Personality Disorders (L2)

Deviations from "normal" on traits that everyone has (e.g. people who are high on distrustfulness might have paranoid PD)

• Inflexible thoughts/feelings compared to normal personality

• Originates in early development

• Present in early adulthood

• Dysfunctional (sometimes only experienced by others as such)

• Related to high healthcare costs, healthcare consumptions, societal costs and low quality of life

• A way of "Who I am"

• Personality disorders are ego-syntonic

Three primary personality types, divided into subtypes along dimensions (normal and abnormal)

A dimensional model of personality

Created psychopathic PD types. This was influential for DSM thinking - PDs are deviations from normality, not categorically different

• Persistent

Stable and long duration, since early adulthood

• Pathological

Problematic (causes distress towards you or someone else or impairment)

• Pervasive

Needs to be there in multiple domains

• A habitual way of thinking, feeling and acting

Consistent(ish) across time, but situational variance is high

Personality is not unchanging, but stabilizes with increasing age, with largest changes around 25- 30 because of increasing responsibilities and corrective feedback from the environment (conditioning)

General population: 9-13%

Outpatient care: 30-50%

Inpatient care: 50-70%

• Almost no international studies

• Different sampling methods, study instruments

• Poor diagnostic reliability

Develops in adolescence \n • Improves during development \n • Not more chronic compared to chronic syndrome disorders (schizophrenia/ bipolar)

Monothetic: Members must met the same properties of criteria

Polythetic: There can be different ways to come up with a definition (some criteria must be met)

DSM is a polythetic system because you only need some criteria to have the disorder, but the criteria doesn't need to be the same for every person

• Most disorders are dimensional (exceptions: schizotypal, autism, SUDs)

• DSM is categorical, arbitrary cut-off

  • Dimensional diagnosis is very difficult because people naturally think in different categories

Bizarre (variant psychosis)

• Paranoid PD (Distrust)

• Schizotypal  (Ideas of reference, psychotic fear)

• Schizoid PD (isolation; no desires or flattened affectivity)

Dramatic, emotional, impulsive

• Histrionic (theatrical, attention seeking)

• Narcissistic (superiority, wanting to be around high-status people)

• Borderline (emotional instability)

• Criminal behaviour (no conformation norms, criminal)

Internalizing (anxious, fearful)

• Avoidant PD (Avoiding for fear of negative evaluation)

• Dependent PD (Clinging to a helper, feel that they cannot make decisions on their own)

• Obsessive-compulsive PD: odd one out lol

Personality Change due to another medical condition (Stroke, brain trauma)

Other specified personality disorder

• Satisfies multiple criteria of various PDs, but does not satisfy criteria for 1 single PD

• Non-DSM PDs

• Most commonly diagnosed

Unspecified PD

• Rule rather than exception

Within PDs

Often:

• Cluster C (avoidant and obsessive-compulsive)

• Cluster B (antisocial and borderline)

• Between clusters (borderline and avoidant)

• Avoidant PD and depression

• OCPD and burnout/depression

• Borderline PD and PTSD

  • General comorbidity: PDs with anxiety, depression and addiction (SUDs)

On average, 18 years shorter

Risk highest before 44 years (10x mortality rate)

Because of stress, medication

Risk of cardiovascular diseases

Risk of intergenerational transmission

To also assess comorbid syndrome disorders

To use a semi-structured interview (diagnoses based on clinical expertise have low reliability)

To beware of stigma (to not over- or underdiagnose something because of the client belonging to a certain group)

• Internalized (blaming self for all problems, leads to low self-esteem and/or depression)

• Discrimination (in housing, jobs, etc)

• Seeing the person as a danger or blaming them for all their problems

Often in BPD and APD

Specialized psychotherapy (treatments developed to treat PDs) work best.

Additional treatment can be effective (e.g. for PTSD or phobias)

• Needs to be sufficient motivation

• Social psychiatric treatment (if first choice is not possible, lack of motivation)

• Pharmacological treatment cannot treat personality disorders, only other symptoms that arise from them

There is an exception for this of BPD, but it’s important to consider

Emotional, sexual, physical abuse

Emotional and physical neglect

Between 11% sexual abuse, 26.7% emotional abuse

Leads to:

• Poorer mental health

• PTSD

• Physical diseases

• Personality disorders

Borderline very associated w sexual abuse, Antisocial PD with physical abuse

Emotional abuse associated with Cluster C disorders (inconsistent parental reinforcement)

Attachment:

(insecure attachment and distrust of others)

• Approach-avoidance

Emotion regulation

• Coping

• Negative self-views

  • Memory encoding

Study: Amount of problematic parenting behaviours positively correlated with the probability of child developing a PD

Problematic parenting behaviour mediates the model - it doesn't matter if parents have disorders as long as they are good parents

Psychodynamic model: every syndrome disorder is the result of underlying personality problems, so treatment should focus on the personality disorder.

CBT model: (initially) denied the existence of personality disorders, so treatment should focus solely on the syndrome disorder.

• Parallel treatment: rarely, highly specialized treatments parallel treatments are offered.

• Stepped care: currently, (presumed) syndrome disorders are usually treated first. Only when this does not provide sufficient improvement, patients are offered a treatment for the specific PD. In few cases where personality problems are so pronounced that they overshadow any syndrome disorder (often in borderline PD), treatment is directly aimed at PD.

Whichever disorder is the primary disorder (aka which problem is the most serious/urgent)

In general, psychosocial treatments can be used when a syndrome disorder is the primary disorder. However, it is recommended that this treatment does not continue for too long: if unsuccessful, the problem might not be sufficiently independent of PD.

When PD is the main focus, specialized psychotherapy is the treatment of choice. These therapies are based on specific theories about the development and maintenance of PDs.

For borderline PD, these treatments include a) dialectical behavior therapy (DBT), b) schema therapy (ST), c) transference-focused therapy (TFP), and d) mentalization-based treatment (MBT). For the other PDs, they include ST, and specialized types of CBT and psychodynamic psychotherapy.

Specialized psychotherapies for PDs systematically outperform treatment as usual, while more generic treatments do not

No, but individuals with comorbid PDs may experience more severe problems

Because there are no detection instruments, the clinician has to pay attention to long-lasting dysfunctional patterns of cognitions, emotions and behaviour.

When there are strong beliefs related to mistrust, magical thinking, need for control, avoidance of emotions, dependence or hopelessness.