Management of Severe Personality Disorders

Dr. J. S. Parker

OPD

Lentegeur Hospital and UCT Dept of Psychiatry and Mental Health

John.parker@westerncape.gov.za

Some General Principles

• Recognition is Key

• Managing oneself - mindfulness

• Developing the therapeutic alliance: Exploring diagnosis Implications and risks MI and PST Metaphor

• Setting and securing the boundaries

• Playing the long game

Personality Disorder

• Defn: Patterns of inflexible and maladaptive traits that cause subjective distress or significant impairment in social or occupational functioning or both.

• Foster vicious cycles• Deviate markedly from cultural norms• Generally safer to talk about “traits” than a

personality disorder• Considered enduring and pervasive rather than

episodic• DSM IV: Axis II but DSM V mono-axial system

DSM V

• Attempt at hybrid dimensional/categorical approach abandoned at the last minute as “too complicated”, but retained in section III for reference

• New approach retained 6 types: Borderline, Antisocial, Narcissistic, Avoidant, O-C and Schizotypal

• New: Personality Disorder -Trait Specified, allows for recognition of mixed traits

DSM V (cont)

• Reliability studies done on clinical populations rather than general population

• Borderline PD criteria found to be highly reliable, OCPD and ASPD found to be “of questionable reliability”, insufficient numbers for other studies

• Single axis

ICD 10

• Specific: Paranoid; Schizoid; Dissocial; Emotionally Unstable (impulsive & borderline types); Histrionic; Anankastic; Anxious (avoidant); Dependent; Other

• Mixed disorders

• Enduring personality changes

DSM: Personality Disorder Clusters

• A. “odd and eccentric”- Paranoid; Schizoid; Schizotypal

• B. “dramatic; emotional and egocentric”- Antisocial; Borderline; Histrionic; Narcissistic

• C. “anxious and fearful”- Avoidant; Dependant; Obsessive-Compulsive

Paranoid• A pervasive mistrust and

suspiciousness of others .• Suspects others are

exploiting them.• Doubts the loyalty of friends.• Reluctant to confide in

others.• Bears grudges• Feels attacked by others and

reacts to this• Suspects partner of

unfaithfulness.

Paranoid PD

• NB to establish a trusting and non-threatening relationship: formal, honest and professional discussion.

• Caution! Avoid being too friendly, too warm or too humorous, expect accusations and belittling comments.

• Avoid direct confrontation, MI and problem solving techniques very useful

• CBT and Schema-based therapy

Schizoid PD

• Detachment from relationships

• Restricted range of affect

• Few close friends

• Little sexual interest

• “Loner by choice”

• Allow space

• Avoid over-involvement

• Relatives often need reassurance

• Exclude schizophrenia

Schizotypal PD• Acute discomfort with

close relationships• Cognitive or perceptual

distortions or eccentricities of behaviour

• Ideas of reference• Odd beliefs, thinking,

speech and affect• Eccentric appearance opr

behaviour• Differentiate from

schizophrenia• Relatives may need advice

and reassurance• NB! Cultural context

Antisocial PDA pervasive pattern of disregard for and violation of the rights of others.Repeated acts that are grounds for arrestDeceitful, impulsive, irritable and aggressiveRecklessIrresponsible Lack remorseConduct disorder before age 15

Antisocial PD

• “Psychopath”: charm; intelligence; egocentric; exploitative; lack remorse

• Malingering; substance abuse

• NB! Identify early: focus on parenting skills, problem solving, emotional awareness, improved self-concept, control of arousal and emotions

• Caution! Firm boundaries.

Borderline PD• A pervasive pattern of instability of interpersonal

relationships, self-image and affects, and marked impulsivity

• Abandonment issues• Unstable and intense relationships• Identity disturbance• Impulsivity• Suicidal behavior• Affective instability• Chronic feelings of emptiness• Inappropriate anger• Transient paranoia or dissociation under stress

(“micropsychotic episodes”)

Borderline PD

Borderline PD: Management• Beware of idealization, be realistic about

treatment targets as well as risks and side effects.• A cautious, structured approach, maximising

collaboration is key.• Treat presenting pathology• BUT: Know what you are dealing with, avoid “red

herrings” eg. “depression” “voices in the head”• Be honest, consistent and non-judgmental• Long-term perspective – NO QUICK FIXES• BALANCE

Borderline PD: Treatment • Pharmacotherapy (adjunct)

– Cochrane Review (2010):SSRI’s not recommended for as first choice for affective dysregulation & impulsivity, nor low dose antipsychotics for cognitive-perceptual symptoms

– SSRI only for MDD– Affective dysregulation: topiramate, valproate,

lamotrigine, aripiprazole, olanzapine & haloperidol– Impulsive-behavioural: lamotrigine & topiramate,

omega-3 fats, flupenthixol; aripiprazole– Cognitive-perceptual: olanzapine, aripiprazole– Self mutilation and suicidal behaviour: none.

