1. Personality Disorders 101 Mike Pett MSW;RSW Advanced Practice Clinician Complex Mental Illness Program

2. + Objectives for the Presentation -Common Pathways of Offending for SMI population -Personality Disorders Defined -Cluster B personality disorders: Borderline, Narcissistic, and Anti- social/Psychopathic -Treatment of Personality Disorders -Question Period

3. + Conventional Path to Offending: Part 1. Biological: Temperament Family history Cognitive ability Psychological: Antisocial attitudes Social: Poor parent-child rel’ns Social learning of antisocial behaviour Conduc t Disorde r ASPD/ Psychopath y Substance Use Andrews & Bonta 2006

4. + Proximal motivations (the “weather”) Conventional Path to Offending: Part 2 Peterson et al. 2010 High Risk Individual Instrumental Reactive Motives: material gain, sexual, power, jealousy, revenge Motives: anger, intoxication, perceived threat, emotional stressor Disadvantage d Motives: minor crimes for food, shelter Substance s Motives: obtain drugs of abuse

5. + Paths to Offending in SMI Positive Symptoms Serious Mental Illness Disorganization High Risk Individual (ASPD) Instrumental Reactive Disadvantage d Substance s SMI vs. Gen Pop: Higher rate of Conduct dis. Higher rate of ASPD Higher rate of substance Higher rate of poverty The direction of these relationships is unclear The proportion of each motivation is unclear

6. + The False Dichotomy Symptom Driven Conventional Motives

7. + Personality Disorders 101

8. + Personality Disorder Clusters Cluster A (“mad”) Schizoid Schizotypal Paranoid Cluster B (“bad”) Borderline Antisocial Narcissistic Histrionic Cluster C (“sad”) Obsessive-Compulsive Avoidant Dependent

9. + Activity: Personalities ‘R Us Corporate Structure: President: ? Vice President: ? Personnel: ? Advertising: ? Legal Department: ? Research: ? Customer Service: ?

10. + Personalities ‘R Us Corporate Structure President: Narcissist Vice President: Paranoid Personnel: Borderline Middle Management: Advertising: Histrionic Research: Schizo-typal Legal Department: Anti-social Customer Service: Passive-Aggressive

11. + Borderline Personality Disorder Recorded on Axis II of the DSM-IV Defined by the DSM-IV: “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment” Not the result of: Cultural and social expectations Another mental disorder A substance or general medical condition

12. + Borderline Personality Disorder: What is it? DSM-IV: “ A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts.”

13. + Borderline Personality Disorder: DSM-IV Criteria Five or more of the following: Frantic efforts to avoid real or imagined abandonment A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation Identity disturbance: markedly and persistently unstable self- image or sense of self Impulsivity in at least two areas that are potentially self-damaging Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior Affective instability due to a marked reactivity of mood Chronic feelings of emptiness Inappropriate, intense anger or difficulty controlling anger Transient, stress-related paranoid ideation or severe dissociative symptoms

14. + Borderline Personality Disorder: Instability & Impulsivity Instability of: Mood Self-image and identity– overdetermined by the environment Interpersonal relationships Marked impulsivity (5 S’s): 1. Spending 2. Sex 3. Substance use 4. Speeding (reckless driving) 5. Satiety (binge eating) (6.) Suicidal/self-harm behavior (has its own criterion)

15. + Borderline Personality Disorder: Demographics & Course Female > Male (3:1) 2% of community samples ; 15-25% of clinical populations; 13- 56% of hospitalized substance abusers Completed suicide in ~8-10% (particularly high if comorbid substance use) High rates of functional deficits, mental health utilization costs Rocky course during first decade of treatment (high drop out rates); but many improve by second decade of treatment

16. + Borderline Personality Disorder: Etiology Environmental: Invalidating Caregivers Biological: Emotional Vulnerability Emotional Dysregulation  Most researched is Marsha Linehan’s biosocial theory High sensitivity/reactivity to emotional stimuli Slow return to baseline Indiscriminately rejects internal emotional experiences Punishes emotional expressions and intermittently reinforces emotional escalation

17. + Anti-social Personality Disorder vs. Psychopathic Personality Disorder

18. + “All psychopathic personalities are anti- social but not all anti-social personalities are psychopathic”

