<ul><li>Construct </li></ul><ul><li>History </li></ul><ul><li>Clinical concerns </li></ul><ul><li>Measuring Tools  </li></...
19 th  century  <ul><li>Four Humors – Greek Models </li></ul><ul><ul><li>Choleric, sanguine, phelgmatic and bilious </li><...
Late 19 th  century <ul><li>‘ Personality’ - Hume and Kant </li></ul><ul><li>Subjective aspects of self – original mean. <...
A brief History of Personality Disorders <ul><li>Pinel – Manie sans De`lire  (mania without confusion) </li></ul><ul><li>P...
History contd.. <ul><li>Degeneration theories – Benedict Morel ‘Inheritance of criminal tendencies’ </li></ul><ul><li>Otto...
Personality and Disorders <ul><li>16PF,Big 5, MMPI, Briggs-Myers, EPQ  </li></ul><ul><li>DSM approach: </li></ul><ul><ul><...
First Force
Second Force
Third force
Definition ? <ul><li>Consistency and regularity of TFB across time  </li></ul><ul><li>Not episodic /  Not rare </li></ul><...
Clinical concerns <ul><li>Well recognised but oft Disregarded by clinicians </li></ul><ul><ul><li>Elusive boundaries </li>...
Prevalence  <ul><li>10-14 % meet criteria at least 1 PD </li></ul><ul><ul><li>(1989,1993,1997) – U.S ECA </li></ul></ul><u...
Prevalence
Global burden Increased relational problems in adulthood Increased mortality in adults Co morbid issues Substance abuse De...
DSM4 -P.D -Major Clusters <ul><li>Cluster A </li></ul><ul><li>Paranoid </li></ul><ul><li>Schizoid </li></ul><ul><li>schizo...
Cluster A: Odd, Eccentric Group Psychotics   <ul><li>Paranoid personality disorder:  </li></ul><ul><ul><li>SUSPECT  (4 cri...
Cluster A: Odd, Eccentric Group Psychotics <ul><li>Schizoid personality disorder:  DISTANT  (4 criteria).   </li></ul><ul>...
Cluster A: Odd, Eccentric Group Psychotics <ul><li>Schizotypal personality disorder:  ME PECULIAR  (5 criteria).  </li></u...
Cluster B: Dramatic, Erratic Group <ul><li>Antisocial personality disorder:  CORRUPT   </li></ul><ul><li>(3 criteria).  </...
Cluster B: Dramatic, Erratic Group <ul><li>Borderline personality disorder:  AM SUICIDE   </li></ul><ul><li>(5 criteria). ...
Cluster B: Dramatic, Erratic Group <ul><li>Histrionic personality disorder:  PRAISE ME  (5 criteria).  </li></ul><ul><li>P...
Cluster B: Dramatic, Erratic Group <ul><li>Narcissistic personality disorder:  SPECIAL  (5 criteria).  </li></ul><ul><li>S...
Cluster C Anxious, Fearful : Neurotics <ul><li>Avoidant personalty disorder:  </li></ul><ul><li>CRINGES  (4 criteria).  </...
Cluster C Anxious, Fearful : Neurotics  <ul><li>Dependent personality disorder:  RELIANCE  (5 criteria).  </li></ul><ul><l...
Cluster C Anxious, Fearful : Neurotics <ul><li>Obsessive-compulsive personality disorder:  </li></ul><ul><li>LAW FIRMS (4 ...
some or all Axis 1symptoms find its way in to personality disorders.. <ul><li>Loss </li></ul><ul><li>Self esteem  </li></u...
Dimensional or categorical
Dimensional
How much are these criteria valid? <ul><li>‘ Latent’  structure of DSM4 personality disorder criteria: Com. psychiatry 47/...
Newer attempts to classify!  <ul><li>IPDE – 89 trait variables correlating with 10PD </li></ul><ul><li>ASP – 8  </li></ul>...
What can we expect in future ? <ul><li>VALIDITY OF DSM CONSTRUCT ? </li></ul><ul><li>The new ‘BIG 5’ </li></ul><ul><li>Sig...
Putative causes  <ul><li>5HT – inverse relationship with impulsivity and aggression </li></ul><ul><li>Structural findings:...
Early experiences <ul><li>Social stressors: ASPD,BD </li></ul><ul><li>Sexual abuse: BD </li></ul><ul><li>Having a psychopa...
Other issues.. <ul><li>Personality disorders in childhood and adolescents : ADHD, Conduct problems </li></ul><ul><li>Genet...
Psychotherapy <ul><li>Some borderline are treatable </li></ul><ul><li>Aim: To reduce risk of suicide/ distress (aged less ...
Medication <ul><li>Low dose neuroleptics </li></ul><ul><li>Tricyclic anti depressants </li></ul><ul><li>MAOI </li></ul><ul...
Outcome  <ul><li>Tip of ice berg engaged with MHS </li></ul><ul><li>Merger with main stream – worse outcome </li></ul><ul>...
Upcoming SlideShare
Loading in …5
×

