Personality Disorder: An introduction

1. Personality Disorder: An introduction Westminster Rough Sleeping Services January 2016 Dr Brett Grellier

2. Agenda • What is personality? • What is personality disorder? • Psychodynamic approaches • CBT • DBT • Compassion Focused approach • Understanding and managing the emotional impact

3. What is personality? • Not easy to pin down • The words we use to describe people tend to have wide meanings – and these meanings often overlap and cover more than one kind of experience. • For example, ‘shyness’ describes the feeling of awkwardness with other people, but also how we behave by being quiet in company. • The way we behave - and appear to other people - can be very different in different situations(person vs. situation debate). • Some argue that personality is not an intrinsic characteristic of people and exists only in the mind of the beholder.

4. Psychiatric definitions • The word ‘personality’ refers to the collection of characteristics or traits that we have developed as we have grown up and which make each of us an individual. • These include the ways that we: • Think • Feel • Behave • By our late teens, or early 20s, most of us have developed our own personality. • We have our own ways of thinking, feeling and behaving. • These stay pretty much the same for the rest of our life. • Usually, our personality allows us to get on reasonably well with other people.

5. Personality dimensions/traits • Many contemporary personality psychologists believe that there are five basic dimensions of personality. • The five broad personality traits described by the theory are extraversion, agreeableness, openness, conscientiousness, and neuroticism. • Previous trait theories suggested a various number of possible traitsincludingAllport’s list of 4,000 personality traits, Cattell’s 16 personality factorsand Eysenck's three-factor theory. • There is a significant body of literature supporting this five-factor model of personality across populations and cultures around the world. • Many psychologists now believe that the five personality dimensions are not only universal; they also have biological origins.

6. Big Five personality traits McCrae & Costa (1987) • Extraversion: This trait includes characteristics such as excitability, sociability, talkativeness, assertiveness and high amounts of emotional expressiveness. • Agreeableness: This personality dimension includes attributes such as trust altruism,kindness, affection, and other prosocial behaviours. • Conscientiousness: Common features of this dimension include high levels of thoughtfulness, with good impulse control and goal-directed behaviours. Those high in conscientiousness tend to be organized and mindful of details. • Neuroticism: Individuals high in this trait tend to experience emotional instability, anxiety, moodiness, irritability, and sadness. • Openness: This trait features characteristics such as imagination and insight, and those high in this trait also tend to have a broad range of interests.

7. Big Five – Your results • http://www.truity.com/test/big-five-personality-test • In pairs or small groups discuss your test results: • Were there any surprises? • What can you bring to interactions with clients? • What might be more challenging for you? Tip: Think in terms of over-identification or polar opposites.

8. What is Personality Disorder? • The term ‘disorder’ has no precise meaning in medicine or psychology. • Originate in complex interactions of biological, familial, and social influences. • Personality Disorder can be defined as variations or exaggerations of normal personality attributes. • Part of a continuum of personality functioning, rather than discreet abnormalities. • Enduring characteristics of a person that impair their well-being or functioning. • A pejorative and stigmatising label. • The term can attract fear, anger and disapproval rather than compassion, support and understanding • It is widely accepted that the psychiatric classification of personality disorders is unsatisfactory.

9. DSM-IV definition • A. An enduring pattern of inner experience and behaviour the deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: • 1. Cognition (i.e., ways of perceiving and interpreting self, other people and events) • 2. Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response) • 3. Interpersonal functioning • 4. Impulse control • B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. • C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. • D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. • E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. • F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma)

10. DSM-5 criteria • The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met: • A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning. • B. One or more pathological personality trait domains or trait facets. • C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations. • D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or sociocultural environment. • E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

11. ICD-11 (proposed criteria) • Instead of categories, a dimensional model will be applied in which degree of severity: personality difficulty, mild PD, moderate PD and severe PD will be established and personality will be assessed in four domains.

