Transcript Personality Disorders

Personality Disorders
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Definitions
 Personality disorders are not time-limited
 Pervasive, lifelong difficulties with interpersonal
relationships and self-identity.
 While these disorders are diagnosed after age 18,
they almost always have earlier roots
• Related to early attachment or adjustment disorders
• Sexual abuse is common
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Prevalence
 No firm estimates, as most people do not seek
treatment
 Perhaps 1-10% of the population (Million et al, 2004)
 Often identified as a comorbid or recurring
condition
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substance use
depression, with or without suicidal ideation/attempts
anxiety
eating disorders
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Case History
 Molly suffered repeated severe physical, sexual and emotional
abuse at the hands of several family members throughout her
childhood and adolescence. Even as a young adult, she remained at
risk whenever she had any contact with her family. She was
removed from the care of her parents several times during
childhood, but on each occasion was eventually returned to their
care.
 Frustrated, ashamed, and convinced that she was responsible for all
the problems in her family, Molly began to hit herself with belts,
cords, and sticks when she was 12 years old. She described how
she learned “cutting” from another patient while in a psychiatric
hospital.
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Case History
 By the time of her diagnosis, she had a history of more than 50
overdoses, using medications prescribed by different physicians as
well as those available over the counter. She had added burning her
limbs and alcohol abuse to her repertoire of self-injury.
 None of this self-abuse caused physical pain, but each episode was
temporarily effective in relieving her frustration. Massively obese,
constantly starving and overeating, she spent more time in hospital
than in the community. No treatment programmes helped; borderline
personality disorder was diagnosed, and she began to feel and fear
the inevitable rejection of her caretakers.
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Case History 2
 The patient is a 37 year old female. Between the ages of
four and twelve, she reportedly was the victim of severe,
repetitive abuse by her grandfather, both physical and
sexual including insertion of sharp, painful objects (e.g.,
knives), and hanging her from pulleys. According to the
patient, physical and sexual abuse occurred every weekend
during this time period. The grandfather threatened to kill
her if she ever revealed the abuse. It finally ended with the
grandfather’s death.
 It is important to note that the patient’s parents were not
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Case History 2
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Case History 2
 The patient is currently an elementary school teacher who
reported an initial alter enactment while instructing a class
of students; a four year old girl emerged who began to
color with the crayons she, as teacher, used with her
students. Later, another alter emerged who began to trash
the classroom because she did not want to be back at
school.
 The “alters” coexisted without full awareness of one
another, and in particular, she as an adult could intuit but
did not know directly what had been expressed by them
when they enacted; it was like material from a kind of
dream state. Nevertheless, as an adult, she was able to
maintain control and appear to be an integrated person.
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Case History 2
 When the “dominant personality” re-emerged, the patient
would roll or close her eyes, seem semi-stuporous for a few
moments, and then gradually regain orientation and
awareness over the next twenty or thirty seconds. There
was a distinctly post-ictal quality to these re-emergences of
the controlling adult, a returning back, as it were, from a
trance or dream.
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DSM-IV General Criteria
A. An enduring pattern of inner experience and
behaviour that deviates markedly from the
expectations of the individual’s culture. This
pattern is manifested in two (or more) of the
following areas:
 cognition (ways of perceiving self, other people,
and events)
 affectivity (range, intensity, lability, and
appropriateness of emotional response)
 interpersonal functioning
 impulse control (anger management)
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DSM-IV General Criteria
B. The enduring pattern is inflexible and pervasive
across a broad range of personal and social
situations.
C. The pattern is stable and of long duration and its
onset can be traced back at least to adolescence
or early adulthood.
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Subtypes
Cluster B
Cluster A
(Dramatic(Odd-Eccentric)
Emotional
Cluster C
(AnxiousFearful)
Paranoid
Antisocial
Avoidant
Schizoid
Borderline
Dependent
Schizotypal
Histrionic
ObsessiveCompulsive
Other
(Classed
separately)
Dissociative
Identity
Disorder
Narcissistic
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Provisional Subtypes
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Depressive
Sadistic
Masochistic
Negativistic
Etc, etc.
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1. Antisocial Personality Disorder
 Pattern of disregard for and violation of the rights of others
that begins in childhood or early adolescence and continues
into adulthood.
 Deceitfulness, impulsivity, aggressiveness, lack of remorse
or conscience.
 Also called psychopathy, sociopathy, or dyssocial
personality disorder.
 Prevalence more common in males than females (5:1)
 More likely to be diagnosed in prison or forensic samples
• up to about 30-50% of incarcerated populations (Drugge,
2002)
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2. Borderline Personality Disorder
 Pervasive pattern of instability of
interpersonal relationships, self-image,
and affects
 Marked impulsivity, severe mood swings
 See self, others, world, in black and white
 Undermine their own achievements
 Dramatic, particularly when threatened
 More common in females (4:1)
 About 60% of clinical populations referred
for borderline personality disorders
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3. Dissociative Identity Disorder
 Formerly multiple personality disorder
 It is not strictly classed in the DSM as a personality
disorder, but it does meet the criteria for general diagnosis
 Presence of two or more distinct identities or personality
states that recurrently take control of behaviour
 An inability to recall important personal information, but it
is not due to poor memory
 There is usually a primary identity, and alternates
 Identities tend to emerge under certain circumstances (not
typically under volitional control)
 Prevalence estimates unknown
 3-9 times more common in females
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Common Neurobiology
 Few neurobiological studies on personality
disorders
 Implication of Cortisol, DA, NE, 5HT in most
populations studied (van der Kolk, 1995; Millon et al.,
2004)
 Structural areas (typically noted as lower in
volume, and deficient in NT function)
• Hippocampus
• Frontal lobes
• Amygdala
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Etiologies: Diverse and Uncertain
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Heredity (on average ranges from 20-50% concordance for
first degree relatives) (Livesley et al., 2003)
Intrafamilial abuse - sexual abuse in particular (McLean,
2003)
Environmental confounders:
Parental mental illness
Family discord - attachment
Faulty learning of behaviours/problem solving skills
Social isolation (reduced socialization)
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Controversy?
 Treatment or acceptance?
 What is behaviour that deviates markedly from
the expectations of the individual’s culture?
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