Personality disorder tutorial

4,129 views
3,949 views

Published on

Presentation made by Dr JP Rajendran in 2007, last updated Aug 2008

Published in: Education
1 Comment
13 Likes
Statistics
Notes
No Downloads
Views
Total views
4,129
On SlideShare
0
From Embeds
0
Number of Embeds
278
Actions
Shares
0
Downloads
11
Comments
1
Likes
13
Embeds 0
No embeds

No notes for slide

Personality disorder tutorial

  1. 1. <ul><li>Construct </li></ul><ul><li>History </li></ul><ul><li>Clinical concerns </li></ul><ul><li>Measuring Tools </li></ul><ul><li>Prevalence studies </li></ul><ul><li>Course and prognosis </li></ul><ul><li>Classification and future </li></ul><ul><li>Consensus </li></ul><ul><li>What next ? </li></ul>Disorder
  2. 2. 19 th century <ul><li>Four Humors – Greek Models </li></ul><ul><ul><li>Choleric, sanguine, phelgmatic and bilious </li></ul></ul><ul><li>Faculty Vs Associationism </li></ul><ul><ul><li>(tri-partite models Vs experiential) </li></ul></ul><ul><li>Constitution,Temperament, self, character, personality – new Meanings </li></ul><ul><li>Self – Descarte ‘Ontological continuity’ </li></ul><ul><li>Character – Kant, ‘ingrained behaviours’ </li></ul>
  3. 3. Late 19 th century <ul><li>‘ Personality’ - Hume and Kant </li></ul><ul><li>Subjective aspects of self – original mean. </li></ul><ul><li>Difficulty in isolating personality </li></ul><ul><li>Pathological changes in awareness </li></ul><ul><li>How to measure? </li></ul><ul><ul><li>Types and traits </li></ul></ul><ul><ul><li>Galton – hereditary influences to types – 14yr </li></ul></ul>
  4. 4. A brief History of Personality Disorders <ul><li>Pinel – Manie sans De`lire (mania without confusion) </li></ul><ul><li>Pritchard </li></ul><ul><li>Esquirol – monomanie </li></ul><ul><li>Schneider – First taxonomy of PD </li></ul><ul><li>Personality theories  DSM 3/ 4 , ICD10 </li></ul><ul><li>Mental diseases cannot become ill independently ! </li></ul>
  5. 5. History contd.. <ul><li>Degeneration theories – Benedict Morel ‘Inheritance of criminal tendencies’ </li></ul><ul><li>Otto Gross  Jung Introverts/extroverts </li></ul><ul><li>Psychodynamic –Character Neurosis </li></ul><ul><li>Kahn , Henderson </li></ul><ul><li>Doctrine of constitution – France- 8 groups </li></ul>
  6. 6. Personality and Disorders <ul><li>16PF,Big 5, MMPI, Briggs-Myers, EPQ </li></ul><ul><li>DSM approach: </li></ul><ul><ul><li>Direct reports </li></ul></ul><ul><ul><li>Autobiographical accounts </li></ul></ul><ul><ul><li>Narratives by others </li></ul></ul><ul><li>Reliability and validity = sources of info. </li></ul><ul><li>Applying scientific paradigm </li></ul>
  7. 7. First Force
  8. 8. Second Force
  9. 9. Third force
  10. 10. Definition ? <ul><li>Consistency and regularity of TFB across time </li></ul><ul><li>Not episodic / Not rare </li></ul><ul><li>More than sum of traits </li></ul><ul><li>Fundamental psycho-physiological coherence </li></ul><ul><li>_________________________________ </li></ul><ul><ul><ul><li>Temperament - Biological / Inherited/ child </li></ul></ul></ul><ul><ul><ul><li>Character – nature and Nurture </li></ul></ul></ul>
  11. 11. Clinical concerns <ul><li>Well recognised but oft Disregarded by clinicians </li></ul><ul><ul><li>Elusive boundaries </li></ul></ul><ul><ul><li>Non reliable diagnostic tools </li></ul></ul><ul><ul><li>Pessimism around Rx </li></ul></ul><ul><ul><li>Limited training in careers </li></ul></ul>
