Personality Disorders

Personality Disorders

• Clinical traits can include disrupted emotional regulation and impaired personality
• Disrupted emotional regulation is considered a clinical trait
• Impaired personality presents through issues with self-esteem, and a lack of sense of self independent of others known as enmeshment
• Interpersonal problems are a clinical trait
• Difficulty maintaining and making social connections, and inability to share are interpersonal problems
• Personality disorders are defined by an all or nothing and lack of dimensional approach.
• Pathology related to the Big 5 personality traits includes: antagonism, negative affect, psychoticism, detachment and disinhibition
• Antagonism presents as low agreeableness
• Psychoticism presents as odd beliefs
• Detachment presents as social avoidance
• Disinhibition presents as irresponsibility
• Personality disorders are chronic, non episodic and different from other disorders
• Personality disorders cause impairment and stress
• People are usually unaware that their personality is the root problem of their impairment with personality disorders.
• Lifetime prevalence is 10%
• Personality disorders are very comorbid because criteria are not well defined
• Traits can be inflexible and persistent compared to other disorders
• People do not want to change and lack the insight that they even have a problem with personality disorders
• Goals of treatment may be different from therapist to patient
• Diagnosing can be difficult because criteria is not well defined
• Research surrounding personality disorders is limited besides antisocial or borderline personality

Borderline Personality

• Must meet at least 5 criteria for diagnosis

• Criteria includes: chronic emptiness, emotional instability, intense anger and suicidal behavior

• Additional criteria includes: dissociative behavior and impulsive behavior

• Also included is: Spitting (unstable relationships, loving someone to death then quickly intensely hating them), abandonment and threat of suicide, and unstable self image of self esteem

• 2-5% of the general population has borderline personality disorder

• It is 4x as common in females than males

• High comorbidity with eating, mood, and substance disorders due to a high emotional outlet

• There is high inpatient care because of suicide and self harm threats

  • 11% require outpatient psychiatry
  • 25% require acute inpatient psychiatry
  • 50% require long term inpatient psychiatric care

• Biological causes include genetics: serotonin transporter gene

• Additional biological causes can include overactive amygdala, and oversensitive noradrenergic system releasing norepinephrine and cortisol

• Additional biological causes include neuroticism, impulsivity and low serotonin

• Family factors include 90% report abuse, and child sexual abuse

• Identity, self esteem, and schema are altered from child sexual abuse

• Families that are neglectful or uninvolved is a family factor

• Also invalidating environments where parents directly punish or criticize

• Medications are not the only answer for treatment

  • Atypical antipsychotics, antidepressants and mood stabilizers are often used in medication treatment

• Psychotherapy is also a form of treatment

  • CBT has not been shown to be effective
  • Dialectical Behavior Therapy (DBT) uses CBT with an added component of meditation focused on tolerating and accepting distress and impermanence

• Mindfulness, stress management, and interpersonal effective strategies are taught

  • 24 hour therapist support with support groups
  • There is a high success rate and can create lower hospitalization and self harm

Antisocial Disorder

• Criteria includes: a long term course and must present before 15 years old, and cannot be better explained by juvenile delinquency; at least 3+ criteria must be met before 15

• Lack of remorse, disregard of safety of others and deceitfulness are all criteria

• Additional symptoms include: scamming, reckless and irresponsible behaviors, impulsivity or aggressiveness, and consistent irresponsibility related to work and parenting

• More common in males than females

• Lifetime prevalence: 1-3%

• High comorbid with suicide and substance disorder, especially recklessness

• Moderate genetic contribution

  • Offspring with biological parents with a criminal background are more likely to develop antisocial disorders than adoptees with biological parents without criminal backgrounds
  • Gene-environment factor: those with biological criminal parents that have a stressful adoptee life are at the highest vulnerability

• Neurobiological Factors:

  • Less amygdala activation when shown sad and frightening faces
    • May explain the lack of remorse
  • Self report questionnaires show less fear and anxiety
  • Longitudinal study of criminals show less fear conditioning compared to those without a criminal background
  • More of a focus on reward, even when it is unattainable like with scamming

