Anxiety and Personality A Developmental View

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1 Anxiety and Personality A Developmental View Dr. Sonja Vermaak FRCPC (psychiatry), cert child and adolescent psychiatry (SA), FcPscyh(SA), LMCC, MBBch (wits) Child Psychiatry Clinic- Western Health No disclosures

2 Overview Classification General Anxiety Disorders Personality Disorders Neurobiology Anxiety Disorders Personality Disorders Psychosocial influences Anxiety Disorders Personality Disorders Natural History Anxiety Disorders Personality Disorders Anxiety in Personality Disorders Personalities of anxious people

3 Classification General Normative versus Pathological Categorical Discreet illness? Dimensional Variant of normal Risks vs benefit

4 Classification General DSM 5 ICD 11 Rdoc Psychodynamic formulations Systemic (where the child happens to be the focus of an environmental problem)

5 Classification Anxiety Disorders Defining Fear Defining Anxiety. Defining pathological anxiety what one can or cannot control? Specific Phobia Separation Anxiety Disorder Social Anxiety Disorder Selective Mutism Panic Disorder Illness Anxiety Disorder Agoraphobia Substance/ medication induced anxiety

6 Classification Anxiety Disorders Generalized Anxiety Disorder Obsessive Compulsive Disorder

7 Classification Anxiety Disorders

8 Classification Anxiety Disorders Psychological classifications / theories of anxiety Psychoanalytic repression of drives Attachment theory Bolby, Mary Ainsworth Cognitive Behaviour Theory

9 Classification Personality Disorders Pattern of perceiving, relating to and thinking about the environment and self across multiple contexts showing stability over time. Psychodynamic Theory Forces that impel us (drives) and forces that hold impulses in check Freud/ Crowne Interpersonal Theory Interpersonal situations which characterize a human life Sullivan

10 Classification Personality Disorders Humanistic Theory Thought, feeling and behaviour derive from experiences of the individual and can only be understood from that point of view Rogers Learning Theory Behavioural attributes of a person arises from genetic makeup and environmental contingencies

11 Classification Personality Disorders Trait Specified- Dimensional and Individualistic DSM 5 Section III Impairment in 2 of following Identity Sees self as unique, clear boundaries between self and others Stability of self esteem, accuracy of self appraisal Capacity for and ability to regulate range of emotional experience Self-direction Pursuit of coherent and meaningful short and long term goals Utilization constructive and prosocial internal standards of behaviour Ability to self reflect productively

12 Classification Personality Disorders Empathy Comprehension and appreciation of others experiences and motivation Ability to tolerate differing perspectives Understanding the effects of ones own behaviour on others Intimacy Depth, duration, connection with others Desire, capacity for closeness Mutuality of regard reflected in interpersonal behaviour

13 Classification Personality Disorders One or more pathological personality trait domains 1. Negative Affectivity (vs. Emotional Stability) 2. Detachment ( vs. Extraversion) 3. Antagonism (vs. Agreeableness) 4. Disinhibition (vs. Conscientiousness) 5. Psychoticism (vs. Lucidity)

14 Classification Personality Disorders- Traditional Cluster A Paranoid Schizoid Schizotypal Cluster B Histrionic Narcisstic Borderline Antisocial Cluster C Avoidant Dependent OCPD PD NOS

15 Neurobiology Anxiety Disorders

16 Neurobiology Anxiety Disorders

17 Neurobiology Anxiety Disorders

18 Neurobiology Anxiety Disorders

19 Neurobiology Anxiety Disorders

20 Neurobiology Anxiety Disorders

21 Neurobiology Anxiety Disorders

22 Neurobiology Anxiety Disorders

23 Neurobiology Anxiety Disorders Mother s genetic imprint. eg. Mother s with history of CSA already have altered daily cortisol release pattern and passed onto children- increase baseline anxiety in children. Stress in first trimester associated with increase in anxiety disorders in children. Post partum (peri-partum) depression associated with increased anxiety in children. Genetic 5HTTLPR s-allele associated with increased anxiety in offspring (Macaque mother monkeys, genetic load and stressed environment.)