Olanzapine unfavourable effect

Borderline PD: Treatment • Psychotherapy (Mainstay) :

– DBT : suicide and affective dysregulation – Transference-based psychotherapy– Mentalization-based psychotherapy– Schema-focussed therapy

– General Principles• Focus on patient-therapist relationship in the “here and now”• Utilize countertransference to explore relationship• Educate patients to recognise their affective reactions and what

triggers them• Connect actions with thoughts and feelings, both their own and

others (Kernberg; 2009)

Histrionic PD• Excessive emotionality and

attention seeking• Needs to be the center of attention• Seductive or provocative• Rapidly shifting, shallow expressed

emotions• Uses physical appearance to draw

attention to self• Impressionistic style of speech• Exaggerates emotions • Exaggerates intimacy of

relationships• Need long-term consistent support• NB when relationships lost• Vulnerable to abuse

Narcissistic PD • Grandiosity, need for

admiration and lack of empathy.

• Self important• Fantasies of unlimited

success• Believes is special• Requires excessive

admiration• Sense of entitlement• Arrogant and exploitative• Lacks empathy

Narcissistic PD• Persona a shield for internal vulnerability and

dysregulation. Can be powerfully expressed or a more muted perfectionism.

• Relationship problems• Substance abuse• Mid-later life crises when no longer able to satisfy

inflated sense of self • Depression • Suicide• Psychotherapy may be helpful but “need to be

ready”

Narcissistic PD• Alliance building early on

is key - Flexible!• Attention to motivational

focus, clarification of experiences and formulation of difficulties

• Must accommodate difficulty with self-reflection, affect tolerance and regulation of self-esteem

Dependent PD

• Anxiety disorders and depression common, especially after separation

• Vulnerable to abusive relationships• Common pathology in stalkers• Need long term support and structure• CBT

•Need to be taken care of•Excessive need for support/nurturance•Submissive and clingy•Struggles to take initiative, responsibility or to disagree•Uncomfortable alone•Preoccupied with fear of being left alone

Avoidant PD

• Probably on a spectrum with social phobia.• CBT • SSRI’s, SNRI and RIMA’s

•“Left out” •Social inhibition, feelings of inadequacy; hypersensitivity to criticism•Avoids people, relationships, exposure, risks•Views self as inept, unappealing or inferior•Preoccupied with rejection/ridicule

Obsessive-compulsive PD• Order, perfection and control

at the expense of flexibility, openness and efficiency

• Preoccupied with rules and lists

• Inflexible moralists• Cannot discard objects• Excessively devoted to work• Can be rigid and stubborn

•Thorough approach but NB to avoid focus on uncertainties and variables •Treat anxiety: psychotherapy; SSRI

Motivational Interviewing

1. Ask for permission to discuss the problem – raise awareness

2. Elicit talk about change. Evoke ideas of advantages and disadvantages of change possibilities and taking the first step.

3. Importance check - rate readiness to change (scale: 1-10). (Reinforces talk about change)

4. Ability check (1-10) (assess pt’s confidence in ability to change and elicits possible barriers.)

5. End with summary of discussion points, what has been agreed and what remains uncertain.

Problem Solving

1. Identify the problem. Specify and define.

2. Consider multiple solutions – brainstorm all possible alternatives

3. Look at pros and cons and choose most suitable solutions.

4. Seek commitment with specific details (eg By when?)

5. Summarise and schedule follow up, acknowledging that further barriers may be encountered and that solutions for these will also be found.

Resources

• Valkenberg Hospital OPD: Tel 021 4403100

• Valkenberg Ward 1: Tel 021 4403100

• Lentegeur Hospital OPD: 0213701430

• Lentegeur Hospital Pathways (Wd 15): 0213701132

• Stikland Hospital: 0219404400