NORTHWESTERN SCHOOL OF PSYCHIATRY MRCPsych COURSE
P E R S O N A L I T Y D I S O R D E R II
Epidemiology, Assessment, Diagnosis
Dr Rachel Thomasson Speciality Trainee-5
Overview
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Epidemiology
Assessment frameworks
Revision MCQs
Diagnosis and differentials
Personality disorders are
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Enduring
Persistent
Pervasive
Clinically significant distress and/or impairment in
social/occupational functioning
• Out of keeping with societal and cultural norms
• Not an artefact of another mental health problem
(affective disorder, psychosis, substance misuse,
organically based psychiatric disorder e.g. brain
injury, dementia)
Epidemiology
• General prevalence of PD : 4-13%
• Commoner in working age adults (25-44)
• Inter rater reliability re: diagnosis is poor
• More likely to be separated, divorced, never
married, unemployed, poor social and
interpersonal function but not less educated
Epidemiology – general population
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Paranoid 0.5-3%
Schizoid 0.5-7%
Schizotypal 0.5-5%
Antisocial 2-3.5%
Borderline 1.5-2%
Histrionic 2-3%
Narcissistic 0.5-5%
Anankastic 1-2%
Avoidant 0.5-1%
Dependent 0.5-5%
• Overall prevalence in
community :
– cluster A 1.6%
– Cluster B 1.2%
– Cluster C 2.6%
– Overall 4.4%
(Coid BJP 2006)
Primary and secondary care
• Primary care – Anankastic most prevalent,
followed by EUPD
• EUPD most common in psychiatry out
patients
• Prevalence of PD increased in substance
misuse and Eating disorders
PD in UK prison settings
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Prevalence of any PD:
78% males on remand
64% sentenced males
50% sentenced females
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Antisocial PD
63% males on remand
49% sentenced males
31% sentenced females
Antisocial personality disorder
• UK general population 0.6% (1% males, 0.2%
females), other quotes as high as 2-3%.
• M:F ratio = 4:1
• 25-44yr age group
• Associated with leaving school early,
homelessness, increased mortality in early
adulthood.
• Commoner in urban pops.
• 20% still meet criteria at 45 years of age.
Antisocial personality disorder and psychopathy
– Two different constructs though some overlap of traits
– Psychopathy no longer included in personality
disorders in ICD 10
– Hare’s PCL-R assessment tool – assessment of
affective, interpersonal and behavioural aspects of
psychopathy
– Score of 25 or more indicative of psychopathy
• Current interest in children diagnosed with
conduct disorder with callous unemotional traits.
?Longitudinal studies to determine whether
precursor for psychopathy in adulthood
Associations in the literature
• Paranoid PD – commoner in males, low SEC,
relatives of individuals with schizophrenia
• Schizoid PD - more common in offender
populations, males. Association with schizotypal
PD
• Schizotypal PD – commoner in relatives of
individuals with schizophrenia (15%) and assoc
with schizophrenia. Classified with psychotic
disorders in ICD-10
Associations in the literature
• Narcissistic PD – commoner in male forensic samples antisocial PD highly comorbid in this sample
• Histrionic PD – divorce, separation, parasuicidal
behaviour, females with medically unexplained
symptoms, men with substance misuse
• Anankastic PD – white, male, well educated, married,
unemployed
• Avoidant PD– comorbid with dependent PD and social
phobia
Borderline PD
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2% general population
10% Psychiatry outpatients
15-20% Psychiatry inpatients
Male:female ratio 1:3
5 times more common in first degree relatives
Increased rates of depression in relatives.
Associations - white females, age 20-35, urban
populations, single, unemployed
• Comorbid with PTSD.
A GENERAL NOTE ON COMORBIDITY
• Presence of a major affective or psychotic
disorder may be distorted, exaggerated or
masked by an underlying PD so look for it as it
may adversely affect outcome.
• How?
– Think propensity towards and style of help seeking
behaviour, coping mechanisms, compliance, risk
taking, quality of social support, substance
misuse.
