Download Personality Disorders (PD)

Personality Disorders
3FM CU
Module Neurobehavioural Sciences II
5th year
Practice
Barbora Kohútová
Personality Disorders (PD)
CONTENTS:
• Personality: definition, structure, historical development of typology
and classification
• PD: definition, classification according to DSM-IV and ICD-10
• Specific PD: general and specific diagnostic criterions, clinical
picture
• PD: Diagnostics, differential diagnostics
• Etiology and pathogenesis
• Treatment: psychotherapy and psychopharmacology
Definitions of personality
• A dynamic and organized set of characteristics
possessed by a person
that uniquely influences his or her cognitions,
motivations, and behaviors in various situations.
→ A relatively stable and enduring set of characteristic
behavioral and emotional traits (the set of emotional
qualities, ways of behaving, etc.)
that makes a person different from other people.
It manifests itself in sociocultural enviroment.
• Personality is thought to be determined by
genetics and biology, and its developement is
completed by environment and experiences
• around 50% of personality traits is genetically
determined
Components of personality
Temperament
Biological component
Character
Social and psychological component
Intelligence
modifies both these basic components
TEMPERAMENT
• Congenital component of
personality (particuraly
genetically determined)
• „temper“, „excitability“
• It is related to way of emotional
manifestation in specific
situations
CHARACTER
• Aquired component of
personality
• „nature“
• Arises during early
developement by psychosocial
learning (mental maps)
• Moral and behavioral traits in
sociocultural enviroment
Personality typology: historical viewpoint
• Hippokrates:
– Sanguine, Melancholic, Choleric, Phlegmatic
•
•
C.G.Jung:
– Extraverted / Introverted
460-377 BC
Kretschmer (constitutional body types
1875 - 1961 associated
with certain personality traits ):
– asthenic/leptosomic (thin, small, weak), athletic
(muscular, large–boned), and pyknic (stocky, fat)
•
1895-1978
Vondráček:
– Dysthymia, Cyclothymia
1888-1964
Personality typology: historical viewpoint
Hans Eysenck (1916-1997)
- 1947 he described two personality dimensions:
extraversion and neuroticism (E and N)
• High N and high E = Choleric type
– emotionall unstable extraverted
• High N and low E = Melancholic type
– emotionall unstable introverted
• Low N and high E = Sanguine type
– emotionall stable extraverted
• Low N and low E = Phlegmatic type
– emotionall stable introverted
What does
personality disorder („psychopathy“)
mean?
• An enduring pattern of inner experience and
behavior that deviates markedly from the
expectations of the individual’s culture,
–
–
–
–
is pervasive and inflexible,
has an onset in adolescence or early adulthood,
is stable over time,
and leads to distress or impairment
• It is not „mental illnes“ in the right meaning
• People with personality disorder are not matured, they are lacking in
empathy and fail in interpersonal relationship.
Definition of PD due to DSM-IV
An enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the
individual's culture. This pattern is manifested in two (or
more) of the following areas:
– Cognition (i.e., ways of perceiving and interpreting
self, other people and events)
– Affectivity (i.e., the range, intensity, liability, and
appropriateness of emotional response)
– Interpersonal functioning
– Impulse control
• DSM-5: Latest revision of DSM, May 2013
DSM-5: definition of PD
The essential features of a personality disorder are
•
impairments in personality
– self functioning
– interpersonal functioning
•
the presence of pathological personality traits
Specific P.D.:
10 types, each type is defined by a specific pattern of impairments and
traits.
DSM-5: General Criteria for a PD
•
•
•
Significant impairments in self (identity or selfdirection) and interpersonal (empathy or intimacy)
functioning.
One or more pathological personality trait domains
or trait facets.
These changes
– are relatively stable across time and consistent
across situations
– are not better understood as normative for the
individual‟s developmental stage or socio-cultural
environment
– are not solely due to the direct physiological effects
of a substance (e.g., a drug of abuse, medication) or
a general medical condition (e.g., severe head
trauma)
Specific PD
10 distinct types of P.D.
