Personality Disorder:

(1)

Personality Disorder:

An update for Primary Care

Dr Pardeep Dhillon

With inputs from Dr Chris Bench and Dr Neelima Reddi(Consultant Psychiatrists)

(2)

ICD-10

“Ingrained patterns of behaviour indicated by inflexible and disabling

responses that significantly differ from how the

average person in the culture perceives, thinks and feels, particularly in relating to others”

(5)

DSM-IV

An enduring pattern of

psychological experience and behaviour that differs

predominantly from cultural expectations, as shown in two or more of:

Cognition (ie perceiving and

interpreting the self, other people or events)

Affect (ie the range, intensity,

lability and appropriateness of emotional response

Interpersonal functioning Impulse control

(6)

Additional Criteria: ICD-10

Markedly disharmoniousattitudes and behaviour, involving usually several

areas of functioning, eg affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others.

The abnormal behaviour pattern is enduring, of long standing, and not limited

to episodes of mental illness.

The abnormal behaviour pattern is pervasive and clearly maladaptive to a broad

range of personal and social situations.

The above manifestations always appear during childhood or adolescence and

continue into adulthood.

The disorder leads to considerable personal distressbut this may only become

apparent late in its course.

The disorder is usually, but not invariably, associated with significant problems

(7)

Additional Criteria: DSM-IV

The pattern must appear inflexible and pervasive across a

wide range of situations, and lead to clinically significant distress or impairment in important areas of functioning.

The pattern must be stable and long-lasting, have started

as early as at least adolescence or early adulthood.

The pattern must not be better accounted for as a

manifestation of another mental disorder, or to the direct physiological effects of a substance (eg a drug or

medication) or a general medical condition (eg head trauma).

(8)

ICD-10 and DSM identify 11 Personality Disorders ICD-10 Paranoid Schizoid Dissocial Emotionally unstable Impulsive type Borderline type Histrionic Anankastic Anxious (avoidant) Dependent DSM-IV Cluster A Paranoid Schizoid Schizotypal Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependent Obsessive -compulsive

(9)

In practice

Cluster A: Odd and eccentric

– Paranoid – Schizoid – Schizotypal

Cluster B: Dramatic / erratic

– Borderline / emotionally unstable / impulsive – Antisocial

– Histrionic – Narcissistic

Cluster C: Anxious / avoidant

– Avoidant – Dependent

(10)

Can we do better in terms of classification?

Criteria for the current 11 PDs are not supported by good

empirical evidence

They are “committee” diagnoses

May be better to regard them as risk factors and

complicating factors for a wide range of mental disorders (like obesity is risk factor for DM, IHD, Breast cancer etc)

Distinction between personality traits (part of normal

functioning) and symptoms which are unpleasant and alien and undesirable

(11)

ICD-11

Abolish individual categories of PD Do not include borderline PD

Replace with 5 levels of severity – No personality disturbance – Personality difficulty

– Personality disorder

– Complex personality disorder – Severe personality disorder

Severity qualified by trait domains – Schizoid domain

– Anankastic domain

– Externalising domain (sociopathic) – Internalising domain (neurotic)

(12)

ICD-11

Severity determined by:

– Number of domains involved (more = greater severity)

– The degree of social dysfunction

(13)

DSM -5

Current Edition has abolished axis 2, Infact it has abolished the first three axis There are a lot of issues with the current edition

National Institute for mental health has withdrawn support

The proposal was similar to ICD11 a with move towards six personality hybrids and further categorisation

based on severity

American psychiatric association has decided to retain the use of DSM4 for the time being

The hybrid methodology retains six personality disorder types:

•Borderline Personality Disorder

•Obsessive-CompulsivePersonality Disorder

•Avoidant Personality Disorder

•SchizotypalPersonality Disorder

•AntisocialPersonality Disorder

(14)

(15)

Parking lot of the Personality Disordered

Paranoid – cornered

(16)

Narcissistic – largest car, big hood ornament

(17)

Dependent – relies on being close to other

(18)

Passive aggressive – parks car to take up two

(19)

