Personality Disorders
Dr Andrea Williams
Consultant Psychiatrist in Psychotherapy
Personality Disorder and Homelessness Team
NHS Greater Glasgow and Clyde
What we will cover
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•
•
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Overview
Definitions
Prevalence and course
Types of personality disorder
– Dissocial
– Borderline
• Attachment basis
• Treatment/ management
• PD and Legislation
Overview
Personality Disorder:
What’s in a name?
Stigma
Untreatable?
Excluded from Services
Stigma
People with a PD can be seen as
troublesome patients in medical terms/
troublesome people in society.
They do not improve rapidly; offer few
rewards to those treating them; can make
us feel impotent/ guilty/ angry and many
other things.
Stigma – changing?
All of this improves if more effort to
UNDERSTAND and ADDRESS the nature
of the difficulty
Requires attention to how services delivered
User groups claiming the diagnosis as a
useful tool for accessing services
Untreatable?
not true
Emerging evidence that a number of
psychological approaches can help –
particularly in BORDERLINE PD
• Mentalisation Based Therapy
• DBT(Dialectical behavioural therapy)
Excluded from Services ?
shouldn’t be
• “Personality Disorder – no longer a diagnosis of
exclusion” document in England
• NICE guidelines for treatment
• Scotland – “Personality Disorder – Demanding
patients or Deserving People?” (CCI, 2005)
Excluded from Services ?
• Scottish Personality Disorder Network
(SPDN) co-ordinates regular conferences
to share expertise and good practice
• More recently- Borderline PD included as
one of categories in Integrated Care
Pathways being implemented across all
Health Boards in Scotland.
Definitions
What Do we mean by Personality
Disorder?
• Deeply ingrained maladaptive patterns of
behaviour
• Extreme/ significant deviation from the
way the average person in that culture
perceives/ thinks/ feels and relates to
others. (MAKES THEM DIFFERENT)
• Recognisable from adolescence
What Does it Mean?
• Disturbed ways of RELATING
• Difficulties with MOOD CONTROL
and IMPULSIVITY
• Disturbed ways of THINKING
What Does it Mean?
• Enduring – long lasting
• Pervasive – affects all areas of
person’s life
• Considerable personal distress
Prevalence
and
Course
How Enduring?
• Most recent studies have shown with
Borderline Personality Disorder:
• at 2 years, 1/3 no longer meet criteria for
diagnosis
• at 4 years, 1/2 no longer meet criteria
• at 6 years 2/3 no longer meet criteria
(Zanarini et al 2003)
How enduring? (cont)
Older wisdom was that personality mellowed with
age, but this had limited support from long-term
follow up
Studies show that marked disturbance continues,
although some of the more noticable behaviours
became less frequent
i.e. TRAITS are enduring, but expression of these
may modify with age/ experience
How Common Is It?
• 5-10% of general adult population
(zimmerman and coryell, 1990)
• 35% + of those in Psychiatric Hospital
• 50% of female prisoners
• 60-80% of male prisoners
Types of
Personality
Disorder
Psychiatric Classifications
ICD-10 Categories
(similar to DSM-IV)
CLUSTER 1
•PARANOID
•SCHIZOID
•SCHIZOTYPAL
CLUSTER 2
•DISSOCIAL
•BORDERLINE
•HISTRIONIC
CLUSTER 3
•ANXIOUS/ AVOIDANT
•DEPENDENT
•ANANKASTIC
• New DSM – V due May 2013
After much debate – little change to
classifications
• New ICD – 11 due 2015
Likely to move to Dimensions (how
badly affected is the person) rather
than Categories (what type)
Dissocial Personality Disorder
• Callous unconcern for the feelings of
others
• Irresponsible. No regard for social norms,
rules and obligations.
• Unable to maintain lasting relationships,
though having no difficulty in starting them.
Dissocial Personality Disorder
• Easily becomes frustrated, angry or
violent.
• Not able to feel guilt or to profit from
experience or punishment.
• Tends to blame others, or to offer
explanations, for the behaviours that has
brought the patient into conflict with
society.
“Psychopathy”
• Extreme form of antisocial/ dissocial
personality disorder
• Psychopathy Check-List – Revised
– Cold, callous self-centred, predatory
individuals
– Strongly correlated with risk of future violence
• Narrower group than dissocial category –
often also fulfil antisocial/ narcissistic/
histrionic and paranoid
Borderline Personality Disorder
• Does NOT mean the person may or may
not have a PD
• Historical terminology designating a
condition on the “borderline” between
Neurotic (anxiety/ phobias/ depression)
and Psychotic (schizophrenia) conditions
Borderline Personality Disorder
• BPD is called
Emotionally Unstable Personality Disorder
in the ICD-10 classification
• It is sub-divided into
– Impulsive Type
And
– Borderline Type
Borderline Personality Disorder
• Emotionally unstable.
• Person’s self-image, aims and internal
preferences (including sexual) are often
unclear or disturbed.
• Chronic feelings of emptiness.
Borderline Personality Disorder
• Becomes involved in intense and unstable
relationships, with repeated emotional
crisis.
• Extreme efforts to avoid real or imagined
abandonment.
• Recurrent suicidal threats, gestures and
behaviours or self-harming behaviours.
Borderline Personality Disorder
• Tend to act without considering
consequences
• Lack of Impulse control
• Transient stress-related paranoid ideas or
severe dissociative symptoms.
