11

““See the See the PERSONPERSON in in PERSONPERSONality Disorder”ality Disorder”

Civil or ForensicCivil or Forensic

22 June 200622 June 2006John D McGinley/Lindsay JohnsonJohn D McGinley/Lindsay Johnson

The State Hospital/Caledonian UniversityThe State Hospital/Caledonian University

22

See the person in personality disorderSee the person in personality disordercivil and forensiccivil and forensic

• Losing the personLosing the person

• AttitudesAttitudes

• Legal issuesLegal issues

• Clinical issuesClinical issues

• Political issuesPolitical issues

• Finding the personFinding the person

• User focusUser focus

• Traumatic Traumatic experiencesexperiences

• Emotional Emotional intelligenceintelligence

• Moral maturityMoral maturity

• Clinical governanceClinical governance

33

ICD 10ICD 10 DSM IVDSM IVParanoid Paranoid ParanoidParanoidSchizoid Schizoid SchizoidSchizoid Cluster ACluster A

SchizotypalSchizotypalDissocialDissocial AntisocialAntisocialEmotionally unstable/borderline Emotionally unstable/borderline BorderlineBorderlineHistrionic Histrionic HistrionicHistrionic Cluster BCluster B

NarcisisticNarcisisticAnxious(avoidant)Anxious(avoidant) AvoidantAvoidantDependentDependent DependentDependent Cluster CCluster CAnankasticAnankastic OCDOCD

____________________________________________________________________________________________________________________Emotionally unstable/impulsiveEmotionally unstable/impulsive Passive-aggressivePassive-aggressive

DepressiveDepressiveMental retardationMental retardation

PERSONALITY DISORDERS

44

DSM IV TR - Personality DisorderDSM IV TR - Personality Disorder

““Personality Personality traitstraits are enduring patterns of are enduring patterns of perceiving, relating to, and thinking about the perceiving, relating to, and thinking about the environment and oneself, that are exhibited in a environment and oneself, that are exhibited in a wide range of social and personal contexts. Only wide range of social and personal contexts. Only when personality traits are inflexible and when personality traits are inflexible and maladaptive and cause functional impairment or maladaptive and cause functional impairment or subjective distress do they constitute Personality subjective distress do they constitute Personality

Disorders”. (APA, 2000, p. 686)Disorders”. (APA, 2000, p. 686)

55

DSM IV TR - Diagnostic CriteriaDSM IV TR - Diagnostic Criteria

A)A) An enduring pattern of inner experience that deviates An enduring pattern of inner experience that deviates markedly from the expectations of the individual’s markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of culture. This pattern is manifested in two (or more) of the following areas:the following areas:

– Cognition - i.e., ways of perceiving and interpreting Cognition - i.e., ways of perceiving and interpreting selfself, other people and events, other people and events

– Affectivity Affectivity - i.e., the range, intensity, lability and - i.e., the range, intensity, lability and appropriateness of emotional responsesappropriateness of emotional responses

– Interpersonal functioningInterpersonal functioning– Impulse controlImpulse control

66

DSM IV TR - Diagnostic CriteriaDSM IV TR - Diagnostic CriteriaB.B. The enduring pattern is inflexible and pervasive across a The enduring pattern is inflexible and pervasive across a

broad range of personal and social situationsbroad range of personal and social situations

C.C. The enduring pattern leads to clinically significant The enduring pattern leads to clinically significant distress or impairment in social, occupational, or distress or impairment in social, occupational, or important areas of functioningimportant areas of functioning

D.D. The pattern is stable and or long duration and its onset The pattern is stable and or long duration and its onset can be traced back at least to adolescence or early can be traced back at least to adolescence or early childhoodchildhood

E.E. The enduring pattern is not accounted for as a The enduring pattern is not accounted for as a manifestational consequence of another mental disordermanifestational consequence of another mental disorder

77

Clinicians Attitudes to Personality DisorderClinicians Attitudes to Personality Disorder

• Those patients viewed as “not really ill” tend to be ignored Those patients viewed as “not really ill” tend to be ignored (MacIIwaine, 1981)(MacIIwaine, 1981)

• ““Few psychiatric staff prefer to care for this patient group and tend to Few psychiatric staff prefer to care for this patient group and tend to dislike this population” dislike this population” (Moran & Mason, 1996)(Moran & Mason, 1996)

• ““..plentiful evidence exists that staff become alienated from disliked ..plentiful evidence exists that staff become alienated from disliked patients.” patients.” (Bowers, 2002)(Bowers, 2002)

• ““..therapeutic pessimism about PD is widespread among psychiatric ..therapeutic pessimism about PD is widespread among psychiatric professionals, adding to profoundly negative attitudes towards PD professionals, adding to profoundly negative attitudes towards PD patients..” patients..”

