1. Personality Disorder: What is it?
Jackie Moon
Val Gorbould
Wednesday 22nd October 2014

2. PERSONALITY DISORDERS
Disturbances in personality and behaviour, difficulties in relating, distress and impairment
Characterised in clusters A, B, and C
Useful but crude and not consistently validated
Clients may present with co-occurring personality disorders from different clusters
Essential features:
Enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture and is manifested in at least 2 of the following areas:
Cognition
Affectivity
Interpersonal functioning
Impulse control
This enduring pattern is inflexible and pervasive across a broad range of personal and social situations
Leads to significant distress or impairment in social, occupational and other important areas of functioning
Pattern is stable and of long duration. Onset from adolescence or early adulthood
Not better explained by another mental disorder
Not due to substance use or head trauma

3. CLUSTER A May appear odd or eccentric
Paranoid: distrust or suspicion of others, unforgiving, sensitive to setbacks
Schizoid: detachment from social relationships, emotional expression limited, solitary
Schizotypal: discomfort in close relationships, cognitive or perceptual distortions
Paranoid
Expect others to harm exploit, deceive
Argumentative
Hostile aloofness
Secret, devious, “cold”
Schizoid
Detachment from social relationships
Restricted range of emotional expression in interpersonal settings
Loners
Schizotypal
Acute discomfort and reduced capacity for social relationships
Cognitive or perceptual distortions
Eccentricities of behaviour
Odd beliefs or magical thinking not consistent wit cultural subnorms

4. CLUSTER B Can be dramatic, emotional, erratic
Antisocial: disregard for others, lack of concern for their feelings
Borderline: instability in interpersonal relationships, self-image and affects. Feelings of emptiness. Marked impulsivity, tendency to self-destructive behaviour
Antisocial
Disregard for and violation of rights of others
Deceit
Failure to plan ahead
Irritability and aggressiveness
Recless disregard for safety
Irresponsible behaviour
Lack of remorse
Borderline
Instability of interpersonal relationships, self-image and affects
Marked impulsivity
Frantic efforts to abandon real or imagined abandonment
Idealisation/devaluation in relationships
Unstable self image, sense of self
Impulsivity, potentially self damaging in at least 2: spending, driving, sex, eating, substance
Recurrent suicidal and self mutilating behaviour
Affective instability due to marked reactivity of mood
Chronic feelings of emptiness
Inappropriate or intense anger, or difficulty controlling anger
Transient, stress-related paranoid ideation or severe dissociative symptoms

5. CLUSTER B
Histrionic: excessive emotionality and attention seeking. Shallow and labile affectivity
Narcissistic: grandiosity, need for admiration, lack of empathy
Histrionic
Pervasive and excessive emotionality
Attention seeking behaviour; if not the centre, uncomfortable
Often inappropriately sexually seductive or provocative behaviour
Displays rapidly shifting and shallow displays of emotion
Uses physical appearance to draw attention to self
Style of speech: excessively impressionistic and lacking in detail
Self dramatisation, theatrical
Suggestible
Considers relationships to be more intimate than they actually are
Narcissistic
Pervasive pattern of grandiosity, need for admiration, lack of empathy
5 or more:
Grandiose sens eof self importance
Preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
Believes self special, unique
Requires excessive admiration
Has sense of entitlement: unreasonable expectations
Interpersonally exploitative
Lacks empathy
Often envious or believes others to be envious of him
Arrogant, haughty attitudes and behaviours

6. CLUSTER C May appear anxious or fearful
Avoidant: social inhibition, feelings of inadequacy, hypersensitivity, wants to be liked and accepted
Dependent: submissive and clinging behaviour, passive reliance on others and therefore compliance, feelings of helplessness,
Obsessive-compulsive: pre-occupation with orderliness, perfectionism and control. Feelings of doubt. Checking.
Avoidant
Social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation
Avoids occupational activities that involve significant interpersonal contact: fears criticism or rejection
Unwilling to get involved unless certain of being liked
Shows restraint within intimate relationships because of fear of being shamed or ridiculed
Preoccupied with being shamed or ridiculed in social situations
Inhibited in interpersonal situations because of feelings of inadequacy
Views self as inept, inferior to others
Unusually reluctant to take personal risks or engage in new activities: fear of embarrassment
Pervasive and excessive need to be taken care of which leads to clinging and submissive behaviour
5 or more:
Difficulty making everyday decisions without advice and reassurance
Needs others to be responsible for major areas of own life
Has difficulty expressing disagreement: may lose support
Difficulty initiating projects or doing things alone: lack of self confidence in judgement
Goes to excessive lengths to obtain nurturance and support
Feels uncomfortable and helpless when alone: exaggerated fears that cannot care for self
Urgently seeks new relationship if previous one ends
Unrealistically preoccupied with fears of being left to take care of self
Obsessive-compulsive
Preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness and efficiency
4 or more:
Preoccupied with details, rules, lists, order: major point of activity is lost
Shows perfectionism that interferes with task completion
Excessively devoted to work and productivity to the exclusion of leisure and friendships
Overconscientious and scrupulous, inflexible: morals and ethics
Unable to discard worn out and or worthless objects even when they have no sentimental value
Reluctant to delegate, work with if not as they would have done it
Miserly spending style: hoards
Shows rigidity and stubbborness

