Personality Disorders

Question 1

What is the definition of personality disorder?

Answer 1

• ICD-10 (WHO, 1992)
  
  • Enduring and deeply ingrained ways of behaving, thinking, feeling and relating
  • Deviate significantly from the norm
  • Sufficient to cause significant personal and social distress and disruption
  • Usually present since adolescence or childhood and persists throughout most of adult life.

Effects every domain of function - really pervasive.

A lot of people have bizarre personality traits but they find their place in society, jobs etc - with PD it must cause some of personal distress of hindrance. If weird but fine then don’t have PD.

Also needs to be clear that the disorder was present at some point during adolescence. Been going on for a while.

Question 2

How do ICD and DSM cluster personality disorders into groups?

Answer 2

Cluster A = odd
Cluster B = difficult
Cluster C = anxious

Might consider cluster first then work back to the specific PDs after that during diagnosis.

Question 3

What are the problems with classification of personality disorder?

Answer 3

• Most patients meet criteria for >1 PD
• Extreme heterogeneity within PD diagnoses
• Arbitrary diagnostic thresholds
• Poor coverage (PD NOS the most common)
• Poor convergent validity
• Longitudinal course more like Axis 1 than previously realised
• Problems communicating about dimensions to other clinicians.

Question 4

What does the DSM 5 say about personality disorder?

Answer 4

• PPDWG Proposal
  
  • Hybrid categorical dimensional model
  • Evaluation of impairments in personality functioning
  • Six specific patterns of traits: borderline; obsessive-compulsive; avoidant; schizotypal; antisocial; narcissistic
  • “PD – Trait specified” if fail to meet criteria for specific PD
• Rejected at last minute by the APA Board of Trustees
  
  • Placed in Section III, “Emerging Measures and Models”
  • Retains DSM-IV diagnostic criteria
  • Single axis system

Tried to think about a combination of a dimensional approach with some categories, but it was rubbish

Question 5

What was the McLean study of adult development?

Answer 5

• McLean Study of Adult Development Zanarini et al. (2006)
• Prospective study of borderline PD
• 70% meet remission criteria at 8 years
• ~6% of remissions experience recurrence within 8 years
• Different symptoms resolve at different rates
○ Impulsivity resolves most quickly, followed by interpersonal, cognitive and then affective symptoms.

This contradicts the idea that it is a diagnosis for life. Behavioural symptoms seem to resolve early on, but emotional issues are more enduring.

Question 6

What is the prevalence of personality disorder?

Answer 6

• Community
  
  • 10-13% (2% antisocial PD) De Girolama and Dotto (2000)
• Primary care
  
  • 10-30% (Cluster C most common) Moran et al. (1999)
• Inpatients
  
  • 36% Pilgrim and Mann (1990)
• Drug and alcohol services
  
  • 78% of alcohol inpatients De Jong et al. (1993)
• Prison
  
  • 60-70% Singleton et al. (1998)

Question 7

What sit eh border of personality disorder?

Answer 7

• Mortality and accidents
• Mental illness
• Poor treatment outcome
• Increased service utilisation
• Antisocial behaviour
• Deliberate self-harm
• Suicide

Outcome of any other disorders is made worse by PD - not go to appointments, into take medications properly, self harm, etc.

Tend to use services more, don’t go to monthly appointments but go to A+E, police etc - use all the services they shouldn’t be

Self harm more common in some forms of PD than others, in particular borderline PD.

Question 8

About personality disorder and violence…

Answer 8

• Personality disorder in high risk populations
• Mean 3.6 in high secure hospital/prison sample.
• Violence in epidemiological samples
• Cluster B: x10 criminal convictions; x8 time in prison.
• Any PD + substance dependence – 52% violent in previous 5 years.
• ~1:2 ASPD not violent in previous 5 years.
• Violent vs. non-violent offenders
• ñASPD in violent offenders (23.6% vs. 14.6%)
• ASPD corr. with violent convictions in violent offenders
• Cohort studies
• Cluster A in adolescence associated with burglary and threatening behaviour.
• Cluster B (excl. ASPD) associated with any violent act, including arson, vandalism, fights, robbery.
• Role of alcohol in mediating relationship.
See Duggan and Howard (2009) in McMurran and Howard (eds.) for review.

