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Definitions and
classifications
Eccentric
personalities
Emotional
personalities
Anxious
personalities
Controversies
Causes
The author
PROFESSOR LOUISE NEWMAN,
professor of developmental
psychiatry and director, centre
for developmental psychiatry
and psychology, Monash
University, Melbourne, Victoria.
PERSONALITY DISORDERS
— Part 1
Background
THE term ‘personality disorder’ is
frequently used in clinical practice
to describe individuals with pervasive difficulties in interpersonal functioning, self-concept, emotional regulation and behaviour.
These difficulties frequently present in an interpersonal context and
can result in conflict, relationship
breakdown and poor functioning in
key social roles such as work and
family.
In the clinical setting the so-called
‘difficult’ patient may have long-term
problems in interpersonal functioning and be vulnerable to adjustment
difficulties in the face of illness. They
can present major management challenges. Many clinicians have experienced a sense of frustration and lack
of confidence when confronted with
patients with personality disorders.
Part 1 of this two-part series will
review current concepts of personality
dysfunction, risk factors for the development of personality disorders, classification and common presentations.
Part 2 will examine personality disorders in clinical contexts and review
approaches to intervention and treatment.
It is important not to use the term
‘personality disorder’ as a form of clinical shorthand and to avoid its use as a
diagnostic label in the absence of a
careful clinical assessment. The term
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should not be automatically used to
describe all ‘difficult customers’ (or colleagues), or used in a negative or
derogatory fashion.
Difficulties in personality functioning are potentially disabling conditions and are associated with significant distress and interpersonal
difficulties. They can also impact on
key areas of life such as work and
parenting.
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HOW TO TREAT Personality disorders — Part 1
Defining personality and personality disorder
THE DSM-IV describes personality traits as enduring
patterns of perceiving relating to, and thinking about,
the environment and the
self. These traits are consistent across a variety of personal and social contexts
and are the core of what is
usually referred to as ‘personality’ — patterns of
managing the self, emotions
and relationships.
Personality traits develop
from early childhood and
are shaped by the context
of parenting and attachment
experiences, genetic and
biological contributions and
sociocultural factors.
A personality disorder is
an enduring pattern of inner
experience and behaviour
that:
• Deviates markedly from
the expectations of the
individual’s culture.
• Is inflexible and pervasive
across a broad range of
personal and social situations.
• Leads to clinically significant distress or impairment in social, occupational, or other important
areas of functioning.
• Is stable and of long duration, with onset able to be
traced back at least to
adolescence or early
adulthood.
• Is not the result of
another mental disorder,
drug or physical condition.
Personality disorders
occur in about 5-13% of the
community and in about
30% of primary care attendees. Prevalances of 70-90%
Gender influences
the characteristic
styles of both
expressing and
managing distress.
in psychiatric services and
prisons have been reported.
The diagnosis of personality disorder requires an evaluation of the individual’s characteristic and long-term
patterns of functioning and
should not be made at a time
of crisis in the absence of
longer-term history, or in the
face of acute mood disorders,
substance intoxication, or
other transient disturbance of
mental state.
Assessment of an individual’s personality functioning also needs to take into
account variations in cultural expression and differ-
Table 1: Personality disorder clusters in DSM-IV – TR
Cluster
Subtype
Key features
A. Odd/
eccentric
Paranoid
Suspicious
Schizoid
Socially indifferent
Schizotypal
Eccentric
Antisocial
Unempathic, callous
Borderline
Unstable identity
Histrionic
Attention-seeking
Narcissistic
Self-centred, grandiose
Avoidant
Inhibited
Dependent
Submissive, anxious
Obsessive
Perfectionistic, rigid
B. Dramatic/
emotional
C. Anxious/
fearful
ences in interpersonal communication and behaviour.
Gender also influences
the presentation of personality difficulties, with more
men diagnosed with antisocial personality disorder and
more women diagnosed
with histrionic and dependent personality disorder.
Gender influences the characteristic styles of both
expressing and managing
distress, but clinicians need
to be aware that social
stereotypes about typical
gender roles and behaviours
can influence the diagnosis.
The DSM-IV – Text Revision (TR) uses a categorical
approach to personality disorders that defines several
distinct types of disorder.
This attempt to define types
of personality disorder has
led to ongoing discussion
and the finding that the
types of disorder tend to fall
into three main clusters:
• Cluster A — odd/eccentric.
• Cluster B — dramatic/
emotional.