(Bowers, 2002)(Bowers, 2002)

• “ “ Recommend no change to current psychiatric practice regarding Recommend no change to current psychiatric practice regarding compulsory detention” (Personality Disorder Report, Forensic compulsory detention” (Personality Disorder Report, Forensic Network 2005)Network 2005)

88

Personality Disorders: Personality Disorders: legal and clinical issueslegal and clinical issuesMH (Care and Treatment) (S) Act 2003MH (Care and Treatment) (S) Act 2003

CriteriaCriteria 1. Mental disorder

mental illnesspersonality disorderlearning disability

2. Medical treatmentprevent worseningalleviate symptomsavailable

3. Significant risk to person or safety of others4. Compulsion necessary5. Impairment of ability to make decisions about

treatment (civil application only)

99

Personality disorders: political issue Personality disorders: political issue DSPD Criteria: England and WalesDSPD Criteria: England and Wales

• Criterion 1. Criterion 1. Severe PDSevere PD:: Significant disorder of personalitySignificant disorder of personality

• Criterion 2. Criterion 2. High riskHigh risk: : More likely than not to commit an More likely than not to commit an offence that might be expected to lead to serious physical or offence that might be expected to lead to serious physical or psychological harm from which the victim would find psychological harm from which the victim would find difficult difficult or impossible to recoveror impossible to recover

• Criterion 3. Criterion 3. Functional linkFunctional link: : The risk presented appears to be The risk presented appears to be functionally linked to the personality disorderfunctionally linked to the personality disorder

1010

Personality disorders: Personality disorders: political and clinical issuepolitical and clinical issue DSPD Criterion 1: Severity of personality disorderDSPD Criterion 1: Severity of personality disorder

• Very high psychopathy: PCL-R Very high psychopathy: PCL-R score 30+score 30+

• High psychopathy:High psychopathy: PCL-R PCL-R score 25-29score 25-29 DSM IV-TR DSM IV-TR PD x 1 (Not PD x 1 (Not

APDAPD

• Comorbid PD:Comorbid PD: DSM IV-TR DSM IV-TR PD x 2 PD x 2

1111

Personality disorders: Personality disorders: clinical and political issue clinical and political issue DSPD criterion 2: level of riskDSPD criterion 2: level of risk

• More likely than notMore likely than not

• Personality disorder:Personality disorder:– IPDEIPDE– SCID-1SCID-1

• Actuarial risk instrumentsActuarial risk instruments– VRAG VRAG violence riskviolence risk– Static 99 Static 99 sexual risksexual risk

• Structured clinical judgementStructured clinical judgement– HCR 20HCR 20– Risk Matrix 2000Risk Matrix 2000

• Dynamic riskDynamic risk– VRSVRS– SARNSARN

1212

Personality disorders: Personality disorders: political and clinical issue political and clinical issue DSPD criterion 3: functional linkDSPD criterion 3: functional link

• Clinical formulationClinical formulation

• Functional analysisFunctional analysis

• Patterns of past offendingPatterns of past offending

• Risk typeRisk type

• Presence of risk related behavioursPresence of risk related behaviours

1313

Personality disorders: clinical issues Personality disorders: clinical issues co morbidityco morbidity

• ““the co morbidity of Axis II diagnoses and the degree of the co morbidity of Axis II diagnoses and the degree of heterogeneity within diagnostic groups raise as yet heterogeneity within diagnostic groups raise as yet unresolved questions concerning the validity of a diagnostic unresolved questions concerning the validity of a diagnostic approach”approach”

(Roth and Fonagy, 1996)(Roth and Fonagy, 1996)

• ““Both clinical practice and available research suggest Both clinical practice and available research suggest strongly that an individual can suffer from both Axis I strongly that an individual can suffer from both Axis I condition as well as personality disorder simultaneously”condition as well as personality disorder simultaneously”

(Lenzenweger & (Lenzenweger & Clarkin, 2005)Clarkin, 2005)