12. If it is difficult to: • Make or keep close relationships • Get on with people at work • Get on with friends and family • Keep out of trouble • Control feelings or behaviour • Listen to other people • And this makes the person unhappy or distressed and/oroften upsets or harm other people then it could be an indication of a personality disorder

13. Experience of Personality Disorder • Personality can develop in ways that make it difficult for the person to live with themselves and/or with other people. • An inability to be able to learn from the things that happen to them. • Finding it very difficult to change the bits of their personality (traits) that cause the problems. • These traits, although they are part of who they are, just go on making life difficult for themselves - and often for other people as well. • It is common for these characteristics to interfere with a person’s ability to cope with life and may also lead to difficulties in social interactions. • When these difficulties are extreme and persistent, and when they lead to significant personal and/or social problems they are described as personality disorders.

14. Prevalence • 10% of general population meet the criteria for PD. • Around 80% of Psychiatric patients. • 50-78% of adult prisoners. • Psychopathy is rare, affecting less than 1% of the household population • A 2009 study showed Psychopathy prevalence for prisoners at 8% for men and 2% for women (using Hare’s Psychopathy checklist)

15. Co-morbidity (from U.S national comorbidity survey, 2007) • Cluster A (odd and eccentric) – 41.1% also had an axis 1 disorder • Cluster B (dramatic, emotional & erratic) – 70.2% • Borderline Personality Disorder (Cluster B) – 84.5% • BPD – common co-morbidities include depression, anxiety disorders, Bi-Polar, Substance Use and ADHD. • Cluster C (anxious and fearful) – 49.7% • Axis 1 disorders – 25% also met criteria for axis 2 (personality disorders) • People often meet the criteria for more than one personality disorder particularly within the clusters. Note: The DSM-5 no longer distinguishes between axis 1 and 2.

16. Different kinds of personality disorders • Research suggests that personality disorders tend to fall into three groups, according to their emotional 'flavour': • Cluster A: Odd or Eccentric • Cluster B: Dramatic, Emotional, or Erratic • Cluster C: Anxious and Fearful

17. Cluster A: 'Odd and Eccentric' • Paranoid • Suspicious • Feel that other people are being nasty (even when evidence shows this isn’t true) • Feel easily rejected • Tend to hold grudges • Schizoid • Emotionally 'cold' • Don't like contact with other people, prefers own company • Have a rich fantasy world • Schizotypal • Eccentric behaviour • Odd ideas • Difficulties with thinking • Lack of emotion, or inappropriate emotional reactions • See or hear strange things • Sometimes related to schizophrenia, the mental illness

18. Cluster B: 'Dramatic, Emotional and Erratic' • Antisocial, or Dissocial • Don't care much about the feelings of others • Easily get frustrated • Tend to be aggressive • Commit crimes • Find it difficult to make close relationships • Impulsive - do things on the spur of the moment without thinking about them • Don’t feel guilty about things you've done • Don’t learn from unpleasant experiences • Borderline, or Emotionally Unstable • Impulsive - do things on the spur of the moment • Find it hard to control emotions • Feel bad about yourself • Often self-harm, e.g. cutting yourself or making suicide attempts • Feel 'empty’ • Make relationships quickly, but easily lose them • Can feel paranoid or depressed • When stressed, may hear noises or voices

19. Cluster B: 'Dramatic, Emotional and Erratic’ • Histrionic • Over-dramatiseevents • Self-centred • Have strong emotions which change quickly and don't last long • Can be suggestible • Worry a lot about their appearance • Crave new things and excitement • Can be seductive • Narcissistic • Have a strong sense of your own self-importance • Dream of unlimited success, power and intellectual brilliance • Crave attention from other people, but show few warm feelings in return • Take advantage of other people • Ask for favours that you do not then return

20. Cluster C: 'Anxious and Fearful' • Obsessive-Compulsive • Worry and doubt a lot • Perfectionist - always check things • Rigid in what you do, stick to routines • Cautious, preoccupied with detail • Worry about doing the wrong thing • Find it hard to adapt to new situations • Often have high moral standards • Judgemental • Sensitive to criticism • Can have obsessional thoughts and images • Avoidant (Anxious/Avoidant) • Very anxious and tense • Worry a lot • Feel insecure and inferior • Have to be liked and accepted • Extremely sensitive to criticism • Dependent • Passive • Rely on others to make decisions for you • Do what other people want you to do • Find it hard to cope with daily chores • Feel hopeless and incompetent • Easily feel abandoned by others

21. Personality disorder party • Imagine a party where all the people there had personality disorders… • Read the scenarios on the handout and write down which personality disorder each person at this party has.

