MRCPsych course CT2-3
General adult module
Personality Disorders
‘You either love them or you hate them’
Dr Claudia Murton ST5 general adult and liaison psychiatry
Learning objectives?
Mine are:
• Cover background information on
aetiology, diagnostic criteria(ICD10 and
DSM IV), treatments
• Discuss case examples if time.
• Exam practice; CASC role play and
discussion
Yours?:
Definitions:
ICD 10:
Personality disorder represents extreme or significant deviations from
the way in which the average individual in a given culture perceives,
thinks, feels and particularly, relates to others.
Behaviour patterns tend to be stable and to encompass multiple domains
of behaviour and psychological functioning.
They are frequently, but not always, associated with various degrees of
subjective distress and problems of social performance
Classification: ICD vs DSM
DSM V: AXIS II disorders
Cluster A: paranoid, schizoid, schizotypal
Cluster B: antisocial, borderline, histrionic, narcissistic
Cluster C: avoidant, dependent, obsessive-compulsive
Personality Disorder NOS
ICD 10
F60.0 Paranoid PD
F60.1 Schizoid PD
F60.2 Dissocial PD
F60.3 Emotionally unstable PD
F60.4 Histrionic PD
F 60.5 Anankastic PD
F60.6 Anxious (avoidant) PD
F60.7 Dependent PD
F60.8 Other specific PD
F60.9 PD unspecified
Differences between ICD and
DSM?
•Names
•Inclusions and exclusions
Prevalence (community sample by Coid)
Personality disorder
% of population
Antisocial
0.6-3.0
Borderline
0.7-2.0
Narcissistic
0.4-0.8
Histrionic
2.1
Paranoid
0.7-2.4
Schizoid
0.4-1.7
Schizotypal
0.1-5.6
Avoidant
0.8-5.0
Dependent
1.0-1.7
Compulsive
1.7-2.2
Any
4.4-13.0
Aetiology: Nature or Nurture?
•Attachment disorders? “I hate you…don’t
leave me!”
• Biologically based?
Temperament
Constitutionally based individual differences in emotion, motor,
reactivity and self-regulation consistent across situations and over
time
Temperament is biologically based: Heredity, neural, and hormonal
factors affect response to the environment.
Temperament can be modulated by environmental factors e.g.
parental response: Rutter M, Bjpsych 1987 150: 443-458
Thomas and Chess. Alexander Thomas, Stella Chess,
Herbert G. Birch, Margaret Hertzig and Sam Korn began the
classic New York Longitudinal study in the early 1950s
regarding infant temperament (Thomas, Chess & Birch, 1968).
•Activity
•Regularity
•Initial reaction
•Adaptability
•Intensity
•Mood
•Distractibility
•Persistence
•Attention span
•Sensitivity
Aetiology of PD Coid 1999 BJPsych
• Population study to establish aetiological
association between Axis II disorders and
certain risk factors
• Family Hx mental disorder (1st degree
relative)
• Neurobiological risk
• Early environmental adversity
Demographics and IQ
Population sample survey indicated BPD
associated with females and narcissistic,
antisocial, histrionic were associated with males.
Those with ASPD were of a lower socioeconomic
class.
Those with paranoid, antisocial, borderline and
dependent were found to have slightly lowered
full-scale IQ’s whilst narcissistic PD was
associated with a higher IQ.
Family History and early
environmental adversity
• Population survey found BPD associated with
a family history of depression and parental
dischord, other studies have disagreed
Gunderson and Philips 1991.
• ASPD associated with family history of PD and
a range of factors including sexual abuse,
poverty, cruelty and criminality in families
• Schizoid PD was characterised by absence of
early adversity
Biological and neuropsychiatric risk
factors
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Schizoid PD associated with perinatal complications,
motor and speech delay. It is associated with schizotypal
PD. Suggested may fit better in neurodevelopmental
classification
Schizotypal PD is common in relatives of people with
schizophrenia (Baron et al 1985) and is not included in
ICD10 personality disorders
Narcissistic and antisocial PD not associated with
neuropsychiatric risk factors. There is correlation between
the two (Coid 2003) and also psychopathy.
Aetiological factors are varied. Biological
susceptibility interacts with environmental
adversity to varying degrees.
BPD: the adult outcome of
interactions between constitution
and environment
Genetic theory: Human serotonin
transporter gene
Some evidence found polymorphisms in the 5HT transporter
gene to be associated with psychopathological phenotypes
related to disturbed impulse control, anxiety, depression and
violent behaviour
Psychotherapeutic theories of PD
Melanie Klein: The Paranoid-Schizoid position (1946)
Part of normal development age 4-6 months. It can be normal to move in
and out of this and more mature positions, however some operate in this
much of the time. It is the more primitive position; a person will progress
through it if environment and upbringing is satisfactory.
Object Relations theory; Klein sees emotions as always related to other
people or objects of emotions. Relations during these first months are not
to whole objects but only to part objects (e.g. breast).
Good Breast / Bad breast
Paranoia: fear of invasive malevolence experienced as external. Derived from
sense of destruction or death instinct. Paranoid-schizoid is before internalisation of a
good object and the immature ego deals with paranoid anxiety by splitting off bad
feelings and projecting them out.
Schizoid: Defence of splitting. Separation of good from bad; means good can be
identified with and introjected. This can protect good from being destroyed by bad.
Depressive: Later when the ego has developed bad can be integrated and
ambivalence and conflict tolerated. Leads to mourning of the idealised object.
Formulation: splitting
The Borderline Solution
Sit on the fence
Oscillation
One foot in each
camp
Substance Misuse
Opiates and Amphetamine
ESCAPE
ESCAPE
ENTER
• Fear of falling forever
Case discussion if wanted?
Video examples
Narcissistic PD
Borderline PD
Antisocial PD
Management:
Biological, Psychological, Social?
Caution- NICE guidance:
• Pharmacotherapy should not be used
routinely to specifically treat borderline PD or
for individual symptoms or behaviour
associated with it e.g repeated DSH,
emotional lability, risk taking and transient
psychotic symptoms
• Pharmacological intervention should not be
routinely used for treatment of ASPD or
associated behaviour, aggression or
impulsivity.
NICE recommend integrated
approach to BPD
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•
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Person centred care: autonomy and choice
Care planning (including endings)
Psychological treatment (including close supervision)
Specialist personality disorder services
Risk assessment and crises management
Managing self harm (separate guideline)
ASPD
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Emphasis on treating comorbid disorders keeping in mind tendency to
poor concordance, prescription and illicit drug and alcohol misuse and
offending behaviour
Group therapies based on cognitive and behavioural models: Aim at
impulsivity, interpersonal problems, antisocial behaviour
Reasoning and rehabilitation: focussed on reducing offending and
other antisocial behaviour.
Close supervision of those working with people with psychopathy
CASC scenarios
Summary and recap of learning
objectives?
Any other questions?
Anything else needed to be covered?