Personality Disorders (PD) Summary (print version)

Transcription

1 Personality Disorders (PD) Summary (print version) 1/ Definition A Personality Disorder is an abnormal, extreme and persistent variation from the normal (statistical) range of one or more personality attributes (traits), causing the individual and/or family and/or society to suffer. A diagnosis is unlikely to be given before age 16 or 17. It is important to distinguish from mental illness (they may coexist in clinical practice and both can result in an abnormal mental state & behavioural). It not only increases vulnerability to mental illness, but also worsens the course and treatment response especially in depression, anxiety and alcohol & drug abuse. 2/ Classification ICD (International Classification of Disease)-10 published in 1992, is used in all countries. PD is under Chapter V with Codes: F60 - Specific PD F61 - Mixed and other PD F62 - Enduring personality changes, not attributable to brain damage and disease DSM (Diagnostic and Statistical Manual of Mental Disorders) - 5 published in 2013 by the American Psychiatric Association for use in America - DSM-5 (compare to the DSM-IV) has moved from the multi-axial to a mono-axial system used under DSM-4, so that removes the arbitrary boundaries between personality disorders and other mental disorders. However, the same ten types of personality disorder are retained. - DSM-5 use three clusters (and this classification structure is not found in ICD-10: Cluster A Odd, bizarre, eccentric Cluster B Dramatic, erratic Cluster C Anxious, fearful

2 ICD-10 DSM-5 Note: Paranoid Paranoid (Cluster A) Schizoid Schizoid (Cluster A) (Schizotypal) Schizotypal (Cluster A) Dissocial Antisocial (Cluster B) Emotionally unstable Borderline (Cluster B) Impulsive type Borderline type Histrionic Histrionic (Cluster B) - Narcissistic (Cluster B) Anankastic (OC) Obsessive-Compulsive (Cluster C) Anxious (avoidant) Avoidant (Cluster C) Dependent Dependent (Cluster C) - Passive-aggressive In ICD-10, Schizotypal PD (F21) is no longer included under PD but alongside schizophrenia as schizotypal disorder In ICD-10, Narcissistic PD (F60.8 other PD) & Passive-aggressive PD (for further study) are not included In ICD-10 and DSM-5, Multiple PD is classified under Dissociative disorders (F44.81) In DSM-5, Cluster not specified for Passive Aggressive; Depressive; Sadistic; Self-defeating (Masochistic); Psychopathy PD In DSM-5, Emotionally unstable PD, Impulsive type (F60.30) & Enduring Personality changes (F62) are not included 3/Epidemiology 10% of population Up to 50% of psychiatric patients : % psychiatric ward % of psychiatric patients treated in the community Around 10-30% of patients - GP More commonly diagnosed between the ages of 18 and 35, in males, in lower social class and less education - Antisocial PD more common among men - Borderline / Histrionic PD more frequently in women

3 4/ Aetiology Genetic factors 1. XYY increased criminality 2. 1 st degree relatives of patients with Borderline PD are 10 x more likely to be treated for Borderline PD Neurophysiology low level of 5-hydroxytryptamine metabolite was found in the cerebrospinal fluid in patients with impulsive and aggressive behaviour Prenatal effects 1. impaired nutrition during pregnancy 2. hypoxia at birth 3. birth complications Childhood development & Early life experiences 1. parenteral loss 2. trauma physical / emotional / sexual abuse 3. social learning in childhood - maternal deprivation / attachment issues / lack of consistent rules in the family / growing up in an antisocial family 4. violence in family 5. behavioural problems in childhood - sever aggression / disobedience / repeat temper tantrums 6. parents using excessively drugs incl alcohol Brain disease / head injury minor degrees of brain injury might be a cause of antisocial personality (otherwise classified under organic mental disorders) Some people with antisocial personality disorder have very slight differences in the structure of their brains, and in the way some chemicals work in their brains. However, there is no brain scan or blood test for a personality disorder. Psychodynamic theories Cognitive behavioral theories Triggers 1. using a lot of drugs or alcohol 2. problems getting on with your family or partner 3. money problems 4. anxiety, depression or other mental health problems 5. important events 6. stressful situations

4 5/ Assessment Accurate assessment of enduring and pervasive pattern of emotional expression, interpersonal relationships, social functioning, views of self and other Information from other sources Good history Describe interference with functioning occupational, family, relationships, offending Coping strategies Instruments: 1. Self-rated questionnaire (Personality diagnostic questionnaire, Personality assessment inventory) 2. Observed-rated structured interview (International PD Examination) 3. Interview based (Structure clinical interview, Psychodynamic formulation) 4. other - Rorschach test, Thematic apperception test 5. Diagnostic Interview schedule 6. Psychopathy checklist revised 7. Borderline personality disorder scale 6/ Differential Diagnosis The principal differential diagnosis of PD is from affective disorders, substance misuse, psychotic disorders, anxiety disorders (especially phobia and panic disorder), obsessive-compulsive disorder, learning disability, dementia, and autism. 7/ Management PD are lifelong disorders but many tend to improve in middle and old age. Important complications include depressive disorder, substance misuse, and deliberate self-harm and suicide. General points to consider in planning and delivering treatment for PD: What sort of disorder is it? How severe is it? How far has it spread? Is there co-morbid illness? What is their attitude to help-seeking or eliciting? Are they actively psychotic, addicted or depressed?

