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

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Presentation on theme: "Personality Disorder: What is it? Jackie Moon Val Gorbould Wednesday 22 nd October 2014."— Presentation transcript:

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

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

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

5 CLUSTER B Histrionic: excessive emotionality and attention seeking. Shallow and labile affectivity Narcissistic: grandiosity, need for admiration, lack of empathy

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.

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

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 I

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 84

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 0

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


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