Psychotherapy and
personality Disorder
Dr Linda Treliving
Consultant Psychiatrist in psychotherapy
NHS Grampian
linda.treliving@nhs.net
DSM IV CLUSTER CLASSIFICATION
• Cluster A, including paranoid, schizoid, and schizotypal PDs, which may
manifest in cognitive distortions and an interpersonal style that is odd, eccentric,
or detached.
• Cluster B, consisting of antisocial, borderline, histrionic, and narcissistic
PDs, which often involve behaviour that appears dramatic, erratic, impulsive,
aggressive, or affectively dysregulated.
•
Cluster C, which includes avoidant, dependent, and obsessive-
compulsive PDs that tend to involve fear, anxiety, apprehension, or perceived
avoidance of harm.
Epidemiology
• Approximate prevalence of PD in;
• Community 10 %
• General practice 20 %
• Psychiatric outpatients 30%
• Psychiatric inpatients 40%
• Prison 20-80 %
“The distinction between personality disorder and
mental illness”
• …… it is commonplace for a diagnosis of personality disorder to be
used to justify a decision not to admit someone to a psychiatric ward,
or even to accept them for treatment……
B.J.Psych.
Volume 180,February 2002,pp 110-115
KENDELL, R. E.
Are personality disorders treatable?
• Lewis & Appleby (1988)
2 case vignettes , one with a history of PD.
- pd was an enduring pejorative label
- distinct from genuine illness
- attribution of responsibility and control
- less deserving of treatment
- treatment unlikely to work
Treatment utilization by patients with personality
disorders
PD more extensive usage than major depression of –
• Psychiatric outpatient
• Psychiatric inpatient
• Psychopharmacologic treatment
Bender et al (2001).
American Journal of Psychiatry, 158, 295–302.
Malcolm Pines, Group analyst
• “…..those attending personality disordered patients feel impelled to
conform to a pattern imposed by the patient, so that we begin to feel
provoked, hostile, persecuted and have to behave exactly as the
patients need us to, becoming rejecting and hostile…..”
• Group Analysis, (1978), 11, 115-126
DSM IV diagnosis of BPD
• A pervasive pattern of instability
• of interpersonal relationships
• self-image
• affects
• marked impulsivity
• beginning by early adulthood
• present in a variety of contexts,
• as indicated by five (or more) of the following:
BPD = 5 or more of the following
1.Frantic efforts to avoid real or imagined abandonment
2.Unstable and intense interpersonal relationships.
3.Identity disturbance:
4.Impulsivity.
5.Recurrent suicidal behavior
6.Affective instability
7.Chronic feelings of emptiness
8.Inappropriate, intense anger
9.Transient, stress-related paranoid ideation or severe dissociative symptoms
The biopsychosocial model of BPD
PDQ IV scores for 129 prisoners in Cornton
Vale, 2011
Cornton Vale audit 2011
• 53% Borderline PD
• 52% Antisocial PD
• 35% Borderline PD and Antisocial PD
Cornton Vale audit, Childhood trauma
questionaire
Secure attachment
....... should engender a positive, coherent, and consistent self-image
and a sense of being worthy of love, combined with a positive
expectation that significant others will be generally accepting and
responsive.
The hyperactivation of
attachment in BPD
• The attachment system in BPD is hypersensitive and
triggered too readily
• Indications of attachment hyperactivity in core
symptoms of BPD
• Frantic efforts to avoid abandonment
• Pattern of unstable and intense interpersonal relationships
• Rapidly escalating tempo moving from acquaintance to
great intimacy
Attachment Disorganisation in
relationship to practitioner
Mild Distress/
Anxiety
Emotionally Challenging
Experience in Relation to the
Emotional Challenge
practitioner
Activation of attachment
Proximity seeking
The ‘hyperactivation’ of
the attachment system
17
Attachment provocation
• In the ward
•
•
•
•
•
•
Stimulation of attachment system in admission
Changing shifts
Negotiating levels of observation,
Discussing discharge
Managing incidents
Negotiating availability – “in 5 minutes”
Attachment provocation
At interview
• Clinician lowering voice
• Increasing intimacy
• Responding to demands
• Refusing to respond to demands
• Boundary violation however small
Attachment theory and the psychiatrist–
patient relationship
• An empathic response on the part of the doctor, with accurate verbal
identification of emotion, produces assuagement of attachment
behaviours, triggering ‘vitality affects’ and the beginnings of
‘companionable exploration’ – the reasons for coming and history of
presenting symptoms.