Borderline – rams into car of ex-lover

(20)

Antisocial – deliberately obstrusts other cars

(21)

Histrionic – parks dramatically in centre – “look at me”

(22)

Histrionic – parks dramatically in centre – “look at me”

(23)

Obsessional – perfect alignment in parking

(24)

Avoidant – parks in corner

(25)

Schizoid – cannot tolerate being close

(26)

Schizotypal – intergalactic

(27)

(28)

Clustering in mental health

Now There is a move to PBR in Secondary care, based on

HoNoS

The HoNoS PBR or “Clustering Assessment”

– 13 current items rate symptoms and need in the last 2

weeks

– 5 historical items consider problems which occur in

(29)

Making the Diagnosis

May be better made by GP

Longitudinal perspective

Often better able to distinguish between new,

transient and enduring patterns of behaviour

GP less likely to make specific PD diagnosis

(30)

Borderline personality (BPD)

People with BPD are likely to:

Feel they do not have a strong sense of who they really are, and others

may describe them as very changeable

Suffer from mood swings, switching from one intense emotion to

another very quickly, often with angry outbursts

Have brief psychotic episodes, hearing voices or seeing things that

others don’t

Do things on impulse which they later regret

Have episodes of self harm, and suicidal thoughts Have a history of stormy or broke relationships

Have a tendency to cling on to damaging relationships, because they

(31)

Borderline personality (BPD)

Does not mean it’s borderline whether there is a personality

disorder or not

Does refer to the borderline between being “neurotic” and

“psychotic”

Some patients do flip alarmingly into a (brief) psychotic

(32)

Antisocial personality

People with ASPD are likely to:

Act impulsively and recklessly, often without considering the consequences for

themselves or others

Behave dangerously and sometimes illegally Behave in ways that are unpleasant for others

Do things – even though they may hurt people – to get what they want, putting their

needs above others

Feel no sense of guilt in they have mistreated others

Blame others and offer plausible rationalisations for their behaviour Be irritable and aggressive and get into fights easily

Be very easily bored and may find it difficult to hold down a job for long Have a criminal record

Have had a diagnosis of conduct disorder before age 15 Say …”now look what you made me do”…

(33)

Epidemiology

Prevalence:

Community: 3 – 10% (~1 in 20 of these has severe PD)

Primary Care: 10 – 30%

Secondary Care:

– Inpatients: 50% – Outpatients: 50%

– Substance Use services: 70%

Prison populations:

– Male remand: 78%

– Female remand 50%

(34)

BPD - Clues from the assessment

Disruptions / adversity in personal history History of self harm

Difficulty in initiating or sustaining intimate relationships Repeated history destructive relationships

Poor work history / sickness

Difficulty in sustaining working relationships

Substance use

Forensic history

Splitting within / between teams

…”you’re the best doctor I’ve ever seen, not like that one I saw here last week”

(35)

BPD - Clues from the assessment

How are they in the room with you?

Strong emotional reactions

– Transference / counter-transference – Heartsinks and favourites

– Rescue fantasies

Do you find yourself behaving atypically

Marked variation in colleagues reactions

Difficulty in engaging patient in addressing health care

(36)

Re-enactments

Imagine a patient with an early experience of neglect or

abuse

Their underlying expectations will persist largely

unconsciously but become more active when seeking help

They will tend towards acting in a way that is designed to

meet those expectations

Their approach encourages those around them to act in a

way that complements that

(37)

Illness Behaviour

In primary care the re-enactments often manifest through

abnormal illness behaviour:

– Medically unexplained symptoms – Frequent attending

– Unpredictable use of healthcare (DNAs then requests for

emergency appts)

– High use of psychotropics / medication – Self harm

– Complaints

It can be hard to remember that PD patients are asking for

(38)

Management in Primary Care

The consistent relationship is the key

Keep to task in the consultation

Keep to time in the consultation

Keep to your normal structure

If you are doing something very different from normal it’s

probably not the right thing

Continue to manage the Physical and Mental health needs

in the face of whatever challenge they bring (wherever possible)

(39)

What can help in Primary Care?