  12. 12. Prevalence <ul><li>10-14 % meet criteria at least 1 PD </li></ul><ul><ul><li>(1989,1993,1997) – U.S ECA </li></ul></ul><ul><li>20% general population meet criteria for 1 PD in UK. </li></ul><ul><ul><li>(BJP/May 2006) </li></ul></ul><ul><ul><li>2 phases </li></ul></ul><ul><ul><li>Large scale </li></ul></ul><ul><ul><li>Cluster B – more correlating with major mental illnesses. </li></ul></ul>
  13. 13. Prevalence
  14. 14. Global burden Increased relational problems in adulthood Increased mortality in adults Co morbid issues Substance abuse Depression SEMI- SCHZ/ BAD Employment problems Homelessness Self Harm Suicide Criminal acts School drop outs Child abuse Spousal abuse Substance abuse
  15. 15. DSM4 -P.D -Major Clusters <ul><li>Cluster A </li></ul><ul><li>Paranoid </li></ul><ul><li>Schizoid </li></ul><ul><li>schizotypal </li></ul><ul><li>Cluster B </li></ul><ul><li>Borderline </li></ul><ul><li>Histrionic </li></ul><ul><li>Antisocial </li></ul><ul><li>Narcissistic </li></ul><ul><li>Cluster C </li></ul><ul><li>Avoidant </li></ul><ul><li>Dependent </li></ul><ul><li>Obsessive – </li></ul><ul><li>compulsive </li></ul><ul><li>Coming soon!!! </li></ul><ul><li>Depressive PD </li></ul>
  16. 16. Cluster A: Odd, Eccentric Group Psychotics <ul><li>Paranoid personality disorder: </li></ul><ul><ul><li>SUSPECT (4 criteria). </li></ul></ul><ul><li>S : Spouse fidelity suspected U : Unforgiving (bears grudges) S : Suspicious of others P : Perceives attacks (and reacts quickly) E : &quot;Enemy or friend&quot; (suspects associates, friends) C : Confiding in others feared T : Threats perceived in benign events </li></ul>
  17. 17. Cluster A: Odd, Eccentric Group Psychotics <ul><li>Schizoid personality disorder: DISTANT (4 criteria). </li></ul><ul><li>D : Detached (or flattened) affect I : Indifferent to criticism and praise S : Sexual experiences of little interest T : Tasks (activities) done solitarily A : Absence of close friends N : Neither desires nor enjoys close relations T : Takes pleasure in few activities </li></ul>
  18. 18. Cluster A: Odd, Eccentric Group Psychotics <ul><li>Schizotypal personality disorder: ME PECULIAR (5 criteria). </li></ul><ul><li>M : Magical thinking or odd beliefs E : Experiences unusual perceptions </li></ul><ul><li>P : Paranoid ideation E : Eccentric behavior or appearance C : Constricted (or inappropriate) affect U : Unusual (odd) thinking and speech L : Lacks close friends I : Ideas of reference A : Anxiety in social situations R : Rule out psychotic disorders and pervasive developmental disorder </li></ul>
  19. 19. Cluster B: Dramatic, Erratic Group <ul><li>Antisocial personality disorder: CORRUPT </li></ul><ul><li>(3 criteria). </li></ul><ul><li>C : Conformity to law lacking O : Obligations ignored R : Reckless disregard for safety of self or others R : Remorse lacking U : Underhanded (deceitful, lies, cons others) P : Planning insufficient (impulsive) T : Temper (irritable and aggressive) </li></ul>
  20. 20. Cluster B: Dramatic, Erratic Group <ul><li>Borderline personality disorder: AM SUICIDE </li></ul><ul><li>(5 criteria). </li></ul><ul><li>A : Abandonment M : Mood instability (marked reactivity of mood) </li></ul><ul><li>S : Suicidal (or self-mutilating) behavior U : Unstable and intense relationships I : Impulsivity (in two potentially self-damaging areas) C : Control of anger I : Identity disturbance D : Dissociative (or paranoid) symptoms that are transient and stress-related E : Emptiness (chronic feelings of) </li></ul>
  21. 21. Cluster B: Dramatic, Erratic Group <ul><li>Histrionic personality disorder: PRAISE ME (5 criteria). </li></ul><ul><li>P : Provocative (or sexually seductive) behavior R : Relationships (considered more intimate than they are) A : Attention (uncomfortable when not the center of attention) I : Influenced easily S : Style of speech (impressionistic, lacks detail) E : Emotions (rapidly shifting and shallow) </li></ul><ul><li>M : Made up (physical appearance used to draw attention to self) E : Emotions exaggerated (theatrical) </li></ul>
