Personality Disorder, Slides of Psychiatry

Download Personality Disorder and more Slides Psychiatry in PDF only on Docsity! Ministry of Defence Synopsis of Causation Personality Disorder Author: Dr David M B Christmas, University of Dundee, Ninewells Validator: Dr Jonathan Bisson, Senior Lecturer in Psychiatry, University Hospital of Wales, Cardiff September 2008 2 Disclaimer This synopsis has been completed by medical practitioners. It is based on a literature search at the standard of a textbook of medicine and generalist review articles. It is not intended to be a meta- analysis of the literature on the condition specified. Every effort has been taken to ensure that the information contained in the synopsis is accurate and consistent with current knowledge and practice and to do this the synopsis has been subject to an external validation process by consultants in a relevant specialty nominated by the Royal Society of Medicine. The Ministry of Defence accepts full responsibility for the contents of this synopsis, and for any claims for loss, damage or injury arising from the use of this synopsis by the Ministry of Defence. 2 1.3.4 One of the key differences between ICD-10 and DSM-IV is the multi-axial approach of the US classification. Mental illness is classified on the first axis, whilst personality disorder, if present, is classified on the second axis. Axes III- V cover physical illness, social stressors, and level of functioning. 1.3.5 The DSM-IV organises personality disorders into one of three “clusters” which contain disorders that share similar groups of symptoms and personality dysfunction. Like the ICD-10, there are no definitions of key terms to assist in assigning the person to the appropriate cluster. Cluster A (odd/eccentric). This cluster contains paranoid personality disorder, schizoid personality disorder, and schizotypal personality disorder • • • Cluster B (dramatic/emotional/impulsive). This group consists of antisocial personality disorder, borderline personality disorder, histrionic personality disorder, and narcissistic personality disorder Cluster C (anxious/fearful). This cluster contains avoidant personality disorder, dependent personality disorder, and obsessive-compulsive (anankastic) personality disorder 1.3.6 In terms of diagnostic criteria, for some personality disorders (histrionic, dissocial, and anxious/avoidant), ICD-10 has a slightly higher threshold, requiring more criteria to be met for diagnosis. It should also be noted that although most people with personality disorder will fit one specific type, some people with personality disorder have features of several different types. 1.4. ICD-10 criteria for personality disorder4 1.4.1 There is evidence that the individual's characteristic and enduring patterns of inner experience and behaviour as a whole deviate markedly from the culturally expected and accepted range. Such deviations must be manifest in more than one of the following areas: Cognition (i.e. ways of perceiving and interpreting things, people and events, forming attitudes, and images of self and others) • • • • Affectivity (range, intensity and appropriateness of emotional arousal and response) Control over impulses and gratification of needs Manner of relating to others and of handling interpersonal situations 1.4.2 The deviation must manifest itself pervasively as behaviour that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations. 1.4.3 There is personal distress or adverse impact on the social environment, or both. 1.4.4 There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence. 5 1.4.5 The deviation cannot be explained as a manifestation or consequence of other adult mental disorders. 1.4.6 Organic brain disease, injury, or dysfunction must be excluded as the possible cause of the deviation. 1.5. DSM-IV criteria for personality disorder 1.5.1 An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture. This pattern is manifested in 2 (or more) of the following areas: Cognition (i.e. ways of perceiving and interpreting self, other people, and events) • • • • Affectivity (i.e. the range, intensity, lability, and appropriateness of emotional response) Interpersonal functioning Impulse control 1.5.2 The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. 1.5.3 The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. 1.5.4 The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. 1.5.5 The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. 1.5.6 The enduring pattern is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. head trauma). 6 2. Clinical Features 2.1. For each of the disorders below, the cardinal features required for diagnosis using ICD- 10 are italicised under the heading “clinical features”. Typically, 3-4 of these features should be present along with the core features of personality disorder described above. 2.2. General 2.2.1 Epidemiology. Most studies show relatively consistent rates of personality disorders within the general population and among specific groups of individuals. Among community samples the prevalence rate of DSM-IV disorders is approximately 9%, with lower rates (5.1%) for ICD-10 disorders.6 The prevalence of all personality disorders is raised in psychiatric patients and, among community mental health teams, the rates of comorbid personality disorder in patients with a psychotic illness may be as high as 92%.7 2.3 Paranoid personality disorder 2.3.1 Epidemiology. 