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
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