PS3013 ClinP personality disorder 7ab

Personality Disorder: 

Personality Disorder Dr. Steven Allan

Aims of Lecture: 

Aims of Lecture Provide a definition of personality disorder Describe the different clusters of personality disorder Briefly outline the aetiology of personality disorder Give overview of treatments for personality disorder

PD: Definition (1): 

PD: Definition (1) Enduring pattern of inner experiences andamp; behaviour that deviates markedly from the expectations of the individual’s culture.

PD: Definition (2): 

PD: Definition (2) This Enduring Pattern is manifest in 2 (or more) of following areas: 1) Cognition (way of perceiving or interpreting self, others, events 2) Affect (range, intensity, fluctuating, appropriateness of emotional response) 3) Interpersonal functioning 4) Impulse Control

PD Definition (3)The “3P’s” = Not PD unless: : 

PD Definition (3) The '3P’s' = Not PD unless: Problematic (clinically significant distress or problems for self or others; may be difficulties in social life, work, law) Persistent (pattern is stable andamp; long-standing; present since early adulthood or adolescence and continues to adulthood) Pervasive (pattern is inflexible; andamp; in broad range of personal or social situations)

Prevalence of PD: 

Prevalence of PD Range of Estimates: 1-3% of General Population 10-20% Psychiatric Outpatients 10-60% Psychiatric Inpatients

Generally recognised: 

Generally recognised Personality disorders are common conditions. However, there is a large variation in severity, in degree of distress and dysfunction (hence the ranges in the prevalence data). People with a personality disorder are: More vulnerable to other clinical problems, especially depression. More likely to experience relationship, housing, and employment difficulties. More likely to suffer from alcohol/drug problems

DSM IV Clusters: 

DSM IV Clusters Cluster A (often appear odd/eccentric) Cluster B (often appear dramatic, emotional, or erratic) Cluster C (often appear anxious or fearful)

Cluster A: 

Cluster A Paranoid: Distrust andamp; suspicious of others Schizoid: Detached from social relationships; restricted range emotional expression. Schizotypal: Discomfort with close relationships; cognitive/perceptual distortions; eccentric behaviour

Cluster B: 

Cluster B Antisocial: Disregard for andamp; frequent violations of the rights of others Borderline: Instability of relationships, self-image, emotions, control over impulses. Histrionic: Excessive emotionality andamp; attention seeking. Narcissistic: Grandiosity, need for admiration, andamp; lack of empathy.

Cluster C: 

Cluster C Avoidant: Social inhibition, feelings of inadequacy, hypersensitive to negative evaluation. Dependent: Excessive need to be taken care of, leading to submissive and clinging behaviour. Obsessive-compulsive: Preoccupied with orderliness and perfectionism at expense of flexibility.

Aetiology of PD: 

Aetiology of PD Little firm evidence Many different 'explanations' Explanations often some variant of 'temperament interacting with adverse childhood experiences' Particular explanations may be overly dependent on the particular theoretical orientation of author(s) Beware of 'simple' explanations

Cluster A Difficulties: 

Cluster A Difficulties Considered odd or eccentric Leads to difficulties FORMING relationships. Example of vicious circle Poor relationships  social isolation Social isolation  negative emotions, mood disorders, anxiety Unhappiness  increase in odd or eccentric behaviour

Cluster A Treatment: 

Cluster A Treatment Very little research evidence Rarely present for treatment IF present to services then offer help for mood, anxiety plus interventions aimed at assisting with social consequences e.g., family disruption, employment, housing

Cluster A: Do not seek treatment: 

Cluster A: Do not seek treatment Typical reasons Paranoid: Do not seek help, suspicious andamp; distrustful of others, if do present then tend to drop out of therapy. Schizoid: Socially withdrawn, tend not to engage with therapy, treatments offered at present leads to little progress.

Schizotypal: 

Schizotypal More research due to ?behaviour having some similarity to schizophrenia ?genetic link with schizophrenia Anti-psychotic drugs  very limited improvement (also side-effects!) Therapy: Aim to reconnect client to social world andamp; recognise limits of their thinking (but limited success)

Cluster A: Summary: 

Cluster A: Summary At present- Very little research on Cluster A Therefore- Very little evidence of what works Main approach with Cluster A clients is to provide help with the social consequences of their condition. e.g., Family disruption; Loss of employment; Loss of housing

Cluster C (anxious/fearful): 

Cluster C (anxious/fearful) Avoidant: Social inhibition, feelings of inadequacy, hypersensitive to negative evaluation. Dependent: Excessive need to be taken care of, leading to submissive and clinging behaviour. Obsessive-compulsive: Preoccupied with orderliness and perfectionism at expense of flexibility.

