1. Psychotherapy and personality Disorder
Dr Linda Treliving
Consultant Psychiatrist in psychotherapy
NHS Grampian

2. DSM IV CLUSTER CLASSIFICATION
Cluster A, including paranoid, schizoid, and schizotypal PDs, which may manifest in cognitive distortions and an interpersonal style that is odd, eccentric, or detached.
Cluster B, consisting of antisocial, borderline, histrionic, and narcissistic PDs, which often involve behaviour that appears dramatic, erratic, impulsive, aggressive, or affectively dysregulated.
Cluster C, which includes avoidant, dependent, and obsessive- compulsive PDs that tend to involve fear, anxiety, apprehension, or perceived avoidance of harm.

3. Epidemiology Community 10 % General practice 20 %
Approximate prevalence of PD in;
Community 10 %
General practice 20 %
Psychiatric outpatients 30%
Psychiatric inpatients 40%
Prison %

4. “The distinction between personality disorder and mental illness”
…… it is commonplace for a diagnosis of personality disorder to be used to justify a decision not to admit someone to a psychiatric ward, or even to accept them for treatment……
B.J.Psych.
Volume 180,February 2002,pp
KENDELL, R. E.

5. Are personality disorders treatable?
Lewis & Appleby (1988)
2 case vignettes , one with a history of PD.
- pd was an enduring pejorative label
- distinct from genuine illness
- attribution of responsibility and control
- less deserving of treatment
- treatment unlikely to work

6. Treatment utilization by patients with personality disorders
PD more extensive usage than major depression of –
Psychiatric outpatient
Psychiatric inpatient
Psychopharmacologic treatment
Bender et al (2001).
American Journal of Psychiatry, 158, 295–302.

7. Malcolm Pines, Group analyst
“…..those attending personality disordered patients feel impelled to conform to a pattern imposed by the patient, so that we begin to feel provoked, hostile, persecuted and have to behave exactly as the patients need us to, becoming rejecting and hostile…..”
Group Analysis, (1978), 11,

8. DSM IV diagnosis of BPD A pervasive pattern of instability
of interpersonal relationships
self-image
affects
marked impulsivity
beginning by early adulthood
present in a variety of contexts,
as indicated by five (or more) of the following:

9. BPD = 5 or more of the following
1.Frantic efforts to avoid real or imagined abandonment 2.Unstable and intense interpersonal relationships. 3.Identity disturbance: 4.Impulsivity. 5.Recurrent suicidal behavior 6.Affective instability 7.Chronic feelings of emptiness 8.Inappropriate, intense anger 9.Transient, stress-related paranoid ideation or severe dissociative symptoms

10. The biopsychosocial model of BPD

11. PDQ IV scores for 129 prisoners in Cornton Vale, 2011

12. Cornton Vale audit 2011 53% Borderline PD 52% Antisocial PD
35% Borderline PD and Antisocial PD

13. Cornton Vale audit, Childhood trauma questionaire

14. Secure attachment
should engender a positive, coherent, and consistent self-image and a sense of being worthy of love, combined with a positive expectation that significant others will be generally accepting and responsive.

16. The hyperactivation of attachment in BPD
The attachment system in BPD is hypersensitive and triggered too readily
Indications of attachment hyperactivity in core
symptoms of BPD
Frantic efforts to avoid abandonment
Pattern of unstable and intense interpersonal relationships
Rapidly escalating tempo moving from acquaintance to great intimacy

17. Attachment Disorganisation in relationship to practitioner
Mild Distress/
Anxiety
Emotionally Challenging Experience in Relation to the practitioner
Emotional Challenge
Activation of attachment
Hyperactivation of attachment system may be core aspect of BPD
Proximity seeking
The ‘hyperactivation’ of
the attachment system 17 17

18. Attachment provocation
In the ward
Stimulation of attachment system in admission
Changing shifts
Negotiating levels of observation,
Discussing discharge
Managing incidents
Negotiating availability – “in 5 minutes”

19. Attachment provocation
At interview
Clinician lowering voice
Increasing intimacy
Responding to demands
Refusing to respond to demands
Boundary violation however small