• Cluster C — anxious/
fearful.
Within each cluster there
are specific types of personality disorder with their own
diagnostic criteria (table 1).
The complexity and
imprecise nature of the
DSM system and the overlap of personality disorder
types has also been a longstanding issue for both clinicians and researchers. In
clinical practice it is often
most useful to think about
the predominant personality
issues in terms of a cluster.
These are described below.
Cluster A personality disorders: odd/eccentric personalities
THESE are individuals with longstanding difficulties in relating to
others, ranging from distrust (paranoid) to detachment (schizoid) to
social deficits (schizotypal).
(particularly Asperger’s syndrome)
and may sometimes be a precursor
of schizophrenia.
Schizotypal personality
disorder
Paranoid personality disorder
Paranoid personality disorder is
characterised by pervasive distrust
and suspiciousness and a tendency
to interpret others as malevolent in
some way (exploitative, harmful or
deceiving). These individuals may
be preoccupied with unspecified
doubts about the motives of others
and are reluctant to confide, as
they fear information will be used
maliciously against them.
They may read hidden, demeaning or threatening meaning into
benign remarks or events and persistently bear grudges. They may
perceive attacks on their character
or reputation and are quick to
react angrily or to counterattack.
Some paranoid individuals have
recurrent suspicions about a spouse
or sexual partner.
Schizoid personality disorder
The essential feature of schizoid
personality disorder is detachment
from social relations and a
restricted range of expression of
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emotions in interpersonal settings.
Schizoid individuals appear to lack
a desire for intimacy and do not
seem to enjoy close relationships.
They tend to choose solitary activities and have few friends. They
may have little interest in sexual
experiences and appear indifferent
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to the approval or criticism of
others.
In terms of social behaviour they
may appear oblivious to social cues
and appear socially inept, aloof or
‘bland’. This clinical picture clearly
develops with some features of pervasive developmental disorders
Schizotypal personality disorder
refers to a pattern of reduced
capacity for interpersonal relatedness with cognitive distortions and
eccentricities of behaviour. Individuals with schizotypal personality
disorder often have ideas of reference, that is, they incorrectly interpret external events as having
unusual and specific meaning for
them.
Schizotypal individuals may be
interested in the paranormal and
have a range of beliefs about their
own mental powers. They are
likely to be considered ‘odd’ or
eccentric and to have difficulties
relating to others.
It is important to distinguish
this condition from schizophrenia
or other psychotic disorders,
although under stress, brief transient psychotic experiences may
occur. A small proportion of individuals with schizotypal personality disorder go on to develop
schizophrenia.
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HOW TO TREAT Personality disorders — Part 1
Cluster B personality disorders: dramatic/emotional personalities
Antisocial personality
disorder
ANTISOCIAL personality
disorder refers to a pervasive
pattern of disregard for the
rights of others and has been
previously known as psychopathy or sociopathy.
Antisocial individuals frequently have a history of
childhood maltreatment and
behavioural disturbances,
including aggression from an
early age.
They have seemingly failed
to develop an understanding
of the feelings of others and
are described as unempathic.
They manipulate or use
others for their own advantage and are considered
manipulative and deceptive.
Many engage in criminal
activity and are insensitive
to the rights and feelings of
others. Some antisocial individuals are superficially
charming and confident and
can be successful in exploiting others.
Many engage in
criminal activity
and are insensitive
to the rights and
feeling of others.
• Identity and self-image.
• Control of feelings and
impulses.
• Interpersonal functioning.
These individuals frequently have pervasive difficulties in maintaining relationships and tolerating real
or imagined abandonment.
They tend to have volatile
and unstable relationships
and engage in extreme
behaviour to prevent abandonment, including suicidal
behaviour and self-harm.
They have difficulty tolerating negative-feeling states
and can turn to substance use
and risk-taking behaviours to
avoid intense emotional experiences. Individuals with borderline personality disorder
are found in about 20% of
psychiatric inpatients and in
around 10% of those in outpatient mental health and primary care services. Interactions with clinicians and carers
are quite difficult.
Borderline personality disorder is currently seen as the
result of early childhood
trauma and attachment disruption of vulnerable individuals. Early abuse or neg-
lect disrupts the development
of key domains of personality, including:
Narcissistic personality
disorder
Histrionic personality disorder involves a pattern of
excessive emotionality and
attention-seeking behaviour.