  22. 22. Cluster B: Dramatic, Erratic Group <ul><li>Narcissistic personality disorder: SPECIAL (5 criteria). </li></ul><ul><li>S : Special (believes he or she is special and unique) P : Preoccupied with fantasies (of unlimited success, power, brilliance, beauty, or ideal love) E : Entitlement C : Conceited (grandiose sense of self-importance) I : Interpersonal exploitation A : Arrogant (haughty) L : Lacks empathy </li></ul>
  23. 23. Cluster C Anxious, Fearful : Neurotics <ul><li>Avoidant personalty disorder: </li></ul><ul><li>CRINGES (4 criteria). </li></ul><ul><li>C : Certainty (of being liked required before willing to get involved with others) R : Rejection (or criticism) preoccupies one's thoughts in social situations I : Intimate relationships (restraint in intimate relationships due to fear of being shamed) N : New interpersonal relationships (is inhibited in) G : Gets around occupational activity (involving significant interpersonal contact) E : Embarrassment (potential) prevents new activity or taking personal risks S : Self viewed as unappealing, inept, or inferior </li></ul>
  24. 24. Cluster C Anxious, Fearful : Neurotics <ul><li>Dependent personality disorder: RELIANCE (5 criteria). </li></ul><ul><li>R : Reassurance required for decisions E : Expressing disagreement difficult (due to fear of loss of support or approval) L : Life responsibilites (needs to have these assumed by others) I : Initiating projects difficult (due to lack of self-confidence) A : Alone (feels helpless and discomfort when alone) N : Nurturance (goes to excessive lengths to obtain nurturance and support) C : Companionship (another relationship) sought urgently when close relationship ends E : Exaggerated fears of being left to care for self </li></ul>
  25. 25. Cluster C Anxious, Fearful : Neurotics <ul><li>Obsessive-compulsive personality disorder: </li></ul><ul><li>LAW FIRMS (4 criteria). </li></ul><ul><li>L: Loses point of activity (due to preoccupation with detail) </li></ul><ul><li>A: Ability to complete tasks (compromised by perfectionism) </li></ul><ul><li>W: Worthless objects (unable to discard) </li></ul><ul><li>F: Friendships (and leisure activities) excluded (due to a preoccupation with work </li></ul><ul><li>I: Inflexible, scrupulous, overconscientious (on ethics, values, or morality, not accounted for by religion or culture) </li></ul><ul><li>R: Reluctant to delegate (unless others submit to exact guidelines) </li></ul><ul><li>M: Miserly (toward self and others) </li></ul><ul><li>S: Stubbornness (and rigidity) </li></ul>
  26. 26. some or all Axis 1symptoms find its way in to personality disorders.. <ul><li>Loss </li></ul><ul><li>Self esteem </li></ul><ul><li>Abnormal beliefs/perceptions </li></ul><ul><li>Panic </li></ul><ul><li>Phobia </li></ul><ul><li>Drug use dependency </li></ul><ul><li>Grandiosity / irritability </li></ul><ul><li>Body image disturbances </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>intrusive horrible thoughts </li></ul><ul><li>_________________________________________ </li></ul><ul><li>Raises co-morbid issues, Unclear boundaries </li></ul>P.D
  27. 27. Dimensional or categorical
  28. 28. Dimensional
