P E R S O N A L I T Y D I S O R D E R IIEpidemiology, Assessment, Diagnosis

Dr Rachel Thomasson Speciality Trainee-5

NORTHWESTERN SCHOOL OF PSYCHIATRY MRCPsych COURSE

Overview

• Epidemiology• Assessment frameworks• Revision MCQs • Diagnosis and differentials

Personality disorders are

• Enduring• Persistent• Pervasive• Clinically significant distress and/or impairment in

social/occupational functioning• Out of keeping with societal and cultural norms• Not an artefact of another mental health problem

(affective disorder, psychosis, substance misuse, organically based psychiatric disorder e.g. brain injury, dementia)

Epidemiology

• General prevalence of PD : 4-13%• Commoner in working age adults (25-44)• Inter rater reliability re: diagnosis is poor

• More likely to be separated, divorced, never married, unemployed, poor social and interpersonal function but not less educated

Epidemiology – general population• Paranoid 0.5-3%• Schizoid 0.5-7%• Schizotypal 0.5-5%• Antisocial 2-3.5%• Borderline 1.5-2%• Histrionic 2-3%• Narcissistic 0.5-5%• Anankastic 1-2%• Avoidant 0.5-1%• Dependent 0.5-5%

• Overall prevalence in community :– cluster A 1.6% –Cluster B 1.2%–Cluster C 2.6%– Overall 4.4% (Coid

BJP 2006)

Primary and secondary care

• Primary care – Anankastic most prevalent, followed by EUPD

• EUPD most common in psychiatry out patients

• Prevalence of PD increased in substance misuse and Eating disorders

PD in UK prison settings

• Prevalence of any PD:• 78% males on remand• 64% sentenced males• 50% sentenced females

• Antisocial PD • 63% males on remand• 49% sentenced males• 31% sentenced females

Antisocial personality disorder

• UK general population 0.6% (1% males, 0.2% females), other quotes as high as 2-3%.

• M:F ratio = 4:1• 25-44yr age group• Associated with leaving school early,

homelessness, increased mortality in early adulthood.

• Commoner in urban pops. • 20% still meet criteria at 45 years of age.

Antisocial personality disorder and psychopathy

– Two different constructs though some overlap of traits– Psychopathy no longer included in personality

disorders in ICD 10– Hare’s PCL-R assessment tool – assessment of

affective, interpersonal and behavioural aspects of psychopathy

– Score of 25 or more indicative of psychopathy

• Current interest in children diagnosed with conduct disorder with callous unemotional traits. ?Longitudinal studies to determine whether precursor for psychopathy in adulthood

Associations in the literature• Paranoid PD – commoner in males, low SEC,

relatives of individuals with schizophrenia

• Schizoid PD - more common in offender populations, males. Association with schizotypal PD

• Schizotypal PD – commoner in relatives of individuals with schizophrenia (15%) and assoc with schizophrenia. Classified with psychotic disorders in ICD-10

Associations in the literature

• Narcissistic PD – commoner in male forensic samples -antisocial PD highly comorbid in this sample

• Histrionic PD – divorce, separation, parasuicidal behaviour, females with medically unexplained symptoms, men with substance misuse

• Anankastic PD – white, male, well educated, married, unemployed

• Avoidant PD– comorbid with dependent PD and social phobia

Borderline PD

• 2% general population• 10% Psychiatry outpatients• 15-20% Psychiatry inpatients• Male:female ratio 1:3 • 5 times more common in first degree relatives• Increased rates of depression in relatives. • Associations - white females, age 20-35, urban

populations, single, unemployed• Comorbid with PTSD.

A GENERAL NOTE ON COMORBIDITY

• Presence of a major affective or psychotic disorder may be distorted, exaggerated or masked by an underlying PD so look for it as it may adversely affect outcome.

• How?– Think propensity towards and style of help seeking

behaviour, coping mechanisms, compliance, risk taking, quality of social support, substance misuse.

