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

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

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

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

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

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

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

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

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

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

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

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

Strange Situation http://www.youtube.com/watch?v=s608077NtNI

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

Disorganised Attachment http://www.youtube.com/watch?v=8BA8CcEUP84

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

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

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

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

Lack of Marked Mirroring http://www.youtube.com/watch?v=apzXGEbZht0  

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

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

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

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:

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

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

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

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

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

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

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

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

Form of Treatment 2 PD Pathway: Introduction to Mentalisation 12 week group, 1 ½ hours per week 3 day a week 12-18 month Therapeutic Community 1 day a week 12-18 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

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

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?

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

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 Email 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

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

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?

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