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Personality Disorder

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Title: Personality Disorder


1
Personality Disorder
  • Dr. Steven Allan

2
Aims of Lecture
  • Provide a definition of personality disorder
  • Describe the different clusters of personality
    disorder
  • Briefly outline the aetiology of personality
    disorder
  • Give overview of treatments for personality
    disorder

3
PD Definition (1)
  • Enduring pattern of inner experiences behaviour
    that deviates markedly from the expectations of
    the individuals culture.

4
PD Definition (2)
  • This Enduring Pattern is manifest in 2 (or more)
    of following areas
  • 1) Cognition (way of perceiving or interpreting
    self, others, events
  • 2) Affect (range, intensity, fluctuating,
    appropriateness of emotional response)
  • 3) Interpersonal functioning
  • 4) Impulse Control

5
PD Definition (3)The 3Ps Not PD unless
  • Problematic (clinically significant distress or
    problems for self or others may be difficulties
    in social life, work, law)
  • Persistent (pattern is stable long-standing
    present since early adulthood or adolescence and
    continues to adulthood)
  • Pervasive (pattern is inflexible in broad
    range of personal or social situations)

6
Prevalence of PD
  • Range of Estimates
  • 1-3 of General Population
  • 10-20 Psychiatric Outpatients
  • 10-60 Psychiatric Inpatients

7
Generally recognised
  • Personality disorders are common conditions.
  • However, there is a large variation in severity,
    in degree of distress and dysfunction (hence the
    ranges in the prevalence data).
  • People with a personality disorder are
  • More vulnerable to other clinical problems,
    especially depression.
  • More likely to experience relationship, housing,
    and employment difficulties.
  • More likely to suffer from alcohol/drug problems

8
DSM IV Clusters
  • Cluster A
  • (often appear odd/eccentric)
  • Cluster B
  • (often appear dramatic, emotional, or erratic)
  • Cluster C
  • (often appear anxious or fearful)

9
Cluster A
  • Paranoid Distrust suspicious of others
  • Schizoid Detached from social relationships
    restricted range emotional expression.
  • Schizotypal Discomfort with close relationships
    cognitive/perceptual distortions eccentric
    behaviour

10
Cluster B
  • Antisocial Disregard for frequent violations
    of the rights of others
  • Borderline Instability of relationships,
    self-image, emotions, control over impulses.
  • Histrionic Excessive emotionality attention
    seeking.
  • Narcissistic Grandiosity, need for admiration,
    lack of empathy.

11
Cluster C
  • Avoidant Social inhibition, feelings of
    inadequacy, hypersensitive to negative
    evaluation.
  • Dependent Excessive need to be taken care of,
    leading to submissive and clinging behaviour.
  • Obsessive-compulsive Preoccupied with
    orderliness and perfectionism at expense of
    flexibility.

12
Aetiology of PD
  • Little firm evidence
  • Many different explanations
  • Explanations often some variant of temperament
    interacting with adverse childhood experiences
  • Particular explanations may be overly dependent
    on the particular theoretical orientation of
    author(s)
  • Beware of simple explanations

13
Cluster A Difficulties
  • Considered odd or eccentric
  • Leads to difficulties FORMING relationships.
  • Example of vicious circle
  • Poor relationships ? social isolation
  • Social isolation ? negative emotions, mood
    disorders, anxiety
  • Unhappiness ? increase in odd or eccentric
    behaviour

14
Cluster A Treatment
  • Very little research evidence
  • Rarely present for treatment
  • IF present to services then offer help for mood,
    anxiety plus interventions aimed at assisting
    with social consequences e.g., family disruption,
    employment, housing

15
Cluster A Do not seek treatment
  • Typical reasons
  • Paranoid Do not seek help, suspicious
    distrustful of others, if do present then tend to
    drop out of therapy.
  • Schizoid Socially withdrawn, tend not to engage
    with therapy, treatments offered at present leads
    to little progress.

16
Schizotypal
  • More research due to
  • ?behaviour having some similarity to
    schizophrenia
  • ?genetic link with schizophrenia
  • Anti-psychotic drugs ? very limited improvement
    (also side-effects!)
  • Therapy Aim to reconnect client to social world
    recognise limits of their thinking (but limited
    success)

17
Cluster A Summary
  • At present- Very little research on Cluster A
  • Therefore- Very little evidence of what works
  • Main approach with Cluster A clients is to
    provide help with the social consequences of
    their condition.
  • e.g., Family disruption Loss of employment Loss
    of housing

18
Cluster C (anxious/fearful)
  • Avoidant Social inhibition, feelings of
    inadequacy, hypersensitive to negative
    evaluation.
  • Dependent Excessive need to be taken care of,
    leading to submissive and clinging behaviour.
  • Obsessive-compulsive Preoccupied with
    orderliness and perfectionism at expense of
    flexibility.

19
Cluster C Research
  • No controlled treatment outcome studies.
  • One treatment outcome study (not controlled) for
    those with either avoidant or obsessive-compulsive
    PD. Barber et al., 2002
  • 50 weekly treatment sessions
  • 39 APD still had APD diagnosis at end of trial
  • 15 OCPD retained diagnosis at end.