Individuals with narcissistic
personality disorder are
grandiose, with a need for
admiration. They often have
a sense of self-importance
and overestimate their abilities and accomplishments.
Underlying this they often
have a fragile self-esteem.
They have a limited capacity to understand the feelings
or experiences of other
people and can be hurtful
and inconsiderate. Relationships are often based around
the individual’s constant
need for reassurance.
eral personality traits and
sees personality disorder at
one end of a continuum.
Another controversial
issue is that of the stability
over time of the diagnosis of
personality disorder. It is
clear that at least some types
of personality disorder show
improvement over time and
that even severe conditions
such as borderline personality disorder improve with
both time and treatment.
There is also an argument
that the severity of a person-
ality disorder varies between
individuals and this is of
great clinical significance,
even though it is not part of
standard diagnostic systems.
Individuals with severe personality disorder can be
clearly disabled in terms of
social, occupational and
interpersonal functioning
and can face a risk to themselves and others. These individuals can be as severely
disabled as those with
chronic or enduring mental
illness such as schizophrenia.
Histrionic personality
disorder
Borderline personality
disorder
These individuals are often
dramatic in style and
demand to be the centre of
attention. At times they can
be provocative or seductive.
They demonstrate generally
shallow or superficial emotional expression and a lack
of reflection. They may
attempt to engage others in an
over-familiar fashion and try
to please the other through
flattery or expressions of
affection. Histrionic individuals are prone to exaggeration
and are highly suggestible.
Cluster C personality disorders: anxious/fearful personalities
Avoidant personality disorder
INDIVIDUALS with avoidant personality
disorder are socially inhibited and hypersensitive to the negative evaluation of others.
They tend to avoid social interaction and
relationships because of fear of ridicule or
rejection. They have difficulties in forming
intimate relationships and expressing emotions.
Avoidant individuals tend to be highly
interpersonally sensitive and expect to experience rejection. To others they often appear
lonely and isolated or shy. This condition
can overlap with anxiety disorders such as
social phobia and panic disorder with agoraphobia, with major impact on social and
occupational functioning.
Dependent personality disorder
Dependent personality disorder refers to a pervasive and excessive need to be taken care of
that leads to clinging behaviour with others and
a fear of separation. These individuals experience ongoing difficulty in making decisions and
taking initiative and responsibility in their lives.
They are at risk of being dominated and
exploited by others and may acquiesce to unrea-
sonable demands rather than risk disagreement
or potential abandonment. They may have
chronic low self-esteem and appear submissive
and self-sacrificing to an extreme degree. They
may form very close relationships in an indiscriminate fashion. They feel unable to function
in an autonomous way.
Obsessive–compulsive personality
disorder
Obsessive–compulsive personality disorder
describes individuals who are preoccupied
with order and control and are seen as perfectionists and rigid in thinking and behaviour. They tend to be focused on minutiae
and rules, pay excessive attention to detail
and have difficulties in task completion.
The perfectionism and self-imposed high
standards of performance cause significant
dysfunction and distress and impact negatively in interpersonal relationships and activities. They find it hard to relate to others or
take pleasure in non-work-related activities,
and can be socially and emotionally isolated.
Some become preoccupied with order and
rules, hoard objects, or have difficulty spending money.
Controversies in the classification of personality disorder
AS in other defined mental
disorders, personality disorder should only be diagnosed
when the individual is significantly impacted by the condition to the extent that they
have major difficulties in
functioning in most aspects
of their life. Personality disorders have long-term impact
on social functioning and is a
persistent and pervasive pattern of relating.
Although individuals with
personality disorder can also
have features of an Axis 1
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mental disorder (Axis 1
includes all mental health
conditions except personality disorders and mental
retardation), their personality features are more persistent and often more significant in looking at overall
outcome.
Having a personality disorder can also significantly
impact on a concurrent Axis 1
disorder and influence its
course and chronicity. For
example, a clinical depressive
disorder can be more difficult
to treat and is more persistent
in an individual with difficulties in personality and interpersonal functioning.
A major issue in the DSMIV approach to defining categories of personality disorder is that many people
qualify for more than one
category, that is, categories
overlap. The alternative to
categorical diagnosis is a
dimensional approach that
views personality as a
dimension or continuum.
This approach looks at gen-
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Causes of personality disorder
THE causes of personality disorder
are multiple, with a complex mix of
genetic and temperamental factors,
early childhood experiences and
trauma all contributing. Severe personality disorders such as borderline
personality disorder are thought to
result from the impact of trauma and
neglect in early development on vulnerable individuals.
Disruption to the child’s early
attachment relationships and care
impacts on the development of
models or ‘internal representations’ of self and relationships.
Insensitive and unempathic early
parenting can impair the development of social cognition and
understanding of interpersonal
functioning.
In severe cases of psychological
trauma and abuse there may be an
effect on neurodevelopment and
implications for development of
core regulatory functions to do
with emotional regulation and
impulse control. These effects can
be seen in individuals with some
difficulties in regulating behaviours, impulses and emotions.
There is some evidence for a
genetic contribution to personality
traits and disorder. Because of
either genetic or environmental factors, cluster B traits are often found
in the first-degree relatives of index
patients, and genetic factors may
influence traits of affective instability, self-harm, and impulsivity.
One twin study found an overall
heritability of 0.60 for DSM IV
Cluster B personality disorders.1
Genetic variations also influence
the individual’s response to childhood maltreatment and impact on
the development of the stress-regulating systems such as the hypothala-
mic–pituitary–adrenal (HPA) axis.
Trauma during critical periods of
early neurological development has
also been implicated in disturbances
of personality development.
Trauma resulting in the excessive
exposure of the developing nervous
system to stress-related hormones
such as cortisol impacts on neurodevelopment and the wiring of
brain networks involved in stress
regulation.
Longitudinal research has found
persistent dysregulation of the HPA
axis and structural changes in the
brains of adolescents who had
experienced trauma in their early
years, suggesting that changes in
neurological function resulting from
trauma are long term.2
Several mechanisms of potential
damage may be involved:
• Neurotoxic effects of cortisol.
• Dysregulation of the developing
HPA axis and ongoing vulnerability to stress.
• Disruption of limbic system regulation.
• Effects on neurotransmitter systems
(opioid, dopaminergic and serotonergic).
The effects of trauma on brain
development may result in difficulties in tolerating stress, managing emotions and impulses, and
regulating mood states and inter-
personal functioning.
Biological studies of adults with
severe personality disorder provide
support for the existence of biobehavioural dysfunction underlying
many symptom domains. There is
now considerable evidence from
studies of maltreated children that
environmental factors, including the
quality of emotional interaction and
care, shape the development of brain
regulatory systems and that early
trauma influences core psychological functioning.
The term ‘severe personality disorder’ is often used synonymously
with borderline personality disorder
and describes individuals whose overall level of functioning is significantly
impaired. These individuals may
become frequent users of clinical and
welfare services and are at increased
risk of:
• Social exclusion.
• Poverty.
• Drug and alcohol use.
• Criminal conviction.
• Self harm.
• Completed suicide.
Multiple services are often
involved. The histories of individuals
with severe personality disorder usually reveal significant trauma and vulnerabilities. The Author’s case study
described below illustrates this intersection of risk factors.
Author’s case study
Brittany
BRITTANY, 25, is a young
woman with a two-year-old
child living in community
housing. She presents with
symptoms of depression and
a request for benzodiazepines to help with sleeping and “stress”.
She tells you that she has
recently separated from her
child’s father and that their
relationship had been conflictive and unsupportive.
She describes being hit and
punched by her partner, who
had difficulties with anger
and was very controlling of
her.
Brittany is tearful and distressed and says that she
feels she is “worthless” and
a “bad mother”. She says
that when she feels bad she
becomes “wound up “ and
agitated. She has been superficially cutting her forearms
with a razor blade but denies
suicidal intent. She has one
noticeable burn mark on her
leg which is self-inflicted.
She describes being irritable with her child and drinks
to calm herself. She has a
long history of benzodiazepine use and has used
these for symptoms of panic.
In the past she has resisted
discussing her drug use and
has become very angry.
Brittany has a background
of early abuse and neglect.
She describes her own
mother as having suffered
depression and being abused
by Brittany’s father, who had
a serious alcohol problem.
She experimented
with drugs and
described
episodes of
depression, low
self-esteem, selfharming and
impulsive risktaking behaviour.
He deserted the family when
Brittany was six years old
and her mother then had a
series of partners, two of
whom sexually and physically abused Brittany.
When Brittany at age 10
told her mother about the
abuse, her mother did not
believe her and Brittany was
punished for telling lies. From
that time Brittany had a very
difficult relationship with her
mother and became oppositional. She failed at school,
was diagnosed with ADHD
and was started on psychostimulants with little effect.
She was abused by
another one of her mother’s
partners at age 14 and ran
away from home. During
her adolescence she lived in
several refuges and with a
series of older men. She
experimented with drugs
and described episodes of
depression, low self-esteem,
self-harming and impulsive
risk-taking behaviour. She
said she had little trust in
anyone and, although she
had some contact with a
youth mental health service,
she did not really engage
with services.
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Brittany’s most recent relationship had lasted for three
years and was the most
stable relationship she had
experienced. However, her
partner appears to have been
emotionally and physically
abusive and kept Brittany
isolated and controlled. He
was very suspicious of her
behaviour and preoccupied
with the notion that she may
be seeing other men.
Brittany said she stayed
with him to protect her child
but she was worried he
would take the infant to
spite her. The relationship
ended when he recently left
her for another woman,
telling Brittany she was old
and useless. Since this separation Brittany has become
depressed and anxious.
She now presents with
feelings of depression and
agitation and some selfharming behaviours. She is
not suicidal but is seeking an
escape from her feelings. She
is having nightmares about
her experience of child abuse
and tries to avoid anything
that reminds her of her
childhood. She also has worries about her interaction
with her child.
She has little tolerance for
being alone and wonders
when she will find another
partner, although she
acknowledges that her
choices in relationships are
usually poor and discloses
that she has been abused by
all her intimate partners in
the past. She would like to
feel more confident and have
non-abusive relationships.
She has no contact with
any family members, few
friends or interests, and has
ongoing issues with substance misuse.
Discussion
Brittany describes a significant history of ongoing early
abuse and a failure of her
social environment to protect her. Her distress and
behavioural disturbance as a
child led to a diagnosis of
ADHD, which did not lead
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HOW TO TREAT Personality disorders — Part 1
from previous page
to any recognition of her
maltreatment.
She did disclose abuse to
her mother but this account
was not accepted, leaving
her with a feeling of abandonment and betrayal. Her
mother then continued to
expose her to risk and harm.
Brittany responded to this
with feelings of anger and
expressed this in her adolescence with difficult behaviour. Her drug use and risk
taking can be seen as ways
of trying to deal with strong
negative emotions.
Psychologically Brittany
has several features of poor
personality function related
to her early trauma. She has
major difficulties tolerating
negative feelings and managing her impulses. She has
problems in modulating or
finetuning her emotional
reactions. These features of
affect dysregulation are
common in individuals with
histories of early trauma and
can cause major disruption
to relationships and personal
behaviour.
Self-harm can become a
significant issue, and a
repeated and compulsive
pattern of behaviour for
some individuals. In a paradoxical way it helps the individual feel more in control
of their mood and mental
state and restores a sense of
balanced functioning for a
short time. It can become a
stress-reducing behaviour
and a difficult pattern to
break.
Brittany is also experiencing features of recurrence of
her past trauma in the form
of nightmares and unwanted
memories of abuse. She tries
to avoid these, and her drug
use is a form of self-medication for these anxiety symptoms. These symptoms sug-
gest her early trauma is still
impacting on her mental
functioning and is unresolved.
Brittany also has significant difficulty with interpersonal functioning and a tendency to re-enact or repeat
dysfunctional relationships
in her adult life. She has
been involved with several
abusive partners and this
compounds her feelings of
low self-esteem and worthlessness. She has a chronic
low-grade depression or dysthymic disorder and difficulties in maintaining a positive
self-image.
Diagnosing personality disorder
THE case of Brittany highlights some
of the complexity in the diagnosis of
personality disorder. Like Brittany,
many individuals with personality
disorder present in a crisis or after a
significant psychosocial stressor. At
these times feelings of depression,
emotional turmoil and distress can
be high and self-harm or suicidal
ideation may be present.
Some individuals may present with
features of dissociation, including
feelings of numbness, loss of contact
with the environment, or states of
preoccupation resulting in a loss of
sense of time. These features are usually stress-related and transient.
Severe reaction to stress can sometimes include transient paranoid feelings.
A diagnosis of personality disorder should only be made when there
is a clear long-term pattern of maladaptive ways of responding to
stress, and core difficulties in regulating emotions, impulses and interpersonal functioning. Personality disorders are usually diagnoses made over
time and should reflect a chronic
pattern of impaired self-function and
self-understanding.
At the time of presentation an
individual with personality disorder
may clearly meet diagnostic criteria
for a concurrent Axis 1 disorder such
as depression or post-traumatic stress
disorder, but this does not imply that
their major issues are not related to
an underlying developmental disorder of personality functioning.
A history of early attachment difficulties and possible abuse and neglect
are important to clarify in individuals
presenting with personality difficulties. Even in the absence of frank
abuse, a history of poor early care,
neglect and attachment disruption
may be the core of an individual’s
difficulties and problems in maintaining a stable sense of identity.
The clinical manifestations of
severe personality disorder have been
described as the consequences of disrupted psychosocial development
and the attempts the individual
makes to regulate themselves, however maladaptive.3 In this model the
symptoms of severe personality disorder are organised into four main
groupings:
• Disorganised attachment behaviour
— unstable and intense interpersonal relationships; identity disturbance; difficulties with intimacy.
• Cognitive processing dysfunction
— poor understanding of one’s
own thinking and mental states;
difficulties describing emotional
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| Australian Doctor | 5 November 2010
Conclusion
PERSONALITY disorders
are diverse conditions with
many contributing factors,
including possible genetic
and neurobiological underpinnings. They are frequently associated with early
disturbances of attachment
and care, and present with
ongoing difficulties in interpersonal functioning and
management of emotional
states.
They are common in clinical settings and present difficulties for clinicians in terms
of management. While diagnosis and classification are
imprecise, it is important to
recognise the significant
social and functional impairment personality disorders
can produce.
References
Even in the absence of
frank abuse, a history
of poor early care,
neglect and attachment
disruption may be the
core of an individual’s
problems in
maintaining a stable
sense of identity.
states; stress-related dissociation
and paranoid ideation.
• Emotional dysregulation — unstable moods; feelings of numbness
and emptiness; inappropriate and
intense anger; lack of strategies for
management of feelings and
impulses.
• Behavioural dysregulation — reenacting past trauma; impulsivity
and self-damaging behaviours;
efforts to avoid abandonment; selfharming behaviours.
Another useful concept in understanding personality disorder is that
of mentalisation, or reflective selffunction. Mentalisation refers to the
capacity to understand self and others
in terms of underlying mental states
— feelings, wishes, beliefs, intention
and motivation. It is an essential psychological ability that is needed for
understanding human behaviour and
interpersonal functioning.
Mentalisation typically develops
in early childhood, and the parent
has a crucial role in helping the child
develop a model of mental functioning. Children who are abused or neglected appear to have deficits in the
development of mentalisation, resulting in problems in the management
of their own feelings, and in understanding feelings in others (empathic
function).
Abuse and trauma also result in
strong emotional states that the child
has little capacity to manage and
which have ongoing negative impacts
on development. Individuals with
personality disorder often have
deficits in mentalisation that impact
on their ability to understand interwww.australiandoctor.com.au
personal interaction and contribute
to the tendency to feel rejected or
misunderstood, or to draw inaccurate conclusions about the behaviour
of self or others. Some have major
difficulties in empathy and see others
as objects rather than persons, as in
severely narcissistic individuals who
may even pose a risk to others.
Problems in mentalisation also contribute to difficulties in understanding
past trauma as abuse, as the individual
may not be able to understand why
this abuse occurred. This makes it
more likely that they remain preoccupied with past events and still experience trauma-related symptoms such as
nightmares.4
While not all individuals experience
extreme behavioural dysregulation,
psychosis or urges to self-harm, all
have difficulties with attachment and
interpersonal functioning. This has led
some authors to comment that what is
called personality disorder is essentially
an attachment-related disorder, the features of which become apparent in
interpersonal encounters.
Specifically, the individual usually
has major deficits in mentalisation,
and thus in social cognition. This of
course includes the encounter with
the clinician, who becomes a focus of
the individual’s attempts to find a
safe and secure attachment figure.
This may result in the common experience of the patient being very needy
in the encounter, sometimes even
demanding, but at the same time not
really being able to follow advice.
These clinical interactions will be discussed in more detail in Part 2 of
this article.
1. Torgersen S. Genetics of
patients with borderline
personality disorder.
Psychiatric Clinics of
North America 2000;
23:1-9.
2. De Bellis MD.
Developmental
traumatology: the
psychobiological
development of
maltreated children and
its implications for
research, treatment, and
policy. Developmental
Psychopathology 2001;
13:539-64.
3. Bateman AW, Fonagy P.
Psychotherapy for
Borderline Personality
Disorder: Mentalisationbased Treatment. Oxford
University Press, Oxford,
UK, 2004.
