Psychopharmacology: Personality Disorders

A. The behaviour must affect the ability to control impulses While many people with personality disorder do have difficulty with impulse control (A), it is not necessary for a diagnosis. ICD-10 specifies that the individual’s inner experiences or behaviour must be manifest in more than one of the following areas (but not necessarily all). Cognition Affectivity Control over impulses Manner of relating to others. This behaviour cannot be limited to one situation or stimulus, but must pervade across the individual’s inner and social worlds and must be inflexible, maladaptive and dysfunctional (B). There must be distress, either to the individual themselves, their social environment, or usually both (C). The disorder must have arisen during late childhood or adolescence (D), and should be ‘stable’ and of long duration. Changes occurring within adulthood themselves do not qualify as personality disorders, but may represent personality change, usually as the result of severe and enduring stress. An organic cause cannot be responsible for the disorder (E) – there is a separate diagnostic category for ‘organic personality disorder’ – an example would be frontal lobe injury

D. It is now generally accepted that personality can be described by three

factors

There are a bewildering number of personality theories and constructs. However, it is becoming increasingly accepted that five (not three) factors can adequately describe personality. These can be remembered with the mnemonic ‘OCEAN’ - Openness to experience, Conscientiousness, Extraverson/intraversion, Agreeableness and Neuroticism (D). Kretschmer originally described three body-types that he believed were associated with specific personality types (A). However, empirical research has not shown any reliable link between the two. Freud hypothesized that for normal personality development, an individual must successfully pass through various developmental stages of ‘the libido’, namely oral, anal and genital (B). Failure at one, e.g. anal, would result in personality difficulties in later life (in this case, obsessional traits). Idiographic personality theories are concerned with the uniqueness of every individual (C), compared to nomothetic theories in which personality is thought to be made up of differing degrees of stable factors, and individuals differ only in the amount of each of these factors that they possess. The environment as well as our genetic makeup of course are responsible for how our personality develops (E) – this has been backed up by numerous twin and other studies.

A. Co-morbid mental disorder

While there are specific examples when co-morbid mental disorder (which excludes personality disorder) would increase dangerousness (e.g. the presence of violent command hallucinations, high levels of perceived threat in paranoid states), overall, very little violence is directly attributable to mental illness (A). People with mental illness are more likely to be the victims of violence than perpetrators of it. Co-morbid substance misuse is positively correlated with dangerousness (B). The aetiology of this relationship, however, is extremely complex. Juvenile delinquency (C) may predict a tendency towards psychopathy (which itself is related to dangerousness). This forms part of one of the most commonly used assessment tools for psychopathy, the Hare Psychopathy Checklist – Revised (PCL-R), as part of Factor 2 – ‘Socially Deviant Lifestyle’. (D) and (E) are also part of the PCL-R for psychopathy, but fall into Factor 1 of the checklist – ‘Aggressive Narcissism’.

D. Discharge from accident and emergency with follow-up

from her key worker

The most appropriate option is to discharge her with follow-up from her key worker (D). She is currently in a service designed specifically to cope with the difficulties people with personality disorder face. There is little evidence here that an inpatient admission would be helpful (A). People with borderline personality disorder often feel chronically abandoned and not listened to, so while admission may make both the clinician and patient feel safer, it is seldom useful in the long term. People with personality disorder often use admissions as justification for their behaviours. Firm boundaries coupled with thoughtful empathy are necessary to help these individuals. Again, like their being no justification for admission, there is no evidence for using the MHA (and indeed it is unlikely she would be detainable). Therefore (B) and (C) would not be appropriate – and in fact one could not use Section 5(2) in any case as this is only applicable to current inpatients, not to patients in accident and emergency. Banning the patient from accident and emergency (E) will only serve to confirm the woman’s feelings of abandonment – the behaviour is likely to escalate rather than stop, and will just occur in another department where she is not known, which is potentially much more dangerous.