Question 9

What specific personality disorders have a link with violence?

Answer 9

• Four dimensions operate as clinical risk factors for violence:
  
  • Impulse control
  • Affect regulation
  • Narcissism
  • Paranoid cognitive personality style
• ASPD and BPD selectively co-occur
  
  • Co-occurrence increases with security level.
• Cluster C PDs may be protective
  
  • Particularly obsessive-compulsive personality disorder

Poor impulse control, regulating emotions, rules are for other people/exploiticism/only few people understand you (narcissism), hypervigilance, thinking people will attack you so you pre-emptively attack etc.

Antisocial and borderline PD tend to co-occur, diagnostic system not very discriminative and people often have more than one kind. Increases risk of being admitted to high security hospitals.

Always look for functional impairment, don’t exclude other types etc.

Question 10

What is the assessment of personality disorder?

Answer 10

• Interview-based measures
  
  • International Personality Disorder Examination (IPDE)
  • Structured Clinical Interview for DSM-IV Axis II Personality Disorder (SCID-II)
• Self-report measures
  
  • Millon Clinical Multiaxial Inventory (MCMI)
  • Minnesota Multiphasic Personality Inventory Personality Disorder Scales (MMPI-PD)

Prompting the accurate answers, eg asking if other people think they are a certain way in which they might say yes, whereas if you asked if they thought they were they would completely disagree as they don’t see it.

Self-report measures important as in time constraints at appointments they can have sent back response before hand so got an idea beforehand. Not as systematic as interviews but still a useful tool.

Question 11

What is borderline PD?

Answer 11

• Frantic efforts to avoid abandonment
• Unstable and intense interpersonal relationships
• Identity disturbance
• Impulsivity
• Affective instability
• Chronic feelings of emptiness
• Difficulty controlling anger
• Transient psychotic or dissociative symptoms
• Recurrent self-harm and/ or suicidal behaviour

Anxiety of abandonment in relationships - can manifest through appointments also, don’t leave on time, don’t come, etc. relationships tend to be quite unstable and intense.

Anger is disproportionate.

If asking about self-harm try and figure out the meaning of it for them, could be a way of managing emotions, could be because they feel chronically empty and want to feel something, may be attempts to manipulate relationships such as the doctor seeing they need to carry on looking after them etc.

Question 12

How do we measure PD outcomes?

Answer 12

• Methodological problems
  
  • Lengthy evaluation period required
  • Treatment rejection
  • Multifaceted; comorbidity
  • Lack of consensus on outcome measures
• Outcome measures
  
  • Symptoms; personality
  • Quality of life; social functioning
  • Behaviour; recidivism
  • Service use

Some people are treatment rejecting - don’t think they’ve got a problem, actively reject, schizo don’t interact with other or seek out treatment.

Lots of different parts to the diagnosis so might get some areas really improving and others seeing no change.

Meta-analyses, only really possible is using the same kinds of outcome and that doesn’t work in PD research, looking at all sort of different outcomes only recently have they begun looking at the same things to get the results

Quality of life, relationships improving, working and jobs, other community integration measures.

Behavioural includes self harm, accidents, reoffending behaviour.

The best studies have looked at one outcome in at least 4 or 5 of these areas. Tricky but manageable and improving.

Question 13

Where is the evidence for PD?

Answer 13

• ‘What works’ literature
  
  • Behaviour focused
  • Ignores PD
• Mental health literature
  
  • Non-offenders
  • Usually borderline PD

What works literature is the prison literature form offending behaviour programmes looking at how effective they are. They are relevant because the vast majority of people engaging in them have PD and the focus is on reducing behavioural issues.