ASSESSMENT - pitfalls

• Not always possible to clinch the diagnosis in one interview:

• Poor historian• Poor insight• Repression of/unwilling to disclose early

experience• Intrinsic properties of personality under

scrutiny may make assessment tricky

Assessment framework

• Longitudinal history and collateral history is key

• In an ideal world:• Self report (checklist)• Informant report (checklist, interview)• Clinical interview

• In reality– Clinical assessment, collateral from

GP/CMHT/family/partner

Assessment tools - examples• Millon Clinical Multiaxial Inventory (MCMI)• Minnesota Multiphasic Personality inventory (MMPI)• Personality disorder Questionnaire (PDQ-IV)• Zanarini rating scale for Borderline personality disorder• Diagnostic interview for borderline patients• Borderline personality disorder scale• Schedule for schizotypal personalities• Psychopathy checklist revised• Personality inventory for DSM V

Assessment of personality traits

• Self concept• Views towards others• Interpersonal relationships• Impulse control• Patterns of mood, affect and expression• Cognitive themes• Social function• Associated mental health problems

Assessing personality

• Characteristics of self – clear or ill defined sense of self, grandiose, shy, extrovert, suspicious, impulsive, sensitive to rejection, criticism, being ignored, scrutiny by others, coping mechanisms.

• E.g. Do you feel you have a good sense of who you are as a person? What do you like about yourself? Are you comfortable around other people? How do you take it when someone is being critical?

Assessing personality

• Impulse control - meticulous and careful, orderliness and control, reckless and impulsive

• E.g. Would people describe you as reckless? Would you describe yourself as a perfectionist? Do you often act on impulse without thinking things through? Do you avoid risky situations and activities? Do you tend to do what people think you should do? Do you find yourself making rash decisions? Are you good at planning ahead? Do you send a lot of time making sure things are exactly right?

Assessing personality

• Views towards others and events – people aren’t to be trusted, people let you down, people abandon you, people hurt you, people just don’t get me, people scare me, people are a disappointment, I don’t really notice others, I don’t really care what others think.

• E.g. Do you tend to trust other people? Do you find people are generally trustworthy/have good intentions? Are other people important – do they matter to you? Do people understand you?

Assessing personality

• Interpersonal relationships –what is needed from others?

• Isolative, loner, indifferent to others• Difficulties being alone, feels lonely• Enjoys being with others, enjoys being the centre of

attention, dreads being the centre of attention• Views on team work• Prioritising self vs others, respect for others• Longevity and intensity of relationships• Manipulating others vs manipulated by others

Assessing personality

• Patterns of mood, affect and expression (range, lability, intensity, appropriateness)

• E.g. labile, anxious, angry, dramatism, cold fish, shallow affect, unable to contain difficult emotions, responses to praise and criticism, responses to others in difficulty.

Assessing personality

• Cognitive themes – conspiracy, mistrust of others, fantasy, bizarre ideas, power and brilliance, immediate needs, fear of rejection

• Social function – current and previous relationships, friendships, connections to family, educational history, employment history and status, forensic history, pastimes.

• Degree of distress and impairment of function (family, friends, work, criminal record)

Revision MCQs

• Diagnostic subtypes of PD (last lecture)• Differential diagnoses to inform clinical

assessment

• The following are based on MCQ’s from past MRCPsych papers

Which of the following is NOT a personality disorder in ICD-10?

• Schizoid personality• Paranoid personality• Emotionally unstable personality• Schizotypal personality• Anankastic personality

Which of the following is not part of the Big Five personality traits?

• Agreeableness• Carefulness• Neuroticism• Openness• Extraversion

Which of the following is NOT a personality disorder in ICD-10?

• Narcissistic personality• Dependent personality• Histrionic personality• Emotionally unstable personality• Dissocial personality

A 42 year old man presents to a local police station with an insurance claim form and a letter to his MP. He states that his neighbours are deliberately playing loud music to get to him and that people in his local area “have it in for him”. He lists names of officers who did nothing the last four times he has contacted the police and demands immediate action (Answer- next slide).

• Histrionic• Anankastic• Paranoid• Dependent• Schizoid

Paranoid personality disorder

• Differential – delusional disorder, schizophrenia, mood disorder with psychotic symptoms, sensory impairment, paranoia associated with substance misuse

• Beliefs are of key importance – are they plausible? Inkeeping with cultural and societal norms? Reasonable evidence base? Overvalued idea or delusional? Any psychotic symptoms? Any family history of psychosis? Episodic or constant? Chronology – age at onset and evolution?

A 36 year old man is visited at home by his GP. There is very little furniture, no television, no ornaments or pictures on the wall. He is indifferent to these observations, stating he has no need of those things. He has limited contact with his family and does not have any friends. He is clear he does not feel lonely or depressed (Answer- next slide). .