  29. 29. How much are these criteria valid? <ul><li>‘ Latent’ structure of DSM4 personality disorder criteria: Com. psychiatry 47/2006 ,Elsevier pub. </li></ul><ul><li>Internal construct validation: previous studies. </li></ul><ul><ul><li>DSM3 – only OCDP </li></ul></ul><ul><ul><li>DSM 3 - later BDP, SchizTypal,,avoidant and ocpd </li></ul></ul><ul><li>No.742 people -John Hopkins centre- thorough methodolgy – 2 years follow up. </li></ul><ul><ul><li>DSM3 – aspd, narcissistic and bdp </li></ul></ul>
  30. 30. Newer attempts to classify! <ul><li>IPDE – 89 trait variables correlating with 10PD </li></ul><ul><li>ASP – 8 </li></ul><ul><li>Avoidant – 7 </li></ul><ul><li>Borderline 9 </li></ul><ul><li>Dependant – 8 </li></ul><ul><li>Histrionic – 8 </li></ul><ul><li>Narcissistic – 8 </li></ul><ul><li>Obs Comp – 7 </li></ul><ul><li>Paranoid 7 </li></ul><ul><li>Schizoid 7 </li></ul><ul><li>Schizotypal -8 </li></ul><ul><li>_________________________ </li></ul><ul><li>Only 2 conditions correlates </li></ul><ul><li>Five super factors rather than 10 </li></ul><ul><li>5 factor model of abnormal personality – Nestadt </li></ul><ul><li>COMPULSIVE </li></ul><ul><li>ALOOF </li></ul><ul><li>NEUROTIC AVOIDANT </li></ul><ul><li>IMPULSIVE CALLOUS </li></ul><ul><li>EGO CENTRIC </li></ul>
  31. 31. What can we expect in future ? <ul><li>VALIDITY OF DSM CONSTRUCT ? </li></ul><ul><li>The new ‘BIG 5’ </li></ul><ul><li>Sig. Correlates well with disabilities </li></ul><ul><li>Compulsive less disabilities </li></ul><ul><li>Newer classificatory system </li></ul><ul><li>More sensitive to disabilities and identifying needs </li></ul>
  32. 32. Putative causes <ul><li>5HT – inverse relationship with impulsivity and aggression </li></ul><ul><li>Structural findings: temporal lobe and hippocampus, VBR. Some supportive links </li></ul>
  33. 33. Early experiences <ul><li>Social stressors: ASPD,BD </li></ul><ul><li>Sexual abuse: BD </li></ul><ul><li>Having a psychopathic father in family – ASPD </li></ul><ul><li>Divorcing parents – BD </li></ul><ul><li>Erratic punishment – ASPD </li></ul><ul><li>_______________________________ </li></ul><ul><li>Specificity of effect: </li></ul><ul><li>Family stressors – Interpersonal and affective . </li></ul><ul><li>Social stressors - behavioural and psychopathy </li></ul>
  34. 34. Other issues.. <ul><li>Personality disorders in childhood and adolescents : ADHD, Conduct problems </li></ul><ul><li>Genetics :Not all traits are inheritable </li></ul><ul><li>Criminal justice system – complex interplay and implications </li></ul><ul><li>Personality traits & PD traits </li></ul><ul><li>Rare personalities: </li></ul><ul><ul><li>Depressive PD </li></ul></ul><ul><ul><li>Multiple PD </li></ul></ul>
  35. 35. Psychotherapy <ul><li>Some borderline are treatable </li></ul><ul><li>Aim: To reduce risk of suicide/ distress (aged less than 30) </li></ul><ul><li>Cluster B impulsive: limit setting group </li></ul><ul><li>Chronic depression, high motivation, psychological mindedness, low impulsivity, secure living  expressive therapy </li></ul><ul><li>Therapist enthusiasm and commitment </li></ul><ul><li>Address co-morbid issues </li></ul><ul><li>DBT/CBT – variable benefits </li></ul>
  36. 36. Medication <ul><li>Low dose neuroleptics </li></ul><ul><li>Tricyclic anti depressants </li></ul><ul><li>MAOI </li></ul><ul><li>SSRI </li></ul><ul><li>Lithium </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Anti – epileptic drugs </li></ul>
  37. 37. Outcome <ul><li>Tip of ice berg engaged with MHS </li></ul><ul><li>Merger with main stream – worse outcome </li></ul><ul><li>Man is like a novel : one doesn’t know until the very last pge how things will end. </li></ul><ul><ul><ul><ul><ul><li>(Yevgeny 1924) </li></ul></ul></ul></ul></ul>

×