Mental health literature less on prisoners and focusses on general borderline PD.

Question 14

What is the ‘what works’ literature on PD?

Answer 14

• Behaviour focused – ignores PD diagnosis
• ~ 10% reduction in reoffending overall
• Evidence for CBT, relapse prevention and multisystemic therapy
• Evidence for DTCs if stay >18 months and high risk
• Drop outs do very badly
• Low risk offenders do worse in treatment
See Craig et al. (2013) for review

Focussing purely on behavioural.
Most people in prison have PD - exceptionally high prevalence
Underwhelming results - 10% reduction - might expect a lot more.
Therapeutic communities - residential treatment programmes. Daily community meetings, real effort in giving residents responsibility and making them accountable of their behaviour. There are 3 or 4 now which are based in prisons, previously just in general community.
Those who drop out often do worse than those who don’t have any treatment at all, this is why it is important to consider what treatment methods might be best for each individual.
Can be destabilising, if someone is low risk might have less of an impact.

Question 15

What is the mental health literature on PD?

Answer 15

• Non-offenders; usually borderline PD
• Evidence supports the following manualised treatment models:
  
  • Mentalisation-based treatment
  • Transference-focused psychotherapy
  • Schema-focused therapy
  • Dialectical Behaviour therapy
  • Cognitive therapy
  • Cognitive analytic therapy
  • Systems training for predictability and problem solving
• Evidence from cohort studies for therapeutic community treatment

Whole range of model based on a rang elf things

Question 16

What is mentalisation based treatment (MBT) for PD?

Answer 16

MBT - mentalisation based treatment

• Borderline PD (?antisocial PD)
• Enhancing mentalisation will promote emotion regulation and more adaptive cognitive functioning
• RCT MBT vs. treatment as usual (5 year follow-up):
• Suicide attempts (23% vs. 74%)
• Reduced A&E visits, hospitalisation and OPD
• Reduced medication use(0.02 vs. 1.9 using 3+)
• BPD diagnosis (13% vs. 87%)
• Global functioning (45% vs. 10% GAF >60)
• Vocational status (3.2 vs. 1.2 years employed/in education)
Bateman and Fonagy (2009)

Mentalisation is relatively new therapy model based on attachment theory formed by psychodynamic thinking. Try and understand own and other peoples minds through what they’re thinking/feeling/their intentions/what’s going on in their mind.
Evidence that its really effective in BPD, trail in antisocial PD
About trying to get people to identify when they’ve stopped mentalising and need to start improving this.
Outcomes are quite pervasive - reduced suicide attempts, medication use, symptoms, improved function, more likely to be in employment.

Been followed up for 8 years now - works and persists.
Quite often know when not mentalising as something comes unexpectedly from an interaction - haven’t kept and open mind and curiosity about their intent and how they might feel.

Question 17

What are definitions of metallisation?

Answer 17

• The mental process by which an individual implicitly and explicitly interprets the actions of himself and others as meaningful on the basis of intentional mental states such as personal desires, needs feelings, belief, and reasons.
  
  • To see ourselves from the outside and others from the inside
  • Understanding misunderstanding
  • Having mind in mind
  • Introspection for subjective self-construction – know yourself as others know you but also know you subjective self (your experience)

Question 18

What is SFT?

Answer 18

• Borderline PD
• Modifying dysfunctional schema modes will reduce dysfunctional beliefs and maladaptive thinking
• Detached protector; punitive parent; abandoned/abuse child; angry/impulsive child
• RCT SFT vs. TFP: both work, but SFT:
• Reduce BPD severity index
• Improved “general psychopathologic function”
• Improved measures of SFT
• Improved quality of life
Giesen-Bloo et al. (2006)

Schema focussed therapy

Depending on the environment you’re in you develop beliefs
about the world which are protective and adaptive helping you survive that environment

Schema are a set of beliefs that go together

Can develop a protective schema by not trusting people, suspicious of help etc if been abused for example and wouldn’t survive with out this - if continue it in adults life etc it makes it really DIFFICULT for you to survive as it is no longer adaptive. Makes v difficult to regulate emotions, relationships etc

Attempts to get modification of individuals schemas, challenging them and trying to move them into a healthy adult mode.