0.7% of the general population has this disorder which is found in 4 times as many men than women.8 2.3.2 Clinical features (4 should be present). People with paranoid personality disorder tend to be overly suspicious, and misconstrue the neutral intentions of others as being hostile or threatening. They are mistrustful, interpreting events as being conspiratorial. They are sensitive to setbacks, and have a tendency to bear grudges. They are typically argumentative and their sense of personal rights is out of keeping with the situation. Their relationships are characterised by jealousy, repeatedly doubting the sexual fidelity of their partner. Most patients are self-centred, with a self-referential and self-important outlook. 2.4 Schizoid personality disorder 2.4.1 Epidemiology. Approximately 1% of the UK population has schizoid personality disorder.8 It is more common in men than women. 2.4.2 Clinical features (4 should be present). These individuals are humourless, with few activities providing pleasure. They are seen by others as “loners”, tending to be emotionally cold, with little expression of emotion. Indeed, they tend to be detached - having limited ability to express warmth, tenderness, or even anger towards other people. In social situations, they appear indifferent to praise or criticism. Their activities are solitary and they are loveless, showing minimal interest in having sexual relationships with other people. They have no desire for close friendships and most appear to be friendless. Many schizoid people are introspective, and preoccupied by fantasy. In keeping with their indifference to social relationships, they often appear to be unconventional, showing little sensitivity to social norms and conventions. 2.5 Dissocial personality disorder 2.5.1 Epidemiology. Dissocial personality disorder is much commoner in men than women with up to 3-5% of men in the general population having the disorder.6 7 3. Aetiology 3.1. Introduction 3.1.1. The aetiology of personality disorder is largely unknown. Indeed, whilst certain associations have been described between specific life experiences and later personality disorder(s), the mechanism by which this influences behaviour is not known. Similarly, the development of most personality disorders is believed to have a genetic component, but the precise mechanism of interaction between a genetic predisposition and later experience is yet poorly understood. 3.1.2. Most theories of abnormal personality development reflect psychodynamic theories of the self. Such theories focus on early childhood experiences and how these affect the development of a person’s relationships with the world and other people. Most psychodynamic theories relate to early life (typically childhood) and such theories predicate that the effects of adverse experience as a teenager will be very different to that of an infant. There is no evidence that adverse experience in an individual over the age of 16 can cause personality disorder by itself. Indeed, in most cases there is evidence of disturbance of functioning prior to this, and such a diagnosis would be extremely rare in someone with normal personality functioning prior to the late teens. 3.1.3. It should be noted that most personality disorders research is conducted on relatively small numbers of patients, and it is difficult to confidently extrapolate findings to all cases of personality disorder. 3.2. Paranoid personality disorder 3.2.1. Some have found that the incidence of schizophrenia-like personality disorders is higher in first-degree relatives of those with schizophrenia.9 The nature of this link is not established. Others have proposed that deficits in childhood care might account for the development of paranoia and hostility in adulthood, but such ideas are largely theoretical and unsupported by evidence. 3.2.2. Other theories suggest that abnormalities of the dopaminergic system in the brain (which shows abnormalities in schizophrenia) may account for dysfunctional patterns of thinking which are reflected in distorted interpretations of the world.10 3.3. Schizoid personality disorder 3.3.1. The dopaminergic system in the brain is involved with behavioural adaptation to rewarding stimuli. Associations have been reported with polymorphisms of the dopamine D2 receptor and schizoid/avoidant behaviours,11 suggesting that common abnormalities of dopamine function may contribute to disorders on the schizophrenic spectrum. Such findings have yet to be replicated by other genetic studies and remain associations only. 10 3.4. Dissocial personality disorder 3.4.1. The causes of this disorder, as other personality disorders, are likely to involve a complex interaction between genetic influences, developmental factors, and social behaviour. 3.4.2. Family studies would support a genetic component to antisocial behaviour, with twins sharing a greater number of antisocial characteristics.12 This, together with similar findings from adoption studies, supports the view that genetic factors account for some degree of antisocial behaviour.13,14 3.4.3. Reduced central serotonergic activity has been associated with impulsive aggression in a subset of patients with personality disorder.15 A common finding in other studies supports a relationship between violent suicide attempts and low metabolites of serotonin in the cerebrospinal fluid.16 However, the evidence would not support the conclusion that serotonergic abnormalities underlie antisocial behaviour in all cases of dissocial personality disorder. 3.4.4. The evidence for structural and functional brain abnormality is weak. Reported findings include: frontal lobe hypoperfusion in some cases of antisocial behaviour;17 reduced activity in the limbic system when processing emotional information in criminal psychopaths;18 and reduced volume of the prefrontal cortex in antisocial personality disorder.19 Neuroimaging studies tend to be small (typically 15-20 individuals) and such findings, however interesting, should not be seen as underpinning all cases of dissocial behaviour. 