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PERSONALITY DISORDER
Developments,
Diagnosis and Treatment
Dr Scott Ferris
Consultant Psychiatrist in Psychotherapy
Farnham Road Hospital
[email protected]
Prevalence (Coid, et al 2006)
 UK population- 5%
 Primary care- 10-20%
 CMHRS- 30-40%
 Inpatient Psychiatry- 40-50%
 SABP- Only 12%
Personality
 (RCPscyh) : Characteristics, ‘traits’ that we
develop as we grow up, which make us individuals,
this includes how we:
-Think
-Feel
-Behave
Eg/ Fearless, charming, dutiful…
 Personality is adaptive, but also determined by biology and
temperament
Personality disorder
 Parts of personality develop in ways that makes I
It difficult to live with yourself and/ or others. Traits
become ‘maladaptive’
…ruthless, cold (Bond)
 May have been adaptive in past and remain so
in some circumstances, but maladaptive in others.
- Are Bonds traits maladaptive in his current environment? When is a
personality disordered?
Epistemic Trust (Fonagy and others)
Epistemic Trust (Fonagy and others,UCL)
Cultural Evolution (pleistocene period)- based on learning
and transmission of knowledge, as opposed to genes.
Importance of Epistemic Trust in social and cultural
learning. Determining who and what to trust. Linked with
attachment.
A problem in people with personality disorder (attachment
disruption)– difficult to change, adapt, ‘evolve’. Cant learn
how to use these ‘tools’. Therapeutic implications.
Would you trust this man?
DSM-5
Vs
ICD-11 – The Great Debate
DSM 5 (APA-2013)
 DSM- 5: Retains the PD categories
• Cluster A, B, C
PD categories (DSM-5)
 Cluster A- ‘odd, eccentric’ :
Paranoid, schizoid, schizotypal
 Cluster B- ‘dramatic, emotional, erratic’ :
Borderline, histrionic, antisocial, narcissistic
 Cluster C- ‘anxious, fearful’ :
Avoidant, dependent, obsessive-compulsive
Study:
Samuels et al., 2002 Crawford et al., 2005 Lenzenweger et al., 2007
Instrument Used:
IPDE
SCID-II
IPDE
Sample Size:
(742)
(644)
(5692)
-Paranoid
0.7%
5.1%
2.3%
-Schizoid
0.9%
1.7%
4.9%
-Schizotypal
0.6%
1.1%
3.3%
-Antisocial
4.1%
1.2%
1.0%
-Borderline
0.5%
3.9%
1.6%
-Histrionic
0.2%
0.9%
-
-Narcissistic
-
2.2%
-
-Avoidant
1.8%
6.4%
5.2%
-Dependent
0.1%
0.8%
0.6%
-Obsessive-Compulsive -
4.7%
2.4%
PD Unspecified
-
-
1.6%
Any PD
9.0%
15.7%
9.1%
DSM-5
Vs
ICD-11 – The Great Debate
ICD- 11 (Due 2015)
Focus on dimensions, with trait domains
Mild, moderate, severe PD
Personality difficulty (Z-code)
Reflects research and clinical experience, allow patients to
‘progress’, reduce stigma.
ICD-11- Proposed trait domains
Anankastic
Concern over control and regulation of behaviour. Eg/ perfectionism,
stubbornness, deliberation.
Detached (schizoid)
Social indifference and impaired capacity for pleasure. Eg/ aloof, solitary,
unassertive.
Dissocial (antagonistic)
Disregard for social convention and rights of others. Eg/ lack of empathy,
aggression, inability to maintain pro-social goal orientated behaviour.
Emotional distress
Tendency to evaluate and respond negatively to self, world and others.
Eg/ self-conscious, fearful, emotional dysregulation.
How to diagnose?
Diagnostic criteria (ICD-10)
 Patterns of inner experience and behaviour that deviate markedly from ‘norm’
in 1+ areas:
•
Cognition
•
Affectivity
•
Impulse control
•
Manner of relating to others
 Deviation must be pervasive, inflexible, dysfunctional
 Cause personal distress or adverse environmental affects
 Stable and enduring since adolescence
 Not caused by other psychiatric disorder or organic brain disease
Diagnosing
 Clinical:
• History, collateral history, mental state exam, experience in
consultation room (‘countertransference’) and others in GP
surgery (receptionist)
•
Attend 5X more, less concordant with treatment,
dissatisfied with GP care (Moran et al, 2000)
 Psychometric tools:
• SCID-II : structured clinical interview
• MCMI-III (Millon) : patient questionnaire
• PCL-R (Hare) : semi-structured interview +notes
Differential Diagnosis
Many psychiatric disorders. High co-morbidity, Axis I & II.
