Consultant Psychiatrist in Psychotherapy Personality Disorder Dr Ray Haddock Consultant Psychiatrist in Psychotherapy Sheffield Care Trust Acknowledgements, Many including Peter Tyrer, Yvonne Agazarian, psychologists and neurobiologists Draw attention to change in behaviour at start - did anyone tell you how to behave? Any one here not got a personality?

What is personality that it gets disordered? How do we decide if it is disordered? When is it disordered? Where is it disordered? When is a disordered personality not disordered?

Objectives of Lecture 1. To briefly consider how personality is defined. 2. To describe and compare main diagnostic systems How to diagnose personality disorder What does NICE say Treatment and Management evidence and the lack of it. The future - some speculation

What is personality? http://dictionary.reference.com/browse/personality The visible aspect of one's character as it impresses others: He has a pleasing personality. A person as an embodiment of a collection of qualities: He is a curious personality. Psychology . a. the sum total of the physical, mental, emotional, and social characteristics of an individual. b. the organized pattern of behavioral characteristics of the individual.

The quality of being a person; existence as a self-conscious human being; personal identity. The essential character of a person.

Personality from first principles Genes Birth Gene pool Community Work Intimate Reproduction Personal preference and choice Adolescence Early adulthood Family, school peers Childhood Caregiver Development Neurobiological Physical Nutritional Educational Emotional Models Attachment Social learning Psychoanalysis Piaget Maslow Etc Adulthood Personality Adaptability to context Transition Home to community Adaptation Context Life Stage Of Personality

Definitions of Personality Disorder ICD 10 “….clinically significant conditions and behaviour which tend to be persistent and are the expression of an individual’s characteristic lifestyle and mode of relating to others…….as a result of both constitutional factors and social experience…..” DSM IV “…. is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment.” Is personality neurobiologically fixed by the time we are “grown up” ? Can whatever seems to be fixed be changed?

DSM-5 (No Longer Axis II) The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose personality disorder, the following criteria must be met. Significant Impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning One or more pathological personality trait domains or trait facets

General diagnostic criteria for a personality disorder (derived from ICD 10 and DSM IV From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann An enduring pattern of inner experience that 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, lability and appropriateness of emotional response 3) Interpersonal functioning 4) Impulse control

General diagnostic criteria for a personality disorder (derived from ICD 10 and DSM IV From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann An enduring pattern of inner experience that 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, lability and appropriateness of emotional response 3) Interpersonal functioning 4) Impulse control

Comparison of DSM and ICD DSM-IV-TR DSM-IV-TR/DSM 5 ICD-10 Cluster A Schizoid/Removed Schizoid Paranoid/Removed Paranoid Schizotypal Cluster B Borderline Emotionally Unstable -Impulsive -Borderline Antisocial Dissocial Narcissistic Histrionic/Removed Histrionic Cluster C Avoidant Anxious (avoidant) Dependent/Removed Dependent Obsessive-Compulsive Anankastic

Differences between mental state and personality disorders From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann Mental State Disorders Personality Disorders Temporary (Usually) Permanent (or at least long standing) Reactive Generative Dominated more by symptoms than behaviour Dominated more by behaviour and relationships with others Diagnosed mainly on mental state Diagnosed on basis of long term function May develop into other mental states Tends to remain stable

DSM-5 The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose personality disorder, the following criteria must be met. Significant Impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning One or more pathological personality trait domains or trait facets

General diagnostic criteria for a personality disorder - DSM 5 The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations The impairments in personality functioning and the individual’s personality trait expressions are not better understood as normative for the individual’s developmental stage or socio-cultural environment. The impairments in personality functioning and the individual’s 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

DSM-5 IN Antisocial Avoidant Narcissistic Obsessive Compulsive Schizotypal PD Trait specific Negative affectivity Detachment Antagonism Disinhibition vs Cmpulsivity Psychotisism

DSM-5 Out Paranoid Schizoid Histrionic Dependant

DSM 5 specific criteria for each PD Significant Impairments in personality functioning 1. Impairments in self functioning (a or b) a. Identity b. Self-direction 2. Impairments in interpersonal functioning (a or b) a. Empathy b. Intimacy

DSM 5 specific criteria for each PD Pathological Personality traits in the following domains: (e.g. for Antisocial) 1 Antagonism etc 2 Disinhibition

Prevalence General Population - lifetime 2-18% !! Primary Care 5-9% ?? great variation Psychiatric population 30-40% Inpatient populations 40-50% Prison 70% + Conclusion? 9