ASSESSMENT - pitfalls
• Not always possible to clinch the diagnosis in
one interview:
• Poor historian
• Poor insight
• Repression of/unwilling to disclose early
experience
• Intrinsic properties of personality under
scrutiny may make assessment tricky
Assessment framework
• Longitudinal history and collateral history is key
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In an ideal world:
Self report (checklist)
Informant report (checklist, interview)
Clinical interview
• In reality
– Clinical assessment, collateral from
GP/CMHT/family/partner
Assessment tools - examples
• Millon Clinical Multiaxial Inventory (MCMI)
• Minnesota Multiphasic Personality inventory
(MMPI)
• Personality disorder Questionnaire (PDQ-IV)
• Zanarini rating scale for Borderline personality
disorder
• Diagnostic interview for borderline patients
• Borderline personality disorder scale
• Schedule for schizotypal personalities
• Psychopathy checklist revised
• Personality inventory for DSM V
Assessment of personality traits
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Self concept
Views towards others
Interpersonal relationships
Impulse control
Patterns of mood, affect and expression
Cognitive themes
Social function
Associated mental health problems
Assessing personality
• Characteristics of self – clear or ill defined sense
of self, grandiose, shy, extrovert, suspicious,
impulsive, sensitive to rejection, criticism, being
ignored, scrutiny by others, coping mechanisms.
• E.g. Do you feel you have a good sense of who
you are as a person? What do you like about
yourself? Are you comfortable around other
people? How do you take it when someone is
being critical?
Assessing personality
• Impulse control - meticulous and careful, orderliness
and control, reckless and impulsive
• E.g. Would people describe you as reckless? Would you
describe yourself as a perfectionist? Do you often act
on impulse without thinking things through? Do you
avoid risky situations and activities? Do you tend to do
what people think you should do? Do you find yourself
making rash decisions? Are you good at planning
ahead? Do you send a lot of time making sure things
are exactly right?
Assessing personality
• Views towards others and events – people aren’t
to be trusted, people let you down, people
abandon you, people hurt you, people just don’t
get me, people scare me, people are a
disappointment, I don’t really notice others, I
don’t really care what others think.
• E.g. Do you tend to trust other people? Do you
find people are generally trustworthy/have good
intentions? Are other people important – do they
matter to you? Do people understand you?
Assessing personality
• Interpersonal relationships –what is needed from
others?
• Isolative, loner, indifferent to others
• Difficulties being alone, feels lonely
• Enjoys being with others, enjoys being the centre
of attention, dreads being the centre of attention
• Views on team work
• Prioritising self vs others, respect for others
• Longevity and intensity of relationships
• Manipulating others vs manipulated by others
Assessing personality
• Patterns of mood, affect and expression
(range, lability, intensity, appropriateness)
• E.g. labile, anxious, angry, dramatism, cold
fish, shallow affect, unable to contain difficult
emotions, responses to praise and criticism,
responses to others in difficulty.
Assessing personality
• Cognitive themes – conspiracy, mistrust of others,
fantasy, bizarre ideas, power and brilliance,
immediate needs, fear of rejection
• Social function – current and previous
relationships, friendships, connections to family,
educational history, employment history and
status, forensic history, pastimes.
• Degree of distress and impairment of function
(family, friends, work, criminal record)
Revision MCQs
• Diagnostic subtypes of PD (last lecture)
• Differential diagnoses to inform clinical
assessment
• The following are based on MCQ’s from past
MRCPsych papers
Which of the following is NOT a
personality disorder in ICD-10?
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Schizoid personality
Paranoid personality
Emotionally unstable personality
Schizotypal personality
Anankastic personality
Which of the following is not part of
the Big Five personality traits?
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Agreeableness
Carefulness
Neuroticism
Openness
Extraversion
Which of the following is NOT a
personality disorder in ICD-10?
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Narcissistic personality
Dependent personality
Histrionic personality
Emotionally unstable personality
Dissocial personality
A 42 year old man presents to a local police station
with an insurance claim form and a letter to his MP.
He states that his neighbours are deliberately playing
loud music to get to him and that people in his local
area “have it in for him”. He lists names of officers
who did nothing the last four times he has contacted
the police and demands immediate action (Answernext slide).
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Histrionic
Anankastic
Paranoid
Dependent
Schizoid
Paranoid personality disorder
• Differential – delusional disorder, schizophrenia,
mood disorder with psychotic symptoms, sensory
impairment, paranoia associated with substance
misuse
• Beliefs are of key importance – are they
plausible? Inkeeping with cultural and societal
norms? Reasonable evidence base? Overvalued
idea or delusional? Any psychotic symptoms? Any
family history of psychosis? Episodic or constant?
Chronology – age at onset and evolution?
A 36 year old man is visited at home by his GP. There
is very little furniture, no television, no ornaments or
pictures on the wall. He is indifferent to these
observations, stating he has no need of those things.
He has limited contact with his family and does not
have any friends. He is clear he does not feel lonely or
depressed (Answer- next slide). .
