1. Consultant Psychiatrist in Psychotherapy
Personality Disorder
Dr Ray Haddock
Consultant Psychiatrist in Psychotherapy
Sheffield Care Trust
Acknowledgements, Many including Peter Tyrer, Yvonne Agazarian, psychologists and neurobiologists
Draw attention to change in behaviour at start - did anyone tell you how to behave?
Any one here not got a personality?

2. What is personality that it gets disordered?
How do we decide if it is disordered?
When is it disordered?
Where is it disordered?
When is a disordered personality not disordered?

3. Objectives of Lecture
1. To briefly consider how personality is defined.
2. To describe and compare main diagnostic systems
How to diagnose personality disorder
What does NICE say
Treatment and Management evidence and the lack of it.
The future - some speculation

4. What is personality?
The visible aspect of one's character as it impresses others: He has a pleasing personality.
A person as an embodiment of a collection of qualities: He is a curious personality.
Psychology . a.
the sum total of the physical, mental, emotional, and social characteristics of an individual. b.
the organized pattern of behavioral characteristics of the individual.

5. The quality of being a person; existence as a self-conscious human being; personal identity.
The essential character of a person.

6. Personality from first principles
Genes
Birth
Gene pool
Community
Work
Intimate
Reproduction
Personal preference and choice
Adolescence
Early adulthood
Family, school peers
Childhood
Caregiver
Development
Neurobiological
Physical
Nutritional
Educational
Emotional
Models
Attachment
Social learning
Psychoanalysis
Piaget
Maslow
Etc
Adulthood
Personality
Adaptability to context
Transition
Home to community
Adaptation Context
Life Stage
Of Personality

7. Definitions of Personality Disorder
ICD 10
“….clinically significant conditions and behaviour which tend to be persistent and are the expression of an individual’s characteristic lifestyle and mode of relating to others…….as a result of both constitutional factors and social experience…..”
DSM IV
“…. is an enduring pattern of inner experience and behaviour 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.”
Is personality neurobiologically fixed by the time we are “grown up” ?
Can whatever seems to be fixed be changed?

8. DSM-5 (No Longer Axis II)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose personality disorder, the following criteria must be met.
Significant Impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning
One or more pathological personality trait domains or trait facets

9. General diagnostic criteria for a personality disorder (derived from ICD 10 and DSM IV From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann
An enduring pattern of inner experience that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: 1) Cognition, i.e. Ways of perceiving and interpreting self, other people and events 2) Affectivity, i.e. The range, intensity, lability and appropriateness of emotional response 3) Interpersonal functioning 4) Impulse control

10. General diagnostic criteria for a personality disorder (derived from ICD 10 and DSM IV From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann
An enduring pattern of inner experience that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: 1) Cognition, i.e. Ways of perceiving and interpreting self, other people and events 2) Affectivity, i.e. The range, intensity, lability and appropriateness of emotional response 3) Interpersonal functioning 4) Impulse control

11. Comparison of DSM and ICD
DSM-IV-TR
DSM-IV-TR/DSM 5
ICD-10
Cluster A
Schizoid/Removed
Schizoid
Paranoid/Removed
Paranoid
Schizotypal
Cluster B
Borderline
Emotionally Unstable
-Impulsive
-Borderline
Antisocial
Dissocial
Narcissistic
Histrionic/Removed
Histrionic
Cluster C
Avoidant
Anxious (avoidant)
Dependent/Removed
Dependent
Obsessive-Compulsive
Anankastic

13. Differences between mental state and personality disorders
From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann
Mental State Disorders
Personality Disorders
Temporary (Usually)
Permanent (or at least long standing)
Reactive
Generative
Dominated more by symptoms than behaviour
Dominated more by behaviour and relationships with others
Diagnosed mainly on mental state
Diagnosed on basis of long term function
May develop into other mental states
Tends to remain stable

14. DSM-5
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose personality disorder, the following criteria must be met.
Significant Impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning
One or more pathological personality trait domains or trait facets

15. General diagnostic criteria for a personality disorder - DSM 5
The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations
The impairments in personality functioning and the individual’s personality trait expressions are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
The impairments in personality functioning and the individual’s trait expression 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

16. DSM-5 IN
Antisocial Avoidant Narcissistic Obsessive Compulsive Schizotypal PD Trait specific Negative affectivity Detachment Antagonism Disinhibition vs Cmpulsivity Psychotisism

17. DSM-5
Out
Paranoid Schizoid Histrionic Dependant

18. DSM 5 specific criteria for each PD
Significant Impairments in personality functioning 1. Impairments in self functioning (a or b) a. Identity b. Self-direction 2. Impairments in interpersonal functioning (a or b)
a. Empathy b. Intimacy

19. DSM 5 specific criteria for each PD
Pathological Personality traits in the following domains: (e.g. for Antisocial) Antagonism etc 2 Disinhibition

