1. Disturbance and development Personality disorder, psychodynamics and the internal world Gwen Adshead Broadmoor Hospital

2. Psychodynamics ‘Dynamic’ implies movement A paradox: we experience ourselves as the same over time Yet we know that we change and develop The Self as a dynamic process, not a state

3. Internal and external worlds What do we mean by an internal world? What do we mean by the external world? Do we mean the same thing? What is the boundary between these worlds? The individual and the group

4. The experience of the self To function optimally, we need A regulated and coherent sense of self Flexibility in responses Appropriate responses The capacity to modulate (+/-) Metacognition or second order thoughts

5. Regulation Of mood Of arousal in response to different types of stress: Loss Fear Illness or pain A challenge to coherence

6. Aspects of regulation Emotions (somatic) and feelings (mental) Modulation ( up or down) Threat perception threshold ( low or high) Appropriate responses to threats/stress Sympathetic responses Parasympathetic responses

7. The regulated self A sense of integration and coherence Stability over time: memory and coherence A narrative sense of self Metacognition and self-reflective function Self-reflective function and other-reflective function

8. The regulated self (2) Can examine itself Has sense of others as real Is composed of different aspects that resonate with others and the environment in a modulated way Can self-soothe and use others for help Care giving and care eliciting

9. Dysregulation Right orbitofrontal cortex Connections with hypothalamus, amygdala and hippocampus Development of the ROFC affected by early relationships Trauma: overwhelms the capacity to respond

10. Dysregulation (2) Unmodulated stress and arousal reactions Hyperarousal to minimal threat Excessive responses to threat Hypersensitive threat perception Somatic responses provoke more unconscious arousal Emotions not feelings

11. DefCon Status Defences against internal and external threat Condition of the defences: high or low alert? Def Con 1-5: levels of alarm Defences help to keep an integrated sense of self

12. The capacity for distress She spoke as one, incapable of her own distress

13. The dysregulated self Reorganised or disorganised Instability of mood, arousal, relationships Instability of self-states Altered reality perception Seeks external soothers Communicates somatically

14. The narrative self Autobiographical competence Loss of a coherent account of the self Gaps and blanks; where speech and thought fall away Alexithymia: inability to put feelings into words ‘What’s your story?’

15. Defences against incoherence Grandiosity and contempt for weakness Dismissing of attachments Preoccupation with attachments Passivity Paranoia Envy and entitlement Alternate realities

16. Psychiatric disorders as disorders of the self Psychotic disorders: altered realities, lowered threat perception, hyperarousal to threat, the self as victim Personality disorders: similar but not so pronounced + mood disorders Disorders of the sense of self: passivity, helplessness, intrusive thoughts, delusions and hallucinations

17. The story of the illness What is the patient’s story? Who is the narrator? Who has the agency? Is this a story of victims and perpetrators?

18. Multiple stories The patient’s The carers The health care professionals Family Social and cultural stories

19. The therapist’s story The impact of working with personality disordered patients Disability and chronicity Containment and the provision of security Damage limitation Living with grief

20. Conclusion Self-development: ‘from the cradle to the grave’ The self as the function of an inner world group ‘There’s something between us that isn’t there’