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What is a Personality Disorder?
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Management & Containment
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There’s no “I” in “Team”
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A Personality Disorder is a mental illness
A person with a personality disorder is unable
to control their actions
The most effective intervention for DSH is a
psychiatric admission
Personality disorders are attention seeking
The purpose of a diagnosis is to refer to
statutory services
Its normal to feel annoyed when working with
someone with a personality disorder
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‘personality’ refers to the collection of
characteristics/traits developed
By our late teens we have developed our own
personality (thinking, feeling and behaving).
These stay pretty much the same for the rest
of our life. Usually, our personality allows us
to get on reasonably well with other people.
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For some of us, this doesn't happen, personality can develop in
ways that make it difficult to live with self &/or other people.
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The capacity to self reflect & learn is limited and there’s difficulty
changing personality (traits) that cause the problems.
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A personality disorder is an enduring pattern of inner experience
and behavior that deviates from the norm.
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The enduring pattern is inflexible and pervasive across a broad
range of personal and social situations.
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The pattern is stable and of long duration, and its onset can be
traced back to early adulthood or adolescence.
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Most experts agree that there is no single cause of personality
disorder It is likely to be caused by a combination of factors.
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genetics – genes inherited may make people more vulnerable,
given certain environmental factors (see below)
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neurotransmitters –neurotransmitters can have a significant
effect on mood and behaviour
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neurobiology –
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environmental factors – events that happened in a person’s past,
i.e. relationship with your family, abuse, lack of validation,
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People with a diagnosis of personality disorder have not,
in the past, had enough help from mental health services.
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These services have been more focussed on mental
illnesses like schizophrenia, bipolar disorder.
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There have been arguments about whether mental health
services can offer anything useful to people with
personality disorders.
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Some Personality Disorders are more receptive to
treatment.
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Harm minimisation approach
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Yes.
There is evidence that they tend to improve
slowly with age.
Antisocial behaviour and impulsiveness, in
particular, seem to reduce in your 30s and
40s
Why?
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Research suggests that personality disorders
tend to fall into three groups.
As you read through the descriptions of each
type, you may well recognise some aspects of
your own personality.
Traits
Disorder
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There are different ways to describe mental
disorders, and to put them into categories.
The first step is to see if there are patterns,
or collections of personality traits that are
shared by a number of people.
Research suggests that personality disorders
tend to fall into three groups, according to
their emotional 'flavour':
Cluster A: 'Odd or Eccentric
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Paranoid Personality Disorder: long standing pattern of pervasive
distrust/suspiciousness
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Schizoid Personality Disorder: long standing pattern of detachment from social
relationships and exhibit difficulty expressing emotions to others
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Schizotypal Personality Disorder: eccentricity & great difficultly in maintaining close
relationships
Cluster B: 'Dramatic, Emotional, or Erratic'
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Antisocial Personality Disorder: long standing patterned disregard for other people's
rights, often crossing the line and violating those rights. It usually begins in childhood
or in teens and continues into their adult lives.
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Borderline, or Emotionally Unstable Personality Disorder: exhibits a pervasive partner of
instability interpersonal relationships, self image and emotions.
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Histrionic Personality Disorder: long standing pattern of attention seeking behaviour and
extreme emotionality
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Narcissistic Personality Disorder: long standing pattern of grandiosity, an overwhelming
need for admiration and usually a complete lack of empathy toward others
Cluster C: 'Anxious and Fearful'
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Obsessive-Compulsive Personality Disorder: preoccupation with orderliness,
perfectionism
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Avoidant Personality Disorder: long standing feelings of inadequacy, lead to social
inhibition and isolation which in turn are associated with avoidance of school, work etc
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Dependent Personality Disorder: long standing need to be taken care of and fear of
being abandoned or separated. This leads to dependence, submission and clinging
behaviours
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long-standing pattern of a disregard for other
people’s rights, often begins in childhood.
a person’s pattern of antisocial behavior has
occurred since age 15.
lack empathy, callous, cynical, superficial charm,
arrogant self appraisal, contemptuous of the
feelings, rights, and sufferings of others.
Aggression and violence is often behaviours
associated with this diagnosis
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Failure to conform to social (lawful) norms, repeatedly
performing acts that are grounds for arrest
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Deceitfulness, as indicated by repeated lying, use of
aliases, or conning others for personal profit or pleasure
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Impulsivity or failure to plan ahead
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Irritability and aggressiveness, as indicated by repeated
physical fights or assaults
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Reckless disregard for safety of self or others
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Consistent irresponsibility, repeated failure to sustain
work behaviour or honour financial obligations
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Lack of remorse, as indicated by being indifferent or to
rationalizing having hurt, mistreated, stolen from another
TRAITS & VULNERABILITIES
ANTI SOCIAL
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Identity
arrogant self appraisal
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Challenging Behaviour
repeated actions that lead to arrest
Impulsivity
failure to plan ahead
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Self Reflection
lack of remorse
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Emotional Response
irritability & aggressiveness
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Relationships
deceitfulness/conning others
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Safety
disregard for safety of self & others
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The main feature of BPD is a pervasive pattern of instability in
interpersonal relationships, self-image and emotions. An
impulsivity often times demonstrating self-injurious behaviors
(cutting, suicide attempts).
