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
unstable. Benzodiazepines (D) should be used with extreme caution in
people with borderline personality disorder because of their potential for
dependence. Group psychotherapy (E) has been used for many years in the
management of individuals with personality disorder. One advantage of
this method is that issues of transference are not limited to the therapist,
but spread out amongst the group. The evidence suggests that on the whole
cognitive behavioural therapy (CBT) is more effective than medication for
generalized anxiety disorder (C). The effects of both are probably additive,
with the most success being for a combined approach of CBT and SSRIs.
While CBT is commonly conducted with just one client and therapist (E),
there is no reason that family members may not be invited to sessions and
in fact may even act as co-therapists in certain situations