(3 basic clusters)
• A - Odd or Eccentric:
– Paranoid
– Schizoid
– Schizotypal
• B – Dramatic or Erratic:
–
–
–
–
Antisocial
Narcissistic
Borderline
Histrionic
• C- Anxious:
– Avoidant
– Dependent
– Obsessive-compulsive
The hybrid methodology for
clinicians (6 types):
•
•
•
•
•
•
Borderline
Obsessive-Compulsive
Avoidant
Schizotypal
Antisocial
Narcissistic
• PD-TS (personality
disorder – trait specified)
- PD is present, but the
criteria for a specific
personality disorder are
not fully met (must be
noted)
Highlights of differences
between DSM-5 and ICD-10 classifications
• ICD-10: 10 + 1 basic types
– Paranoid, Schizoid, Antisocial, Histrionic, Emotional unstable, Avoidant,
Anankastic (Obsessive–compulsive), Narcissistic, Pasive-agressive PD
+ Schizotypal disorder
– Schizotypal disorder is not in PD (F6x), but in psychotic
disorders (F2x)
– Emotional unstable PD (F60.4) is divided into impulsive and
borderline type
– Narcissistic and passive-aggressive PD are cathegorized in
Others PD (F61)
• DSM-5: 10 basic types
– Passive-aggressive PD is not described
– Emotional unstable, respectively Impulsive PD is not described
(only Borderline PD)
Paranoid PD
• Pervasive distrust
• Suspiciousness of others
• Touchiness
• They believe that other people’s motives
are suspect or even malevolent
• Distortion and wrong interpretation of
neutral or friendly motives as unfriendly
or contemptuous
• Jealousy - they suspect their partner
from infidelity
Criteria of Paranoid PD
• Pervasive Distrust
• Suspiciousness
• Interpret Motives as Evil
•
•
•
•
•
Feels Attacked
Preoccupation with Distrust
Jealous
Won’t Confide
Misinterprets Motives
Schizoid PD
• Detached
• Few emotions - emotionally cold
•
•
•
•
•
•
•
Closeness
No Close Friends
Solitary
Indifferent, cold
Low Sex Interest
They don´t enjoy activities
Unrealistic phantasies, goals,
„inner world“
„Party at the Technical University“
Schizotypal PD: DSM-5 Criteria
• Eccentricity
– Odd, unusual, or bizarre behavior or appearance;
saying unusual or inappropriate things
• Cognitive and perceptual dysregulation
– Odd or unusual thought processes; vague,
circumstantial, metaphorical, over-elaborate, or
stereotyped thought or speech; odd sensations in
various sensory modalities
• Unusual beliefs and experiences
– Thought content and views of reality that are viewed
by others as bizarre or idiosyncratic; unusual
experiences of reality
Antisocial PD
• Disregard rights and emotions of
others
• Disorderly conduct
• Unlawful
• Irresponsible
• Impulsive
• Lack Remorse
• Aggressive
• „Criminal types“
• „Psychopaths“
DSM-5 Criteria of Antisocial PD
• Antagonism
– Manipulativeness
– Deceitfulness: Dishonesty and fraudulence
– Callousness: Lack of concern for feelings or problems of others;
lack of guilt or remorse about the negative or harmful effects of
one„s actions on others; aggression; sadism
– Hostility: Persistent or frequent angry feelings; anger or
irritability in response to minor slights and insults
• Disinhibition
– Irresponsibility
– Impulsivity: Acting on the spur of the moment in response to
immediate stimuli; acting on a momentary basis without a plan or
consideration of outcomes
– Risk taking
Borderline PD
• Unstable emotional experiences
• Frequent mood changes
• Unstableself-image, often
associated with excessive selfcritisism
• Chronic feeling of emptiness
• Intense, unstable, and conflicted
close relationships
DSM-5 Criteria of Borderline PD
• Negative Affectivity
– Emotional lability: Unstable emotional experiences and
frequent mood changes
– Anxiousness: Intense feelings of nervousness, tenseness
– Separation insecurity: Fears of rejection
– Depressivity: Frequent feelings of being down, miserable, and
/or hopeless
• Disinhibition
– Impulsivity: self-harming behavior under emotional distress
– Risk taking: Risky, and potentially self-damaging activities
• Antagonism
– Hostility: Persistent or frequent angry feelings
„SPLITTING“
Self-harm, self-injury
• It is performed on the grounds of:
– release of inner tension
– cover of feelings of emptiness
– cover of emotional pain with physical pain
• It is not:
– attraction of sb's attention
– suicidal behaviour
Self-harming
Histrionic PD
•
•
•
•
•
•
Self-dramatization
Excessive emotions
Attention seeking
Suggestibility
Exaggerating
Inappropriate seductiveness
• „drama-queen“
Obsessive-Compulsive PD
• „punctiliouos“
• concerned with
details
• perfectionism
• rules, perfect order,
lists
DSM-5 Criteria of Obsessive-Compulsive PD
• Compulsivity
– Rigid perfectionism: Rigid insistence on everything
being flawless, perfect, without errors or faults,
preoccupation with details, organization, and order
• Negative Affectivity
– Perseveration: Persistence at tasks long after the
behavior has ceased to be functional or effective;
continuance of the same behavior despite repeated
failures
Avoidant PD
• Excessive feelings of shame
or inadequacy
•
•
•
•
•
•
•
•
Avoids Social Activity
Reluctant Relationships
Fears Intimacy
Fears Criticism
Avoids New Activities
Sees Self Inferior
Fears Embarrassment
DSM-5 Criteria of Avoidant PD
• Withdrawal
– avoidance of social contacts and activity; lack of initiation of
social contact
• Intimacy avoidance
– avoidance of close or romantic relationships
• Anhedonia
– lack of enjoyment from, engagement in, or energy for life‟s
experiences
• Anxiousness
– intense feelings of nervousness, tenseness, or panic, often
in reaction to social situations; worry about the negative
effects of past unpleasant experiences and future negative
possibilities
Dependent PD
• Needs to be taken care
of
• Fears separation
• Dependence inclination
• often „role of victim“
Narcissistic PD
• „self-love“
• Excessive reference to others
for self-definition and selfesteem regulation
• Exaggerated self-appraisal
• Impaired ability to recognize or
identify with the feelings and
needs of others
DSM-5 Criteria of Narcissistic PD
• Grandiosity
– Feelings of entitlement, either overt or covert; selfcenteredness; firmly holding to the belief that one is
better than others; condescending toward others.
