Clinical Lecture 10 - Prof Samantha Cartwright-Hatton PDF

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Prof Samantha Cartwright-Hatton...

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Clinical Lecture 10: Personality Disorders 1.What is personality?  No universal definition  BPS = coherent and enduring features of individual and the processes underlying these  View of self, attitudes/beliefs, emotions etc.  Big 5 traits 2.What is personality disorder?  Variations/exaggerations of normal personality attribute  Impairs well-being and social functioning  Reduced effectiveness of normal treatment (i.e. CBT etc.)  Enduring pattern (inner experience and behaviour deviating from cultural expectations)  Manifested in 2 or more of cognitive, affective, interpersonal functioning or impulsivity  Inflexible and pervasive  Stable and long duration, not better accounted for by other disorder

3.Issues around diagnosis of personality disorder  Validity of diagnosis and classification - low reliability, not discrete categories  Atheoretical basis of diagnostic classification  Categorical rather than dimensional model – implies qualitative differences  Stigma – “bad person”; negative views of staff  DSM-V o Introduces more dimensional model

o Only 6 remaining personality disorders o Diagnosis based on the degree of impairment o 5 personality traits: negative affect; detachment; antagonism; psychoticism 4.Benefits of retaining diagnosis of personality disorder  Pragmatism (logical thinking)  Communication between staff  Choice of treatment 5.How common is personality disorder?  10% of general population  High prevalence in mental health population  50-70% of adult prisoners  Men and women same level. But there are differences in which categories diagnosed are more frequent in men and women. 6.What are the causes of personality disorder?  Combination of biological, psychological and social factors o Biology = dimensions have variable heritability, genetics etc. o Psychological = attachment type o Social = dysfunction in family, emotional neglect, childhood trauma, and stress-vulnerability  Attachment Theory (Bowlby; Ainsworth): o Behavioural system triggered by need and fear, which is reciprocated by caregiving behaviours  Secure attachment = learn that the world is reasonably safe and predictable  We learn what our feeling are, why we have them and to not be scared by them  Learnt from our caregivers mirroring our feelings in a way that shows us they are not frightening o Disorganised attachment occurs when there is a frightened/frightening caregiver: child experiences fear without solution and alternates between flight, freezing, fighting.

7.Models of therapy for Borderline Personality Disorder  Borderline Personality Disorder

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o Significant instability of interpersonal relationships, self image and mood o Impulsive behaviour o Rapid fluctuations of mood o Fear of abandonment and rejection o Strong tendency to suicidal behaviour and self-harm o Transient psychotic symptoms o Substantial impairment o Risk of suicide Metallization Based Therapy (MBT) o Based on attachment theory o Metallization = working out what’s going on in your mind and the mind of others o Understanding that behaviours come from mental states o Capacity to mentalize arises from attachment o Disorganised attachment = no capacity to mentalize (underlie all BPD features) o Therapeutic relationship focuses on keeping emotional arousal at optimum level o Delivered via weekly group and 1:1 therapy (18 months) Dialectical Behaviour Therapy (DBT) o Developed by Marsha Linehan o Incorporates CBT and Zen Buddhist techniques o Views primary dysfunction as difficulty in emotion regulation o Biosocial model – biological factors interact with invalidating early environment o Skills training to improve emotion regulation, distress tolerance and interpersonal functioning (CBT based) o Key skill taught is “Mindfulness” (Zen approach) o Mindfulness = open attention to current experience or present reality o Dialectics = balancing opposites e.g. acceptance and change o Delivered via weekly skills group and 1:1 therapy (18 months) Schema Based Therapy o Developed by Jeff Young o Comes from cognitive therapy tradition o Behaviours are expression of underlying core belief / schema o Schema is deep structure concerning beliefs about nature of self and others o PD involves Early Maladaptive Schemas (EMS) o EMS provides template for processing later experiences o Interferes with self expression, autonomy, interpersonal relatedness, social validation, social integration o In therapy EMS are explored and related to developmental origins o Focus on constructing personal narrative and identifying what is adaptive o Emphasis on quality of therapeutic relationship – usually 1:1 therapy STEPPS programme o Developed by Nancee Blum o Widely delivered across Sussex Trust

Highly structured psycho-educational 20 week group programme 1:1 reinforcement and teaching for “reinforcement group” Includes teaching about schemas (filters) Taught to identify these during “emotional intensity episodes” Other CBT techniques taught (relaxation, distraction, distancing, problemsolving, life-style and relationship issues, avoiding self damaging behaviours) o Followed by less intensive year long “Stairways” programme 8.Current recommendations for treatment Based on NICE Guidelines 2009 and BPS report 2006 •BPD considered treatable •Goals focus on modification •No clear evidence of superiority of one treatment model •Treatment should be intensive, long-term, theoretically coherent, well structured and wellintegrated •Intervention needs to focus on engagement and collaborative quality of therapeutic relationship o o o o o...