20. Attachment theory and the psychiatrist–patient relationship
An empathic response on the part of the doctor, with accurate verbal identification of emotion, produces assuagement of attachment behaviours, triggering ‘vitality affects’ and the beginnings of ‘companionable exploration’ – the reasons for coming and history of presenting symptoms.
Jeremy Holmes, BJPsych (2008)193, 377

21. Attachment theory and the psychiatrist–patient relationship
People with insecure attachment histories find this process problematic, typically deactivating’ or ‘hyperactivating’ affect, or producing incoherence. Psychiatrists need to identify and understand this sequence of relational expectations and behaviours in themselves and their clients. Jeremy Holmes, BJPsych (2008)193, 377

22. Mentalization
the capacity to recognise and understand the existence of minds, both one’s own and those of others.
The normal ability to ascribe intentions and meaning to
human behaviour
to recognize that human behavior is motivated by mental states–by things like thoughts, beliefs, feelings, and desires.

23. Mentalization Shapes our understanding of others and ourselves
Central to human communication and relationships
Underpins clinical understanding, the therapeutic
relationship and therapeutic change regardless of
modality of therapy

24. What does good mentalizing look like?
Perception of own mental functioning
Appreciation of changeability
Developmental perspective
Realistic scepticism
Awareness of impact of affect
Self-presentation e.g. autobiographical
continuity
General values and attitudes e.g. tentativeness and moderation

26. What does non-mentalizing look like?
Excessive detail to the exclusion of motivations, feelings or thoughts.
Focus on external social factors, such as the school, the council, the neighbours.
Focus on physical or structural labels.
Preoccupation with rules, responsibilities.
Denial of involvement in problem.
Blaming or fault-finding.
Expressions of certainty about thoughts or feelings of others. 26

27. Mentalization Everybody will struggle to mentalize at times.
People with borderline PD and other diagnoses have more consistent difficulty especially under high arousal.
Underpins clinical understanding, the therapeutic relationship and therapeutic change regardless of modality of therapy

28. Mentalization based therapy
Aims to strengthen patients capacity to understand their own and others mental states in attachment contexts in order to address difficulties with –
Affect regulation
Impulse regulation
Interpersonal functioning
All of which contribute to suicide and self harm.
Bateman and Fonagy 2009

29. Why mentalization based therapy?
Evidence based
Psychodynamic treatment
Rooted in attachment and cognitive therapy
Requires limited training with moderate levels of supervision
Implemented by generic mental health professionals.

30. Mentalization based therapy – what does it look like?
Therapist adopts a stance of inquisitive, not knowing – Columbo vs Poirot
Alert to patients mentalizing and level of arousal in session
Intervenes to restore mentalizing
Maintains arousal at optimal level
Collaborative therapeutic relationship

31. MBT Skills
Any situation involving contact with person with Borderline PD is opportunity to use MBT skills
A&E, outpatients, inpatients, substance misuse, eating disorders, forensic etc
Aim is to facilitate the patients capacity to mentalize in the setting whilst being aware of factors which may be jeopardising capacity

32. MBT Skills Things to avoid! Metaphors Interpretations
Promises that can’t be kept
Behaviour that over stimulates attachment
Lowering voice, special relationship, boundary violation however small or apparently insignificant.

33. The hyperactivation of attachment in BPD
Suicide attempts are often aimed at
forestalling the possibility of abandonment:
they seem to be a last-ditch attempt at
reestablishing a relationship
only something extreme would bring about
changes in the adults behavior and the
caregiver used similarly coercive measure

34. MBT skills - Self harm
Means of staff conceptualising incident from different perspective – e.g to avoid abandonment,
Responding with indication of concern for actions rather than “ignoring or minimising for fear of reinforcing bad behaviour”
MBT skills to consider the incident and underlying affect

35. Effective ingredients of treatment (Bateman and Tyrer)
1. to be well structured;
2. to devote considerable effort to enhancing compliance;
3. to have a clear focus,
4. to be theoretically highly coherent to both therapist and patient,
5. to be relatively long term;
6. to encourage a powerful attachment relationship
between therapist and patient,
7. to be well integrated with other services available to the patient.