• Jeremy Holmes, BJPsych (2008)193, 377
Attachment theory and the psychiatrist–
patient relationship
People with insecure attachment histories find this process
problematic, typically deactivating’ or ‘hyperactivating’ affect, or
producing incoherence.
Psychiatrists need to identify and understand this sequence of
relational expectations and behaviours in themselves and their
clients.
Jeremy Holmes, BJPsych (2008)193, 377
Mentalization
• the capacity to recognise and understand the existence of minds,
both one’s own and those of others.
• The normal ability to ascribe intentions and meaning to
human behaviour
• to recognize that human behavior is motivated by mental states–by
things like thoughts, beliefs, feelings, and desires.
Mentalization
• Shapes our understanding of others and ourselves
• Central to human communication and relationships
• Underpins clinical understanding, the therapeutic
relationship and therapeutic change regardless of
modality of therapy
What does good mentalizing look
like?
• Perception of own mental functioning
•
•
•
•
Appreciation of changeability
Developmental perspective
Realistic scepticism
Awareness of impact of affect
• Self-presentation e.g. autobiographical
continuity
• General values and attitudes e.g. tentativeness and moderation
What does non-mentalizing look like?
• Excessive detail to the exclusion of motivations, feelings or
thoughts.
• Focus on external social factors, such as the school, the council,
the neighbours.
• Focus on physical or structural labels.
• Preoccupation with rules, responsibilities.
• Denial of involvement in problem.
• Blaming or fault-finding.
• Expressions of certainty about thoughts or feelings of others.
26
Mentalization
• Everybody will struggle to mentalize at times.
• People with borderline PD and other diagnoses have more consistent
difficulty especially under high arousal.
• Underpins clinical understanding, the therapeutic relationship and
therapeutic change regardless of modality of therapy
Mentalization based therapy
• Aims to strengthen patients capacity to understand their own and
others mental states in attachment contexts in order to address
difficulties with –
• Affect regulation
• Impulse regulation
• Interpersonal functioning
All of which contribute to suicide and self harm.
Bateman and Fonagy 2009
Why mentalization based therapy?
• Evidence based
• Psychodynamic treatment
• Rooted in attachment and cognitive therapy
• Requires limited training with moderate levels of supervision
• Implemented by generic mental health professionals.
Mentalization based therapy – what does it look
like?
• Therapist adopts a stance of inquisitive, not knowing – Columbo vs
Poirot
• Alert to patients mentalizing and level of arousal in session
• Intervenes to restore mentalizing
• Maintains arousal at optimal level
• Collaborative therapeutic relationship
MBT Skills
• Any situation involving contact with person with Borderline PD is
opportunity to use MBT skills
• A&E, outpatients, inpatients, substance misuse, eating disorders, forensic etc
• Aim is to facilitate the patients capacity to mentalize in the setting
whilst being aware of factors which may be jeopardising capacity
MBT Skills
• Things to avoid!
•
•
•
•
Metaphors
Interpretations
Promises that can’t be kept
Behaviour that over stimulates attachment
• Lowering voice, special relationship, boundary violation however small or apparently
insignificant.
The hyperactivation of
attachment in BPD
• Suicide attempts are often aimed at
forestalling the possibility of abandonment:
they seem to be a last-ditch attempt at
reestablishing a relationship
• only something extreme would bring about
changes in the adults behavior and the
caregiver used similarly coercive measure
MBT skills - Self harm
• Means of staff conceptualising incident from different perspective – e.g to
avoid abandonment,
• Responding with indication of concern for actions rather than “ignoring or
minimising for fear of reinforcing bad behaviour”
• MBT skills to consider the incident and underlying affect
Effective ingredients of treatment (Bateman
and Tyrer)
1. to be well structured;
2. to devote considerable effort to enhancing compliance;
3. to have a clear focus,
4. to be theoretically highly coherent to both therapist and patient,
5. to be relatively long term;
6. to encourage a powerful attachment relationship
between therapist and patient,
7. to be well integrated with other services available to the patient.