22. 3 P’s of Personality Disorder • According to the National Offender Management Department (Ministry of Justice) It’s not PD unless the symptoms are... • Problematic- unusual and causing distress to self or others • Persistent- starting in adolescence and continuing into adulthood • Pervasive- affecting a number of different areas in the person’s life

23. Identifying PD • 1. Look for: • • A diagnosis in the file • • Review the offence history • • Evidence of childhood difficulties • • Previous contact with mental health services. • 2. Score the OASys PD screen • 3. Consider interpersonal dynamics • 4. Remember the 3 P’s (Problematic, Persistent, Pervasive)

24. How you find yourself responding? • Do you find yourself responding to the person in a way that is unusual for you? • Forgetting about them or feeling reluctant to engage with them. • Making an exception and offering them special treatment. • Hotly disagreeing with colleagues about how the person should be treated. • Feeling useless and as though you have nothing to offer. • Feeling overwhelmed by the person’s needs. • Finding yourself responding less sympathetically than usual.

25. Behaviours – imaginal exercise • What are the behaviours we associate with people who have Personality Disorder? • How do they make us feel? • Intolerant • Angry • Powerless • Need to ‘fix’ • Fear • Hopeless • Frustrated

26. Sample of observed client behaviours • Emotions • Shame • Ambivalence • Bad • Lonely • Discomfort • Vulnerable • Guilty • Fear • Jealous • Distress • Anger • Sad • Self-hatred • Hides feelings • Unworkable • Suicidal • Self-harming • Non-engaging • Co-dependent • Predatory • Gambling • Blaming • Difficult • Uncooperative • Lazy • Bizarre • Aggressive • Manipulative • Accusatory • Dangerous • Superficial charm • Alcohol/drug use • Attention seeking • Lying • Pushes people away • Unacceptable • Grandiose • Challenging • Fixed • Complaining • Domestic violence • Financial abuse • Splitting • Frightening • Chaotic • Violent • Non-compliant • Assault • Fantasist • Paranoid • Racist • Risky • Macho • Threatening • Scary

27. Quick Questions (Moran et al, 2003) • 1. In general, do you have difficulty making and keeping friends? • 2. Would you normally describe yourself as a loner? • 3. In general, do you trust other people? • 4. Do you normally lose your temper easily? • 5. Are you normally an impulsive type of person? • 6. Are you normally a worrier? • 7. In general, do you depend on others a lot? • 8. In general, are you a perfectionist? • If a person answers yes to several of these questions, and thinks that description applies most of the time in most situations, it may alert you to the possibility they have personality difficulties.

28. OASys PD Screen The Offender Assessment System (OASys) contains within it a number of specific questions which can be selected to screen for what has come to be known as Dangerous and Severe Personality Disorder (DSPD). • Number of convictions aged under 18 years • Breaches when subject to supervision • Diversity of offending categories • Violence/threat of violence/coercion • Excessive use of violence/sadistic violence • Recognises victim impact? g. Financial over reliance on friends, family, others for support h. Predatory lifestyle i. Reckless/risk taking j. Childhood behaviour problems k. Impulsivity l. Aggressive/controlling behaviour. Suggestion The presence of 8 or more items might indicate raised concerns.

29. Hands up if you have never… • Felt suspicious about someone’s motive and later found the person to be well-meaning? • Used white lies or manipulation to get your needs met? • Added in a few embellishments to make a story more entertaining? • Behaviours associated with personality disorder are on a continuum. • It is the rigidity extreme manifestations of the behaviour that is the difference… • …and effect on the person’s well-being and those around them.