1414

Personality Disorders: clinical issues Personality Disorders: clinical issues AssessmentAssessment

• Case and file reviewCase and file review• Categorical model: DSM IV:TR: Categorical model: DSM IV:TR: Axis II: SCID-1Axis II: SCID-1 • Dimensional model: DSM V? Dimensional model: DSM V? • Self report: IPDESelf report: IPDE• Statistical: Neo-Pi-R (5 factor model)Statistical: Neo-Pi-R (5 factor model)• Clinical: Psychopathy Checklist (PCL-R)Clinical: Psychopathy Checklist (PCL-R)• Emotional intelligenceEmotional intelligence• Intelligence quotientIntelligence quotient• Moral reasoningMoral reasoning• Trauma assessmentTrauma assessment• Risk assessmentRisk assessment• Baseline measures (e.g. addictions: anger)Baseline measures (e.g. addictions: anger)• Overall formulationOverall formulation• Outcome measuresOutcome measures

1515

See the PERSONSee the PERSON

Inner selfInner selfConsciousnessConsciousness

Subjective experienceSubjective experienceSpiritualSpiritual

MindfulnessMindfulnessConsistency of thoughts (schema), feelings Consistency of thoughts (schema), feelings

(emotions), behaviours (expression)(emotions), behaviours (expression)More than sum of traitsMore than sum of traits

1616

Personality disorders: clinical issues Personality disorders: clinical issues

Treatment: Treatment: idiopathicidiopathic

• Multiple domains of psychopathologyMultiple domains of psychopathology– Requires combination of interventions tailored to individual needs. Requires combination of interventions tailored to individual needs.

• Common Factors in all cases – different manifestationsCommon Factors in all cases – different manifestations– Require general and individually tailored strategies within all treatmentsRequire general and individually tailored strategies within all treatments

• Complex psychological and biological etiologyComplex psychological and biological etiology– Psychological and biological treatment; aim to enhance adaptationPsychological and biological treatment; aim to enhance adaptation

• Psychosocial adversity influences the contents, processes and Psychosocial adversity influences the contents, processes and organisation of the personality system. organisation of the personality system. – Address all consequences of adversityAddress all consequences of adversity

Livesley 2001Livesley 2001

1717

Personality disorders: clinical issues Personality disorders: clinical issues Treatment: effectivenessTreatment: effectiveness

1.1. Best conceptualised in integrative and biopsychosocial Best conceptualised in integrative and biopsychosocial perspective.perspective.

2.2. Assessing treatability or amenability to treatment is critical to Assessing treatability or amenability to treatment is critical to maximizing treatment planning and outcomes.maximizing treatment planning and outcomes.

3.3. Effective treatment of personality disorders is tailored Effective treatment of personality disorders is tailored treatment.treatment.

4.4. The lower the level of treatability, the more combining and The lower the level of treatability, the more combining and integrating of treatment modalities and approaches is needed.integrating of treatment modalities and approaches is needed.

5.5. The basic goal of treatment is to facilitate movement from The basic goal of treatment is to facilitate movement from personality-disorder functioning to personality-style functioning.personality-disorder functioning to personality-style functioning.

Sperry 2003Sperry 2003

1818

Personality disorders: clinical issues Personality disorders: clinical issues Psychotherapeutic modelsPsychotherapeutic models

• Supportive therapySupportive therapy

• Psycho-educationalPsycho-educational

• PsychodynamicPsychodynamic

• CBT/CAT/DBT CBT/CAT/DBT

• Milieu therapy Milieu therapy

• Community Community

• Pharmacological Pharmacological

Fit treatment to uniqueness of the person:

relationships, integration, combinations,

environmental control, staff consistency multidisciplinary collaboration

1919

Maladaptive and inflexible thinkingMaladaptive and inflexible thinking: : Schema Focused TherapySchema Focused Therapy

Poor integration of concept of self or others: Poor integration of concept of self or others: Psychodynamic TherapyPsychodynamic Therapy

Reformulation in collaboration: Reformulation in collaboration: Cognitive Analytic TherapyCognitive Analytic Therapy

Skills training: Skills training: Cognitive Beh. Therapy Cognitive Beh. Therapy

Personality disorders: Clinical Issues

Psychotherapeutic eclecticism

Attachment and emotional developments: Attachment and emotional developments: Psychodynamic TherapyPsychodynamic Therapy