7. CO-MORBIDITY Examples: Personality disorder with mood disorder
Dual diagnosis: substance misuse and diagnosis of personality disorder

8. TREATMENT Diagnosis- Discussion of difficulties with clients
Medication or Not?-Not recommended as first line of treatment
Psychotherapy
MBT-Mentalization Based Therapy
DBT- Dialectical Behavioural Therapy
CAT- Cognitive Analytical Therapy
“Major tranquillisers” misleading: tranquillise without impairing consciousness and without causing paradoxical excitement
FOR SCHIZOPHRENIA TRANQUILLISING EFFECT IS OF SECONDARY IMPORTANCE
RELIEVE FLORID PSYCHOTIC SYMPTOMS
Patients with acute schizophrenia usually respond better than those with chronic symptoms
Affects dopaminergic transmission
Also cholinergic, alpha-adrenergic, histaminergic, and serotonergic receptors
CONTRAINDICATIONS
Hepatic impairment
Renal impairment
Cardiovascular disease
Parkinson’s
Depression
Elderly with postural hypotension
May get photosensitisation in the elderly

9. Community and Inpatient
How to think about admissions
Care coordination or not
Intensive therapy or not
Management with GP
Management with CMHT
Family and Friends

10. Attachment First Attachment relationships Phenomenon in Mammals
Infant/Child seeks comfort from caregiver; Caregiver has an equally instinctive reaction to signals of unease and responds
Being ‘emotionally regulated’ leads to inner image of attachment person
Infant/child works towards ability to self-regulate through someone else making sense of their emotions

11. Attachment Styles Secure Attachment
Insecure Attachment- Ambivalent/Overinvolved/Resistant;
Distanced/Insecure Avoidant;
Disorganised
Strange situation

12. How Attachment Styles Develop
With the help of the caregiver, infant learns that difficult and distressing feelings can be tolerated and managed.
Marked Mirroring- Mother recognises distress and conveys this to the baby through tone of voice and facial expression
Infant experiences own emotional experience being accurately reflected back to them.
Leads to development of sense of self

13. Strange Situation

14. When marked mirroring does not occur sufficiently…
Infant does not develop a representation of his own emotional experience
Instead internalises an image of the caregiver as part of his self representation
Leads to establishment of what is known as ‘alien self’; not congruent with true self

15. Disorganised Attachment

16. Impact on parents and children
Insecure avoidant children do not orientate to their attachment figure, while investigating the environment/ Are very independent of the caregiver both physically and emotionally
Insecure Ambivalent- Clingy and dependent behaviour, but rejecting of attachment figure when they engage in interaction/Difficult to soothe/This behaviour results in inconsistent responses from the caregiver
Disorganised- High levels of confusion as child both comforted and frightened by attachment figures

17. Mentalisation is when we attribute intentions to each other
when we understand each other and ourselves as driven by underlying motives
and when we recognise that these take the form of thoughts, wishes and various emotions

18. Having mind in mind
Mentalising involves being able to think about our own thoughts and feelings
Developing the capacity to think about, wonder about the thoughts and feelings of others
Being held in mind, holding others in mind

19. Impact on parents and children
Lack of marked mirroring and developing sense of self-regulation means child is not having the experience of being held in mind by the caregiver; difficult feelings are catastrophic rather than potentially manageable; no containment
Unless addressed leads to difficulty helping own child to self-regulate; parent may experience child’s distress as persecutory and overwhelming

20. Lack of Marked Mirroring

21. Making Assumptions We all make assumptions all the time
Mentalising involves developing the capacity to question our own assumptions
This means entertaining different perspectives and different points of view; to tolerate this rather than experience it as threatening and persecutory

22. Different Perspectives
People interpret the same event in different ways
Some interpretations are more plausible that others
Some observations about another or about an event are mentalising while others are not: describing or reflecting

23. Why Mentalising is Important
To understand what is taking place between people
To understand yourself, who you are
To communicate well with close friends and family
To regulate your own feelings
To regulate other people’s feelings
To avoid misunderstandings
To see connection between emotions and actions

24. Mentalising Culture in the Family Home
Points to consider about the culture people grew up in/are living in:
Caregiver perceived as unavailable?
Caregiver lacking skills and empathy?
Oppressive silences?
Taboo areas?
Some form of abuse?
Chaotic and unpredictable?
Leading to:

25. Attachment Conflict
Difficulties and problems in attachment relationships
Impact on the child’s developing mentalising abilities
Inhibiting or exaggerating signals about own emotional states: child fears or is insecure about response of attachment figure
Impulse to get closer inhibited e.g. by fear of punishment or wanting to punish