Cluster C Research: 

Cluster C Research No controlled treatment outcome studies. One treatment outcome study (not controlled) for those with either avoidant or obsessive-compulsive PD. [Barber et al., 2002] 50+ weekly treatment sessions 39% APD still had APD diagnosis at end of trial 15% OCPD retained diagnosis at end.

Cluster C Treatment: 

Cluster C Treatment Involve modifications to the major approaches of (for example) Psychodynamic CBT Marital/family therapy Medication

(e.g.,)Modifications Needed in CBT: 

(e.g.,)Modifications Needed in CBT Greater emphasis on therapeutic relationship. More sessions over longer time period. Focus on core beliefs. Past history of client more important. Emphasis on developing new ways of thinking/behaving rather than changing old ways of thinking/behaving.

Core Beliefs (1): 

Core Beliefs (1) CB’s: Originate in early childhood. CB’s make sense given clients experiences Are unconditional statements about self/others. Act like strict/rigid rules which have been over-learned and which are over-obeyed.

Core Beliefs (2): 

Core Beliefs (2)  Difficult for client to see when 'the rule' is inappropriate. Aim of Therapy Weaken core beliefs Strengthen alternative, more adaptive beliefs

Cluster B: 

Cluster B Borderline: Instability of relationships, self-image, emotions, control over impulses. Antisocial: Disregard for andamp; frequent violations of the rights of others Histrionic: Excessive emotionality andamp; attention seeking. Narcissistic: Grandiosity, need for admiration, andamp; lack of empathy.

Cluster B Research: 

Cluster B Research Research Focus Borderline Antisocial Much Less Research Histrionic Narcissistic

Borderline Personality Disorder: 

Borderline Personality Disorder (DSM IV) Pervasive pattern of instability in: Relationships Self-image Affect Also marked impulsivity.

BPD Characteristics: 

BPD Characteristics Need 5 of these to be present Fear of abandonment Unstable andamp; intense personal relationships Identity disturbance Impulsivity Recurrent deliberate self-harm Unstable affect Feelings of emptiness Difficulties controlling anger Stress related paranoid ideas or dissociation

Risk factors for BPD?: 

Risk factors for BPD? No single psychosocial or biological factor is either necessary or sufficient to cause PD. BUT Retrospective recall of childhood events and more objective information (e.g., court records) suggest: Family breakdown Neglectful parenting (not loving and supportive) Overprotective parenting (not encouraging independence and autonomy) History of severe physical, emotional and/or sexual abuse

BUT need for caution: 

BUT need for caution None of these risk factors are specific to BPD. Many clinicians came to believe that a history of sexual abuse was specifically linked with development of BPD but… 20-40% of those diagnosed BPD do not report childhood abuse. Many who experience childhood sexual abuse do not develop personality disorder

Development of BPD (1)(Linehan suggestion): 

Development of BPD (1) (Linehan suggestion) A tendency to difficulties regulating ones emotions (a heritable trait). Leads to increased experiences/perceptions that others do not understand the intensity of ones feelings. This leads to self feeling invalidated by ones social environment (e.g., feelings are 'dismissed', 'denied'; told what to think/feel). Above may lead to 'BPD like' characteristics or a less severe case of BPD.

Development of BPD (2)(Linehan suggestion): 

Development of BPD (2) (Linehan suggestion) In extreme invalidating environments e.g., child experiences abusive acts (emotional, physical, sexual) Leads to violation of autonomy, respect, freedom of choice and… More severe BPD characteristics develop. Above fits with clinical experience but no empirical evidence.

Common Presenting Problems: 

Common Presenting Problems Those with more severe problems Complex interpersonal difficulties Deliberate self-harm Risk of suicide Risk to others (aggressive/violent or take risks that endanger others) High use of medical andamp; mental health resources

Challenges for Therapist: 

Challenges for Therapist Poor treatment compliance Constant shifting of problems andamp; goals Focus of therapy lost with regular 'crises' Therapist becomes demoralised: 'nothing seems to work'

Challenge for Mental Health Services: 

Challenge for Mental Health Services BPD is one of the most difficult conditions to treat However, it may be the the most common personality disorder seen by adult mental health services. This has led to BPD being (probably) the most researched of all the PD’s.

Research on treatments (e.g.’s): 

Research on treatments (e.g.’s) Individual Psychodynamic approaches Day Hospital approach Therapeutic Community approach Individual Cognitive Therapy Schema Therapy Problem Solving Therapy Dialectical Behaviour Therapy Cognitive Analytic Therapy Medication

Methodological Problems: 

Methodological Problems Small sample sizes   Selection bias [e.g., better functioning clients]   No randomization to treatment and control   Lack of standard outcome measures   Actual interventions sometimes poorly defined.