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Histrionic
Antisocial
Paranoid
Schizotypal
Schizoid
Schizoid personality disorder
• Differential centres on depression, psychosis,
and pervasive developmental disorders.
Overlap in presentation with other cluster A
personality disorders.
• Schizoid PD may indeed be part of the autistic
spectrum.
A 24 year old woman presents to clinic in ill fitting,
stained clothes. She believes that she may be psychic.
She feels she senses “presences” and events before
they happen and knows that if the clock shows 11:11
something good will happen. Her speech is unusually
metaphorical. Affectual range is incongruent, at times
restricted (Answer- next slide). .
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Dependent
Schizotypal
Paranoid
Borderline
Schizoid
Schizotypal disorder
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Differential includes
Delusional disorder
Schizophrenia
Mood disorder with psychotic features
Autistic spectrum disorder
Disorders of language and communication
A 28 year old woman presents to her GP feeling
low in mood. She confides she feels neglected
by the love of her life if she is not the centre of
attention. She is theatrical and flirtatious in
demeanour, with shallow, labile affect. (Answernext slide).
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Histrionic
Antisocial
Schizotypal
Avoidant
Anankastic
Histrionic personality disorder
• Differential includes
• Borderline PD (self destructive, emptiness,
identity disturbance)
• Antisocial PD (antisocial acts, less emotional
exaggeration)
• Narcissistic PD (superiority is key – unwilling to
be fragile to gain attention)
• Dependent PD (lacks flamboyance and
exaggerated emotional spectrum)
A 26 year old man is brought to A+E under section
136 MHA after being found with multiple arm
lacerations. He describes stormy relationships with
his partner and family and frequent risk taking
behaviours. He also mentions his temper is difficult to
control and wonders if he may have bipolar disorder
as he is prone to extreme mood swings. (Answernext slide).
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Borderline
Antisocial
Schizotypal
Avoidant
Dependent
Borderline personality disorder
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Differential includes:
Histrionic PD
Mood disorders (highly comorbid)
Antisocial PD (look at the nature of gain to
help clarify the diagnosis – power/material
gain vs concern of others and avoidance of
rejection)
A 33 year old man has been arrested for drink driving
and taken to a local police station. He is irritable and
aggressive, stating his friend was driving, even though
police witnessed him behind the wheel. He appears
to have little concern for the wellbeing of the
occupants of the car he ran into. (Answer- next slide).
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Histrionic
Antisocial
Paranoid
Dependent
Schizoid
Antisocial personality disorder
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Differential (and comorbidities)includes:
Psychosis
Mania
Substance intoxication/withdrawal
Narcissistic PD
Psychopathy
A 42 year old man feels depressed after being sacked
from his job. He states he is a perfectionist and that
he could not trust others to do the job exactly right.
He describes making detailed lists and schedules for
his everyday life and appears markedly resistant to
taking other’s points of view. (Answer- next slide).
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Histrionic
Anankastic
Paranoid
Dependent
Schizoid
Anankastic personality disorder
• Differential includes:
• OCD
• Narcissistic PD (perfectionism in both,
anankastics are self critical, Narcissists are
not)
A 27 year old man presents to clinic feeling low in
mood. He is socially isolated and works in a job that is
discordant with his educational level. He describes
terror of being ridiculed or rejected and self esteem
appears low. Friendships and intimate relationships
are limited by fears of being inadequate.
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Antisocial
Anankastic
Paranoid
Dependent
Avoidant
Avoidant personality disorder
• Differential includes:
• Social phobia
• Panic disorder with agoraphobia
• Dependent personality disorder (primary focus is
the need to be taken care of rather than
avoidance of humiliation/rejection)
• Schizoid personality disorder (emotional
indifference and actively prefer isolation)
A 29 year old woman is seen in clinic for assessment
of anxiety. She describes longstanding fears of being
left alone and cannot bear to make decisions without
others providing reassurance she is doing the right
thing. She lives with her parents. Her mother cooks
all her meals and shops for her clothes. (Answer- next
slide).
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Histrionic
Anankastic
Paranoid
Dependent
Borderline
Dependent personality disorder
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Differential includes:
Mood disorder
Panic disorder
Agoraphobia
Borderline personality disorder
Histrionic personality disorder
Avoidant personality disorder
Resources
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Oxford textbook of psychiatry
Oxford handbook of psychiatry
ICD-10
DSM IV-TR
DSM V
British Journal of Psychiatry
Millon, T et al. 2004. Personality disorders in
modern life (2nd edition) Wiley.