Which is predominant?

45% patients with medically unexplained motor symptoms have PD
(Crimlisk et al, 1998)
Most common false positives (APA):
 Bipolar disorder (17%)
 Depression (13%)
 Anxiety disorders (10%)
TREATMENT
Borderline PD
1% population, young women commonly
present. Broad variation in presentations.
Instability of interpersonal relationships,
self-image and mood, and impulsive behaviour.
(+/- transient psychotic symptoms). BPO, Mentalizing
Frequent co-morbidity- Axis I and II
Mentalizing (Bateman, Fonagy UCL)
A focus on mental states in oneself or in others,
particularly as an explanation for behaviour.
Form of social cognition.
Loss of mentalizing capacity in emotionally intense
relationships.
Re-emergence of early concrete modes of thinking
Impulsive behaviour in attempt to re-establish equilibrium
Treatment- Borderline PD- NICE Guidance 2009
General Principles
 Person centred, communication, carers
 Access to services, promote autonomy
 Develop trust and optimism
 Manage endings and transitions
 Care/ crisis planning
 Clear pathways and communication between services
Treatment- BPD- NICE 2009.
Primary Care
Recognition- Refer to CMHRS/ CAMHS if deteriorating or
significant emotional disturbance and/or risky behaviours
Crisis Management- assess current risk, ask about previous
episodes and Mx strategies. Try to contain anxiety by
focusing on current problems and identifying manageable
changes that might help (?help re-establish mentalizing)
Offer follow-up appt.
Treatment- BPD- NICE 2009
Drug treatment
No drug should be used specifically to treat BPD or its
manifestations.
Only use drugs for treatment of co-morbidity
In crisis - consider risks and psychological role, only use
short term (<1 week), low dose, safe (overdosing), low
addictive/ misuse properties. (eg. antihistamine).
Provide information, review
Treatment- BPD
Secondary care
CMHRS or CAMHS- Assessment and care planning.
‘Structured clinical management’. STEPPS/ iMBT (psych-ed)
Psychological Treatment
Dialectical Behaviour Therapy (DBT)- managing emotions
Mentalization Based Therapy (MBT)- managing relationships
Specialist PD services
Assess / treat complex/ high risk cases, consultation,
supervision, training, service development.
Treatment- BPD
Inpatient treatment (NICE)
Only admit in crisis if no other way
of managing significant risk
(or under MHA detention)
Actively involve patient in decision, pros/ cons and agree
purpose and length of admission.
HTT- also drop-ins- ‘safe haven’ Café, WBC, Aldershot
Service user-led organisations
Emergence
SUN project
Antisocial PD (NICE guidance, 2009)
Key priorities for implementation
Developing an optimistic and trusting relationship
•Staff working with people with antisocial personality disorder should recognise that a
positive and rewarding approach is more likely to be successful than a punitive approach
in engaging and retaining people in treatment. Staff should:
◦explore treatment options in an atmosphere of hope and optimism, explaining that
recovery is possible and attainable
◦build a trusting relationship, work in an open, engaging and non-judgemental manner,
and be consistent and reliable.
Assessment in forensic/specialist personality disorder services
•Healthcare professionals in forensic or specialist personality disorder services should
consider, as part of a structured clinical assessment, routinely using:
◦a standardised measure of the severity of antisocial personality disorder such as
Psychopathy Checklist–Revised (PCL-R) or Screening version (PCL-SV)
◦a formal assessment tool such as Historical, Clinical, Risk Management-20 (HCR-20) to
develop a risk management strategy.
Treatment of comorbid disorders
•People with antisocial personality disorder should be offered treatment for any comorbid
disorders in line with recommendations in the relevant NICE clinical guideline.
The role of psychological interventions
•Consider offering group-based cognitive and behavioural interventions (for example,
programmes such as 'reasoning and rehabilitation') focused on reducing offending and
other antisocial behaviour.
Multi-agency care
•Provision of services for people with antisocial personality disorder often involves
significant inter-agency working. Therefore, services should ensure that there are clear
pathways for people with antisocial personality disorder so that the most effective multiagency care is provided.
SABP- PD strategy (2014)
Full document available at trust website:
http://nww.sabp.nhs.uk/
Currently series of work streams looking at implementation
of the strategy- run through to 2016
Thank you.
Please ask me for leaflets!