People really like this because instead of saying have made a mistake or done something wrong, theyre able to valdiate that their early beliefs make sense and without them wouldn’t be around, but to understand that they are no longer valid and adaptive and helpful. This is a non-threatening way to get people to adapt from this.

Question 19

What is DBT?

Answer 19

• Borderline PD
• Development of emotion regulation skills improves affect regulation
• RCT DBT vs. expert treatment – 1 year follow-up
• Half as likely to make suicide attempt
• No difference in non-suicidal self-injurious behaviour (cf. previous trials)
• Reduce A&E attendance and hospitalisation
• Half as likely to drop out of treatment
• Improved outcome not attributable to general factors associated with expert psychotherapy
Linehan et al. (2006)

Based mainly on CBT, but includes zen beliefs, radical things - an eclectic mix of beliefs

Challenging these and understanding skill to manage difficult emotions/impulsivity/”a shit life” - can either decide your life is rubbish and dwell on it, or radically accept that is the case, bad tings happen to people and this is a part of life but you get on with it.

Particularly reduces self-harm attempts, mainly in women, but also other aspects too.

Question 20

What are the common factors of SFT and DBT?

Answer 20

• Structure
• Consistent, transparent model of treatment (+/- contract)
• Treatment alliance
• Establish/maintain collaborative treatment alliance
• Consistency
Adherence to treatment model/contract; containment
• Validation
• Recognition/affirmation of patient’s experience as legitimate
• Motivation
• Build motivation and commitment to change; risk-need-responsivity
• Metacognition
• Promote reflective function; culture of curiosity
• Treatment may make patients worse (?10%)

If people develop a therapeutic model they are very invested in it and want it to go the furthest.

Have been comparisons of models and there’s not much evidence for one being better than others.

The key thing is having structure - communicating to the patient what the model is so they understand it, transparency and consistency - can even have a contract with it with what expect to achieve etc.

Important to have some treatment alliance with the patients, some will really struggle and important that an active part of treatment is a stable relationship underlying it

Consistency, need to stick to it not be ruled of fit by unpredictable patients - often like there being boundaries and nothing shifting

Validation is saying that their experience is understandable in the context of their experience

Motivation for treatment as it can be hard - making sure maintain motivation and engagement, avoid at all costs people dropping out.

Metacognition - peoples minds, how you feel, internal curiosity etc this is very important. Getting the sense that talking about feelings is normal and not weird.

Some treatment can make people worse if the timing is wrong for example, not ready to engage or talk about things, may have mismatched the model, may feel coerced to engage in treatment for their sentence for example, really need to match the treatment to the person depending on how risky they are, to their particular needs and responsivity factors - if delivering treatment with someone with literacy problems need to adapt to that and minimise the issues this may have to their engagement.

Question 21

What is risk-need-responsibility (PD)?

Answer 21

• Risk principle
• Intensity of treatment must match risk level
• Need principle
• Treatment must target needs linked to violence risk (criminogenic needs).
• Responsivity principle
• Treatment delivery must accommodate the patients idiosyncratic characteristics (e.g., cognitive abilities, level of motivation)
Andrews and Bonta (2006)

Another set of principles underpinning effective treatments for PS
Must target something that’s a problem and related to need
May be treatment obstacles for that individual and need to address these

Question 22

What are the treatment delivery methods in PD?

Answer 22

• “What will once a week in the community do? I need inpatient treatment.”
  
  • ‘Step-down’ programme more effective than long-term admission or standard psychiatric care
• “I’m not doing a group. I need individual treatment.”
  
