Grace under Duress
Morbidity, assessment and management
principles
October 2005
Steve Pearce, TVI Oxfordshire
• ‘Personality disorder is a device for attaching
the scientific prestige associated with health
with what are essentially judgements of
value’.
•
Barbara Wootton (1956)
• ‘Personality disorder is a concept like body
odour…. indubitably affected by constitution and
environment, a source of distress to both sufferer
and society, yet imbued with ideas of degeneracy
so that its possession is also a personal criticism’.
•
Peter Tyrer & Brian Fergusson (1988)
The origins of PD categories
• Borderline – psychoanalytic
understandings
• Psychopathic disorder – degeneration
theory, criminality
• Anxious PD - social phobia
• Schizotypal PD - adoption studies of
schizophrenia spectrum disorder
Grace under Duress
• How much is out there? (aka epidemiology)
• What problems are associated? (morbidity)
• How can you tell? (assessment and
diagnosis)
• What causes it? (aetiology)
• What can one do about it (management
principles, and why this is a problematic
concept)
• …and what is the problem with all of the
above?
Presentations
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recurrent deliberate self harm
symptoms of depression and anxiety
eating disturbances
interpersonal problems, which may include
violence
parenting problems
substance abuse
behavioural difficulties, including criminal
offences.
somatic symptoms without physical pathology
high level of use of services
Epidemiology
• Community – 4.5% (10-13%), age 2544, male=female
• Primary care – 24% of attendees.
Cluster C. (Moran 2000)
• Psychiatric outpatients – 59-81%
• Psychiatric inpatients – 36% - 67%
Prevalence
• Inpatients with addictions: 78% alcohol
and 91% polydrug addiction
• 69% Eating Disorder Unit inpatients
• 41% of completed suicides suffered
from EUPD
Prevalence of personality disorder in prison
Male
Male
Female
Remand
Sentenced
All
Per cent
Type of personality disorder
Antisocial
63
49
31
Paranoid
29
20
16
Borderline
23
14
20
Avoidant
14
7
11
Obsessive-compulsive
7
10
10
Narcissistic
8
7
6
Schizoid
8
6
4
Dependent
4
1
5
Schizotypal
2
2
4
Histrionic
1
2
1
78
64
50
Any personality disorder
General features
• Enduring pattern of inner experience
and behaviour that deviates markedly
from the expectations of the individuals
culture
• Inflexible and pervasive
• Leading to clinically significant distress
or impairment in social, occupational, or
other important areas
Classification
• Cluster A ‘odd, eccentric’
– Schizoid – detachment from emotional
engagement and restricted emotional
expression (0.5-1%)
– Paranoid – distrust and suspiciousness,
others motives are interpreted as
malevolent (1-2%)
Cluster B ‘flamboyant,
dramatic, emotional, erratic’
– Borderline – instability in interpersonal
relationships, affect and self image, and
impulsivity (women, 1%)
– Impulsive – dominated by emotional instability and
lack of impulse control
– Histrionic – excessive emotionality and attention
seeking (women, 1-3%)
– Dissocial/antisocial – disregard for and violation of
the rights of others (men, 1-3%)
– Narcissistic – grandiosity, need for admiration, lack
of empathy (very variable)
Cluster C ‘anxious, fearful’
– Obsessive-compulsive – preoccupation
with orderliness, perfectionism and control
(2-7%)
– Dependent – submissive and clinging
behaviour related to an excessive need to
be taken care of (women, 1-5%)
– Avoidant – social inhibition, feelings of
inadequacy and hypersensitivity to
negative evaluation (1-4%)
Aetiology
• Where have all the antisocial Taiwanese
gone? (Hwu 1989)
• Schizotypal PD commoner in Scandinavia
• ASPD and probably BPD becoming more
common in USA (Robins 1991, Millon 1993)
(criminality/depr/parasuicide)
• Higher rates of parental separation in Axis II
(Paris 1994)
Aetiology
• social structure breakdown?
• Loss of secure attachments -> affective
instability
• General risks for all PD:
– parental psychopathology
– family breakdown
– traumatic events
• Diathesis - stress model (temperament may
determine category)
Is BPD caused by childhood
abuse?