30. Psychopathy • Psychopathy is among the most difficult disorders to spot. • A combination of features from anti-social and narcissistic Personality Disorders • The psychopath can appear normal, even charming. • Psychopathy is largely impervious to treatment. • It is important to note that the vast majority of people with antisocial tendencies are not psychopaths

31. Link to offending • Schizoid PD has been shown to hold a modest, but significant relationship with risk of violence. It has been found to be present in 7% of prisoners, with higher rates found among violent and sexual offenders; including a subgroup of sexual murderers. • Paranoid PD may facilitate angry aggression due to perceiving others as threatening, undermining, disloyal or dangerous. Linked to domestic abuse and stalking. • Cluster C PD’s in general are not strongly associated with a high risk of serious offending and obsessive compulsive traits in particular confer a particularly low risk. • Narcissistic PD alone is not frequently associated with serious offending but combined with antisocial traits, the likelihood of offending is higher. • Narcissistic traits are evident in some offenders who lash out in response to perceived slights, and in a subgroup of high risk paedophile offenders who believe themselves to be attractive to pubescent boys. • Almost 50% of UK prisoners may meet the criteria for ASPD. It is associated with an increased likelihood of general recidivism, violence and, to a lesser extent, sexual offending. Among sexual offenders it is far more common among rapists than child sexual offenders.

32. Anti-Social Personality Disorder – links to offending • Sufferers may have failed to internalise a social conscience, which might otherwise inhibit antisocial behaviour. • They may have a tendency towards acting out aggressively when faced with inner conflict (such as feelings of frustration, anxiety or helplessness). • They may experience others as threatening and therefore possess a strong need for dominance. • They may be highly impulsive, this is likely to get them in to trouble. • It often occurs in combination with other PD diagnoses. • These traits (such as a paranoid thinking style, problems controlling emotions and a sense of superiority over others) may therefore also contribute to an increased likelihood to offend. • Substance misuse is common and when combined with antisocial traits, risk of harm (self and others) increases considerably.

33. Do personality disorders change with time? • There is evidence that they tend to improve slowly with age • Antisocial behaviour and impulsiveness, in particular, seem to reduce in people’s 30s and 40s. • It can, however, sometimes work in the opposite direction. For example, schizotypal personality disorder can develop into schizophrenia. • This could be evidence of the instability of the construct of personality disorder and fluidity of personality.

34. Recommendations (BPS) • Staff in health and social care, education, criminal justice and voluntary sector require some level of training from basic awareness to specialist training • Clinical supervision of staff working with individuals with Personality Disorder is essential to maintain the emotional health of staff. • People with Personality Disorder need a multidisciplinary and multi-agency service. BPS = British Psychological Society

35. NICE guidance for staff working with Personality Disorder • A positive and rewarding approach is more likely to be successful in engaging and retaining people in services. • Options should be explored in an atmosphere of hope and optimism. • Explain that recovery and change is possible and attainable. • Build a trusting relationship. • Work in an open, engaging and non-judgmental manner. • Be consistent and reliable • Services should ensure clear pathways so that the most effective multi-agency care is provided.

36. Required organisational characteristics (Bateman and Fonagy, 2004) • Structure • Consistent implementation • Coherent theoretical framework • Focus on relationships • Flexibility • Balancing intensity and need • Individualised programme of care • Integrated with other services

37. Causes • It is believed that Personality Disorder originates in complex interactions of biological, familial and social influences. • Upbringing, e.g. physical or sexual abuse in childhood, violence in the family, parents who drink too much or use drugs. • Some evidence of very slight differences in the structure of their brains, and in the way some chemicals work in their brains • A common theme in psychological approaches are memory systems relating to the self and other. • Early problems: severe aggression, disobedience, and repeated temper tantrums in childhood.

38. Bio-Psychosocial model of PD

39. Treatment • There is evidence that people with PD can be successfully treated with psychological therapies. • No clear evidence of superiority of one treatment approach over another. • Successful treatments tend to be intensive, long-term, theoretically coherent, well-structured and integrated with other services. • Engagement and retention in treatment and the quality of the therapeutic rapport are crucial factors • Approaches include Psychodynamic, CBT, CFT and DBT. • Medication.

