Personality Disorders

Personality Disorders

Diagnosis

·        Personality disorder = 

o   An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual‟s culture

o   Is inflexible and pervasive across a broad range of situations

o   Has its onset in adolescence or early adulthood, is stable over time and leads to distress 

o   And is manifested in two or more of the following: interpersonal functioning, affectivity (emotionality), impulse control, cognition (style of thinking)

·        Key characteristics:

o   Rigidity: very pervasive rigidity of cognitions and behaviours 

o   Avoidance: don‟t want to look at or experience their thoughts or feelings ® problem for therapy (compulsory treatment won‟t change anything) 

o   Long-term interpersonal difficulties

·        Differentiating from axis 1: 

o   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)

o   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) 

o  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: 

o  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) 

o  But it is now more functional to use different strategies in different situations 

o  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:

o   Frantic efforts to avoid real or imagined abandonment

o   Unstable and intense relationships alternating between extremes of idealization and devaluation 

o   Impulsivity in areas that are potentially self-damaging: eg spending, sex, substance abuse, binge eating

o   Recurrent suicidal behaviour, parasuicides, threats or self-mutilations

o   Marked reactivity or mood, difficulty controlling anger

·        Characterised by: 

o   Schema: I can‟t control myself ® overdeveloped emotional responsiveness & underdeveloped self-identity, impulse control 

o   Core belief about self: I‟m defective, helpless, vulnerable, bad

o   Belief about others: other people will abandon me, can‟t be trusted 

o   Combination of these two leads to extremes of behaviour: need to depend on others but will be abandoned

o   Hate being alone: may attend A & E or ring friends late at night for company

·        Self-harm:

o   Begins between 10 and 16: often following a major life change 

o   „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 

o   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

o   Strategy in the game of life: to manipulate people or drive them away

o   Always need to screen for concurrent depressive episode: this will need treatment

·        What helps in situations of self-harm

o   Non-judgemental acceptance

o   Teach other ways to self-sooth

o   Deal with trigger event: what causes the negative feelings 

o   Address underlying issues: but shouldn‟t do trauma counselling without also improving coping skills

·        Aetiology: 

o   Genetic loading in temperament: ¯perseverance, ­impulsivity, ¯affect regulation, ­stimulation seeking 

o   Sexual abuse in 75% (but not all severely abused develop the disorder): feeling unsafe, victimisation, trauma, terror 

o   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) 

o   Other societal factors eg invalidating environments (eg neglect), marginalisation 

o   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