Fear of Abandonment: perception of impending abandonment or
rejection. Intence abandonment fears and inappropriate anger,
make frantic efforts to avoid real or imagined abandonment.
Unstable & Intense Relationships: switch quickly from idealizing
people to devaluing them, feeling that the other person does not
care enough, does not give enough, is not “there” enough.
Unstable Sense of Self: persistent unstable self-image or sense
of self. There may be sudden changes in opinions and plans
about career, sexual identity, values, and types of friends.
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Impulsivity: that is self-damaging, ie gamble, spend money
irresponsibly, binge eat, abuse substances, engage in unsafe
sex.
Parasuicidal Behaviour: recurrent suicidal behavior, gestures,
or threats, self-mutilating behaviour (e.g., cutting or
burning). Recurrent suicidality is often the reason that these
individuals present for help.
Emotional Dysregulation: affective instability due to a marked
reactivity of mood (hours). The basic dysphoric mood
disrupted by anger, panic, or despair, rarely relieved by wellbeing or satisfaction - extreme reactivity to interpersonal
stresses.
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Chronic feelings of emptiness.
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Intense anger or have difficulty controlling their anger.
■Frantic efforts to avoid real or imagined abandonment
■A pattern of unstable and intense interpersonal relationships, alternating between extremes of
idealization and devaluation
■Identity disturbance, significant and persistent unstable self-image
■Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance
abuse, reckless driving, binge eating)
■Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
■Emotional instability due to significant reactivity of mood (e.g., intense episodic dysphoria,
irritability, anxiety lasting a few hours and no more than a few days)
■Chronic feelings of emptiness
■Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights)
■Transient, stress-related paranoid thoughts or severe dissociative symptoms
TRAITS & VULNERABILITIES
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Identity
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BORDERLINE
poor sense of self
Challenging Behaviour
suicidal & deliberate self harm
Impulsivity
linked to challenging behaviours
Self Reflection
limited
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Emotional Response
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Relationships
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Safety
emotional dysregulation
fear of
abandonment/rejection/instability
parasuicidal behaviour
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TRAITS/VULNERABILITIES BORDERLINE
ANTI SOCIAL
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Identity
poor sense of self
arrogant self appraisal
Challenging behaviour
suicidal & DSH
repeated actions/arrest
Impulsivity
challenging behaviours
failure to plan ahead
limited
lack of remorse
emotional dysregulation
irritability/aggressiveness
fear abandonment
deceitfulness
parasuicidal behaviour
disregard for safety/others
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Self Reflection
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Emotional response
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Relationships
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Safety
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Motivation
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Self reflection
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Substance misuse
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Post code lottery of Services
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Gender bias??
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Take some time to reflect on our
expectations when working with people with
personality disorders?
Change behaviour?
Establish consistent therapeutic rapport?
Prevent risk?
Being mindful of our expectations can assist s
to have amore confident and consistent
professional therapeutic relationship
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Minimise risk
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Shape behaviour
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Encourage self reflection
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Encourage self efficacy
TRAITS & VULNERABILITIES
ANTI SOCIAL
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Identity
arrogant self appraisal
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Challenging
Behaviour
repeated actions that lead to arrest
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Impulsivity
failure to plan ahead
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Self Reflection
lack of remorse
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Emotional
Response
irritability & aggressiveness
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Relationships
deceitfulness/conning others
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Safety
disregard for safety of self & others
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Identify risk incl historical
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Risk management plan (as well as support plan)
- consistency
- clear boundaries
- mindful of reinforcements
i.e. negative & positive reinforcement,
- immediate consequences i.e. temporary
exclusions
TRAITS & VULNERABILITIES
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Identity
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BORDERLINE
poor sense of self
Challenging
Behaviour
suicidal & deliberate self harm
Impulsivity
linked to challenging behaviours
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Self Reflection
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Emotional
Response
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Relationships
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Safety
limited
emotional dysregulation
fear of abandonment/rejection
instability
parasuicidal behaviour
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Accountable for factors included in risk
assessment
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History – good predictor of future
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Plan & Lethality
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Intent
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Types of Self Injury
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Function of DSH
Self Injury
Dance with Death
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Harm Minimization
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Chronic
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Acute
Suicidal Intent
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History is a predictor of future behavior
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Collaborative
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Shared responsibility
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Clear expectations & boundaries
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Positive risk taking when appropriate
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Share & escalate management plan
“I cant control myself”
“I just react”
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i.e. substance misuse, DSH
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Linked to impulsivity
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Work in the short term – reinforcement
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Often formed at early age – survival
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Continue into adult hood when no longer
required
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No other tools in tool box
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Therapeutic relationship
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Transference and counter transference issues
& most importantly
lashings of
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Validation & Empathy
DEAL WITH DISTRESS FIRST
- Remove from situation
- Strategies to reduce distress i.e. distractions
ONCE DISTRESS REDUCES THEN DISCUSS ISSUE
REFLECTIVE PRAXIS ABC
When I feel [EMOTION] and feel like [BEHAVIOUR],
I will try [INTENSE SENSATIONS] & [DISTRACTIONS]
& then I will talk with a staff member.
If I still feel very unsafe I will call [EMERGENCY #]
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Consistency
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Risk sharing
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Reflective practice & supervision