Making the Diagnosis - 1 History, History History! Recurring patterns of difficulty/symptoms Wide range of previous diagnoses Developmental history Problems at school Abuse/neglect (repeated and recurrent) Family patterns/relationships/breakdowns/violence The internal world of the child Changes in context

Making the Diagnosis 2 “Childhood was normal and all developmental milestones were normal” ! Most developmental, milestones are genetically and biologically driven. Therefore it takes very substantial environmental factors to change them enough to notice as for most the range is variable in any case. There is however an experience of childhood and development in the developmental context

Making the Diagnosis Symptoms All symptoms are possible Interpersonal relationships – child and adult Behaviour reflects perception of reality- go beyond the explanation Move from open to specific questioning

NICE GUIDELINES -Borderline PD Treatment and Management CMHT management CPA Consistent approach to treatment and management No stand alone short term psychological treatments Pharmacological treatments? - only for treatment of co-morbidity

NICE GUIDELINES -Borderline PD Psychological Treatment No overwhelming evidence for any treatment Dialectical Behaviour Therapy (Linehan) - certain groups - female -self harm, impulsivity Psychodynamic therapies - evidence but not gold standard Therapeutic community - for severe No particular role for inpatient treatment

Treatment and management - Summary Make the diagnosis Discuss and put in context – “normalise” Long term treatment and management plan Psycho-education Risk management Impulse management and control Specific interventions (short term to long term) Symptom targeted medication At every step it is important to attend to engagement and collaboration

NICE GUIDELINES - Antisocial Personality Disorder Mostly Tier 4 management No specific treatments Forensic - low/high secure Mental Health services - management of mental illnesses Intervention focussed more on prevention - intervention with children and families

Long term outcomes Some evidence that severity of disorder diminishes with age Exacerbation and reduced recovery rates from neurotic disorders The more severe/co morbidity the smaller the response to interventions Impact of therapy? Mortality? 14

The Future? Models of personality disorder that relate to aetiology - increased understanding Genetic Developmental Neurobiology of social functioning Treatment and management approaches that are based on sound evidence and theoretical models E.G.

Personality from first principles Genes Birth Gene pool Community Work Intimate Reproduction Personal preference and choice Adolescence Early adulthood Family, school peers Childhood Caregiver Development Neurobiological Physical Nutritional Educational Emotional Models Attachment Social learning Psychoanalysis Piaget Maslow Etc Adulthood Personality Adaptability to context Transition Home to community Adaptation Context Life Stage Of Personality

Proposed ICD 11 classification for Personality disorder Severe PD Moderately Severe PD Personality Disorder Personality Difficulty not qualifying as PD No Personality Disturbance Social/ Schizoid Dissocial/ Externalising Anxious dependant/ Internalising Obsessional/ Anankastic Emotional distress/ Instability Proposed ICD 11 classification for Personality disorder

A Histrionic personality B Anankastic personality C Paranoid personality D Dissocial personality E Schizoid personality F Borderline personality – unstable type G Borderline personality – impulsive type Which of the above corresponds best to the following:

140. A man attends with his CPN 140. A man attends with his CPN. He becomes very tearful when speaking about his depression but then changes quickly to talking rather loudly about his plans for the future 141. A man complains that his written complaint to social work is being ignored. He refuses to talk to the psychiatrist about it as “she’ll not do anything about it either”. 142. A woman is kept waiting a couple of minutes by the nurse having to take a telephone call. She smashes a window in the bathroom and is about to slash herself saying “it’s your fault I’m doing this”.

Answers 140. Probably A 141 C 142 G

Theme: personality Eysenck Personality Questionnaire Rorschach test Repertory grid Thematic appreciation test Minnesota Multiphasic Personality Inventory ‘Big 5’ personality test Q sort

Lead in: Which of the above methods used to assess personality has the following features? This projective tests of personality requires individuals to make up a storey based on ambiguous pictures of people and scenes An idiographic test of personality developed by George Kelly This personality tests has scales which measure the tendency to answer questions in a defensive and/or socially desirable manner This personality test posits that one of its dimensions reflects the degree of cortical arousal This test has dimensions measuring openness, conscientiousness extraversion, agreeableness and neuroticism

Theme: personality D C E A F

Useful sources of information Mental Health Foundation – http://www.mentalhealth.org.uk/information/ mental-health-a-z/personality-disorders/ Mind – http://www.mind.org.uk/help/diagnoses_and_ conditions/personality_disorders The Royal College of Psychiatrists – http://www.rcpsych.ac.uk/mentalhealthinfofor all/problems/personalitydisorders/pd.aspx