Personality Disorders Alison Hetherington

Case study Patient Patient –Mrs H –64 years old –Admitted to Heather ward on 23 rd December 2009 HPC HPC –Attempted suicide by taking paracetamol overdose –Feels “dead inside” –Claims to have no feelings for anyone including her family –Weight loss of 2 stones in 3 months

PMHx PMHx –Hypertension –Recurrent UTI –Heart failure Past Psych Hx Past Psych Hx –First engagement with services 1992 –Eating disorder section 3 admission for 6 months –Multiple OD attempts –DSH; burning/cutting/scalding –Diagnosed with depression treated with multiple antidepressants and ECT with no improvement

Personal Hx Personal Hx –Difficult childhood –Abused by father and grandfather (sexual and emotional) –Lived in a children’s home –Divorced in 1989: abusive relationship –3 children ages 39,37,35. Difficult relationship –No employment history –Friend Carolyn; Mrs H feel’s she takes advantage of her and bullies her

Progress on the ward Very little improvement Very little improvement No response to medication or further course of ECT No response to medication or further course of ECT Feel’s neglected and victimised by staff on the ward Feel’s neglected and victimised by staff on the ward Continues to self harm both on the ward and whilst on leave Continues to self harm both on the ward and whilst on leave

Personality Disorders

What is ‘Personality’ ? A collection of characteristics or traits that makes each of us an individual A collection of characteristics or traits that makes each of us an individual These include the way we; These include the way we; –Think –Feel –Behave Personality tends to be set by late teen’s Personality tends to be set by late teen’s It is usually set for the rest of our lives It is usually set for the rest of our lives

Personality ‘Disorder’ When parts of our personality develop in a way that makes it difficult for us to live with ourselves and/or other people When parts of our personality develop in a way that makes it difficult for us to live with ourselves and/or other people Unhelpful ways of thinking/feeling/behaving Unhelpful ways of thinking/feeling/behaving Deeply engrained Deeply engrained Noticeable since childhood Noticeable since childhood Maladaptive Maladaptive Resistant to change Resistant to change

Characteristics They may find it difficult to They may find it difficult to –make or keep relationships –get on with people at work –get on with friends and family –keep out of trouble –Control their feelings and/or behaviour

Types; Cluster A Suspicious Paranoid Paranoid Schizoid Schizoid Schizotypal Schizotypal

Types; Cluster B Emotional and impulsive Antisocial, or Dissocial (psychopathic) Antisocial, or Dissocial (psychopathic) Borderline, or Emotionally Unstable Borderline, or Emotionally Unstable Histrionic Histrionic Narcissistic Narcissistic

Types; Cluster C Anxious Obsessive-Compulsive (aka Anankastic) Obsessive-Compulsive (aka Anankastic) Avoidant (aka Anxious/Avoidant) Avoidant (aka Anxious/Avoidant) Dependent Dependent

Aetiology? Environmental and genetic factors Environmental and genetic factors Neurodevelopmental theories Neurodevelopmental theories Psychoanalytical theories Psychoanalytical theories Social circumstances Social circumstances –Parental deprivation –sexual abuse –impaired attachment

Diagnosis Often a diagnosis of exclusion Often a diagnosis of exclusion Clinical features should begin in adolescence, be stable over time and not only occur during an episode of mental illness Clinical features should begin in adolescence, be stable over time and not only occur during an episode of mental illness Often concurrent mental illness Often concurrent mental illness Clinical classification unreliable and unhelpful Clinical classification unreliable and unhelpful

Treatment strategies Some improvement seen with age Some improvement seen with age Bio-psycho-social Bio-psycho-social Multidisciplinary team Multidisciplinary team –Assessment of sources of distress to self and others –Diagnose co-morbid mental illness –Formulate realistic treatment goals

Treatment continued…. Medication used to treat specific symptoms Medication used to treat specific symptoms –Mood stabilisers –Antipsychotics –Antidepressants Psychosocial interventions Psychosocial interventions –CBT –Supportive psychotherapy –Community outreach

Summary Personality disorder Personality disorder –Maladaptive and deeply engrained –High incidence of concurrent mental illness –Higher rates of suicide and accidental death –Often challenging to manage –Use bio-psycho-social model –Consider effect on your own mental health!