Scottish Personality Disorder Network Conference

1. Scottish Personality Disorder Network Conference Thursday 4th March 2010 Queen Mother Conference Centre Royal College of Physicians of Edinburgh

2. The Roots of Personality – and its disorders Jane Morris

3. The evolution of my own personality....... • Literature • Psychology • Medicine • Motherhood • Cullen • Glasgow • Edinburgh

4. 2002 - 2010 A 7 year adventure into the realms of Child & Adolescent Psychiatry........

5. What did I discover? 1 Child and Adolescent Psychiatry are surprisingly different from Adult Psychiatry 2 Some of this is about different responses and traditions rather than different problems – CAMHS accept referrals where there is social dysfunction even in the absence of ‘diagnosis’ 3 Child psychiatry is genuinely different from Adolescent Psychiatry... 4 ...but fun and playfulness are essential in both 5 The practice of Adolescent psychiatry could teach adult psychiatrists a great deal - it taught me, anyway – about formulation and systemic awareness and daily use of psychotherapeutic approaches....

6. 6 ...and about the evolution of mental illnesses and dysfunctional defences. 7 The role of sleep, activity, rest & nutrition in mental as well as physical development • The very existence of Asperger’s and the autistic spectrum was an eye-opener - Sula Wolff’s ‘Loners’ 9 That transitions need to be handled well – so that the loss and progression are meaningful and educational rather than destructive 10 Above all, that a well-integrated team is wisdom incarnate!

7. 3 good books (and lots of teen lit)

8. TOXIC CHILDHOOD? • Sue Palmer • Harry Burns ‘The Biology of Poverty’ 2008 • My daughter’s school • Suicides at school • Streetwise young people • www-wise young people • Body image conscious & ashamed – obesity & anorexia • Alcohol and other substances (caffeine in Buckfast!) • Child protection, health & safety and other defensive approaches

9. What is personality? PERSONALITY = TEMPERAMENT + CHARACTER If temperament is relatively fixed (New York Longitudinal Study on Infant Temperament, Thomas & Chess 1984) can we at least find interventions that are ‘character-forming’?

10. What is personality? ....and where do traits, constructs, schemata, defences, factors etc etc fit in to all this? Are they learned? If so, when? Can they be un-learned or re-learned? When and how?

11. Pharmacological interventions? • SSRIs and neuroleptics eg olanzapine • Undoubtedly swing the balance in some cases, allowing learning to occur • How do they work? • No coincidence that at high dose SSRIs or low dose neuroleptics are anxiolytic • Reducing the amount of anxiety and arousal the individual has to experience to within a manageable amount

12. What causes conduct/ personality disorder? • Scott recommends a ‘picture fitting’ approach to diagnosis for treatment purposes, though a ‘menu-driven’ approach may be necessary in research • Conduct disorder certainly associated with discord in the family home but what is cause and what is effect? • Scott even considers that disordered attachment may be a consequence as well as a cause of disorder • .. 1982 Patterson found more, unclear and inconsistent commands issued in families of CD children • Virginia Twin study interviewed fathers, mothers and young people for evidence of heritability of CD – based on Dads’ accounts it is 27% herrtable, according to child 36%, according to Mum’s accounts it is 69% heritable!

13. Genetics & environment of aggression • D4DR gene : 1996 2 independent teams reported association of novelty-seeking/risk taking/impulsivity with polymorphism in a gene on short arm of chromosome 11 – associated with dopamine receptor expression • SLC6A4 gene on chromosome 17 associated with reduce serotonin uptake and associated with greater fearfulness/neuroticism – on of at least a dozen genes found to be associated with ‘neuroticism’ • As well as dopamine and serotonin, oxytocin, vasopressin and prolactin involved in social bonding, and hypophyseal-adrenal axis response to social challenge mediates early brain development

14. Genes can have spectacular consequences: Transplanting a gene from the monogamous prairie vole transforms the behaviour of promiscuous mice

15. 1994 Brunner, Nelson et al – MAO gene mutation in Dutch family associated with extreme aggression in males who possessed the gene • 2002 Caspi et al In a large sample of abused children, only those with gene for low MAO activity went on to be antisocial in adult life • Animal evidence also suggests well-preserved serotonin function helps to attenuate aggressive impulses

16. The new science of epigenetics The power of the environment to affect genes - their transmission and expression!

17. Cullen-Rivers Centre 1999-2001,Rillbank Terrace Child Sexual Abuse Service The study of trauma – and of families • The biology of stress hormones, acute and chronic • Their effects on mood, arousal, aggression and learning • Applications to abused and traumatised children and their parents and the interactions between the two • Deblinger and Heflin’s Trauma-focussed CBT for sexually abused children – healing by imaginal exposure and relearning • Parent interventions often shown to benefit the child – do they also benefit the personality of the parents?