40. Medication • Anti-psychotics can help reduce the suspiciousness of the three cluster A personality disorders (paranoid, schizoid and schizotypal) and with borderline personality disorder if people feel paranoid, or are hearing noises or voices. • Anti-depressants can help with the mood and emotional difficulties that people with cluster B personality disorders (antisocial, borderline, histrionic, and narcissistic) have. • Recent NICE guidance (2015) states that there are no drugs that are established as safe and effective in treating borderline or antisocial PD. • NICE says people with BPD or antisocial personality should only be prescribed antipsychotic or sedative medication for short-term crisis management or treatment of comorbid conditions • Some of the SSRIs can help people to be less impulsive and aggressive in borderline and antisocial personality disorders and can reduce anxiety in cluster C personality disorders (obsessive-compulsive, avoidant and dependent). • Mood stabilisers can help with unstable mood and impulsivity that people with borderline personality disorder may experience.

41. Psychodynamic • Object relations refer to enduring patterns of relating to others and the processes of thought and emotion that guide these processes. • Intimate relationships are seen to be externalised mental representations of interpersonal functioning formed in early development through relationships with caregivers. • Distressing or dysfunctional relationships characteristic of PD reflect distortions in these internal representations. • A common goal is to change those internal representations that lead to maladaptive behaviour and long-term emotional and cognitive disturbances. • This is achieved by identifying the dominant object relations emerging in the transference, i.e. the reactivation in therapy of internalised early relationships.

42. Kernberg’s (1996) Object Relations

43. Attachment: Internal working models • A securely attached child will store an IWM of a responsive, loving and reliable mother and of a self worthy of love and attention. • An insecurely attached child may store an IWM of an unresponsive, inconsistent or unreliable mother. This selectively influences perception, cognition and motivation.

44. Mentalising

45. Mentalisation Based Treatment • Developed by Fonagy and Bateman (1998) for the treatment of BPD. • Based on attachment and object relations theory • Proposes that BPD is a disorder of attachment, separation tolerance, and ability to understand others’ mental states (Theory of Mind). • Theory of mindis the ability to attribute mental states — beliefs, intents, desires, pretending, knowledge, etc. — to oneself and others and to understand that others have beliefs, desires, intentions, and perspectives that are different from one's own. • Mentalisation based treatment (MBT) is a time-limited treatment which structures interventions that promote the further development of mentalising

46. Mentalisation • Not directly concerned with content/narrative • Helps the person generate multiple perspectives • This frees himself up from being stuck in the “reality” of one view (primary representations) • To experience an array of mental states (secondary representations) • Finally to recognize them as such (meta-representation)

47. Basic Mentalising • ‘Stop, Listen, Look’ During a typical non-mentalising story: • Stop and investigate • Let the interaction slowly unfold – control it • Highlight who feels what • Identify how each aspect is understood from multiple perspectives • Challenge reactive “fillers” • Identify how messages feel and are understood, what reactions occur • When patient able to mentalise to some degree : • What do you think it feels like for X? • Can you explain why he did that? • Can you think of other ways you might be able to help her really understand what you feel like? • How do you explain her distress/overdose? • If someone else was in that position what would you tell them to do?

48. Example of therapist encouraging a client to mentalise Key worker: “You seem to see me as scary today.” Client (crossly): “What makes you say that?” Key worker: “Well, your head is down, your legs and arms are crossed, and you don’t seem to want to look at me” Client: “Well that’s because you are angry with me”. Key worker: “I am not aware that I am angry. What makes you think I am?” (Taken from Gibson, 2006)

49. Skills practice Client:Be a moderate person and describe a recent difficult interaction - respond to the worker as you think your client would. Monitor how the worker makes you feel – misunderstood, secure, if s/he is interested, makes you think etc. What was it that made you feel like that or altered your mind state? Outreach worker: Use some basic mentalising skills to fully explore the story, whilst maintaining an empathic and validating stance. • Stop, Re-wind, Explore • Lets go back and see what happened just then. • At first you/I seemed to understand what was going on but then… • Lets try to trace exactly how that came about • Hang-on, before we move off let’s just re-wind and see if we can understand something in all this.

50. Psychodynamic approaches – how to incorporate the treatment principles • Theory of mind – developing the capacity • Attachment – creating a new attachment pattern • Changing internal representations – giving feedback • Building ego-strength – e.g. refusal skills, tolerating discomfort • Building ego-concept – creating a sense of self through conversation/feedback.