Personality and Personality Disorders
Transcript of Personality and Personality Disorders
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
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