18. Conduct disorder & antisocial personality • CD the commonest reason for referral to child psychiatry – 5 – 10% all children and adolescents • Often co-exists with ADHD but not interchangeable disorders • Commoner in boys • Seen where lower SES and larger families • Has the 2nd highest continuity into adult life of all traits

19. Conduct disorder • About half of childhood onset CD persist into adult life but only 15% adolescent onset cases persist • Remember to differentiate and treat if co-morbid – - ADHD, - PTSD, - ASD, - Specific & general LDs, - mood disorders - Substance abuse • Differentiate ‘subcultural deviance’

20. Dunedin Study1037 people born 1972, continue to be followedDemonstrated crucial brain development in first 3 years of life – importance of warm secure attachments in this timeFurther Christchurch cohort 1977

21. Forteviot House, Hope Terrace Brenda Renz • Day service for children under 14 • Only one referral to Glasgow IPU in 5 years • Very close adherence to Webster-Stratton Incredible Years programme • Both parenting groups and ‘Dinosaur School’ elements, but in fact parenting intervention known to be almost as effective alone • Warmth, energy, nurturing, play!

22. 6 randomized control group evaluations of the parenting Intervention by the program developer & colleagues and 5 independent replications indicated - • increases in parent positive affect such as praise and reduced use of criticism and negative commands. • Increases in parent use of effective limit-setting by replacing spanking and harsh discipline with non-violent discipline. • Reduced parental depression, increased parental self-confidence.  • Increased positive family communication & problem-solving. • Reduced conduct problems in children’s interactions with parents and increases in their positive affect and compliance to parental commands. ALSO • Maintenence of benefits in 75% cases 5-6 years later

23. BUT....... • How do we select families for the intervention? • When should the child as well as parents be involved? • Are the boundaries between social control and child psychiatric care too blurred? • When the child is creeping like snail unwillingly to school, is this a psychiatric disorder? • How much is enough? - Rutter on Surestart

24. Adolescence – what is normal, what is not? DSH & ‘emerging’ Borderline disorder • Adolescence as a second phase of amazing brain development – scans of Jay Giedd

25. EDINBURGH CONNECTGita Ingram & Fiona Mactaggart After puberty many more cases of conduct disorder, but in general those already present in childhood likely to endure, whereas those of adolescent onset likely to ‘burn out’ by mid twenties Edinburgh Connect uses a tiny staff team to consult with carers of looked after children, including those in Social Work homes and those in foster care, rather than taking on large direct caseloads. Emergence of ‘Borderline Disorder’ now recognised

26. YPU Day Programme Psychiatric clerking and psychology assessment Developmental assessment from parents Home visits School reports & assessment in our schoolroom Observation of patient with peers both in formal groups and informal space Physical and growth records Team formulation meeting and review with young person and family Development (after 6 weeks) of tailormade care plan

27. Day Programme management • Individual work with psychologist and key worker • Dynamic risk management • IPT, DBT, CBT, CAT • Groups – Psychodynamic, DBT, art therapy, practical, out and about, social skills etc • Attention to nutrition, sleep, diurnal rhythms • Medication – or its withdrawal! • Lunches, snacks, games, sitting room, garden – social • Family work, formal family therapy, sometimes BFT • Education – own school or schoolroom • 6 weekly reviews • Careful discharge planning and transition care

28. Dialectical behaviour therapy • Works with DSH risk – avoid rewarding risk taking and instead use attachment to reward healthy responses • Teaches skills of mindfulness, emotion regulation, distress tolerance and interpersonal skills to replace unhealthy acting out • Stresses need for regular team communication and supervision – approach is by team, not by individual therapist • Playful and irreverent

29. Why be pessimistic? • Large scale, cheap versions don’t work! • Not all are helped • The most resistant cases are least likely to benefit but use up the resource • The environment is increasingly toxic and we are not keeping up with its risks (eg new technologies, where most teenagers are savvy but older porfessionals often naive) • Nutrition is getting worse, activity and sleep are reduced, substance abuse is ever more available • It is not inevitable that interventions can help but they CAN harm!

30. Why be optimistic? • Environmental manipulations can even affect genes • There are known effective parenting treatments to address substantial numbers of cases of prepubertal CD and ODD, which are the enduring problems • BPD increasingly appears to be a disorder of immaturity which can mellow out, particularly with therapy, not a life sentence • Medication can help though it may not cure and is not limited to the treatment of comorbid conditions • The study of stress and trauma responses is increasingly open to multidisciplinary exploration • A new generation of clinicians is passionate about personality and psychotherapy!

31. ‘Man is born broken and lives by mending’

32. Scottish Personality Disorder Network Conference Thursday 4th March 2010 Queen Mother Conference Centre Royal College of Physicians of Edinburgh