• Environmental Factors:

  • High conflict environments, and engaging in antisocial behavior dictate social circles Antisocial behaviors may cause familial and relationship stress

• Treatment options are limited

  • Difficult because there are lower dropout rates because of varying alignment of therapist and patient goals, and skills often do not translate to the real world
  • CBT is used to change attitudes, administer anger management (identify triggers), treat substance use, increase self control, and improve social perspective

Psychotic Disorders

• Including Schizophrenia

• Out of touch with reality is also known as psychosis

• Includes oddities of perception of senses

• Most common ages of onset is ages 20-30

• Cannot be explained by another substance

• Hallmark Symptoms: must have at least 3 of these for a month

  • Disorganized speech like loose associations, incoherence, and neologism
  • Loose associations: connections are present, but jumbled up
  • Incoherence: no connections and very difficult to understand
  • Neologism: made up words that follow basic language and grammar rules
  • Disorganized behavior like unpredictable/ odd behavior, impairment of goal directed activities and catatonia
  • Unpredictable/ odd behavior: Ex. wearing many clothes on a hot day
  • Impairment of goal directed activities: hygiene routines
  • Catatonia: inability to move

• Delusions: false beliefs that are firmly held even when proven false (90% of those with schizophrenia have delusions)

  • Persecutory: extreme paranoia, someone is following or surveillance them
  • Reference: news bulletins are in reference to them
  • Erotimoic: celebrities are in love with them
  • Grandiose: hey posses extreme power, worth, and talent
  • Thought insertion: someone else is controlling or inserting their thoughts into their head.

• Hallucinations: sensory experience with the absence of a stimulus

  • Auditory: most common
    • Included command hallucinations which are usually negative
  • Visual: does not include immediately waking up or sleeping
  • Olfactory: frequently the smell of flesh or sewage
  • Tactile: the physical sensation, bugs crawling on your skin
  • Gustatory: taste, blood.

• Negative Symptoms: the absence of normal behaviors

• Affect - Alogia: limited language - Anhedonia: lack of pleasure from daily activities - Antisocial: no desire for social interaction - Aviolotion: no goals or routine - Epidemiology- 0.7 -1%

• More common in men than women by a little

• May be affected by estrogen as symptoms worsen during cycle

• Average onset = 20 - 30 because of final stage of brain maturation

• Biological causes include twin studies

• Monozygotic: 48- 50% and dizygotic: 10-17%

• Higher than most disorders - Heritability - .64-.81

• Parents with schizophrenia have an increased chance of having children who also have it.

• Adoption Studies

  • Adoptees of mothers with schizophrenia have a 8% higher chance of developing schizophrenia than those without
  • Danish Study: retrospective study that found relatives with schizophrenia os current cases
    • Finnish Studies: results are the worst amongst adoptee with biological heritability of schizophrenia with stressful life: gene environment correlation

• Genetic Factors: (polygenic)

  • COMT: gene involved in dopamine metabolism Using high amounts of cannabis during adolescence exemplifies the risk with this gene

• Neurotransmitter System abnormalities:

  • Dopamine dysfunction: increased or decreased attention of different stimulus hallucination
    • Hypothesized because drugs that increase dopamine increase the amount of schizophrenia symptoms
  • Anatomic Differences:
  • Enlarged brain ventricles (filled with fluid ) and therefore have less capacity in the brain for other functions Decreased brain volume (3%) which continues to decline with age
    • Frontal lobe (decision making and planning)
      • Hippocampus and temporal lobe amygdala (emotion, memory, and auditory)
      • Thalamus (relay center for sensory input)

• Birth complications (prolonged labor, decreased oxygen to the brain) - May lead to vulnerability because hypoxia can lead to brain damage and dopamine supersensitivity

• Psychological and Social Factors -Role of stress - May activate underlying biological vulnerability - Dysregulated cortisol is associated with dysregulated dopamine.