  • Equivalent outcomes in RCT of group and individual interpersonal therapy
• “You need to admit me to hospital.”
  
  • Avoid admission of >72 hours
  • Planned; clear aims; avoid sudden discharge

Intensive period of treatment in beginning building motivation, engagement, trust etc
Then some treatment
Then to avoid dependence and too much attachment, and also encouraging them to form other attachments to others, need to do a step down…

People with relationship difficulties a group is a good place to start then go on to individual treatment.

Individual treatment is NOT the gold standard - all about the individuals needs

There is no evidence that admission to hospital is helpful and a lot of evidence that it could be unhelpful. If they need to go in, the best admission route would be for it to be planned with a plan of what will happen during that time, setting goals and knowing when will be discharged. They know what’s coming and then they can leave etc.

Question 23

What are the NICE guidelines for ASPD?

Answer 23

• Develop an optimistic and trusting relationship
  
  • Emphasise that recovery is attainable
  • Open, engaging, non-judgmental, consistent and reliable
• Cognitive behavioural interventions for children aged ≥ 8 years with conduct problems
  
  • If unable to engage in parent training programme or if additional factors e.g., callous unemotional traits
• Use standardised severity and risk measures
  
  • E.g., PCL-SV, HCR-20
• Group-based cognitive behavioural interventions for those in the community or institutional care with history of offending
• Multi agency care
  
  • Pathways; specific interventions at each point; networks

Question 24

What is drug treatment rationale for PD?

Answer 24

• Subsyndrome or spectrum
• Neurotransmitter
• Lack of resources
Panic

There is no evidence base for drug treatment in PD at all.

People think that its like mini-bipolar so should use mood stabiliser, bit like schizophrenia use antipsychotic etc…. But no evidence at all.

Some patients are drug seeking, responsibility of professional is to give best treatment and drugs is not that as no evidence base.

Find that give someone a drug, doesn’t work, and keep on upping it and nothing works and then they end up on loads of unnecessary drugs and then have to stop them and that’s a challenge and not taken well. Much better to not start them - spend a lot more time stopping treatment rather than starting.

Question 25

What are the guidelines for drug treatment of PD?

Answer 25

do not use drug treatment specifically for BPD/ASPD or individual symptoms associated with them (NICE, 2013)

Question 26

What actually happens with drug treatment of PD?

Answer 26

• Patients frequently on 3+ classes of drug

* Stopping/changing medication is perceived as punishment or lack of care

Question 27

In practice what is done with drug treatment of PD?

Answer 27

• Be explicit – best practice; NICE guidelines; there is nor drug treatment for this disorder.
  
  • Think about context/meaning – both of the request and impulse to prescribe (anger, hopelessness)
  • Short-term use of hypnotic (antihistamine)
  • Short-term use of antipsychotics in problematic paranoia
  • Review and stop

Question 28

What is the future of drug treatment of PD?

Answer 28

• Multiple RCTs underway

* LABILE – placebo-controlled randomised trial of lamotrigine in BPD

Question 29

What are the future directions of PD?

Answer 29

• Integrated modular treatment (Livesley et al., 2015)
  
  • Lack of evidence of clinically significant differences between therapy models
  • Lack of substantial differences between specialised models and well-specified, manualised general psychiatric care
  • However, some therapies are better than others in treating specific domains
• General approach + technical eclecticism - i.e. common factors plus methods from diverse models for specific domains (without adopting their associated theories).

Integrated modular treatment - no evidence that any of the 3 letter treatments are better than others. Also if use common factors to them all (good psychiatric practice) and deliver that and compare it to one of them alone no evidence of it being better. Worrying in some ways but good in others.

Mentalisation treatment has some evidence of being better for some domains of PD for example - specifics for specific domains. Focussing on little domains and using bits of the models in the context of good psychiatric care is the probably the best approach.