Peter Kinderman University of Liverpool Simon Duff University of Liverpool

1. Peter Kinderman • University of Liverpool • Simon Duff • University of Liverpool Using ICS to inform clinical work with complex cases

2. Overview … ‘personality disorder’ … … based on the Interacting Cognitive Subsystems model… … “non-discriminative processing” and “interlock” … these two processes, together with abnormal schema content, can explain the rigidity and maladaptive nature of cognitive schemata that are believed to lead to the clinical features of personality disorder. … the implications for psychological therapies with people experiencing such difficulties will be discussed …

3. Personality disorder An enduring pattern of inner experience that deviates markedly from the expectations of the individual’s culture in two or more of, cognition, affect (e.g., range, intensity, lability, appropriateness), interpersonal functioning, and impulse control. (DSM-IV; APA, 1994) It is considered to be pervasive across a wide range of personal and social situations, is characterised by inflexibility (Millon & Davis, 2000), and results in clinically significant stress or impairment for the individual. “In spite of a long history of brilliant cogitations, psychopathologic nosology still resembles Ptolemy’s astronomy of over 2,000 years ago: Our diagnostic categories describe, but they do not really explain.” (Millon et al., 2001).

4. e.g. Psychoanalytic Theory (e.g., Kernberg, 1996) - poor development of the superego, which may come about through abuse. Attachment Theory (e.g., Bartholomew, 1997) - less than optimal development alters the individual’s ability to deal with stress in a flexible manner. Cognitive Theory (e.g., Beck et al., 1990) - particular schemata come to be used preferentially to others, leading to inflexible responses, itself based upon an evolutionary view of schema development. Evolutionary Theory (e.g., Millon, 1990) suggests that personality disorders emerge from the acting out of extreme forms of evolutionary imperatives.

5. An integrative model should be based on the idea that personality disorder is, and personality disorders are: Individual expressions of a shared, underlying mechanism And that personality disorder lies at an extreme end of a continuum, diagnosable when there is a “severe disturbance in the characterological condition and behavioural tendencies of the individual”. By implication, personality disorder is: An extreme expression of normal psychology (an idea that Bentall (2003) has promoted for Axis-I disorders.)

6. Biological factors Mediating psychological processes Psychological and social problems Social factors Circumstantial factors Kinderman, P. (2005) A psychological model of mental disorder. Harvard Review of Psychiatry. 13: 206–217.

8. Social cognition appears dysfunctional, but not deficient, in personality disorder. We need an overarching conceptual framework for understanding social cognition, within which such abnormalities might fit. One good candidate for this is Barnard’s distributed architecture for human cognition, Interacting Cognitive Subsystems (ICS)……

9. Interacting cognitive subsystems ICS describes an integrated, distributed network of subsystems working in principled ways which are responsible for processing specific kinds of information. It has grown out of neuropsychological literature and has been used for describing working memory phenomena, modelling rumination & recollection deficits in dysphoric mood and understanding mood dependent cognition.

10. Interacting cognitive subsystems • ICS consists of 9 major subsystems which share the same structure and functions, • The transformational engine • A memory record • differing only in the mental codes with which they work. • This simplicity of structure supports the richness and complexity of cognition because it is the integration and flow of mental codes which determine the form and content of any particular mental representation.

12. Interacting cognitive subsystems A central feature of ICS is the ability of the system to learn. This learning involves the modification of stored representations through the transformation of information, the transmission of information from one subsystem to another and the combination of such information. If these stored representational schemata are not modified, behaviour will appear rigid and maladaptive.

13. Non-discriminative processing Non-discriminative processing occurs when novel material is recognised as discrepant with existing expectations, but does not lead to a modification of existing representational schemata. In ICS, a subsystem will develop automatic, proceduralised processing if it has developed a learned regularity of (for instance) A  X. If the subsystem then encounters A:B, the presence of B should act as a discrepant stimulus. Such a discrepant stimulus should trigger buffered, non-proceduralised processing and should lead to a new response  Z. However, if the subsystem finds that B is non-discriminative – if it gives no information about possible alternative responses – the discrepant information will not lead to an altered output.

14. Non-discriminative processing Non-discriminative processing is a normal and healthy part of the normal cognitive architecture. If deployed inappropriately – when objectively discriminative stimuli are present – the responses may seem dysfunctional. Non-discriminative processing will occur if the person has LEARNED that the material is non-discriminative.

15. “If you do that again, I won’t love you anymore.” Criticism (A)  withdrawal of affection (X) If repeated a sufficient number of times, in particular situations, this will become a proceduralised response, and concurrent discrepant stimuli will become non-discriminative.

16. Criticism (A)  withdrawal of affection (X) Presence of (B) “I’m not your mother”, is non- discriminative” “Are you leaving that dirty plate on the side?” “You don’t love me and you will leave me.”

17. Interlock Interlock refers to a situation where the unchanged output of subsystem processing is used as the input for another subsystem in a feedback loop. When interlock occurs in the [IMPLIC] subsystem, this reciprocal feedback fails to provide new information, but mirrors the original [IMPLIC] representation because of the individual’s learning history. This leads to cycles of [IMPLIC]  [PROP] : [PROP]  [IMPLIC] which reinforce a current representation. The tendency of the central engine to be prone to interlock could be considered a risk factor for PD and as these loops are considered self-preserving, could explain the maintenance of maladaptive behaviour in the absence of any triggers.

18. “Are you leaving that dirty plate on the side?” fears of desertion   sadness & anger   fears of desertion 

19. Implications Personality disorders arise because the cognitive architecture, coupled with learning history, does not allow new, objectively discriminative material to be made available to the representational schemata. Thus we do not need to change the schemata, we do need to give them access to information represented in other subsystems – to break the functional isolation and locked processing cycles. How to do this? ICS contrasts with the Beckian approach – consciously available material as underlying maladaptive behaviour. In ICS this provides a partial explanation, at the [PROP] level, whereas we suggest it is the [IMPLIC] level which is important.

20. Implications In line with Teasdale’s approach (Teasdale, Segal, & Williams, 1995) for preventing depressive relapse, provide individuals with competing tasks (to reduce resources to interlock processes) concentrating on “here and now” information (providing [PROP] etc input). Enhanced Thinking Skills programmes including inter-personal problem solving skills, social perspective taking, critical reasoning skills etc. have proved effective in reducing recidivism (Friendship et al., 2002) in offenders with personality disorder. Mindfulness - designed to increase awareness of mental processes and perceptual systems normally not attended to – is characterised by direct experience of current reality ‘in the moment’ rather than elaborative, ruminative, thinking about one’s situation.

21. A clinical example Ms D is a 53-year old woman with a long history of dysphoria, depression… and… ‘enduring problems with interpersonal across a range of personal and social situations, characterised by inflexibility and resulting in significant distress and difficulties’. Ms D believed that other people felt her to be insignificant or trivial. Her self-concept was limited and poor…yet she also believed this perceived response by other people to be unfair. Ms D worked as a middle manager in industry. Her office nick-name was “the Rottweiler”, as a consequence of her robust interpersonal style. A fellow-worshipper at her church described Ms D as her “friend”, a situation Ms D dismissed as “… yeah, Lynn has adopted me as her counselling project…”

22. Peter Kinderman • Professor of Clinical Psychology, • University of Liverpool