• Stress can increase the probability of relapse

Early Indications

• Home movies of those who develop schizophrenia versus control showed more motor abnormalities and less positive facial emotion.
• Delayed speech and motor development at age 2

Treatment

• First line of treatment is pharmacotherapy - Antipsychotic: blocks dopamine receptors Different generations are not different in effectiveness rather different side-effects First generation: Haldol and Thorazine: tardive dyskinesia:involuntary movement of lips and tongue, muscle spasms, shaking Second generation: drowsiness, weight gain, more risk of metabolic problems, blood clots cardiac problems and stroke Psychosocial Approaches: Behavior Family Therapy: improve family communication and problem solving to decrease stress Social and living skills training -Cognitive remediation: improve memory, attention, and executive functions

• CBT (recent development) -Cognitive reconstructing: “the voices I hear in my head are not real and are me" - Behavioral experiments: testing the validity of delusions (testing telepathy)

  • Attention training: shifting attention away from distressing voices or thoughts - Normalization and psychoeducation; educating patients that unusual experiences occur in everyone Changing relationship with hallucinations Coping strategies for hallucinations Outcomes

• Poor prognosis before the 1950s because physical containment was the only option before antipsychotics L-ed to the deinstitutionalization of psychiatric hospital 15-25 year outcome studies Good prognosis = 40%

• Not cured but better symptoms = 20% - 20% show minimal impairment Long term institutionalization rate = 12%

Childhood Disorders

• Internalizing Disorders: inward experience and behavior: anxiety, depression, social withdrawal Frequently untreated because it is less disruptive and is easily overlooked. Mood and anxiety disorders
• externalizing Disorders: outward expressing experiences and behaviors: aggressiveness, hyperactive, noncompliance ADHD, conduct disorder, oppositional defiant disorder

###Internalizing Disorders

• Separation Anxiety Disorder

• Extreme anxiety when separated from attachment figure 4-10%

• Symptoms include: avoidance of situations separated from caregiver, nightmares, worries, and physical ailments when separated

###Selective Mutism

• Refusal to communicate with non family members/ comfortability Not a language or vocabulary disorder rather anxiety 1-2% of children Spectrum: some children grow out of it others develop social phobia

###Externalizing Disorders

• Oppositional Defiant Disorder Less intense version of conduct disorder, includes aggressiveness, vindictive, and anger/irritability Symptoms must last at least 6 months. 9-10% of children 30% of these will develop conduct disorder

###Conduct Disorder

• Continuous and repeated pattern of behaviors of Aggression towards animals and humans Destruction of property Deceitfulness and theft Violating basic human rights of others or breaking societal norms

• Symptoms must persist for 12 months Early onset before the age of 10 2-9% of girls and 6-16% boys

• 25%-40% have an increased vulnerability towards antisocial disorder Increased future criminality and risky behaviors

• Biological causes include moderate heritability

• Genes related to increased aggression and impulsivity

• Mild neurological deficits: planning, self control, attention

• Psychological causes include Dodge's cognitive theory of aggression

• Ambiguous stimuli interpreted as aggressive aggression towards others retaliation from others further angry aggression Family Factors Ineffective parenting Harsh and inconsistent punishment Modeling of aggressive behaviors Poor monitoring

• Child abuse is most common Poor attachment/relationships with family and peers Neglectful and respectful relationships

Treatment

• Behavioral Learn strategies for children and parents Decrease hostile attributions, shift attention from negative actions to positive behaviors, rewarding prosocial behaviors (praise and material), effective commands (gentle, not too many) Time outs and token system

• Medication: not very successful when used alone SSRI for comorbid depression and anxiety Atypical antipsychotic

Prevention

• Target youth at high risk Teach social skills, emotional regulation, impulse control Early intervention is key Multisystemic therapy: kids are just one part of the system. Must focus on including family, school, peer contexts
• School based programs to promote social emotional learning.