20. Prevalence General Population - lifetime 2-18% !!
Primary Care 5-9% ?? great variation
Psychiatric population 30-40%
Inpatient populations %
Prison 70% +
Conclusion? 9

21. Making the Diagnosis - 1 History, History History!
Recurring patterns of difficulty/symptoms
Wide range of previous diagnoses
Developmental history
Problems at school
Abuse/neglect (repeated and recurrent)
Family patterns/relationships/breakdowns/violence
The internal world of the child
Changes in context

22. Making the Diagnosis 2
“Childhood was normal and all developmental milestones were normal” !
Most developmental, milestones are genetically and biologically driven. Therefore it takes very substantial environmental factors to change them enough to notice as for most the range is variable in any case.
There is however an experience of childhood and development in the developmental context

23. Making the Diagnosis Symptoms All symptoms are possible
Interpersonal relationships – child and adult
Behaviour reflects perception of reality- go beyond the explanation
Move from open to specific questioning

24. NICE GUIDELINES -Borderline PD Treatment and Management
CMHT management CPA
Consistent approach to treatment and management
No stand alone short term psychological treatments
Pharmacological treatments? - only for treatment of co-morbidity

25. NICE GUIDELINES -Borderline PD Psychological Treatment
No overwhelming evidence for any treatment
Dialectical Behaviour Therapy (Linehan) - certain groups - female -self harm, impulsivity
Psychodynamic therapies - evidence but not gold standard
Therapeutic community - for severe
No particular role for inpatient treatment

26. Treatment and management - Summary
Make the diagnosis
Discuss and put in context – “normalise”
Long term treatment and management plan
Psycho-education
Risk management
Impulse management and control
Specific interventions (short term to long term)
Symptom targeted medication
At every step it is important to attend to engagement and collaboration

27. NICE GUIDELINES - Antisocial Personality Disorder
Mostly Tier 4 management
No specific treatments
Forensic - low/high secure
Mental Health services - management of mental illnesses
Intervention focussed more on prevention - intervention with children and families

28. Long term outcomes
Some evidence that severity of disorder diminishes with age
Exacerbation and reduced recovery rates from neurotic disorders
The more severe/co morbidity the smaller the response to interventions
Impact of therapy?
Mortality? 14

29. The Future?
Models of personality disorder that relate to aetiology - increased understanding Genetic Developmental Neurobiology of social functioning
Treatment and management approaches that are based on sound evidence and theoretical models
E.G.

30. Personality from first principles
Genes
Birth
Gene pool
Community
Work
Intimate
Reproduction
Personal preference and choice
Adolescence
Early adulthood
Family, school peers
Childhood
Caregiver
Development
Neurobiological
Physical
Nutritional
Educational
Emotional
Models
Attachment
Social learning
Psychoanalysis
Piaget
Maslow
Etc
Adulthood
Personality
Adaptability to context
Transition
Home to community
Adaptation Context
Life Stage
Of Personality

31. Proposed ICD 11 classification for Personality disorder
Severe PD
Moderately
Severe PD
Personality
Disorder
Personality
Difficulty not qualifying as PD
No Personality
Disturbance
Social/
Schizoid
Dissocial/
Externalising
Anxious dependant/
Internalising
Obsessional/
Anankastic
Emotional distress/
Instability
Proposed ICD 11 classification for Personality disorder

32. A Histrionic personality
B Anankastic personality
C Paranoid personality
D Dissocial personality
E Schizoid personality
F Borderline personality – unstable type
G Borderline personality – impulsive type
Which of the above corresponds best to the following:

33. 140. A man attends with his CPN
140. A man attends with his CPN. He becomes very tearful when speaking about his depression but then changes quickly to talking rather loudly about his plans for the future
141. A man complains that his written complaint to social work is being ignored. He refuses to talk to the psychiatrist about it as “she’ll not do anything about it either”.
142. A woman is kept waiting a couple of minutes by the nurse having to take a telephone call. She smashes a window in the bathroom and is about to slash herself saying “it’s your fault I’m doing this”.

34. Answers
140. Probably A
141 C
142 G

35. Theme: personality
Eysenck Personality Questionnaire
Rorschach test
Repertory grid
Thematic appreciation test
Minnesota Multiphasic Personality Inventory
‘Big 5’ personality test
Q sort

36. Lead in: Which of the above methods used to assess personality has the following features?
This projective tests of personality requires individuals to make up a storey based on ambiguous pictures of people and scenes
An idiographic test of personality developed by George Kelly
This personality tests has scales which measure the tendency to answer questions in a defensive and/or socially desirable manner
This personality test posits that one of its dimensions reflects the degree of cortical arousal
This test has dimensions measuring openness, conscientiousness extraversion, agreeableness and neuroticism

37. Theme: personality D C E A F

38. Useful sources of information
Mental Health Foundation – mental-health-a-z/personality-disorders/
Mind – conditions/personality_disorders
The Royal College of Psychiatrists – all/problems/personalitydisorders/pd.aspx