Psychiatric Model of Personality
Disorder
• Not very accurate, despite all efforts to pin
categories down
• Looked at again for ICD-11 and DSM-V
• People often fit more than one category
• 2 people with BPD might have very
different symptoms
• Types have been shown to alter and
change
PSYCHODYNAMIC APPROACH
WHAT DOES IT OFFER?
• Theory of Unconscious motivations – not
all “manipulative” behaviour is consciously
under the person’s control
• Takes a developmental view
• Defence mechanisms – the way people
have to act at times to protect themselves
from overwhelming emotional states
What does it offer? (cont)
• The way the person’s internal state
impacts emotionally on others
• The importance of Attachment
• THESE ARE ALL TOOLS TO INCREASE
UNDERSTANDING
ATTACHMENT
Healthy development
The caregiver’s
emotionally
attuned
responses to the
infant’s states
becomes a
source of
information to the
infant about his
internal states
When things go wrong
Still face experiment
Overview of Brain Development
• How does a brain
become a brain?
– Adult brain weighs 3lb
– Quadruples in size between birth and 6 years
– White matter increases throughout childhood;
increasing speed of communication
The Anatomy of Mentalization: A view from developmental neuroimaging (Giedd 2003)
Overview of Brain Development (2)
•
•
•
•
•
Overproduction of cells
Competitive elimination – “survival of the fittest”
Arborisation and pruning
Sensitive periods of development
Enormous plasticity of developing brain
This means that brain pathway development
is affected by environmental (particularly
Attachment) factors.
People with Personality disorder have
problems with how their brain functions,
particularly under stress
Treatment/
Management
Treatment/ Management
• Growing evidence for psychotherapy
approaches – MBT, DBT
– Long-term, fairly intensive treatment
– Not widely available
• Growing consensus on general principles for
good management – NICE guidelines,
Integrated Care Pathway (ICP)
• Above mainly for BPD
Management principles - NICE
• Manage endings and transitions
• Training, supervision and support of staff
• Specialist Psychological Treatment
PLUS
• Structured care (incl. crisis management)
• SHARED theoretical approach
• No short term psychotherapy (<3 months)
• Crisis – explore reason for distress/ empathic/
open questioning
Management principles (from ICP
for BPD)
•
•
•
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Promote reflection
Tolerate intense aggression/ hate
Set necessary limits
Understand dynamics and monitor the
relationship, thereby reducing the potential
for splitting
• Monitor countertransference feelings with
a view to using this to understand the
patient’s difficulties
Treatment/ Management
• Little evidence that standard psychiatric inpatient care is helpful – may be harmful
• Limited role for medication – poor
evidence base
– Important to treat co-morbid conditions
– May be groups of symptoms that respond to
some medications
Legislation
Mental Health (care and treatment)
(Scotland) Act 2003
MENTAL DISORDER
MENTAL
ILLNESS
LEARNING
DISABILITY
PERSONALITY
DISORDER
Use of Compulsory Measures and
Personality Disorder
• PD is included in 2003 Mental Health Act, but
people with PD often not thought to meet criteria
for compulsory measures
• Requires that
– “person has a mental disorder which causes their
ability to make decisions about treatment to be
significantly impaired”
– ? Impaired decision making
Use of Compulsory Measures and
Personality Disorder
• CTO
– requires that “medical treatment is
available which is likely to prevent disorder
worsening or likely to alleviate the
symptoms or effects of the disorder”
- and that there is significant risk to the
patient or any other person if the patient
were not provided with such treatment
“Medical treatment”
is defined as :
• Pharmacological or physical treatment (such as
ECT)
• Psychological and social interventions
• Nursing
• Care
• Habilitation – including education and training in
work, social and independent living skills
• Rehabilitation
Criminal Procedures (Scot) Act
1995, amended by
MH(C&Tr)(Scot) Act 2003
• PD included in 2003 Act as mental disorder
• Criterion of “significantly impaired ability to make
decisions about treatment” is EXCLUDED for
mentally disordered offenders,
therefore
• Issues of treatability are prominent
• Treatability harder to argue for antisocial/
psychopathic disorders
Treatability of Dissocial/ Antisocial
disorders
• Many treatment models thought to be
useful to some degree
– anger management,
– CBT approaches,
– therapeutic community models
No great evidence base for any of these
Use of Compulsory Measures and
Personality Disorder - FORENSIC
• Routine practice in Scotland NOT to admit
on compulsory basis, individuals with a
primary diagnosis of PD to forensic units
• Focus of forensic mental health services is
on psychotic disorders
• 1976 Carstairs incident (Darjee and Crichton
2003)
(cont)
• Challenges re “treatability” – unconditional
discharge of a patient from Carstairs on grounds
that he was untreatable - 1999
• Led to MH(public safety and appeals)(Scotland)
Act 1999 – changed legislative definition of
mental illness to include PD and added a
criterion of serious risk to others – so untreatable
restricted pts could still be detained
Adults with Incapacity (Scotland)
Act 2000
• Usually applies to people with Dementia/
Learning Disability/ Brain Injury
• Can also be used in other severe and
enduring mental disorders where
CAPACITY shown to be impaired
AWI (Scotland) 2000 (cont.)
• For the purposes of the Act, 'incapable'
means incapable of:
• acting on decisions; or
• making decisions; or
– communicating decisions; or
– understanding decisions; or
– retaining the memory of decisions
• in relation to any particular matter due to
mental disorder
Adult Support and Protection
(Scotland) Act 2007
• Adult is engaging (or is likely to engage) in
conduct which causes (or is likely to
cause) self-harm
• Almost the definition of many personality
disorders
• Principles
– Must provide benefit
– Least restrictive