Neurodevelopmental Disorders

• Begins in early childhood and tends to persist and are linked to brain abnormalities Influence how the brain develops and cause impairment in social,cognitive, and emotional functioning

###ADHD

• Inattentiveness, hyperactivity, and impulsivity Need 6+ symptoms for attention focused Fails to give attention to details or makes careless mistakes Difficulty sustaining attention in tasks Difficulty with organization Frequently forgetful Need 6+ symptoms for hyperactivity focus Not able to sit still, fidgety, restlessness Climbing and running at inappropriate times Talking excessively even at inappropriate times Symptoms need to be present before 12 and must have impairment in 2+ settings Epidemiology 3-7% of children worldwide have ADHD 11% in the US ages 4-17 Brings up skepticism if we over diagnose or have different expectation and requirements of children behavior More common in boys 3:1 Girls symptoms are less disruptive and outwardly noticeable and may attritubte to this stat Some persistence to adulthood (30-50%) ADHD in the long term Less likely to hold a higher educational degree, substance use problems, marital problems Higher rates of conduct disorder and ODD

###Causes Biological Neurodevelopmental disorders have high heritability ADHD in specific is .7-.8 20-25% of children with ADHD have a family member with ADHD Sluggish (lower levels) of dopamine: DAT1 gene Motivation, reward, regulating attention Brain vulnerability Less function in the prefrontal cortex especially during tasks that require sustained attention Slightly small brain volume Some data supports that stimulant medication may enhance the typical sluggish brain areas Environment Prenatal: Alcohol or smoking during pregnancy can increase the risk of developing ADHD Birth complications: low weights, premature, decreased oxygen to the brain Psychosocial accounts for contributing or impairing the prognosis and the symptoms rather than causing ADHD Children with ADHD are often seen negatively by peers, teachers, and adults Peer rejection because symtpoms can interfere with friendships leading to social isolation

###Treatment

• Medication (first line of treatment and out performs alone the behavior treatment alone) Stimulant (aderall, ritalin) used to reduce hyperactivity (successful for 60% ) to increase dopamine to a blanched level in the parts of the brain responsible for executive functioning Sife effects: impaired thinking, memory, disruption in growth hormone, and misuse Non stimulus work on norepinephrine and take longer to see effects but are at less of a risk for abuse Behavior Therapy Includes parent training by teaching techniques to reinforce adaptive behaviors Teaching child organizational and planning skills and techniques to decrease: distractibility and procrastination Autism Spectrum (ASD) Affects how one perceives and socalizes with others Three levels of severity -

1. Requiring support
2. Requiring substantial support (language/non verbal)
3. Requiring very substantial support ( needing to constantly monitored) Symptoms (2 domains Deficits in social communication and social interactions (need all 3) Differences in social awareness and understanding social cues difficulty In understanding peoples emotions

• Problems maintaining eye contact, showing facial expressions that are inappropriate or flat Can lead to problems in forming and keeping peer relationships Repreated and ritualistic behavior patterns, interests, or activities Repeating the same speech, movements (hand flapping), using objects in a fixed and stable manner Pattern in staying in routing can become difficult to adapt Focused interests in a small number of interests or objects Very sensitive to sensory inputs (sounds, textures, taste)

###Epidemiology

• 2% of children have autism Increasing rates Onset before age 3 Can see improvement of symptoms but there is no cure More common in boys than girls
• Parents can usually recognize at 12-18 months with standard screening at pediatricians Specifies that refer to the Level of support needed Intellectual impairments 45-60% have average or above average IQs Language impairment

###Causes

• Biological Heritable estimate .8 Glutamate neurotransmitter dysfunction (affects brain development) Oxytocin receptor gene: social bonding Weaker social bonding, lower empathy, difficulty in interpreting social cues and social memory Underactivated fusiform gyrus - involved in perception on emotions Unusal brain and head growth leading to excess neurons that leads to miswiring
• Certain medication used during pregnancy No data towards vaccine holding a causal role Causes -environmental Advanced parental age