• 50-70% CSA in BPD
• BUT also associated with other PDs
• 30% severe CSA trauma, 30% less
severe CSA, 30% none
• BUT independent assoc. CSA-BPD
(Paris 1994, Links 1993)
BPD
• describe parenting as neglectful or
overprotective
• greater temperamental needs, historically all
nurturance perceived as inadequate
• Prospective study (Johnson 1999)
– PDs up in children grossly neglected or abused
– physical or sexual
– cluster B
Aetiology ASPD
• Antisocial behaviour in parent -> ASPD
in child independent of other risk factors
• Capricious and violent parenting,
physical abuse (Pollock 1990)
(?independent of parental psychopathy)
• coercive child training, failure to monitor
child's behaviour (Patterson 1982,1986)
• large family, low IQ (Farringdon 1988)
Mortality and disability
• Comorbid alcohol and drug use
• Increased likelihood of depression and
anxiety
• Increased chance of accidental death,
suicide, homicide
• Relationship difficulties
• Housing problems
• Long term unemployment
Morbidity
• Excessive consumption of psychotropic
medication
• Frequent attenders at GP, emergencies
• ‘difficult consulting behaviour’
• Revolving door syndrome/repeated
psychiatric hospitalisation
Comorbidity
• Cluster A - psychosis (non affective)
• Cluster B - psychosis, anxiety, ED,
substance misuse
• Cluster C - psychosis, mood disorder,
anxiety, ED, somatoform
Compared to depression,
greater use of:
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psychiatric medication
hospitalisation
psychotherapy
day care
social care
Assessment
• often missed
• four domains
– symptoms
– interpersonal function
– social function including work history
– inner experience
• interview an informant
BPD
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symptoms
• Self damaging impulsivity (spending, sex, substance misuse, driving, eating
• Recurrent suicidal behaviour, gestures or threats or self mutilating behaviour
• Transient stress related paranoid ideation or severe dissociative symptoms
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interpersonal function
• Pattern of unstable and intense relationships alternating between idealisation and
devaluation
• Frantic efforts to avoid real or imagined abandonment
–
inner experience
• Identity disturbance: unstable sense of self or self-image
• Affective instability due to marked reactivity of mood
• Chronic feelings of emptiness
• Inappropriate intense anger or difficulties controlling anger
–
social function including work history
Assessment
• Problems should be long term – since late
adolescence/early adulthood
• Problems should be pervasive – generalised
across situations
• Problems should be disabling – produce
suffering in patient or those around them
• Problems will usually affect social,
occupational and personal spheres
Trajectory
• J shaped curve for clusters B and C
(traits not disorders)
• Antisocial personality disorder falls off
>45
Management principles
• 1 – consistency
– all team members substantially involved should
maintain close contact to reduce potential of
‘splitting’ and maintain a consistent approach
– restrict those involved in management to those
with a clear role and task
– ‘core team’
– likely to be optimal in a specialist team approach
Management principles
• 2 - pay close attention to countertransference
• blaming
• the assumption that unconscious processes
are conscious
• understanding past and present dynamics,
avoiding falling into same roles
• supervision
Management principles
• 3 – avoid reinforcing unhelpful behaviours
– attachment rather than rule based
– contingency management
• 4 – encourage reflection and agency in decisions,
explaining rationale
• 5 –management tailored to the individual
• 6 - constancy
– avoid staffing changes. Esp in BPD, problems of loss and
despair get re-enacted
Management principles
• 7: Medication
Practitioner characteristics
• practitioners find it difficult to implement
treatment plans consistently for patients with
personality disorder
• capacity to be steady, skilful and competent
despite provocation, anxiety, and pressure to
transgress boundaries
• Ability to be pragmatic rather than dogmatic
• Personality of therapist may have an effect
• ‘Toughness and tolerance’ - feeling that
worker is indestructible and engaged
General principles
• experience of being the subject of reliable,
coherent and rational thinking
• correlates of the level of seriousness and the
degree of commitment with which teams of
professionals approach the problem of caring
for this group
• have been deprived of exactly such
consideration and commitment during their
early development and quite frequently
throughout their later life
New NSF Psychiatric Services
• Early intervention for Psychosis
• Assertive outreach
• Home treatment teams (crisis resolution)
• The Mental Health Policy Implementation
Guide
http://www.doh.gov.uk/pdfs/mentalhealthim
plowgraphics.pdf
CRISIS RESOLUTION/HOME
TREATMENT TEAMS
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Commonly adults (16 to 65 years old) with severe mental illness (e.g.
schizophrenia, manic depressive disorders, severe depressive disorder) with an
acute psychiatric crisis of such severity that, without the involvement of a crisis
resolution/home treatment team, hospitalisation would be necessary. (NB) In
every locality there should be flexibility to decide to treat those who fall outside
this age group where appropriate.
This service is not usually appropriate for individuals with:
• Mild anxiety disorders
• Primary diagnosis of alcohol or other substance misuse
• Brain damage or other organic disorders including dementia
• Learning disabilities
• Exclusive diagnosis of personality disorder
• Recent history of self harm but not suffering from a psychotic illness or
severe depressive illness
• Crisis related solely to relationship issues
4. ASSERTIVE OUTREACH
4.1 Who is the service for?
Adults aged between 18 and approximately 65 with the following:
2. A history of high use of inpatient or intensive home based care (for example, more
than two admissions or more than 6 months inpatient care in the past two years)
3. Difficulty in maintaining lasting and consenting contact with services
4. Multiple, complex needs including a number of the following:
• History of violence or persistent offending
• Significant risk of persistent self-harm or neglect
• Poor response to previous treatment
• Dual diagnosis of substance misuse and serious mental illness
• Detained under Mental Health Act (1983) on at least one occasion in the past 2 yrs
• Unstable accommodation or homelessness
1. A severe and persistent mental disorder (e.g. schizophrenia, major affective
disorders) associated with a high level of disability