20
Cluster C Treatment
  • Involve modifications to the major approaches of
    (for example)
  • Psychodynamic
  • CBT
  • Marital/family therapy
  • Medication

21
(e.g.,)Modifications Needed in CBT
  • Greater emphasis on therapeutic relationship.
  • More sessions over longer time period.
  • Focus on core beliefs.
  • Past history of client more important.
  • Emphasis on developing new ways of
    thinking/behaving rather than changing old ways
    of thinking/behaving.

22
Core Beliefs (1)
  • CBs Originate in early childhood.
  • CBs make sense given clients experiences
  • Are unconditional statements about self/others.
  • Act like strict/rigid rules which have been
    over-learned and which are over-obeyed.

23
Core Beliefs (2)
  •  Difficult for client to see when the rule is
    inappropriate.
  • Aim of Therapy
  • Weaken core beliefs
  • Strengthen alternative, more adaptive beliefs

24
Cluster B
  • Borderline Instability of relationships,
    self-image, emotions, control over impulses.
  • Antisocial Disregard for frequent violations
    of the rights of others
  • Histrionic Excessive emotionality attention
    seeking.
  • Narcissistic Grandiosity, need for admiration,
    lack of empathy.

25
Cluster B Research
  • Research Focus
  • Borderline
  • Antisocial
  • Much Less Research
  • Histrionic
  • Narcissistic

26
Borderline Personality Disorder
  • (DSM IV)
  • Pervasive pattern of instability in
  • Relationships
  • Self-image
  • Affect
  • Also marked impulsivity.

27
BPD Characteristics
  • Need 5 of these to be present
  • Fear of abandonment
  • Unstable intense personal relationships
  • Identity disturbance
  • Impulsivity
  • Recurrent deliberate self-harm
  • Unstable affect
  • Feelings of emptiness
  • Difficulties controlling anger
  • Stress related paranoid ideas or dissociation

28
Risk factors for BPD?
  • No single psychosocial or biological factor is
    either necessary or sufficient to cause PD.
  • BUT
  • Retrospective recall of childhood events and more
    objective information (e.g., court records)
    suggest
  • Family breakdown
  • Neglectful parenting (not loving and supportive)
  • Overprotective parenting (not encouraging
    independence and autonomy)
  • History of severe physical, emotional and/or
    sexual abuse

29
BUT need for caution
  • None of these risk factors are specific to BPD.
  • Many clinicians came to believe that a history of
    sexual abuse was specifically linked with
    development of BPD but
  • 20-40 of those diagnosed BPD do not report
    childhood abuse.
  • Many who experience childhood sexual abuse do not
    develop personality disorder

30
Development of BPD (1)(Linehan suggestion)
  • A tendency to difficulties regulating ones
    emotions (a heritable trait).
  • Leads to increased experiences/perceptions that
    others do not understand the intensity of ones
    feelings.
  • This leads to self feeling invalidated by ones
    social environment (e.g., feelings are
    dismissed, denied told what to think/feel).
  • Above may lead to BPD like characteristics or a
    less severe case of BPD.

31
Development of BPD (2)(Linehan suggestion)
  • In extreme invalidating environments
  • e.g., child experiences abusive acts (emotional,
    physical, sexual)
  • Leads to violation of autonomy, respect, freedom
    of choice and
  • More severe BPD characteristics develop.
  • Above fits with clinical experience but no
    empirical evidence.

32
Common Presenting Problems
  • Those with more severe problems
  • Complex interpersonal difficulties
  • Deliberate self-harm
  • Risk of suicide
  • Risk to others (aggressive/violent or take risks
    that endanger others)
  • High use of medical mental health resources

33
Challenges for Therapist
  • Poor treatment compliance
  • Constant shifting of problems goals
  • Focus of therapy lost with regular crises
  • Therapist becomes demoralised nothing seems to
    work

34
Challenge for Mental Health Services
  • BPD is one of the most difficult conditions to
    treat
  • However, it may be the the most common
    personality disorder seen by adult mental health
    services.
  • This has led to BPD being (probably) the most
    researched of all the PDs.

35
Research on treatments (e.g.s)
  • Individual Psychodynamic approaches
  • Day Hospital approach
  • Therapeutic Community approach
  • Individual Cognitive Therapy
  • Schema Therapy
  • Problem Solving Therapy
  • Dialectical Behaviour Therapy
  • Cognitive Analytic Therapy
  • Medication

36
Methodological Problems
  • Small sample sizes
  •  
  • Selection bias e.g., better functioning clients
  •  
  • No randomization to treatment and control
  •  
  • Lack of standard outcome measures
  •  
  • Actual interventions sometimes poorly defined.