19. + Derived from Greek psych (soul, breath hence mind) pathos (to suffer) A constellation of affective, interpersonal, and behavioral characteristics that include grandiosity, a callous disregard for others, a lack of empathy, and highly impulsive and irresponsible behavior Differentiation from Sociopathy and Antisocial Personality Disorder

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21. + – Superficial charm & good “intelligence” – Absence of delusions / irrational thinking – Absence of “nervousness” – Unreliability – Untruthfulness and insincerity – Lack of remorse or shame – Inadequately motivated antisocial behavior – Poor judgment / failure to learn by experience – Pathologic egocentricity / incapacity for love – General poverty in major affective reactions – Specific loss of insight – Unresponsiveness in general interpersonal relations – Fantastic and uninviting behavior with drink & sometimes without – Suicide rarely carried out – Sex life impersonal, trivial, and poorly integrated – Failure to follow any life plan

22. + Operationalized the construct of psychopathy in the PCL and PCL-R instruments Factor 1: Interpersonal and affective characteristics Factor 2: Impulsive and antisocial behaviors Prevalence of psychopathy: ~ 1% of general population ~ 20-25% of prison population Robust predictor of violent and non-violent criminal behaviors in adult male offenders (e.g., Harris, Rice, & Cormier, 1991; Hemphill, Hare, & Wong, 1998; Salekin, Rogers, & Sewell, 1996)

23. + Psychopathy Factor 1 Arrogant & Deceitful Interpersonal Style Factor 4 Antisocial Behavior Factor 2 Deficient Affective Experience Factor 3 Impulsive & Irresponsible Behavioral Style

24. + 1. Glibness / Superficial Charm  Insincere and shallow interactional style  Charming, phony, or superficial 2. Grandiose Sense of Self-Worth  Inflated view of abilities and self-worth  Can appear domineering, opinionated, and arrogant 4. Pathological Lying  Deceitful, lying “just for kicks” 5. Conning/Manipulative  Uses deception to cheat, exploit, or manipulate others  Misrepresentation for personal gain

25. + 6. Lack of Remorse or Guilt  Lack of concern for the consequences of their actions on others 7. Shallow Affect  Unable to experience a normal range and depth of emotion  “Play acting” emotions 8. Callous/Lack of Empathy  Disregard for the feelings, rights, and welfare of others  Cynical and selfish 16. Failure to Accept Responsibility for Own Actions  Usually have excuses for behaviors that hurt others  Rationalize or minimize past transgressions

26. + 8. Need for Stimulation / Proneness to Boredom  Chronic and excessive need for novel and exciting stimulation; exciting and risky activities; “on the go” 9. Parasitic Lifestyle  Exploitation of others for basic needs and obligations 13. Lack of Realistic, Long-Term Goals  Inability or unwillingness to formulate plans and commitments; living “day to day” and changing plans frequently

27. + Factor 3-cont 14. Impulsivity  Behaviors are unpremeditated and lacking in reflection; doing things on the spur of the moment; opportunistic15. Irresponsibility  Habitual failure to honor obligations and commitments to others

28. + 10. Poor Behavioral Controls 12. Early Behavioral Problems 18. Juvenile Delinquency 19. Revocation of Conditional Release 20. Criminal Versatility

29. + 11. Promiscuous Sexual Behavior 17. Many Short-Term Marital Relationships

30. + Best Practices for Treatment of Borderline and Anti-social personality disorder

31. + Dialectical Behaviour Therapy for Borderline Personality Disorder (Linehan, 2007) Mindfulness Interpersonal effectiveness Distress Tolerance Emotion Regulation

32. + Best Practices for Psychopathy and Anti- social Personality Disorder “Nothing Works” vs. “What Works”?

33. + Watch Dexter !

34. + “Most Best” Menu of Treatment Strategies Substance Use Treatment Pharmacological treatments for impulse control/cravings. I.M. medication for chronic non-adherence. Anger Management. Assertive outreach Crisis intervention Critical time intervention Volunteerism

35. + Most Best Treatment Options. CTO’s, probation, bail orders as leverage points to motivate recovery. Drug Treatment Court/Mental Health Diversion in cases of precontemplation/low motivation in terms of mental health and addiction treatment. Community placement should be in safe, pro-social neighborhoods where exposure to criminal activities and substance use is limited. Re-training/Re-schooling

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37. + Questions and Comments