24 Neurobiology Personality Disorders Heritability parallels normal personality 20-60% heritability from twin studies Additive genetic influences and unique environment

25 Neurobiology Personality Disorders Cluster A: Familial relationship with Schizophrenia Schizophrenia spectrum disorders Schizotypal PD: Temporal lobe reductions, impaired smooth pursuit eye movements, Impaired exec functioning. CSF HVA concentration SCZ<STPD<other PD Little environmental effects

26 Neurobiology Personality Disorders Cluster B Additive genetic: 32% BPD and ASPD closest genetic links Multiple monoaminergic systems : best data for serotonin link to impulsive aggression Amygdala, orbitofrontal cortex: behavioural inhibition and emotional information processing Interprets neutral events, words, faces as negative

27 Neurobiology Personality Disorders

28 Neurobiology Personality Disorders Borderline Personality Disorder Genetics: 5-10% more common in first degree relatives?serotonin dysfunction Neuroimaging: Bilateral reductions of hippocampus, amygdala, cingulate. Amygdala: increased activity to positive and negative emotion, increased activity to faces regardless of emotional valence- find neutral faces threatening Orbitofrontal cortex- decreased modulation of amygdala, decreased mentalization.

29 Neurobiology

30 Neurobiology Personality Disorders Cluster C Avoidant PD Shared genetic vulnerability with Social Phobia? Environment determines APD vs social phobia Dependent PD Biological component to submissiveness OCPD Some heritability Related to OCD (30% OCPD have OCD)

31 Learning and experiences Direct experience Vicarious acquisition Information and instruction Psychosocial Anxiety Disorders Thoughts, beliefs, assumptions Common anxious patterns of thinking in various anxiety disorders eg dizziness is a dangerous sign, the world is a dangerous place.. Behaviour How a person responds to anxiety has a big impact on whether an anxiety disorder develops!! Especially avoidance, safety behaviours.

32 Psychosocial Anxiety Disorders Anxious attachment and separation anxiety disorder Childhood stressful life events/ trauma Behavioural inhibition (temperament) Chronic medical illnesses : asthma, diabetes, obesity, CV disease) Helicopter parenting stunting of independence and responsibility

33 Psychosocial Personality Disorders Environmental risks Low SES, raised by single parent, welfare, parental death, social isolation Abuse (all types) and neglect All PD s :73% abuse, 82% neglect BPD= highest rates of abuse and neglect

34 Psychosocial Personality Disorders Psychodynamic Defences Cluster A Projection, fantasy, denial Cluster B Splitting, dissociation, denial, Acting out, projective identification Cluster C Isolation, passive aggression, hypochondriasis, undoing

35 Psychosocial Personality Disorders Kernberg 1967 Neurotic-----Borderline------Psychotic

36 Psychosocial Personality Disorders Early insecure attachment results in abandonment fears ( Fonagy, Gunderson) Family Environment marked by high conflict and unpredictability (Gunderson) Emotionally vulnerable temperament transacting with an invalidating environment (Linehan)

37 Psychosocial Personality Disorders Borderline Personality Secure attachment is rare Preoccupied (anxious) attachment most common Impairs development of stable and realistic concepts of self, self regulation of affect and distress and poor template for building stable and healthy relationships.

38 Psychosocial Personality Disorders Borderline Personality BPD versus PTSD??? BPD+PTSD>BPD>PTSD

39 Psychosocial Personality Disorders Avoidant Personality Disorder Anxious attachment Anxious avoidant/ Anxious ambivalent Parents who were inconsistent, absent, abusive, higher rates of rejection than in control groups Temperament Children as young as 21 months manifest increased arousal and avoidant behaviour High neuroticism and low extraversion are a genetic vulnerability (Kendler 2008) Maladaptive avoidance develops as a defense against shame, embarrassment and failure

40 Psychosocial Personality Disorders Dependent Personality Disorder?connected to authoritarian or overprotective parenting- prevents children learning through trial and error Preoccupied attachment style Chronic physical illness, separation anxiety disorder in childhood may predispose to DPD