5 No single treatment approach Bio-Psycho-Social: The type of therapy or treatments offered depends on: what patient with PD wants or prefers the type of difficulties he/she has what is available locally Therapeutic relationship important! Individual needs Managing comorbid disorders (incl medication) Managing crisis Admission - Medication Psychological Therapies Specialist services Outcome: Morbidity and mortality high rates of accidents, suicide, violent detah (esp. cluster B), high rate of other mental disorders Over time some evidence cluster A worsen with age, cluster B improve, cluster C unchanged Management plan for PD within the UK Based on national guidelines for the treatment of PD F60 NICE 2009 a,b 1. Biological: medication Antipsychotic drugs (usually at a low dose) 1. Can reduce the suspiciousness of the three cluster A personality disorders (paranoid, schizoid and schizotypal). 2. Can help with borderline personality disorder if people feel paranoid, or are hearing noises or voices Antidepressant 1. Can help with the mood and emotional difficulties that people with cluster B personality disorders (antisocial or dissocial, borderline or emotionally unstable, histrionic, and narcissistic) have 2. Some of the selective serotonin reuptake inhibitor antidepressants (SSRIs) can help people to be less impulsive and aggressive in borderline and antisocial personality disorders 3. Can reduce anxiety in cluster C personality disorders (obsessivecompulsive, avoidant and dependent) Mood stabilisers Medication such as lithium, carbamazepine, and sodium valproate can also reduce impulsiveness and aggression.

6 2. Psychological: talking treatments or therapies A number of psychotherapies seem to work well, particularly for cluster B personality disorders ('Dramatic, Emotional and Erratic'). They all have a clear structure and idea of how they work which must be explained to the patient. Longer-term therapy can last for years, and may have to be more than once a week. They all involve different ways of talking with a therapist, but are all different from each other. Some have a clear structure to them, others are more flexible. They include: Mentalisation - combines group and individual therapy. It aims to help you better understand yourself and others by being more aware of what s going on in your own head and in the minds of others. It is helpful in borderline personality disorder. Dialectical Behaviour Therapy this uses a combination of cognitive and behavioural therapies, with some techniques from Zen Buddhism. It involves individual therapy and group therapy, and has been claimed to significantly reduce self-harm in patients with borderline personality disorder Cognitive Therapy - a way to change unhelpful patterns of thinking. Schema Focused Therapy - a cognitive therapy that explores and changes collections of deep unhelpful beliefs. Again, it seems to be effective in borderline personality disorder. Transference Focused Therapy - a structured treatment in which the therapist explores and changes unconscious processes. It seems to be effective in borderline personality disorder. Dynamic Psychotherapy - looks at how past experiences affect present behaviour. It is similar to Transference Focused Therapy, but less structured. Cognitive Analytical Therapy - a way to recognize and change unhelpful patterns in relationships and behaviour Treatment in a therapeutic community this is a place where people with long-standing emotional problems can go to (or sometimes stay) for several weeks or months. Most of the work is done in groups. People learn from getting on or not getting on - with other people in the treatment group. It differs from 'real life' in that any disagreements or upsets happen in a safe place. People in treatment often have a lot of say over how the community runs. In the UK, it is more common now for this intensive treatment to be offered as a day programme, 5 days a week. 3. Social : support - Social Services Many people with personality disorder can lead full lives with support. This can be emotional - somebody to talk to - or practical - help with sorting bills out or arranging things. The support can be given by friends and families, self-help groups and networks, as well as your GP or mental health team. Support might be needed occasionally, when things get particularly difficult, or you regularly.

7 Family support and community network (day-based or residential therapeutic community) Admission to hospital usually happens only as a last resort (e.g. when a person with borderline personality disorder is harming themselves badly) and for a short time. A lot of help that was once only offered on hospital wards is now available in day centers and clinics. Complex Needs Service (CNS) for people with long-standing and hard to resolve emotional problems or interpersonal difficulties. A patient may be referred to the CNS by his/her psychiatrist, but in many cases (s)he may be encouraged to selfrefer by calling, writing to, or ing the CNS. After an initial meeting with the member of CNS, the patient may decide to join a weekly options group which aims to prepare him/her for joining a therapeutic community (TC). The patient may attend the options group for up to one year, during which time (s)he can decide whether or not to join TC. Joining a TC involves a commitment to attend a daily programme every weekday for a period of 18 months. This is a very significant commitment, and a demands a very high level of self-motivation. The idea behind a TC is that a patient is best able to change by interacting positively with other people, that is, by forming relationships with other people in an atmosphere of trust and security, and by feeling mutually accepted, valued, and supported. People who have spent time in a TC tend to use less medication and healthcare services than they used to, and also tend to require fewer hospital admissions. Indicators of admission: Crisis intervention Treatment of co-morbid disorders Stabilisation of existing medication regimen Reviewing the diagnosis and treatment plan Full risk assessment Admission : Involve cares, relatives, other agencies Care plan early on Focus on immediate needs Clear boundaries Support groups Early discharge