3 Major Trials : 

3 Major Trials Psychodynamic Orientation Piper et al (Edmonton, Canada) Bateman andamp; Fonagy (Halliwick Psychotherapy Unit, UK) Dialectical Behavioural Therapy Linehan group (Seattle, Washington U.S.) (Pragmatic, CBT - andamp; 'whatever works')

For all 3 Studies Note:: 

For all 3 Studies Note: Very intensive treatment packages Packages are wide ranging with many components The aim of presenting the details of these studies is to give a flavour of the comprehensive treatment approach that may be required with this client group

Piper Study (1): 

Piper Study (1) Day Hospital Program (7hrs/day, 5 days/week, for 4months) Staff: Psychoanalytically trained, very experienced Clients: 80F/40M (not all BPD) Design: Randomised treatment versus control (delayed treatment)

Piper Study (2): 

Piper Study (2) Programme Components Community meetings Small group exploration of difficulties Self-awareness groups Psychodrama sessions Expressive arts (art therapy) Family relations group Problems re-entering community group + daily living skills, recreation/exercise, career help

Piper (3) Measures: 

Piper (3) Measures Measures included: Social dysfunction Family dysfunction Interpersonal behaviour Mood severity Life-satisfaction Self-esteem

Piper (4) Results: 

Piper (4) Results Significant improvements Average 'treated' patient scores exceeded 76% of patients in control group Improvements maintained at 8-month follow-up Waiting list did not improve (no 'spontaneous recovery') Drop out rate near 30% (typical?)

Bateman & Fonagy (1): 

Bateman andamp; Fonagy (1) Day Hospital Program (length =1.5 yrs) Staff: 'Psychodynamically orientated' but not formally trained Clients: 13F/6M All diagnosed BPD Design: Randomised treatment versus control (standard psychiatric care)

Bateman & Fonagy (2): 

Bateman andamp; Fonagy (2) Components of Therapy Community meeting (1/week) Group analytical psychotherapy (3/wk) Psychoanalytic psychotherapy (1/wk) Expressive psychotherapy (e.g., art therapy, psychodrama) (1/wk) + medication review (1/month) + case review (1/month)

Bateman & Fonagy (3): 

Bateman andamp; Fonagy (3) MEASURES (included) Frequency of suicide attempts/self harm Number/duration of inpatient admissions Use of psychotropic medication Self reported depression/anxiety/distress Interpersonal functioning Social adjustment

Bateman & Fonagy (4): 

Bateman andamp; Fonagy (4) RESULTS Significant improvement on all variables Improvement began at 6 months and continued to end of treatment at 18 months Improvements maintained (andamp; continued) at 18-month follow-up TAU did not improve (no 'spontaneous recovery', some deteriorated) Drop out rate 12%

Linehan group (1): 

Linehan group (1) Dialectical behaviour therapy (DBT) DBT = Integration of behaviour therapy and cognitive therapy with other perspectives and practices. Dialectical philosophy guides treatment Fundamental dialectic = need for therapist to both accept client (as they are) AND insist on change. Therapist to think in dialectical way (i.e., not polarised but to see value of opposing viewpoints and finding appropriate synthesis). Involves use of principles and practices of Zen

Linehan group (2): 

Linehan group (2) Specific Aim of DBT = To reduce self-harm in women with BPD Outpatient Program (length =1 yr) Staff: All highly trained in DBT Clients: 44 women diagnosed BPD Design: Randomised treatment versus control (standard psychiatric care/TAU)

Linehan group (3): 

Linehan group (3) Four Primary Modes of Treatment Individual therapy (1hr/week) Group skills training (1/wk) Telephone contact (24hr contact available) Therapist consultation

Linehan group (4): 

Linehan group (4) MEASURES (included) Frequency of suicide attempts/self harm Number/duration of inpatient admissions Self reported anger, depression, etc. Social adjustment

Linehan group (5): 

Linehan group (5) RESULTS Reductions in frequency/severity parasuicidal acts and number of medically treated episodes/days in hospital Improvements in anger, but not in depression, hopelessness. Improved social adjustment In general, improvements maintained at 6- and 12-month follow-up Drop out rate 16%

Conclusions: 

Conclusions Research still at a very early stage Very few randomised controlled trials Numbers in these trials often small Treatments often have many components - isolating the 'critical' components difficult. Way components are brought together or 'patterned' may be critical but difficult to research

Reading/References: 

Reading/References For overview of research on PD see relevant chapter in one or two of the Abnormal Psychology course texts. These will also provide an overview of the treatments for other PDs not covered in the lecture. Specific references for BPD research Bateman andamp; Fonagy (1999). American Journal of Psychiatry, 156, 1563-1569. (the controlled trial) Bateman andamp; Fonagy (2001). American Journal of Psychiatry, 158, 36-42. (18 month follow up) Linehan et al. (1991). Archives of General Psychiatry, 48, 1060-1064. Linehan et al. (1993). Archives of General Psychiatry, 50, 971-974 (follow up study). Piper et al (1993). Hospital and Community Psychiatry, 44, 757-763.