Lecture 7 - Personality Disorders PDF

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Personality Disorders The NHS define them as ‘A person with a personality disorder thinks, feels, behaves or relates to others very differently from the average person’. This definition has overlapping areas with personality, thinking, feeling and behaving. The DSM-5 define personality disorders as something which occur in adolescence or early adulthood. Cannot diagnose an individual with one if they seem to develop it later in life. Causes and Risk Factors - Genetic component – Results from the combination of genes inherited by a person and early environmental influences such as experiencing a distressing childhood experience such as abuse or neglect. - Parenting – Important to look at the parent and child relationship. Patterns of neglect or abuse often are a risk factor. - Socioeconomic status can leave individuals at a higher risk of developing a personality disorder. History The Ancient Greeks (Theophrastus) wrote about 30 characters who deviated from the norm and gave them names e.g. the chatty man, stupid man, coward. They were developed by studying people and looking at individual differences and hints towards the idea of personality traits. In the 20th century, Julius Koch had his own asylum and developed the term ‘psychopathic inferiority’ which influenced later concepts of personality disorders. The DSM-5 introduced an alternative model for personality disorders to address the shortcomings of the conventional model which often has overlap between disorders making it difficult to diagnose as don’t know if it is the right one. The most diagnosed disorder is unspecified personality disorder which means that the individual meets the general criteria, but not for a specific disorder. Additionally, it is based on the categorises perspective which looks at personality with the background of traits. It defines personality disorders as impairments in personality functioning (criterion A) and pathological personality traits (Criterion B). DSM-5 Criterion A - A = Moderate or greater impairment in personality functioning - To diagnose, a person needs to have an impaired self or functioning and there are 4 areas in which impairment must be seen in at least 2. - The clinician rates level of functioning on Level of Personality Functioning Scale (LPFS). - 5 levels with 4 indicating extreme impairment characterised by impairment in identity, weak or distorted self-image and confusion around self-appraisal. - Used for all personality disorders, but there are unique descriptions for what msut be impaired.

DSM-5 Criterion B -

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B = One or more pathological traits. These correspond to the Big Five, but openness to experience is replaced with psychoticism which was proposed by Eysenck. Healthy traits are not always healthy e.g. someone being extremely agreeable might be gullible which is not healthy for an individual. They key for a healthy individual is flexibility.

Other General Criteria - C = Pervasiveness – Symptoms are relatively inflexible and pervasive across situations. - D = Stability – Symptoms are relatively stable across time, onsets in adolescence or adulthood. - E, F and G – Alternative explanations (Differential diagnosis) Antisocial Personality Disorder Typical features - Failure to conform to lawful and ethical behaviour - Egocentric, lack of care for others - Deceitfulness, irresponsibility, manipulativeness, risk-taking B. Six or more of (out of 7).

Individuals at Risk - Not common – less than 1% of the population - More common in men than women - Numbers increase when look at prison population, explained by the disorder being closely associated with unlawful behaviour. - 47% of male and 21% of female prisoners - Heritability estimate of 0.5-0.6 - Genes a little more influential than environmental factors - Links to alcohol and drug misuse - Difficult to treat as people often not motivated to get treatment as they don’t believe that something is not right. Medication is not recommended. Distinction Between Psychopath and Sociopath - They share some features - Psychopaths lack empathy and remorse - Psychopaths are manipulative whereas sociopaths spontaneously commit crimes. - Sociopaths can form relationships and feel remorse whereas psychopaths cannot as they lack empathy.

- Psychopaths show brain differences with little activity in the amygdala - Psychopaths born whereas sociopaths are made. Hare Psychopathy Checklist (PCL-R) - Tool used to diagnose someone with psychopathy. Used in adult males in prisons, criminal psychiatric hospitals and those awaiting psychiatric evaluations or trial. - First part is an interview, second is when the examiner goes through the subjects case history as they might be lying so need to confirm. - Maximum score is 40. 30 is necessary to diagnose with psychopathy. Avoidant Personality Disorder Typical Features - Avoidance of social situations - Inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy. - Anxious preoccupation with negative evaluation and rejection. - Fears of ridicule or embarrassment. B = Three or more, one must be 1 -

Relates to traits of negative affectivity and detachment.

Individuals at Risk - Prevalence rate of 2.36% in general American population. - Equally in males and females - 14.7% of psychiatric outpatients - Debated if social anxiety disorder and avoidant personality disorder are the same or distinct from each other. - Comorbidity of 20-40% - Expected to not improve without treatment - Difficult for therapist to maintain trust with patient. Borderline Personality Disorder Typical Features - Instability of self-image, personal goals, interpersonal relationships and affects - Accompanied by impulsivity, risk taking and/or hostility B – Four or more, at least one must be 5,6 or 7. 1. Emotional lability 2. Anxiousness 3. Separation insecurity 4. Depressivity (Negative emotions)

5. Impulsivity (Disinhibition) 6. Risk taking (Disinhibition) 7. Hostility (Antagonism)

People also often self-harm as they are in so much pain in the time and it stops them feeling emotional pain. Individuals at Risk - 1-5.9% of US population

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More women are affected, however sometimes there is equal frequency between the sexes The most common personality disorders in clinical populations Comorbid with mood, anxiety disorders and substance abuse Self-harm occurs in 30%-80% Lifetime risk of suicide is 3-10% High heritability estimates of 0.65 to 0.75. Medication not promising, but most people can recover with treatment.

Narcissistic Personality Disorder Typical Features - Variable and vulnerable self-esteem with attempts at regulation through attention and approval seeking - Either overt or covert grandiosity - Exaggerated feeling of self-importance B. Both of the following 1. Grandiosity 2. Attention seeking - These are similar to detachment Individuals at Risk - 1% in general population - 2-16% in clinical populations - Higher in men than women - High comorbidity with other disorders such as depressive, anorexia – distorted self-image, substance misuse. - Often don’t seek treatment. When people do it is usually to do with other disorders such as depression. - Treatment rarely sought but focuses on empathy. No medication helps. - High heritability – 0.79 Obsessive-Compulsive Personality Disorder Typical Features - Difficulties in establishing and sustaining close relationships - Associated with rigid perfectionism, inflexibility and restricted emotional expression - Concern with orderliness - Wish to control their environment - Rigid perfectionism takes over so much of life that it is unhealthy. - Unable to relax - Little facial expression B. Three or more, one of which must be 1 1. Rigid perfectionism 2. Perseveration Individuals at Risk - 2.1% - 7.9% in the general population - Most common personality disorder - 2:1 men: women - Uncommon in clinical populations

3. Intimacy avoidance 4. Restricted affectivity

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Long-term psychotherapy HE of 0.6

Schizotypal Personality Disorder Typical Features - Impairments in the capacity for social and close relationships - Eccentricities in cognition, perception and behaviour - Distorted self-image and incoherent personal goals - Suspiciousness and restricted emotional expression B. Four or more 1. Cognitive and perceptual dysregulation 2. Unusual beliefs and experiences 3. Eccentricity 4. Restricted affectivity 5. Withdrawal 6. Suspiciousness Individuals at Risk - Lifetime prevalence of 3.9% in the US - Higher rates among men (4.2%) than women (3.7%) - Uncommon in clinical populations - Common in homeless people - Easy to identify, but difficult to treat with psychotherapy - People often underestimate their symptoms and have anxiety about getting close to a therapist. Summary Personality disorders chronic and long-lasting conditions with a general prevalence of 6-9%. They have frequent co-occurrence with other personality disorders and are difficult to treat as no medication is available. There is also moderate to high HE....