Personality Disorder

1
Personality Disorder

• Dr. Steven Allan

2
What does the term Personality Disorder mean to
you?

• For example what if you were told that a
  neighbour had been diagnosed as having a
  personality disorder?
• Your thoughts, feelings, change in behaviour?
• Take a minute and jot down some brief notes.
• You will not be asked to share your thoughts with
  others at any point.

3
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

4
Personality Traits

• As a research area in psychology this focuses on
• - coherent/enduring features of a person
• - underlying psychological processes
• Traits/Features are
• - regularities in action, thoughts, feelings.
• - tendency (or disposition or likelihood) to
  behave in certain ways in certain circumstances.

5
Personality Disorder (PD)

• When the traits are thought to lead to
  significant levels of distress for self and/or
  others.
• UK term PD became associated with legal
  category of psychopathic disorder
• Originally the term psychopathic just means
  psychologically damaged.

6
Psychopathic Disorder

• Mental Health Acts for England Wales
• 1959 1983
• a persistent disorder or disability of
  mindwhich results in abnormally aggressive or
  seriously irresponsible conduct on the part of
  the person concerned
• Tended to become associate with antisocial PD

7
Clinical Psychology

• Classification of PD is based on idea of a
  personality trait.
• We talk of
• - tendencies
• - enduring patterns in perception
• - consistencies in interpersonal strategies
• - typical ways of thinking about self and others
• That are associated with considerable personal
  social disruption

8
PD Definition (1)

• Enduring pattern of inner experiences behaviour
  that deviates markedly from the expectations of
  the individuals culture.

9
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

10
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)

11
Prevalence of PD

• Range of Estimates
• 1-10 of General Population
• 10-20 Psychiatric Outpatients
• 10-67 Psychiatric Inpatients

12
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

13
Categories Dimensions 1

• Following types of PD are categorical.
• Fits with medical model that assumes
• - need for a diagnosis to inform treatment
• - that there are qualitative differences between
  normality and abnormality (present or absent
• - that there are clear boundaries between
  different categories of problem (ie., between
  different PDs).

14
Categories Dimensions 2

• Personality research mainly use dimensional
  models.
• The Big 5 dimensions i.e.,
• Neuroticism v stability
• Extraversion v Introversion
• Agreeableness v antagonism
• Conscientiousness v lack self-discipline
• Openness to experience v rigidity
• PD types can be represented as combinations of
  extremes on these different dimension (e.g.,
  Widiger Francis, 1994)

15
DSM IV Clusters

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

16
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

17
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.

18
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.

19
Aetiology of PD

• Clear that there is no single known cause of PD
• But little firm evidence on causation.
• Many different studies and plausible
  explanations
• Most explanations offer some variant of
  temperament interacting with adverse childhood
  experiences
• Childhood family dysfunction, neglect, abuse
• Beware of simple explanations

20
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

21
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

22
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.

23
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)

24
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

25
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.

26
Cluster C Therapy

• Fairly common in mental health settings.
• Usually present with mood/anxiety problems
• First focus of therapy is on mood/anxiety
• If no success or re-present then longer-term
  work (e.g., self-esteem work or help with chronic
  social anxiety complaints).

27
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.

28
Cluster C Treatment

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

29
(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.

30
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.

31
Core Beliefs (2)

•  Difficult for client to see when the rule is
  inappropriate.
• Aim of Therapy
• Weaken core beliefs
• Strengthen alternative, more adaptive beliefs

32
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.

33
Cluster B Research

• Research Focus
• Borderline
• Antisocial
• Much Less Research
• Histrionic
• Narcissistic

34
Borderline Personality Disorder

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

35
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

36
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

37
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

38
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.

39
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.

40
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

41
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

42
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.

43
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

44
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.

45
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)

46
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

47
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)

48
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

49
Piper (3) Measures

• Measures included
• Social dysfunction
• Family dysfunction
• Interpersonal behaviour
• Mood severity
• Life-satisfaction
• Self-esteem

50
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?)

51
Piper (5) Limitations

• Good study in a difficult area of research but
• No comparison with other forms of treatment.
• No comparison with level of attention received
  (placebo)
• Program evaluated as a whole not program
  components.

52
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)

53
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)

54
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

55
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

56
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

57
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)

58
Linehan group (3)

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

59
Linehan group (4)

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

60
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

61
Conclusions (Practice)

• General guiding principles of effective therapy
  for PD (Bateman Tyrer, 2002)
• Therapy should
• Be well structured
• Help client (C) stay in/with therapy
• Have a clear focus
• Be theoretically coherent to both therapist (T)
  client
• Be relatively long term
• Be well integrated with other services available
  to the C
• Involve a clear treatment alliance between T and C

62
Conclusions (Research)

• 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

63
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.