Personality Disorders

Personality Disorders Personality Disorders

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 Personality Disorders

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 • substance use • depression, with or without suicidal ideation/attempts • anxiety • eating disorders Personality Disorders

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. Personality Disorders

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. Personality Disorders

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 able or were unwilling to corroborate these allegations nor could the patient provide any external confirmatory evidence.  Personality Disorders

Case History 2 • The patient was diagnosed with Dissociative Identity Disorder (DID) by psychotherapists who had worked with her over a six year period. They indicated that “alters” usually emerged quite abruptly with marked changes in facial expression, tone, and prosody of voice, vocabulary, and gesture; there were also reportedly differences in handwriting, behavioral and affective expressions; some were more playful, informal, warm or witty than the patient’s adult persona.  Personality Disorders

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. Personality Disorders

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. Personality Disorders

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) Personality Disorders

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. Personality Disorders

Subtypes Personality Disorders

Provisional Subtypes • Depressive • Sadistic • Masochistic • Negativistic • Etc, etc. Personality Disorders

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) Personality Disorders

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 Personality Disorders

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 Personality Disorders

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 Personality Disorders

Etiologies: Diverse and Uncertain • 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) Personality Disorders

Controversy? • Treatment or acceptance? • What is behaviour that deviates markedly from the expectations of the individual’s culture? Personality Disorders

Personality Disorders