• Attention seeking
– Excessive attempts to attract and be the focus of the
attention of others; admiration seeking.
Passive-aggressive PD
• Undirect complaints
• Sabotage of teamwork
• Intransigence
• Unproductivity
Mixed PD
• Common in clinical practice
• Examples of combination of personality
traits:
– histrionic + narcissistic
– avoidant + obsessive-compulsive
– narcissistic + antisocial
– paranoid + antisocial
Diagnostics of PD
• Diagnostic tools
– psychiatric investigation
– structured interviews
– psychological assessment (objective qustionnaire)
• MMPI: Minnesota Multiphasic Personality Inventory
• MCMI: Millon Multiaxial Inventory
• TPQ Cloningerův trojrozměrný dotazník
– Neuropsychological test: diagnostics of organic
disorders
• Dg. of adult age, at least 18 years
Etiology a pathogenesis of PD
• Multifactorial
• Biological influence:
– genetics
– perinatal injury
– stress in gravidity
– brain inflammations
•
•
frontal cortex – impulsivity, judgment, abulia
temporal cortex – excitability, psychomotoric
restlessness, religiosity
• parietal cortex – euforia, refusing
Etiology a pathogenesis of PD
• Psychological theories
• Psychoanalytical - Freud
– Oral ( oral personality) 0-1 year
– Anal ( anal personality) 1-2 years
– Uretral 2-3 years
– Phallic 3-6 years
– Latence stage 6-12 let
– Genital 12 years - adult
Neurobiology of PD
Symptoms
PD
Neurobiological changes
↑impulsivity
Emotional lability
Borderline
Antisocial
↑ limbic cortex (amygdala)
↓ prefrontal inhibition
↓ serotoninergní aktivity
prefrontálně
Cognitive
dysregulation and
information
processing
Schizotypal
Paranoid
(Schizophrenia)
↑ dopaminergic activity
limbic area
↓ dopaminergic activity
prefrontally
anxiety
Avoidant
↑ activity amygdala
Obsessive-compulsive ↓ activity prefrontal cortex
Treatment PD
• Combination of pharmacotherapy and
psychotherapy
• Goal of the treatment determination
– Crisis intervension
• Suicidal tendencies, self-harming, aggression
– Short-therm treatment of acute comorbid
disorder (personality decompensation)
• Depressive, anxious, psychotic
– Long-therm treatment of PD
Possibilities od treatment of PD
• Pharmacotherapy
• Supporting psychotherapy
• Dynamic psychotherapy
• Cognitive-behavioral psychotherapy (CBT)
• Group psychotherapy
Common treatment process
• Symptomatic pharmacological treatment of acute
symptoms
– depressive, anxious, psychotic symptoms, ..
– symptoms-related pharmacotherapy
(antidepressants, antipsychotics, mood stabilizers)
• Long-therm psychotherapy treatment of PD
– It takes years, individual od group form of
psychotherapy
Symptomatic pharmacotherapy
Neurotransmiter
Peronality
dimension
Disordes
Primary therapy
Dopamin (D)
↑D
Cognition /
perception
Schizophrenia
SchizotypalPD
Paranoid PD
AP
Serotonin (5-HT)
↓ 5-HT
Impulsivity /
aggressivity
Antisocial PD
Borderline PD
Gambling
SSRI
Affective disorders
(BAP)
Borderline PD
Mood-stabilizers
AD
Noradrenalin (NA) Affectivity
regulation
↑ NA
Inspired by: Dušek, Večeřová, 2010
Děkuji za pozornost.
[email protected]