Personality Disorders
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Personality Disorders Dr M Antonioli, MD Consultant Psychiatrist Why are they important? • Schizophrenia 1% • Bipolar Affective Disorder 1.5% • Major Depressive Disorder 5% • Personality Disorders? Personality (temperament; character). A construct to describe cognitive, emotional and behavioural traits that are peculiar to a particular person. Traits are assumed to be relatively stable and enduring (??). 5 major dimensions (Big Five): Extraversion vs introversion Neuroticism vs emotional stability Open-mindedness vs closed-minded Agreeableness vs antagonism Conscientiousness vs disinhibition A bit of history • The study of human personality or "character" (from the Greek charaktêr, the mark impressed upon a coin) dates back at least to antiquity. In his Characters, Tyrtamus (371-287 B.C.) — nicknamed Theophrastus or "divinely speaking" by his contemporary Aristotle — divided the people of 4th century B.C. Athens into 30 different personality types, including "arrogance," "irony," and "boastfulness." Characters exerted a strong influence on subsequent studies of human personality, such as those of Thomas Overbury (1581-1613) in England and Jean de la Bruyère (1645-1696) in France. • The concept of personality disorder itself is much more recent and tentatively dates back to psychiatrist Philippe Pinel’s 1801 description of manie sans délire, a condition which he characterized as outbursts of rage and violence (manie) in the absence of any symptoms of psychosis, such as delusions and hallucinations (délires). • Across the English Channel, physician JC Prichard (1786-1848) coined the term "moral insanity" in 1835 to refer to a larger group of people who were characterized by "morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions and natural impulses," but the term, probably considered too broad and non-specific, soon fell into disuse. • The German psychiatrist Koch sought to make the moral insanity concept more scientific, and in 1891 suggested the phrase 'psychopathic inferiority', theorized to be a congenital disorder. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgment. His work established the concept of personality disorder as used today. • Some 60 years later, in 1896, psychiatrist Emil Kraepelin (1856-1926) described seven forms of antisocial behaviour under the umbrella of "psychopathic personality," a term later broadened by Kraepelin’s younger colleague Kurt Schneider (1887-1967) to include those who "suffer from their abnormality." • Schneider’s seminal volume of 1923, Die psychopathischen Persönlichkeiten (Psychopathic Personalities), still forms the basis of current classifications of personality disorders, such as those contained in the influential American classification of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders (now at the 5th edition). Personality Disorder • Inflexible, maladaptive and deeply ingrained cognitive, emotional and behavioural patterns that deviate markedly from the norms of generally accepted behaviour, typically apparent by the time of adolescence, and causing long-term difficulties in personal relationships or in functioning in society. It causes significant functional impairment in varies areas – and subjective distress (this is not valid for all PD!). • Traits can be perceived as ego-syntonic or ego-dystonic. • Patient with PD have profound difficulties in self-perception and in relating to their social environment. They may have poor coping skills and abnormal defence mechanisms. Mechanisms of defence Cont… • Distortion • Conversion • Idealisation • Projective identification • Wishful thinking • Withdrawal • Schizoid fantasy • Altruism • Anticipation Some initial considerations on PD (“the grave of the young and not so young psychiatrist”) • Prevalence in general population 15%-20% (paradox of psychiatry!) • Most common diagnosis in psychiatry (40%) • Often misdiagnosed! • Increased mortality (and it is also our fault…) • Less studied and researched than major mental illness • Less evidence-based results • Less resources/competent professionals to treat them • Debate about who should treat them (doctors????) • Legislation (MHA) does not fit • Comorbidity: LD, ASD, ADHD, BAD, PTSD, substances, etc. • Ongoing issues with the use of the MCA in A&E/hospitals (this is relevant for you) Aurelia Brouwers, another young Dutchwoman with a complex history of mental health problems, including borderline personality disorder and PTSD. Brouwers became a household name in the Netherlands last year after her quest for a state- assisted suicide culminated in her death at the age of 29. Like Noa, Brouwers self- harmed. She too had published an autobiographical book, The Girl with the Scissors: Memoir of a Scratcher, and blogged about her desire to die. Ultimately, Brouwers contacted the broadcaster RTL, pitching a documentary about her case. Screened days after her death on January 26 last year, The Last Days of Aurelia Brouwers sparked furious debate about whether the liberal Dutch had gone too far in facilitating the death of a physically healthy young woman. The film’s unforgettable final scene showed Brouwers clutching her beloved toy dinosaur and the bottle of poison prescribed to end her life. She chatted excitedly to the camera about the prospect of “lekker slapen” (delicious sleep) before heading upstairs to her bedroom to drink the poison and die in her friend’s embrace. • A man in the Nederland was allowed to die because he could no longer carry on living as an alcoholic. • Mark Langedijk chose the day of his death and was telling jokes, drinking beer and eating ham sandwiches with his family hours before he passed away. • "My brother suffered from depression and anxiety and tried to 'cure' it with alcohol. He's from a normal family, he did not want this to happen. He did not take an easy way out. Just a humane one”. • Before going on to characterize these 10 personality disorders, it should be emphasized that they are more the product of historical observation than of scientific study, and thus that they are rather vague and imprecise constructs. As a result, they rarely present in their classic "textbook" form, but instead tend to blur into one another. Their division into three clusters in DSM-5 is intended to reflect this tendency, with any given personality disorder most likely to blur with other personality disorders within its cluster. For instance, in cluster A, paranoid personality is most likely to blur with schizoid personality disorder and schizotypal personality disorder. • The majority of people with a personality disorder never come into contact with mental health services, and those who do usually do so in the context of another mental disorder or at a time of crisis, commonly after self-harming or breaking the law. Nevertheless, personality disorders are important to health professionals, because they predispose to mental disorder and affect the presentation and management of existing mental disorders. They also result in considerable distress and impairment, and so may need to be treated "in their own right." Whether this ought to be the remit of the health professions is a matter of debate and controversy, especially with regard to those personality disorders which predispose to criminal activity, and which are often treated with the primary purpose of preventing crime. • Many issues occur with classifying a personality disorder. Because the theory and diagnosis of personality disorders occur within prevailing cultural expectations, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations. Paranoid PD • Paranoid personality disorder is characterized by a pervasive distrust of others, including even friends, family, and partners. As a result, this person is guarded, suspicious, and constantly on the lookout for clues or suggestions to validate his fears. He also has a strong sense of personal rights: he is overly sensitive to setbacks and rebuffs, easily feels shame and humiliation, and persistently bears grudges. Often suspects infidelity and does not confide in people. He is prone to react angrily or “counterattack”. Unsurprisingly, he tends to withdraw from others and to struggle with building close relationships. The principal ego defence in paranoid PD is projection, which involves attributing one’s unacceptable thoughts and feelings to other people. • Querulous subtype: the most feared! (case of C.E.) • Highly prevalent in dictators. Schizoid PD • The term "schizoid" designates a natural tendency to direct attention toward one’s inner life and away from the external world. A person with schizoid PD is emotionally detached and cold and prone to introspection and fantasy. He has no desire for social or sexual relationships, is indifferent to others and to social conventions, and lacks emotional response. Takes pleasure in solitary activities and lacks close friends. A competing theory about people with schizoid PD is that they are in fact highly sensitive with a rich inner life: they experience a deep longing for intimacy, but find initiating and maintaining close relationships too difficult or distressing, and so retreat into their inner world. People with schizoid PD rarely present to medical attention,