Emotionally Unstable
Personality Disorder
Brighton & Hove GP Seminar Series
15th July 2013
Dr Graham Campbell
Consultant Inpatient Psychiatrist
Regency Ward, Mill View Hospital
Sussex Partnership NHS Foundation Trust
GP Seminar
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Introductions
Focus of Session
Brief Tutorial with discussion
Introduction to Lighthouse Recovery
Support
• Questions/Discussion
Personality Disorder
• Severe disturbance associated with considerable personal
and social disruption/distress
• Appears in late childhood/adolescence and continues into
adulthood
• Enduring and longstanding
• Markedly disharmonious attitudes & behaviour
– Affectivity, arousal, impulse control, ways of perceiving & thinking
or relating to others
• Pervasive & clearly maladaptive to a broad range of personal
and social situations
• Significant problems in occupational & social performance
Prevalence
• General population
10%
• MH presentations to GP 5-8% (primary diagnosis)
• Psychiatric outpatient
30-40% (not primary)
• Psychiatric inpatient
40-50% (not primary)
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5-15% (primary)
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• Prison population
25-75%
EUPD/EID
• Also known as Emotional Intensity Disorder (EID) – disorder
of emotional/behavioural regulation
• Likely biological/genetic vulnerability (traits/temperament)
• Possible familial relationship with EUPD and affective disorder
• Often inconsistent emotional support, invalidating emotional
environment, neglect or abuse in the person’s history
• Range of partially dissociated ‘self-states’ – response to
unmanageable external threats and reinforced through
repeated trauma
EUPD – ICD-10
• Impulsive type
– Emotional instability
– Marked tendency to act impulsively without
consideration of the consequences (lack of
self-control)
– Reduced ability to plan ahead
– Intense anger which can lead to violence and
“behavioural explosions”
EUPD – ICD-10
• Borderline type
– Emotional instability
– Disturbance of self-image, aims and preferences
(including sexual)
– Chronic feelings of emptiness
– Intense & unstable relationships
• Repeated emotional crises
• Excessive efforts to avoid abandonment
– Recurrent suicidal threats or acts of self-harm
Understanding the Challenges
Understanding the Challenges
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Limit-setting / boundaries
Medication
Splitting
Idealisation & denigration
Pre-reflective ways of thinking
– Psychic equivalence
– ‘Pretend mode’
• Projection & Projective identification
Understanding the Challenges
Need for continuity, consistency and
connectedness from services
Interpersonal Challenges
• Behaving out of the ordinary?
– Overly worried?
– Angry with the patient?
– Angry with MH services?
– Being taken out of role?
– Loss of time boundaries
• Talk to a colleague or MH worker involved
with the patient
Interpersonal Challenges
• Narrow repertoire of intense emotions expressed
• Managing panic/crisis
• Staying calm, listening and neutral
• Helping patient to see some situations as part of
life and not reinforcing idea that all pain is to be
avoided, distracted from or medicated
• Managing limitations of professionals & services
Managing Self-Harm
• Deal with urgent health crisis
• Listen
• Explore the stressor to allow problem-solving and
consideration of alternative coping strategies
• Encourage awareness of triggers
• Help the individual stay “grounded” and try and
stay grounded yourself!
• Sometimes positive-risk management required
‘Staging’
• Stage 1
– First/early presentation – diagnosis to be verified
– Short-term previous contact with services
– Admissions ideally under 2/52
• Allows for full assessment and risk management
• Consideration of other MH diagnoses (eg.
Substances/Depression)
• Liaise with community re: future management
• Plan to limit further admission frequency and duration
• Consider community treatment, eg. STEPPS, PD service
(Dr Connie Meijer, DoP)
‘Staging’
• Stage 2
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Known to MH service with confirmed diagnosis
Admissions 1-2 times in 12-month period
Presenting in crisis
Admission ideally < 1 week
• Length of stay discussed on admission
• Voluntary treatment at earliest opportunity
• Review meds with community (reduce polypharmacy/benzo
use)
• Liaise with community team in MDT review to update risk &
management plan
• Review benefit of admission if self-harm on the ward
(Dr Connie Meijer, DoP)
‘Staging’
• Stage 3
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Long-term MH contact
Repeated presentation for admission
Admissions more than twice in 12-month period
Usually psychosocial stressors
Admission ideally around 72 hours
• Length of stay discussed on admission
• Voluntary treatment at earliest opportunity (lift section on admission?)
• No major change to medication
• Involvement of care coordinator re: discharge plan
• Review benefit of admission if self-harm on the ward
(Dr Connie Meijer, DoP)
Positive Risk Management (DoH 2007)
• Being aware that risk can never be completely
eliminated
• Management plans inevitably have to include
decisions that carry some risk
• Positive risk-taking “balances QoL & safety needs
of SU, carers and the public…considers benefits
vs harm of one action over another”
– Emphasises the positive aspects of what can be
achieved through risk management rather than simply
the avoidance of undesirable consequences
The Role of Medication
• NICE recommends that medication is not used
for BPD or specific associated symptoms
• Aim to reduce and stop chronic treatments
• Only short-term (< 1/52) sedative medication
• Medication role only for co-morbid diagnoses
STEPPS
Systems Training for Emotional Predictability and Problem-Solving
• Group sessions
– Psychoeducational
– Emotional Management
• distancing, communicating, challenging, distracting, and problem
management
– Behavioural Management
• goal setting, healthy eating behaviors, sleep hygiene, regular exercise,
leisure activities, health monitoring (e.g., medication adherence),
avoiding self-harm, and interpersonal effectiveness
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Two facilitators
Manualised 2 hour sessions
Systems-based
Sessions for family member, carer & professionals
Recovery & Hope
• STEPPS and specialist services have
been shown to help people manage the
more destructive and distressing aspects
of their personality
• Important to maintain hope when making
therapeutic and risk management
decisions