26. Why do we often misunderstand each other and ourselves?
Non-transparency of mind: we cannot know what is going on in another’s mind
Our tendency to attribute thoughts to others: the same as ours
Experience that others understand us without having to tell them
Defensiveness
Difficulty in expressing thoughts and feelings

27. How this might relate to parenting
Assuming the intentions in a child’s behaviour and communication based on own difficult feelings e.g. feeling persecuted, rather than being able to hold the child in mind and think about him or her
Difficulty in recognising and owning own difficult feelings and seeing them as separate from what is going on in the child’s mind

28. What characterises a mentalising stance?
Curiosity about one’s own mind and the minds of others, our own and others’ thoughts and feelings
Openness to different perspectives
Developing a capacity to tolerate not knowing
Pause, reflect back on what has happened; think before you speak

29. Some characteristics of poor mentalising
Black and white thinking
Feeling certain about the motives of others
Little curiosity about mental states
Lots of words spoken with poor content
External factors emphasised at the expense of mental states
Little acknowledgement of accompanying feelings

30. Mentalisation Based Treatment 1
Focuses on the here and now: understanding what is going on in current interactions and relationships
This is of course informed by the past and examples from the past come up, but the emphasis is not on trawling through the past or making interpretations about it
Interpretations most likely lead to the client feeling not heard and misunderstood experiencing not being validated

31. Mentalisation Based Treatment 2
Aims of treatment:
To support client to reflect on their own mental and feeling states
To check out assumptions with others
To recognise failures in mentalising
To link acting out behaviour such as cutting with the context of relationships, interactions and feeling and mental states
To work towards reflecting on this rather than getting rid of feelings by harming self or others
To acknowledge and tolerate difference
To improve quality of relationships and interactions

32. Form of Treatment 1 Group or individual?
Group is highly recommended as the dynamics people frequently encounter will come up in the group and can be thought about by the whole group in the here and now
Groups offer the possibility to return after a difficult exchange and work through it with support
Opportunity to have feedback from peers, not only therapists, and notice similarities and differences
Groups give a different experience of being together with other people

33. Form of Treatment 2 PD Pathway:
Introduction to Mentalisation 12 week group, 1 ½ hours per week
3 day a week month Therapeutic Community
1 day a week month TC informed programme
One group plus one individual session with a different therapist, per week, for one year: MBT programme
CAT, CBT, psychodynamic individual and group therapies
Outreach work: holding sessions for clients, consultation to other services, co-working with other services, offering training, new group for Family and Friends

34. Mentalising as Workers 1
Is it possible to recognise the distress a misunderstanding has caused the client while remaining clear about your own intention and being able to clarify it?
If a client has a pattern of difficult exchanges with professionals then this is likely to happen with you and you can help the client think about this
Acknowledging own errors

35. Mentalising as Workers 2
Do you ever find yourself desperately trying to justify your own point of view?
Is there a space to go back over a difficult encounter with a client so you can both try to understand what happened?
Do you have a space away from the client to talk about the difficult feelings that come up for you?

36. Issues with Assessment
What difficulties do you encounter with the assessment process??

37. PD Pathway: Referral Process
Initial phone call to TCOS to discuss potential referral. Also consult with CMHT and/or GP if these are client’s main point of contact
Putting referral in writing stating why the referral is being made at this point in time and including as much supporting material, e.g. previous reports, as possible
to Specialist Psychotherapy Service Referrals from inside the Trust.
Discussed at weekly referrals meeting and then fed back to referrer
Write to CHAMPRAS (mental health single point of entry), City and Hackney Centre for Mental Health, Homerton Row, E9 6SR, from outside the Trust
They will allocate referral

38. Assessment Process at TCOS and SPS
In depth extended assessment at either TCOS or SPS, communication between the two.
Over several appointments
Active attempts to engage client, working with difficulties in engagement
SCID questionnaire
Discussion in team to think through client’s presentation. Especially important where there is a split amongst professionals
Discussion with client re diagnosis
Treatment plan

39. Screening Questions Are you scared of rejection and abandonment?
Are relationships with family and friends unstable?
Do you see things in absolute terms? All right or all wrong?
Do you have trouble who you are and what is important to you?
Do you act impulsively in ways that might damage you?
Do you self-harm, overdose or behave in a suicidal manner?
Do you have mood swings?
Do you feel empty and need others to make you feel whole?
Do you get very angry in a manner that is to your own detriment?
Do you numb out, dissociate, or sometimes feel overly suspicious or paranoid when stressed?

40. References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-iv-TR). APA, 2000
Bateman, A and Fonagy, P: MBT-Introduction Manual. Anna Freud Centre/UCL, 2012
Bateman, A and Fonagy, P: Psychotherapy for Borderline Personality Disorder: Mentalisation Based Treatment. OUP, 2004
Bateman, A and Kravitz, R: Borderline Personality Disorder: An Evidence Based Guide for Generalist Mental Health Workers. OUP, 2013
Gerhardt, S: Why Love Matters – How Affection Shapes A Baby’s Brain. Routledge 2004
World Health Organisation: International Statistical Classification of Diseases and Related Health Problems. WHO, 1992