Sharing the burden / experience – Informal discussions

– Formal complex cases reviews

– Foster climate of openness with all staff in surgery

– Be curious about range of experiences – they are valid and help in understanding

Buy time – tell the patient you want to consider things carefully

Be frank with the patient – the most burning thing to say is probably the

most important

(40)

When to refer

Threatening patients

– Assessment of diagnosis – Assessment of level of risk

– Formulation of management plan

Repeat deliberate self harm

– Common feature of borderline personality

– Risk factor for future self harm and increased risk suicide

Co-morbidity

– Depression, anxiety, somatization, substance misuse

Marked impairment of psychosocial functioning Vulnerability of self / dependents

(41)

Treatment

Making the diagnosis

Being honest with patient about this

The relationship with the patient

Some specific treatments

Treat co-morbidities

– Depression (if fulfills criteria for depressive episode) – Anxiety

(42)

Drug Treatments

Most randomised trials in the last 20 years are in BPD

Most trials are judged to be of low quality by NICE

NICE (2009)

“antipsychotic drugs should not be used for the medium and long term treatment of borderline personality disorder” “in general drug treatment should be avoided except in an

(43)

Drug Treatments

Lieb et al (2010): British Journal of Psychiatry 196, 4-12

Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials.

Suggested that mood stabilisers and second generation

antipsychotics may be effective for treating a number of core symptoms

Evidence does not support effectiveness for overall severity

of borderline PD

“Pharmacotherapy should be targeted at specific

(44)

Psychological Treatments

More likely to be effective in those patients who can:

Think about and monitor their own thoughts, feelings and behaviour Be honest with themselves about their problems and imperfections Accept responsibility for solving their problems, even if they did not

cause them

Be open to change and stay motivated

(45)

Psychological Treatments

No evidence for any one mode of treatment being more effective than an other Ideally have menu of options available

Common treatment programmes include:

– STEPPS / CBT – Mentalisation

– Dialectical Behaviour Therapy

– Psychodynamic programmes / transference focussed Rx – Therapeutic communities

Treatments tend to be long (1 – 2 yrs), often tiered and much preparation Structured team approach is required for BPD

Cognitive therapeutic approach (group work) for ASPD

(46)

Mentalisation based therapy (MBT)

People with BPD may have a poor capacity to mentalise. Mentalisation is the ability to think about thinking.

– Examining thoughts and beliefs

– Assessing whether they are useful, realistic and based on reality

– Recognising that others have thoughts, emotions etc and that your interpretation of

these may not necessarily be correct

– Being aware of the potential impact your actions will have on other people’s mental

states

MBT aims to improve ability to recognise your own and others’ mental states,

and learn to ‘step back’ from your thoughts about yourself and others and examine them to see if they are valid.

(47)

Dialectical Behaviour Therapy (DBT)

DBT suggests that in order to overcome these problems you need to learn how to control your emotions, and that the first step in doing so is to experience, recognise and accept your emotions. You can then start to reduce their intensity and let them go quicker.

Marsha Linehan developed DBT from CBT for use in BPD

CBT traditionally focuses on helping change unhelpful ways of thinking and

behaving

DBT also helps change but focuses on accepting who you are at the same time DBT uses a balance of change techniques and acceptance techniques

Uses individual and group sessions, out of hours contact, and a team approach Evidence in particular in women with BPD who self harm

(48)

Role of Peer Support

Increasingly core feature of treatment programmes Learn through lived experience

Expert patients

Makes for a normalising process Focusses on people’s strengths

Challenges hopelessness

(49)

Where treatment works

Reduction in destructive behaviours – Self harm

– Substance use

Improved social and occupational function

Reduction in

– GP attendance – A&E attendance

– Psychotropic prescriptions – Crisis presentations

(50)

Prognosis

Variable

May improve over time

Higher incidence of death by violence and suicide. Between 30 and 60% of completed suicides

retrospectively show evidence of a personality disorder.

People with obsessional personality disorders are at a high risk of progression to depressive

illness.

Borderline PD carries a relatively favourable prognosis with clinical recovery in over 50% at 10 to

25 year follow up.