4. Judd P, McGlashan. A
Developmental Model of
Borderline Personality
Disorder. Understanding
Variations in Course and
Outcome. American
Psychiatric Publishing,
Arlington CA, 2003.
Further reading
• Pans J. Personality
Disorder Over Time.
American Psychiatric
Publishing, Arlington CA,
2003.
• Kim Y-R, Tyrer P.
Controversies surrounding
classification of
personality disorder.
Psychiatry Investigation
2010, online
(www.psychiatryinvestigat
ion.org)
cont’d page 36
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HOW TO TREAT Personality disorders — Part 1
GP’s contribution
DR LIZ MARLES
Redfern, NSW
Case study
JODY, 30, has been attending the practice for about a
year after requesting a
mental health plan for her
eating disorder (BMI 17).
Although her primary problem is anorexia (which she
tells me she has had since
she was a teenager), Jody
has also at other times been
diagnosed with bipolar 2
disorder (currently using
quetiapine and valproate),
and an unspecified autoimmune disorder, which
mainly presents with tiredness for which she is being
treated with hydroxychloroquine by a rheumatologist.
In doing the mental health
plan Jody became very
defensive on questions of
suicide. She told me she has
suicidal thoughts every day,
and always feels low, but has
learnt not to react to those
emotions, and did not want
to discuss them further. She
has seen multiple psychiatrists over the years but is
happy with her current psychiatrist, whom she sees
once a week, and the psychologist she also sees on a
weekly basis. Jody also presented me with the name of
a dietitian who specialises in
eating disorders, whom she
would like to see.
Although she had previously started an arts degree,
Jody dropped out, finding
the assessment demands too
stressful. She lives at home
with her parents for financial reasons, but describes
her relationship with them
as one where she is expected
to act as the parent and be a
sounding board for her
mother’s depression.
Jody has previously lived
with friends but feels she is
unable to assert her needs,
and often winds up doing
much of the domestic work
and listening to others’ problems. She has not had any
anxiety as they can contribute
to her presentation. Comorbid
conditions are common in personality disorders and eating
disorders may be part of identity issues.
long-term sexual relationships and does not look for
this, saying that in the past
she has found herself having
unwanted sex and feeling
powerless to stop it.
Since her first visit, Jody
has attended the practice
every 2-4 weeks for the
past three months. I have
scheduled monthly appointments to try to manage her
attendance. On her most
recent visit Jody was feeling very anxious, as her
psychiatrist was stopping
private practice, and her
dietitian was also moving
interstate.
How to Treat Quiz
Questions for the author
What is the likelihood that
Jody has a personality disorder? What further history
would be useful to make the
diagnosis?
Jody describes long-term
problems with her mood and
interpersonal functioning. She
seems to be oriented to looking after others but does not
have her own emotional needs
met. She experiences suicidal
ideation and has needed psychiatric support for many
years. It is likely that she has a
personality disorder but it is
also important to assess her
current level of depression and
Jody has been attending multiple practitioners on a weekly
basis. Is this an appropriate
approach to her care, or is
dependency a risk?
It is important to provide
clear and consistent ongoing
support but not to encourage
over-attendance. Getting this
balance right is difficult and
there should be clear discussion with the patient about
reasonable availability and
development of plans for
emergency support.
Does the existence of a personality disorder change the
treatment goals?
Personality disorder is a
long-term condition but there
is increasing evidence that positive change can occur. A focus
on improving the patient’s
ability to use social support
and to develop skills in dealing
with emotional states and anxiety is appropriate. Focusing
on attainable goals and
improving overall quality of
life is central.
General questions for the
author
At what age/stage of development is it possible to diagnose personality disorders?
Does early intervention lead
to better outcomes?
Personality disorder develops over childhood and often
presents in adolescence in the
context of challenges to relationships and developing a
sense of independent identity.
Personality disorders are
developmental conditions and
the risk factors frequently
relate to early childhood and
parenting. Abuse and neglect
are significant risk factors.
Early intervention and
prevention begins with supports for parents and
approaches to the prevention of child abuse and neglect. Specific services for
adolescents presenting with
features of personality disorder are also important
and should focus on establishing a sense of identity
and trauma recovery.
INSTRUCTIONS
Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
by post or fax.
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.