B. Antisocial personality disorder

Antisocial personality disorder (B), also known as dissocial, psychopathic or sociopathic personality disorder, is commonly seen in forensic settings, and tends to affect men more than women. Aside from the features listed above, these individuals show gross disregard for social norms, cannot maintain meaningful relationships and usually have disordered development in childhood, often with diagnoses such as conduct disorder. This disorder is classified in Cluster ‘B’, a system adopted by DSM-IV (but not ICD-10). Cluster B disorders include those that are overly dramatic, emotional or with impulse control problems. Note that the other options are not explained further here as they are used in subsequent questions.

B. Dependent personality disorder

Dependent personality disorder is described here (B). These people often only come to attention when their spouses leave or die. They tend to allow others to take responsibility for them and will find it extremely hard to make decisions. They tend to not ask things of others but require large amounts of help and advice. This disorder falls into the DSM-IV Cluster ‘C’ category, which includes disorders characterized by anxiety or fear.

D. Schizoid personality disorder

The vignette is describing someone with likely schizoid personality disorder (D). The name is possibly confusing, although it is thought by some to be connected to schizophrenia. However, these people do not have the psychotic symptoms that are the hallmark. Instead, they tend to be isolative, aloof and emotionally detached (although not in the violent way of antisocial personality disorder). They gain little pleasure from things except perhaps unusual intellectual activities, and usually have few friends or relationships. This is a Cluster ‘A’ disorder (characterized by odd or eccentric patterns of behaviour). Schizoid personality disorder should not be confused with schizotypal personality disorder (E). The latter has actually been taken out of the personality disorder section in ICD-10 and placed within the schizophrenia and related disorders category. These individuals present with symptoms of social anxiety as well as odd cognitive and perceptual experiences and beliefs that do not amount to delusions or hallucinations. They may have unusual speech patterns. This disorder is definitely felt to be related to schizophrenia.

A. Anankastic personality disorder

This represents an anankastic personality type (A), also known as obsessive–compulsive personality disorder in DSM-IV. This is not the same as obsessive–compulsive disorder, although the two may give rise to some diagnostic difficulties. However, those with anankastic personality disorders tend to be preoccupied with rules and schedules. They are perfectionists and overly pedantic. They are usually quite rigid and may be stubborn and difficult to get along with as they can come across as extremely judgemental. This is also a Cluster ‘C’ disorder.

C. Histrionic personality disorder

This is a difficult question, as this may get confused with narcissistic traits (D) or with emotionally unstable traits (B). However, this description is very suggestive of histrionic personality disorder (C), in which individuals are prone to overly dramatic displays and occasional self-harm. They are faddish and attention seeking, often sexually. They have a shallow affect and cannot maintain relationships easily. They also tend to be obsessed with their physical appearance. In contrast, emotionally unstable personality disorder (B) does not present quite like this, although obviously self-harming behaviour is prevalent here also. There is also often considerable overlap between them, but emotionally unstable individuals tend to have intense but unstable relationships and go to great lengths to avoid being abandoned, while at the same time pushing people away. They feel chronically empty. Likewise, narcissistic individuals may share some of these characteristics, but the core of narcissistic personality disorder is an inflated sense of self-worth, often being pretentious and boastful. They crave attention as well as celebrity and believe they are above others. They are usually callous and show little regard for the feelings of others.

B. Antipsychotic medications have shown evidence of effectiveness in

management of personality disorder

There are some small studies showing benefits of antipsychotic medication (B) over a wide range of symptoms in personality disorder. However, there is no consensus about who will benefit from these drugs, in what way, and for how long. Individuals with personality disorder may sometimes end up on a vast array of medications which is more likely to be symptomatic of the treating clinician’s feelings of therapeutic impotence than any observable benefit to the individual. Antidepressants (A) similarly may have a role, particularly in terms of helping with impulse control. However, as with antipsychotics, the use of psychotropic medication alone is almost certain to be a failure without consistent and long-term psychological interventions. Dynamic psychotherapy (C) is certainly used for the management of many types of personality disorder, including emotionally