3.4.5. In terms of developmental factors, growing up with an alcoholic or psychopathic father is reported to be associated with adult antisocial behaviour.20 Some studies have found further associations with a history of physical abuse21 and low parental care with maternal overprotection.22 However, such studies are small scale and such putative associations cannot be assumed to reflect common factors in causation. 3.5 Borderline personality disorder (BPD) 3.5.1 Over 85% of people with BPD will have experienced childhood trauma, either physical or sexual.23,24 Psychodynamic theories posit that such trauma impacts on the development of the self, and it is probable that the earlier the abuse occurs the more damaging to the personality it tends to be. 3.5.2 Psychodynamic theories go on to develop the idea that early abuse or neglect affects the individual’s ability to think about their own feelings, as well as those of others. A lack of sense of self has been proposed as the core pathology in BPD. In order to deal with childhood trauma, it is postulated that the individual resorts to “defence mechanisms” which often include dissociation (separation of cognitive and emotional functions) and “splitting” (conflicting yet simultaneous emotions/thoughts), the latter of which is frequently encountered in patient care. 3.6 Histrionic personality disorder 3.6.1 Some researchers have suggested that a similar core pathology underlies histrionic personality disorder in women and dissocial personality disorder in 11 men,25 but empirical evidence for this is lacking. Indeed, there is little research into the aetiology of histrionic personality disorder but as with other personality disorders, it is assumed to have developmental, social, and genetic contributory factors. 3.6.2 Individuals with histrionic or antisocial personality disorders will often share common features in terms of a history of childhood abuse, and lack of emotional care. 3.7 Anankastic personality disorder 3.7.1 Twin studies suggest a degree of heritability to obsessive-compulsive traits.26,27 Many authors argue for the existence of an obsessive-compulsive spectrum, which also includes other disorders such as Tourette’s syndrome and body dysmorphic disorder.28,29 However, only 6% of patients with obsessive- compulsive disorder have obsessive-compulsive personality disorder,30 and the relationship between the two is not clear. 3.8 Anxious (avoidant) personality disorder 3.8.1 Since the core feature of this disorder is avoidance of social situations, it is thought that such individuals may be on a spectrum that includes anxiety disorders such as social phobia.31 As with most personality disorders, a degree of inheritance of biological vulnerability is assumed and those with reduced self-esteem from overly-critical parenting tend to be socially avoidant, which will perpetuate the problem throughout schooling. Little is otherwise known about the causes of this personality disorder. 3.9 Dependent personality disorder 3.9.1 Most theories about the aetiology of this disorder focus on psychodynamic theories of personality development. For example, Sigmund Freud believed that dependent personality was due to fixation on the oral phase of psychosexual development. However, there is little empirical evidence to support such theories and very little is known about the aetiology of this disorder. 3.10 Relationship between military service and personality disorders 3.10.1 Due to the way that personality disorder is defined (i.e. evidence of enduring patterns of behaviour from late childhood or adolescence onwards), the strength of association between personality disorder and military service reduces with advancing age of military experience. A diagnosis of personality disorder is extremely unlikely in someone with no disturbance of function or social relationships during their second decade of life. There is no evidence to suggest that specific experiences associated with military service have any causal link with the development of personality disorder. 3.10.2 There is evidence that premorbid personality factors may act as vulnerability factors for the development of specific mental disorders. For example, Axelrod et al report that features of pre-war borderline personality disorder accounted for variability in post-combat symptoms of post-traumatic stress disorder (PTSD).32 Other studies have identified that individuals with PTSD are more 12 4.3.2 A variety of pharmacological treatments for impulsivity and aggressive behaviour have been suggested, although large, randomised controlled trials are lacking. Lithium has been shown to reduce aggression in prisoners,42 and other drugs used to treat aggression include phenytoin, carbamazepine, propranolol and the antipsychotic drugs.43,44 4.3.3 Outcome. Antisocial behaviour is frequently a lifelong pattern, in most cases developing before the age of 15. Adolescent problem behaviour appears to be a predictor of adult antisocial behaviour,45 although antisocial behaviour tends to decrease with increasing age. This may be due to maturation of the personality, or the presence of a supportive and compensatory relationship. 4.3 Borderline personality disorder (BPD) 4.4.1 Treatment. Dialectical behaviour therapy (DBT) is a novel treatment method which has been designed for the treatment of BPD. It is based on the belief that individuals with BPD have difficulties in self-regulation and interpersonal skills, and it assumes that these can be learnt in therapy. It incorporates a variety of techniques including individual therapy, group skills training, telephone contact, and therapist consultation. DBT has been shown (including in some randomised controlled trials) to reduce self-harming behaviour and reduce hospitalisation of those undergoing therapy.46 4.4.2 Psychoanalytic approaches have been the most commonly used treatment for some time, and have demonstrated effectiveness over 18 months.47 It seems likely that for many people, a stable therapeutic relationship might be helpful in allowing a more functional psychological development. 