Psychological medicine

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Personality Disorders

Diagnosis

  • Personality disorder = 
    • An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual‟s culture
    • Is inflexible and pervasive across a broad range of situations
    • Has its onset in adolescence or early adulthood, is stable over time and leads to distress 
    • And is manifested in two or more of the following: interpersonal functioning, affectivity (emotionality), impulse control, cognition (style of thinking)
  • Key characteristics:
    • Rigidity: very pervasive rigidity of cognitions and behaviours 
    • Avoidance: don‟t want to look at or experience their thoughts or feelings ® problem for therapy (compulsory treatment won‟t change anything) 
    • Long-term interpersonal difficulties
  • Differentiating from axis 1: 
    • There is substantial comorbidity with axis 1 – but must be distinguished from axis 1 (which is episodic, different from normal state. Personality disorders ARE the normal state)
    • Need to exclude other possible factors: eg substance abuse, head injury, general medical condition, mood or psychotic disorder (ie must not occur exclusively in the course of an axis 1 disorder) 
    • Consider axis 2 if: ongoing non-compliance, client unaware of effect of their behaviour on others, client acknowledges need for change but motivation is questionable, always blame others for their behaviour
  • Can‟t diagnose before age 19 (much of the description of the disorders is also descriptive of adolescence)
  • Requires longitudinal assessment and collateral information
  • Must evaluate within a cultural and religious context (DSM 4 is white & American)
  • Labelling someone with a personality disorder can be difficult, given limited information and possible reactions ® often people labelled „traits of disorder X‟
  • Presentation is often not for the disorder (as it could be, for example, for depression), but for the degree of impairment due to excessive or little compliance with treatment
  • Treatment is difficult and long-term: given deeply imbedded nature and genetic predisposition to personality
  • Explanation to client: 
    • Behaviours were probably adaptive to survive difficult childhood experiences (at some point behaviours were helpful – but they‟ve got stuck). Take care to look for an explanation not someone to blame (people usually do the best they can) 
    • But it is now more functional to use different strategies in different situations 
    • Take care of criticising non-compliance: few are proud of „doing what they‟re told‟ – would you rather be a sheep or an eagle?

Examples of Personality Disorders

Borderline Personality Disorder

  • Incidence: 3 – 5 % (cf 1% for Schizoid)
  • Criteria include:
    • Frantic efforts to avoid real or imagined abandonment
    • Unstable and intense relationships alternating between extremes of idealization and devaluation 
    • Impulsivity in areas that are potentially self-damaging: eg spending, sex, substance abuse, binge eating
    • Recurrent suicidal behaviour, parasuicides, threats or self-mutilations
    • Marked reactivity or mood, difficulty controlling anger
  • Characterised by: 
    • Schema: I can‟t control myself ® overdeveloped emotional responsiveness & underdeveloped self-identity, impulse control 
    • Core belief about self: I‟m defective, helpless, vulnerable, bad
    • Belief about others: other people will abandon me, can‟t be trusted 
    • Combination of these two leads to extremes of behaviour: need to depend on others but will be abandoned
    • Hate being alone: may attend A & E or ring friends late at night for company
  • Self-harm:
    • Begins between 10 and 16: often following a major life change 
    • „Toxic self-soothing‟: eases the inner pain – powerful way to feel better. Can either help the dissociation (turn off emotions) or help them feel real 
    • Communication strategy: there is chaos within family and have never asked for help ® can‟t ask for help now. But self-harm is not always a cry for help. For most, self-harm is a private matter
    • Strategy in the game of life: to manipulate people or drive them away
    • Always need to screen for concurrent depressive episode: this will need treatment
  • What helps in situations of self-harm
    • Non-judgemental acceptance
    • Teach other ways to self-sooth
    • Deal with trigger event: what causes the negative feelings 
    • Address underlying issues: but shouldn‟t do trauma counselling without also improving coping skills
  • Aetiology: 
    • Genetic loading in temperament: ¯perseverance, ­impulsivity, ¯affect regulation, ­stimulation seeking 
    • Sexual abuse in 75% (but not all severely abused develop the disorder): feeling unsafe, victimisation, trauma, terror 
    • 75% are female (men more likely to react by becoming antisocial – same motivation but take it out on others rather than themselves – or substance use). Behaviour in collusion with dominant western values (eg emotionality, dependence) 
    • Other societal factors eg invalidating environments (eg neglect), marginalisation 
    • Most affected people have this cluster of factors, but someone can still get it even if the best of upbringings Þ ?stronger than normal predisposing temperaments