People with paranoid and schizotypal PD may progress to persistent delusional disorder, but

those with schizoid PD do not.

The prognosis for personality disorders is improved if the person establishes a stable relationship

(51)

What to expect from secondary care

For all those referred

Assessment / formulation / diagnosis

Assessment of risk

Liaison with other agencies where necessary

– Local authority / safeguarding – Substance use services

– Criminal justice system

Some indication of current treatability

(52)

How Can the GPs help the patient ?

Recognise the use of immature defence mechanisms and the negative coping mechanisms

used by patients with certain types of personality disorder.

Be supportive and try to establish a good rapport.

Provide support for improving social situation, for eg help with social housing, benefits etc.

Try to be non judgemental

Understand that a lot of emotions that we feel could be due to transference and counter

transference and it is important to sometimes take and objective impersonal view.

Seek advice and Support from both primary care and secondary care colleagues

Patients_’illness will also create difficulties in providing care for physical health, perhaps create physical health care plans for patients and ensure they are aware of the plans or perhaps have written copies

(53)

Referrals

1.Initial referrals should be done to CMHRS for care coordination and initial assessment

2.Initial stability is important, so referral are not generally done directly to psychotherapy

3.After initial stabilisation, the referrals are then done to local psychotherapy group within North-West surrey

(54)

Future of local services

Personality disorder strategy is being discussed in the Trust and if approved , it will be

launched towards latter part of the year following an implementation plan.

It will offer:

Good, early, comprehensive assessment with stabilisation of social factors;

Good clinical care with co-morbid physical and mental health problems;

Offering help with drug and alcohol issues and then a tailored treatment plan according to the

needs of the patient across the Trust. This is to ensure uniformity and parity of care across the Trust.

Structured clinical care;

(55)

Local Psychotherapy team

Dr Neelima Reddi: (offers individual, group therapy and MBT in the department) Dr Neelima Reddi: (offers individual, group therapy and MBT in the department) Dr Neelima Reddi: (offers individual, group therapy and MBT in the department) Dr Neelima Reddi: (offers individual, group therapy and MBT in the department) Dr Elaine AlvesDr Elaine AlvesDr Elaine AlvesDr Elaine Alves ---- offers DBT, CAT, ACT;offers DBT, CAT, ACT;offers DBT, CAT, ACT;offers DBT, CAT, ACT;

Rebecca IsherwoodRebecca IsherwoodRebecca IsherwoodRebecca Isherwood----Smith from Transitions Services Smith from Transitions Services Smith from Transitions Services Smith from Transitions Services –––– offer STEPPS, ACT, OT for PD offer STEPPS, ACT, OT for PD offer STEPPS, ACT, OT for PD offer STEPPS, ACT, OT for PD Richard Whitaker who offers Art Therapy and is part of the MBT team.Richard Whitaker who offers Art Therapy and is part of the MBT team.Richard Whitaker who offers Art Therapy and is part of the MBT team.Richard Whitaker who offers Art Therapy and is part of the MBT team.

(56)

Support available

General resources

Choice and Medication website:

http://www.choiceandmedication.org/wlmht/

WLMHT website pages for GPs:

http://www.wlmht.nhs.uk/how-we-can-help/gp-information/

Royal College of General Practitioners:

http://www.rcgp.org.uk/clinical-and-research/clinical-resources/mental-health.aspx

Royal College of Psychiatrists:

(57)

Support available

Specific PD resources

NHS Choices

http://www.nhs.uk/Conditions/Borderline-personality-disorder/Pages/Treatment.aspx

Royal College of Psychiatrists

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/personalitydisordersfacts.aspx

Mind:

http://www.mind.org.uk/media/42894/understanding_bpd_2012.pdf

http://www.mind.org.uk/information-support/drugs-and-treatments/dialectical-behaviour-therapy

Mental Health Foundation:

http://www.mentalhealth.org.uk/help-information/mental-health-a-z/P/personality-disorders/

Everyman (anger management and related for men):

http://www.everymanproject.co.uk

BPD World:

Personality Disorder: