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AD_ 0 2 9 _ _ _ NOV 0 5 _ 1 0 . p d f Pa ge 2 9 2 8 / 1 0 / 1 0 , 1 1 : 5 4 AM HowtoTreat PULL-OUT SECTION www.australiandoctor.com.au COMPLETE HOW TO TREAT QUIZZES ONLINE (www.australiandoctor.com.au/cpd) to earn CPD or PDP points. inside 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 www.australiandoctor.com.au 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. cont’d next page 5 November 2010 | Australian Doctor | 29 AD_ 0 3 0 _ _ _ NOV 0 5 _ 1 0 . p d f Pa ge 3 0 2 7 / 1 0 / 1 0 , 1 1 : 4 5 AM 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 30 | Australian Doctor | 5 November 2010 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 www.australiandoctor.com.au 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. cont’d page 32 AD_ 0 3 2 _ _ _ NOV 0 5 _ 1 0 . p d f Pa ge 3 2 2 7 / 1 0 / 1 0 , 3 : 5 4 PM 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 32 | Australian Doctor | 5 November 2010 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- www.australiandoctor.com.au AD_ 0 3 3 _ _ _ NOV 0 5 _ 1 0 . p d f Pa ge 3 3 2 7 / 1 0 / 1 0 , 3 : 5 5 PM 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. www.australiandoctor.com.au 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 cont’d next page 5 November 2010 | Australian Doctor | 33 AD_ 0 3 4 _ _ _ NOV 0 5 _ 1 0 . p d f Pa ge 3 4 2 7 / 1 0 / 1 0 , 3 : 5 5 PM 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 34 | 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 AD_ 0 3 6 _ _ _ NOV 0 5 _ 1 0 . p d f Pa ge 3 6 2 7 / 1 0 / 1 0 , 3 : 5 6 PM 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