Disturbance and development

1. Disturbance and development • Personality disorder, psychodynamics and the internal world • Gwen Adshead • Broadmoor Hospital

2. Psychodynamics • ‘Dynamic’ implies movement • A paradox: we experience ourselves as the same over time • Yet we know that we change and develop • The Self as a dynamic process, not a state

3. Internal and external worlds • What do we mean by an internal world? • What do we mean by the external world? • Do we mean the same thing? • What is the boundary between these worlds? • The individual and the group

4. The experience of the self • To function optimally, we need • A regulated and coherent sense of self • Flexibility in responses • Appropriate responses • The capacity to modulate (+/-) • Metacognition or second order thoughts

5. Regulation • Of mood • Of arousal in response to different types of stress: • Loss • Fear • Illness or pain • A challenge to coherence

6. Aspects of regulation • Emotions (somatic) and feelings (mental) • Modulation ( up or down) • Threat perception threshold ( low or high) • Appropriate responses to threats/stress • Sympathetic responses • Parasympathetic responses

7. The regulated self • A sense of integration and coherence • Stability over time: memory and coherence • A narrative sense of self • Metacognition and self-reflective function • Self-reflective function and other-reflective function

8. The regulated self (2) • Can examine itself • Has sense of others as real • Is composed of different aspects that resonate with others and the environment in a modulated way • Can self-soothe and use others for help • Care giving and care eliciting

9. Dysregulation • Right orbitofrontal cortex • Connections with hypothalamus, amygdala and hippocampus • Development of the ROFC affected by early relationships • Trauma: overwhelms the capacity to respond

10. Dysregulation (2) • Unmodulated stress and arousal reactions • Hyperarousal to minimal threat • Excessive responses to threat • Hypersensitive threat perception • Somatic responses provoke more unconscious arousal • Emotions not feelings

11. DefCon Status • Defences against internal and external threat • Condition of the defences: high or low alert? • Def Con 1-5: levels of alarm • Defences help to keep an integrated sense of self

12. The capacity for distress • She spoke as one, incapable of her own distress

13. The dysregulated self • Reorganised or disorganised • Instability of mood, arousal, relationships • Instability of self-states • Altered reality perception • Seeks external soothers • Communicates somatically

14. The narrative self • Autobiographical competence • Loss of a coherent account of the self • Gaps and blanks; where speech and thought fall away • Alexithymia: inability to put feelings into words • ‘What’s your story?’

15. Defences against incoherence • Grandiosity and contempt for weakness • Dismissing of attachments • Preoccupation with attachments • Passivity • Paranoia • Envy and entitlement • Alternate realities

16. Psychiatric disorders as disorders of the self • Psychotic disorders: altered realities, lowered threat perception, hyperarousal to threat, the self as victim • Personality disorders: similar but not so pronounced + mood disorders • Disorders of the sense of self: passivity, helplessness, intrusive thoughts, delusions and hallucinations

17. The story of the illness • What is the patient’s story? • Who is the narrator? • Who has the agency? • Is this a story of victims and perpetrators?

18. Multiple stories • The patient’s • The carers • The health care professionals • Family • Social and cultural stories

19. The therapist’s story • The impact of working with personality disordered patients • Disability and chronicity • Containment and the provision of security • Damage limitation • Living with grief

20. Conclusion • Self-development: ‘from the cradle to the grave’ • The self as the function of an inner world group • ‘There’s something between us that isn’t there’