Personality disorders — part 1
— 5 November 2010
1. Which TWO statements are correct?
a) Individuals with a personality disorder (PD)
have difficulties in interpersonal functioning,
self-concept, emotional regulation and
behaviour that are highly context specific
b) Personality traits are transient patterns of
perceiving, relating to, and thinking about the
environment and the self
c) A PD leads to clinically significant distress or
impairment in social, occupational or other
important areas of functioning
d) Onset of a PD can be traced back at least to
adolescence or early adulthood
2. Which TWO statements are correct?
a) The diagnosis of PD is best made at a time of
a crisis
b) Gender tends not to influence the way in
which distress is expressed and managed
c) Individuals with odd/eccentric PDs have
difficulties that may include distrust,
detachment and social deficits
d) The essential feature of schizoid PD is
detachment from social relations and a
restricted range of expression of emotions in
interpersonal settings
3. Which TWO statements are correct?
a) Schizoid individuals appear highly sensitive to
the approval or criticism of others
b) Schizoid individuals may appear oblivious to
social cues and appear socially inept, aloof or
‘bland’
ONLINE ONLY
www.australiandoctor.com.au/cpd/ for immediate feedback
c) With schizotypal PD there are cognitive
distortions and eccentricities of
behaviour
d) It is common for individuals with schizotypal
PD to develop schizophrenia
4. Which TWO statements are correct?
a) Individuals with antisocial PD disregard the
rights of others and have no understanding
of the feelings of others
b) Antisocial PD is characterised by
manipulative, deceptive and exploitative
behaviour
c) Individuals with borderline PD have an
overly developed sense of identity and selfimage
d) Individuals with borderline PD readily
engage with their own intense negative
emotional experiences
5. Which TWO statements are correct?
a) Individuals with histrionic PD usually
have deep and intense emotional
expression
b) Histrionic individuals are not easily
influenced by others
c) Individuals with narcissistic PD often
have a sense of self-importance and
overestimate their abilities and
accomplishments
d) Individuals with narcissistic PD tend
to have fragile self-esteem, and need
constant reassurance in relationships
6. Which TWO statements are correct?
a) Individuals with avoidant PD are socially
inhibited and hypersensitive to the negative
evaluation of others
b) Avoidant PD can overlap with social phobia,
with a major impact on social and
occupational functioning
c) Individuals with dependent PD resist being
dominated by, or acceding to, the wishes of
others
d) Individuals with dependent PD tend not to
form very close relationships easily
7. Which THREE statements are correct?
a) Individuals with a severe PD can pose a risk
to themselves and to others
b) Disruption to the child’s early attachment
relationships and care affects the
development of concepts of self and
relationships with others
c) In severe cases of trauma and abuse,
neurodevelopment related to emotional
regulation and impulse control may be
affected
d) Hormonal and brain structural changes
related to childhood trauma tend to be short
term
8. Which TWO statements are correct?
a) Cortisol protects the brain from the effects of
childhood psychological trauma
b) Dysregulation of the developing
hypothalamic–pituitary–adrenal axis may
occur as a result of childhood psychological
trauma
c) The quality of emotional interaction and care
of a child tends not to affect the
development of brain regulatory systems
d) Dissociative symptoms include feelings of
numbness, and loss of contact with the
environment
9. Which TWO statements are correct?
a) Dissociative symptoms tend to be
persistent and unrelated to a particular
stressor
b) A diagnosis of depression or post-traumatic
stress disorder excludes a PD
c) Poor early care, neglect and attachment
disruption in childhood can result in a PD
d) Mentalisation is the capacity to understand
self and others in terms of feelings, wishes,
beliefs, intention and motivation
10. Which THREE statements are
correct?
a) Deficits in mentalisation result in difficulties
with empathy
b) Problems in mentalisation contribute to
difficulties in understanding past trauma as
abuse
c) Most individuals with a PD will have extreme
behavioural dysregulation, psychosis or
urges to self-harm
d) All individuals with PDs have difficulties with
attachment and interpersonal functioning
CPD QUIZ UPDATE
The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2008-10 triennium. You can
complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or
fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
HOW TO TREAT Editor: Dr Giovanna Zingarelli
Co-ordinator: Julian McAllan
Quiz: Dr Giovanna Zingarelli
NEXT WEEK In Part 2 of How to Treat Personality disorders, common presentations of personality disorders in clinical practice are discussed and approaches to management, assessment and clinical
intervention are outlined. It describes approaches to improving communication with these complex patients and ways in which clinicians can better understand their own reactions.
36
| Australian Doctor | 5 November 2010
www.australiandoctor.com.au