• Histrionic• Antisocial• Paranoid• Schizotypal• Schizoid

Schizoid personality disorder

• Differential centres on depression, psychosis, and pervasive developmental disorders. Overlap in presentation with other cluster A personality disorders.

• Schizoid PD may indeed be part of the autistic spectrum.

A 24 year old woman presents to clinic in ill fitting, stained clothes. She believes that she may be psychic. She feels she senses “presences” and events before they happen and knows that if the clock shows 11:11 something good will happen. Her speech is unusually metaphorical. Affectual range is incongruent, at times restricted (Answer- next slide). .

• Dependent• Schizotypal• Paranoid• Borderline• Schizoid

Schizotypal disorder

• Differential includes • Delusional disorder• Schizophrenia• Mood disorder with psychotic features• Autistic spectrum disorder• Disorders of language and communication

A 28 year old woman presents to her GP feeling low in mood. She confides she feels neglected by the love of her life if she is not the centre of attention. She is theatrical and flirtatious in demeanour, with shallow, labile affect. (Answer- next slide).

• Histrionic• Antisocial • Schizotypal• Avoidant• Anankastic

Histrionic personality disorder

• Differential includes• Borderline PD (self destructive, emptiness,

identity disturbance)• Antisocial PD (antisocial acts, less emotional

exaggeration)• Narcissistic PD (superiority is key – unwilling to

be fragile to gain attention)• Dependent PD (lacks flamboyance and

exaggerated emotional spectrum)

A 26 year old man is brought to A+E under section 136 MHA after being found with multiple arm lacerations. He describes stormy relationships with his partner and family and frequent risk taking behaviours. He also mentions his temper is difficult to control and wonders if he may have bipolar disorder as he is prone to extreme mood swings. (Answer- next slide).

• Borderline• Antisocial • Schizotypal• Avoidant• Dependent

Borderline personality disorder

• Differential includes:• Histrionic PD• Mood disorders (highly comorbid)• Antisocial PD (look at the nature of gain to

help clarify the diagnosis – power/material gain vs concern of others and avoidance of rejection)

A 33 year old man has been arrested for drink driving and taken to a local police station. He is irritable and aggressive, stating his friend was driving, even though police witnessed him behind the wheel. He appears to have little concern for the wellbeing of the occupants of the car he ran into. (Answer- next slide).

• Histrionic• Antisocial • Paranoid• Dependent• Schizoid

Antisocial personality disorder

• Differential (and comorbidities)includes:• Psychosis• Mania• Substance intoxication/withdrawal• Narcissistic PD• Psychopathy

A 42 year old man feels depressed after being sacked from his job. He states he is a perfectionist and that he could not trust others to do the job exactly right. He describes making detailed lists and schedules for his everyday life and appears markedly resistant to taking other’s points of view. (Answer- next slide).

• Histrionic• Anankastic• Paranoid• Dependent• Schizoid

Anankastic personality disorder

• Differential includes:

• OCD• Narcissistic PD (perfectionism in both,

anankastics are self critical, Narcissists are not)

A 27 year old man presents to clinic feeling low in mood. He is socially isolated and works in a job that is discordant with his educational level. He describes terror of being ridiculed or rejected and self esteem appears low. Friendships and intimate relationships are limited by fears of being inadequate.

• Antisocial• Anankastic• Paranoid• Dependent• Avoidant

Avoidant personality disorder

• Differential includes:

• Social phobia• Panic disorder with agoraphobia• Dependent personality disorder (primary focus

is the need to be taken care of rather than avoidance of humiliation/rejection)

• Schizoid personality disorder (emotional indifference and actively prefer isolation)

A 29 year old woman is seen in clinic for assessment of anxiety. She describes longstanding fears of being left alone and cannot bear to make decisions without others providing reassurance she is doing the right thing. She lives with her parents. Her mother cooks all her meals and shops for her clothes. (Answer- next slide).

• Histrionic• Anankastic• Paranoid• Dependent• Borderline

Dependent personality disorder

• Differential includes:• Mood disorder• Panic disorder• Agoraphobia• Borderline personality disorder• Histrionic personality disorder• Avoidant personality disorder

Resources

• Oxford textbook of psychiatry• Oxford handbook of psychiatry• ICD-10• DSM IV-TR• DSM V• British Journal of Psychiatry• Millon, T et al. 2004. Personality disorders in

modern life (2nd edition) Wiley.