37
3 Major Trials
  • Psychodynamic Orientation
  • Piper et al (Edmonton, Canada)
  • Bateman Fonagy (Halliwick Psychotherapy Unit,
    UK)
  • Dialectical Behavioural Therapy
  • Linehan group (Seattle, Washington U.S.)
  • (Pragmatic, CBT - whatever works)

38
For all 3 Studies Note
  • Very intensive treatment packages
  • Packages are wide ranging with many components
  • The aim of presenting the details of these
    studies is to give a flavour of the comprehensive
    treatment approach that may be required with this
    client group

39
Piper Study (1)
  • Day Hospital Program
  • (7hrs/day, 5 days/week, for 4months)
  • Staff Psychoanalytically trained, very
    experienced
  • Clients 80F/40M (not all BPD)
  • Design Randomised treatment versus control
    (delayed treatment)

40
Piper Study (2)
  • Programme Components
  • Community meetings
  • Small group exploration of difficulties
  • Self-awareness groups
  • Psychodrama sessions
  • Expressive arts (art therapy)
  • Family relations group
  • Problems re-entering community group
  • daily living skills, recreation/exercise,
    career help

41
Piper (3) Measures
  • Measures included
  • Social dysfunction
  • Family dysfunction
  • Interpersonal behaviour
  • Mood severity
  • Life-satisfaction
  • Self-esteem

42
Piper (4) Results
  • Significant improvements
  • Average treated patient scores exceeded 76 of
    patients in control group
  • Improvements maintained at 8-month follow-up
  • Waiting list did not improve (no spontaneous
    recovery)
  • Drop out rate near 30 (typical?)

43
Bateman Fonagy (1)
  • Day Hospital Program (length 1.5 yrs)
  • Staff Psychodynamically orientated but not
    formally trained
  • Clients 13F/6M All diagnosed BPD
  • Design Randomised treatment versus control
    (standard psychiatric care)

44
Bateman Fonagy (2)
  • Components of Therapy
  • Community meeting (1/week)
  • Group analytical psychotherapy (3/wk)
  • Psychoanalytic psychotherapy (1/wk)
  • Expressive psychotherapy (e.g., art therapy,
    psychodrama) (1/wk)
  • medication review (1/month)
  • case review (1/month)

45
Bateman Fonagy (3)
  • MEASURES (included)
  • Frequency of suicide attempts/self harm
  • Number/duration of inpatient admissions
  • Use of psychotropic medication
  • Self reported depression/anxiety/distress
  • Interpersonal functioning
  • Social adjustment

46
Bateman Fonagy (4)
  • RESULTS
  • Significant improvement on all variables
  • Improvement began at 6 months and continued to
    end of treatment at 18 months
  • Improvements maintained ( continued) at 18-month
    follow-up
  • TAU did not improve (no spontaneous recovery,
    some deteriorated)
  • Drop out rate 12

47
Linehan group (1)
  • Dialectical behaviour therapy (DBT)
  • DBT Integration of behaviour therapy and
    cognitive therapy with other perspectives and
    practices.
  • Dialectical philosophy guides treatment
  • Fundamental dialectic need for therapist to
    both accept client (as they are) AND insist on
    change.
  • Therapist to think in dialectical way (i.e., not
    polarised but to see value of opposing viewpoints
    and finding appropriate synthesis).
  • Involves use of principles and practices of Zen

48
Linehan group (2)
  • Specific Aim of DBT To reduce self-harm in
    women with BPD
  • Outpatient Program (length 1 yr)
  • Staff All highly trained in DBT
  • Clients 44 women diagnosed BPD
  • Design Randomised treatment versus control
    (standard psychiatric care/TAU)

49
Linehan group (3)
  • Four Primary Modes of Treatment
  • Individual therapy (1hr/week)
  • Group skills training (1/wk)
  • Telephone contact (24hr contact available)
  • Therapist consultation

50
Linehan group (4)
  • MEASURES (included)
  • Frequency of suicide attempts/self harm
  • Number/duration of inpatient admissions
  • Self reported anger, depression, etc.
  • Social adjustment

51
Linehan group (5)
  • RESULTS
  • Reductions in frequency/severity parasuicidal
    acts and number of medically treated
    episodes/days in hospital
  • Improvements in anger, but not in depression,
    hopelessness.
  • Improved social adjustment
  • In general, improvements maintained at 6- and
    12-month follow-up
  • Drop out rate 16

52
Conclusions
  • Research still at a very early stage
  • Very few randomised controlled trials
  • Numbers in these trials often small
  • Treatments often have many components - isolating
    the critical components difficult.
  • Way components are brought together or
    patterned may be critical but difficult to
    research

53
Reading/References
  • For overview of research on PD see relevant
    chapter in one or two of the Abnormal Psychology
    course texts.
  • These will also provide an overview of the
    treatments for other PDs not covered in the
    lecture.
  • Specific references for BPD research
  • Bateman Fonagy (1999). American Journal of
    Psychiatry, 156, 1563-1569. (the controlled
    trial)
  • Bateman Fonagy (2001). American Journal of
    Psychiatry, 158, 36-42. (18 month follow up)
  • Linehan et al. (1991). Archives of General
    Psychiatry, 48, 1060-1064.
  • Linehan et al. (1993). Archives of General
    Psychiatry, 50, 971-974 (follow up study).
  • Piper et al (1993). Hospital and Community
    Psychiatry, 44, 757-763.
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