorkIntimateReproductionPersonal preference and choice

AdolescenceEarly

adulthood

Family, school peersChildhood

CaregiverDevelopment

NeurobiologicalPhysicalNutritionalEducationalEmotional

ModelsAttachment

Social learningPsychoanalysis

PiagetMaslow

EtcEtcEtc

Adulthood

Personality

Adaptability to context

Transition Home to

community

Adaptation Context

Life StageOf

Personality

Personality from first principles

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Severe PD

ModeratelySevere PD

PersonalityDisorder

PersonalityDifficulty not qualifying as PD

No PersonalityDisturbance

Social/Schizoid

Dissocial/Externalising

Anxious dependant/Internalising

Obsessional/Anankastic

Emotional distress/Instability

Proposed ICD 11 classification for Personality disorder

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A Histrionic personality B Anankastic personality C Paranoid personality D Dissocial personality E Schizoid personality F Borderline personality – unstable type G Borderline personality – impulsive type

Which of the above corresponds best to the following:

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140. A man attends with his CPN. He becomes very tearful when speaking about his depression but then changes quickly to talking rather loudly about his plans for the future

141. A man complains that his written complaint to social work is being ignored. He refuses to talk to the psychiatrist about it as “she’ll not do anything about it either”.

142. A woman is kept waiting a couple of minutes by the nurse having to take a telephone call. She smashes a window in the bathroom and is about to slash herself saying “it’s your fault I’m doing this”.

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Answers

140. Probably A 141 C 142 G

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Theme: personality Eysenck Personality Questionnaire Rorschach test Repertory grid Thematic appreciation test Minnesota Multiphasic Personality Inventory ‘Big 5’ personality test Q sort

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Lead in: Which of the above methods used to assess personality has the following features?

This projective tests of personality requires individuals to make up a storey based on ambiguous pictures of people and scenes

An idiographic test of personality developed by George Kelly

This personality tests has scales which measure the tendency to answer questions in a defensive and/or socially desirable manner

This personality test posits that one of its dimensions reflects the degree of cortical arousal

This test has dimensions measuring openness, conscientiousness extraversion, agreeableness and neuroticism

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Theme: personality D C E A F

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Useful sources of information Mental Health Foundation –

http://www.mentalhealth.org.uk/information/mental-health-a-z/personality-disorders/

Mind – http://www.mind.org.uk/help/diagnoses_and_conditions/personality_disorders

The Royal College of Psychiatrists –http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/personalitydisorders/pd.aspx