4.4.3 A variety of pharmacological treatments have been trialled for the treatment of BPD. Olanzapine, an antipsychotic, has been found to improve the mood symptoms and behavioural disturbance associated with BPD, although the numbers involved were small.49,50 SSRIs have also been used to treat the emotional instability and dysphoria of BPD. 4.4.4 Outcome. The long-term outcome of BPD may not be as pessimistic as many psychiatrists believe. Whilst 3-9% of patients will have committed suicide at 10-25 year follow-up, 50-60% will have shown a clinical recovery.51 4.5 Histrionic personality disorder 4.5.1 Treatment. Individuals with histrionic personality disorder will often present with depressive symptoms, and treatment with antidepressants and/or psychological approaches is necessary. 4.5.2 For the disorder itself, psychotherapy is probably the treatment of choice with the goals being the prevention of depressive episodes, and stability of mood. 4.5.3 Outcome. Like many of the personality disorders, histrionic personality disorder may become less problematic with advancing age, as the individual matures and learns more constructive coping behaviours. Many people with histrionic personality disorder will have depressive episodes, and self-harming behaviour is not uncommon. 15 4.6 Anankastic personality disorder 4.6.1 Treatment. Those individuals who experience a high degree of anxiety as a result of doubt and indecision may respond to trials of antidepressants with serotonergic activity. The SSRIs and clomipramine are the preferred drugs. Antidepressants should be considered where the individual has comorbid depressive disorder. 4.6.2 Psychological treatment focuses on the cognitions associated with perceived failure – a cognitive behavioural approach would be the intervention of choice. 4.6.3 Outcome. In most western societies conscientiousness and perfectionism are valued personality traits and individuals with this disorder may find occupational roles in which such traits offer an advantage. They may be able to sustain relationships in which their partner tends to be submissive. 4.6.4 Due to their rigidity, they often have difficulty in adjusting to changes in circumstances, and depressive episodes are not uncommon in later life. 16 5. Summary 5.1. Personality disorders are a heterogeneous group of diagnoses which are united by the impact that a particular set of personality traits has upon an individual’s life. Prevalence rates for all personality disorders combined are approximately 10% in the general population but the rate increases among psychiatric inpatients and other populations. 5.2. The causes of each disorder are relatively poorly understood but, for a diagnosis to be made, the dysfunctional patterns of behaviour must be stable, present since late adolescence and not due to any other mental illness or disease. Personality disorders are likely to be caused by a combination of inherited vulnerability and early life experience. Whilst an individual may experience greater difficulties due to the disorder at times of stress, specific life events in adulthood are unlikely to have a role in the causation of the disorder. 5.3. Historically, it was believed that personality disorders would not respond well to treatment and that there was little to offer. However, there is some evidence that symptomatic improvements can be obtained from psychotherapy, although there is uncertainty as to which form of therapy is best and which group of patients will respond. Whatever the answer, for many individuals the improvements from treatment will be modest at best. 17 post-traumatic stress disorder (PTSD) A common anxiety disorder that develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. psychodynamic psychotherapy A type of psychotherapy that draws on psychoanalytic theory to help people understand the roots of emotional distress, often by exploring unconscious motives, needs, and defences. schizophrenia One of several brain diseases with symptoms that may include psychosis, disturbance of behaviour, social withdrawal and impairment of normal functioning, and abnormal emotional responses. It may also include catatonia. serotonergic Relating to serotonin (a neurotransmitter also known as 5-HT). SSRI Abbreviation for selective serotonin reuptake inhibitors, commonly prescribed drugs for treating depression, OCD and anxiety disorders. Tourette syndrome Gilles de la Tourette syndrome/Tourette Syndrome is a neurological disorder characterised by persistent motor and/or vocal tics. It usually presents in childhood. trait In genetics, a trait refers to any genetically determined characteristic. In personality, it refers to a distinguishing characteristic. There is insufficient evidence to conclude that specific personality traits are genetically determined. 20 8. References 1. Tyrer P. Personality disorder. Br J Psychiatry 2001;179(1):81-4. 2. Perry JC. Problems and considerations in the valid assessment of personality disorders. Am J Psychiatry 1992;149(12):1645-53. 3. Lewis G, Appleby L. Personality disorder: the patients psychiatrists dislike. Br J Psychiatry 1988;153(1):44-9. 4. World Health Organisation. International statistical classification of diseases and related health problems, 1989 Revision. Geneva: World Health Organisation; 1992. 5. American Psychiatric Association. 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