Motivational engagement:Motivational engagement: Cognitive Beh. TherapyCognitive Beh. Therapy

Therapeutic alliance and validation:Therapeutic alliance and validation: Dialectical Beh. Therapy Dialectical Beh. Therapy

2020

Personality disorders: clinical issues Personality disorders: clinical issues Treatment: Difficulty in EngagingTreatment: Difficulty in Engaging

• Enduring and relatively stable patterns• Maladaptive interpersonal behaviour • Persistent over time• Label and stigma attached to experience and distress • Difficult to motivate into engaging in treatment• Resistant to therapeutic change.• Previous failed attempts at change.• Excluded by low motivation and ‘untreatability’• Progress requires coordinated clinical and social support • Progress requires immersion: suitable milieu• Maintenance requires social integration • Maintenance requires extended support

2121

Personality disorders: clinical issues Personality disorders: clinical issues Personality and riskPersonality and risk

PD: PD: Dynamic Dynamic RiskRiskFactorFactor

Functional Functional relevancerelevanceFormulationFormulation

MaintainMaintainClinicallyClinically relevantrelevant behavioursbehaviours

MotivateMotivateEngageEngageLearningLearningChangeChange

SustainedSustainedIntegrated Integrated carecare

pathwaypathway

Risk assessment-----risk management-----risk reduction-----public safetyRisk assessment-----risk management-----risk reduction-----public safety

Person engagement-----treatment progress-----community re-integrationPerson engagement-----treatment progress-----community re-integration

2222

• needs of the PERSON – holisticneeds of the PERSON – holistic

• restore self respectrestore self respect

• contract, cooperation, engagementcontract, cooperation, engagement

• match needs with treatmentmatch needs with treatment

• adapt to suit PERSONadapt to suit PERSON

• system of integration of person experiencesystem of integration of person experience

• develop new treatments develop new treatments

• evaluate effectivenessevaluate effectiveness

• right place, right time, right treatmentright place, right time, right treatment

PERSONALITY DISORDERS: CLINICAL ISSUESPERSONALITY DISORDERS: CLINICAL ISSUESPERSON Focused (PFPI)PERSON Focused (PFPI)

2323

Emotional Impairment and psychopathyEmotional Impairment and psychopathy

• Psychopathy identifies one form of Psychopathy identifies one form of pathology associated with high levels of pathology associated with high levels of antisocial behaviour: individuals who antisocial behaviour: individuals who present with a particular form of emotional present with a particular form of emotional impairmentimpairment

The Psychopath: emotion and The Psychopath: emotion and brainbrain

James Blair et al (2005)James Blair et al (2005)

2424

Emotional intelligenceEmotional intelligence

Self awarenessSelf awareness

MotivationMotivation

Self regulationSelf regulation

EmpathyEmpathy

Social skillsSocial skills Goleman Goleman

19981998

2525

Emotional competence frameworkEmotional competence framework

• Self awarenessSelf awareness– Emotional awarenessEmotional awareness

– Accurate self assessmentAccurate self assessment

– Self confidenceSelf confidence

2626

Emotional competence frameworkEmotional competence framework

• Self regulationSelf regulation• Self controlSelf control

• TrustworthinessTrustworthiness

• ConscientiousnessConscientiousness

• AdaptabilityAdaptability

• InnovationInnovation

2727

Emotional competence frameworkEmotional competence framework

• MotivationMotivation• Achievement driveAchievement drive

• CommitmentCommitment

• InitiativeInitiative

• OptimismOptimism

2828

Emotional competence frameworkEmotional competence framework

• EmpathyEmpathy• Understanding othersUnderstanding others

• Developing othersDeveloping others

• Service orientationService orientation

• Leveraging diversityLeveraging diversity

• Political awarenessPolitical awareness

2929

Emotional competence frameworkEmotional competence framework

• Social skillsSocial skills• InfluenceInfluence• CommunicationCommunication• Conflict managementConflict management• Leadership Leadership • Change catalystChange catalyst• Building bondsBuilding bonds• Collaboration and Collaboration and

cooperationcooperation• Team capabilitiesTeam capabilities

3030

Person and moral maturity: 1. StagesPerson and moral maturity: 1. Stages

• Pre-conventional stagePre-conventional stage State 1 Punishment/obedienceState 1 Punishment/obedience State 2 Instrumental relativist State 2 Instrumental relativist