41 Natural History Anxiety Disorders

42 Natural History Personality Disorders When can you diagnose them? Risks/ benefit? Adolescence? normal borderline-like behaviour of adolescence? immaturity.. Also often worse in intellectual disability and ADHD fewer positive social relationships due to impulsivity etc..? adolescent identity disturbance? emotional dysregulation disorder Peak age of borderline symptoms = 15 Note complaints of anxiety vs. agitation/ irritability, anger, volatility Early indicators High persistent aggression Emotional Dysregulation Poor peer relations / interpersonal conflicts Risk factors as described early childhood adverse events

43 Natural History Personality Disorders Improvement is the norm of DSM diagnosed PD DSM diagnosis predicts acute function not necessarily long term Traits more stable predictor but Personality traits did decrease in intensity, similar to that found in community based studies that demonstrate a mellowing of personality with age with declines in neuroticism, extraversion, openness and increases in agreeableness and conscientiousness Terraccioano 2010

44 Natural History Personality Disorders Schizotypal PD: Global functional impairment, does not seem to improve as symptoms over time. 10% convert to Schizophrenia Paranoid PD: Hypersensitive as kids, poor peer relationships, marked reduction in quality of life, improves with time, symptoms more than function

45 Natural History Personality Disorders Avoidant PD Normal shyness in children tends to decrease in adolescence and early adulthood but will increase in avoidant PD due to increased role of relationships Shyness tends to decrease in the elderly Most Severe Dysfunction of personality Disorders

46 Anxiety in Personality Disorders Paranoid Personality Suspiciousness, fear of being taken advantage of. Schizotypal Personality Disorder Acute discomfort with and reduced capacity for close relationships..versus social anxiety disorder Excessive social anxiety that does not improve with familiarity. Associated with paranoid fears/ mistrust rather than negative judgements about self

47 Anxiety in Personality Disorders Borderline Personality Socially anxious in regard to rejection Fear of abandonment Fear of aloneness

48 Anxiety in Personality Disorders Avoidant Personality Disorder: avoids occupational activities that involve significant interpersonal contact because fears criticism, disapproval or rejection unusually reluctant to take personal risks, engage in new activities because they may prove embarrassing Restrained in intimate relationships due to fear of being shamed or ridiculed Avoidance social situations, inhibition in interpersonal relationships, feelings of inadequacy, anxious preoccupation with negative evaluation and rejection, fears of ridicule/ embarrassment Most impaired of all the personality disorders

49 Anxiety in Personality Disorders Avoidant Personality Disorder: Versus Social Phobia? APD and SP :42% SP and APD :62% Genetic studies = shared genetic but unique environmental variance High comorbidity with anxiety disorders

50 Anxiety in Personality Disorders Dependent Personality Disorder Clingy behaviour, fears of separation Fear of aloneness Fears of loss of support/ approval Lack of self confidence Preoccupied with fears of being left to take care of himself or herself

51 Personalities of anxious people Childhood Pattern avoidance Decreased normal experiences Academic underachievement Social underachievement Increased manipulation, control, oppositional behavior Adulthood Disability Irritability and relational difficulties Anxiety related to an overwhelming focus on self and overuse of default mode network internally focused tasks/ thoughts vs use of sensori-motor networks (involved in goal directed behaviour and cognitive tasks outside of self) increased happiness with increase in these circuits?

53 References Anxiety Disorders overview : Mark Watling, MD DSM V Personality Disorders : Deanne Mercer : EK Koryani course Kaplan and Sadock- Synopsis of psychiatry

Slide 1. Slide 2. Slide 3 Similar observations in all subsets of the disorder. Personality Disorders. General Symptoms. Chapter 9

Slide 1. Slide 2. Slide 3 Similar observations in all subsets of the disorder. Personality Disorders. General Symptoms. Chapter 9 Slide 1 Personality Disorders Chapter 9 Slide 2 General Symptoms Problems must be part of an enduring pattern of inner experience and behavior that deviates significantly from the expectations of the individual