• Conventional stageConventional stageState 3 Good boy-Nice girlState 3 Good boy-Nice girlState 4 Law and orderState 4 Law and order

• Autonomous stageAutonomous stageState 5 Social contractState 5 Social contractState 6 Universal ethical principleState 6 Universal ethical principle

KolbergKolberg

3131

Person and moral maturity: 2.QualitiesPerson and moral maturity: 2.Qualities

• Stage development is invariantStage development is invariant

• Cannot comprehend beyond next stageCannot comprehend beyond next stage

• Cognitive attraction to next stageCognitive attraction to next stage

• Development depends on cognitive Development depends on cognitive disequilibriumdisequilibrium

3232

Personality DisordersPersonality Disorders: Clinical Governance: Clinical Governance

UnderstandingUnderstanding Personality Disorder: BPS June 2006 Personality Disorder: BPS June 2006

• Treatment: core services in mental health and forensic settingsTreatment: core services in mental health and forensic settings

• Access to specialist multi-disciplinary personality disorder teamsAccess to specialist multi-disciplinary personality disorder teams

• Multi-agency collaboration Multi-agency collaboration

• Clinical and forensic psychologists: clinical leadersClinical and forensic psychologists: clinical leaders

• Training of team and agencies essential: awareness of specialismsTraining of team and agencies essential: awareness of specialisms

• Structured assessmentsStructured assessments

• Focus on formulating person’s needsFocus on formulating person’s needs

• User views, user research and user involvementUser views, user research and user involvement

3333

• It is the responsibility of psychiatrists to offer treatment It is the responsibility of psychiatrists to offer treatment where ever possiblewhere ever possible

• Improve teaching of psychiatry traineesImprove teaching of psychiatry trainees

• Prioritise limited capacity of psychiatric servicesPrioritise limited capacity of psychiatric services

• Develop preventive interventions in child and adolescent Develop preventive interventions in child and adolescent servicesservices

• Develop clearer definition of treatment goalsDevelop clearer definition of treatment goals

• Ensure multidisciplinary cooperation Ensure multidisciplinary cooperation

Personality Disorders: Clinical GovernancePersonality Disorders: Clinical GovernanceRoyal College of Psychiatrists Council Report CR 71, February 1999

3434

Personality Disorders: ethical issuesPersonality Disorders: ethical issues

Challenge assumptionsChallenge assumptions • Harder to engageHarder to engage

• Higher attrition rates Higher attrition rates

• Poorer outcomePoorer outcome

• More clever psychopath!More clever psychopath!

• Service “abusers” rather than “users”Service “abusers” rather than “users”

• UntreatableUntreatable

• Alienation: disliked patientsAlienation: disliked patients

• Split the team!Split the team!

3535

Hope and developmentsHope and developments

• Service users stories of hopeService users stories of hope

• New century re-birth of hope and raising expectationsNew century re-birth of hope and raising expectations

• Hearing voices networksHearing voices networks

• See meSee me

• Proud of our experienceProud of our experience

• Improving alliance with service usersImproving alliance with service users

• Improved assessment proceduresImproved assessment procedures

• Developing effective treatment paradigmsDeveloping effective treatment paradigms

• Collaborative relationships – practitioner (the expert by Collaborative relationships – practitioner (the expert by training) and service user (the expert by experience) training) and service user (the expert by experience)

3636

ConclusionsConclusionsPerson distressed by a personality disorder Person distressed by a personality disorder deserves consideration under mental health deserves consideration under mental health legislation for care and treatmentlegislation for care and treatment

When assessing the impact of a mental When assessing the impact of a mental disorder, in all circumstances, all persons disorder, in all circumstances, all persons being assessed should be screened for being assessed should be screened for personality disorderpersonality disorder

3737

WORKSHOP 2WORKSHOP 2

Covert versus Overt Covert versus Overt

Personality Disorder diagnosis? Personality Disorder diagnosis?

What are the barriers to the effective What are the barriers to the effective involvement of service users and staff?involvement of service users and staff?

Lindsay Johnston and John McGinleyLindsay Johnston and John McGinley

3838

““See the See the PERSONPERSON in in PERSONPERSONality Disorder”ality Disorder”

Civil or ForensicCivil or Forensic

22 June 200622 June 2006John D McGinley/Lindsay JohnsonJohn D McGinley/Lindsay Johnson

The State Hospital/Caledonian UniversityThe State Hospital/Caledonian University