1. 1 “See the PERSON in PERSONality Disorder” Civil or Forensic 22 June 2006 John D McGinley/Lindsay Johnson The State Hospital/Caledonian University

2. 2 See the person in personality disorder civil and forensic Losing the person Losing the person Attitudes Attitudes Legal issues Legal issues Clinical issues Clinical issues Political issues Political issues Finding the person Finding the person User focus User focus Traumatic experiences Traumatic experiences Emotional intelligence Emotional intelligence Moral maturity Moral maturity Clinical governance Clinical governance

3. 3 ICD 10DSM IV Paranoid Paranoid Schizoid SchizoidCluster A Schizotypal Schizotypal Dissocial Antisocial Emotionally unstable/borderline Borderline Histrionic HistrionicCluster B Narcisistic Narcisistic Anxious(avoidant) Avoidant Dependent DependentCluster C Anankastic OCD __________________________________________________________ Emotionally unstable/impulsivePassive-aggressive Depressive Mental retardation PERSONALITY DISORDERS

4. 4 DSM IV TR - Personality Disorder “ Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself, that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause functional impairment or subjective distress do they constitute Personality Disorders”. (APA, 2000, p. 686) “ Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself, that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause functional impairment or subjective distress do they constitute Personality Disorders”. (APA, 2000, p. 686)

5. 5 DSM IV TR - Diagnostic Criteria A) 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: – Cognition - i.e., ways of perceiving and interpreting self, other people and events – Affectivity - i.e., the range, intensity, lability and appropriateness of emotional responses – Interpersonal functioning – Impulse control

6. 6 DSM IV TR - Diagnostic Criteria B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or important areas of functioning D. The pattern is stable and or long duration and its onset can be traced back at least to adolescence or early childhood E. The enduring pattern is not accounted for as a manifestational consequence of another mental disorder

7. 7 Clinicians Attitudes to Personality Disorder Those patients viewed as “not really ill” tend to be ignored Those patients viewed as “not really ill” tend to be ignored (MacIIwaine, 1981) “Few psychiatric staff prefer to care for this patient group and tend to dislike this population” (Moran & Mason, 1996) “Few psychiatric staff prefer to care for this patient group and tend to dislike this population” (Moran & Mason, 1996) “..plentiful evidence exists that staff become alienated from disliked patients.” (Bowers, 2002) “..plentiful evidence exists that staff become alienated from disliked patients.” (Bowers, 2002) “..therapeutic pessimism about PD is widespread among psychiatric professionals, adding to profoundly negative attitudes towards PD patients..” “..therapeutic pessimism about PD is widespread among psychiatric professionals, adding to profoundly negative attitudes towards PD patients..” (Bowers, 2002) “ Recommend no change to current psychiatric practice regarding compulsory detention” (Personality Disorder Report, Forensic Network 2005) “ Recommend no change to current psychiatric practice regarding compulsory detention” (Personality Disorder Report, Forensic Network 2005)

8. 8 Personality Disorders: legal and clinical issues MH (Care and Treatment) (S) Act 2003 Criteria 1. 1.Mental disorder mental illness personality disorder learning disability 2.Medical treatment prevent worsening alleviate symptoms available 3.Significant risk to person or safety of others 4. 4.Compulsion necessary 5.Impairment of ability to make decisions about treatment (civil application only)

9. 9 Personality disorders: political issue DSPD Criteria: England and Wales Criterion 1. Severe PD: Significant disorder of personality Criterion 1. Severe PD: Significant disorder of personality Criterion 2. High risk: More likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find difficult or impossible to recover Criterion 2. High risk: More likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find difficult or impossible to recover Criterion 3. Functional link: The risk presented appears to be functionally linked to the personality disorder Criterion 3. Functional link: The risk presented appears to be functionally linked to the personality disorder

10. 10 Personality disorders: political and clinical issue DSPD Criterion 1: Severity of personality disorder Very high psychopathy: PCL-R score 30+ Very high psychopathy: PCL-R score 30+ High psychopathy: PCL-Rscore 25-29 High psychopathy: PCL-Rscore 25-29 DSM IV-TR PD x 1 (Not APD DSM IV-TR PD x 1 (Not APD Comorbid PD: DSM IV-TR PD x 2 Comorbid PD: DSM IV-TR PD x 2

11. 11 Personality disorders: clinical and political issue DSPD criterion 2: level of risk More likely than not More likely than not Personality disorder: Personality disorder: – IPDE – SCID-1 Actuarial risk instruments Actuarial risk instruments – VRAG violence risk – Static 99 sexual risk Structured clinical judgement Structured clinical judgement – HCR 20 – Risk Matrix 2000 Dynamic risk Dynamic risk – VRS – SARN

12. 12 Personality disorders: political and clinical issue DSPD criterion 3: functional link Clinical formulation Clinical formulation Functional analysis Functional analysis Patterns of past offending Patterns of past offending Risk type Risk type Presence of risk related behaviours Presence of risk related behaviours

13. 13 Personality disorders: clinical issues co morbidity “ the co morbidity of Axis II diagnoses and the degree of heterogeneity within diagnostic groups raise as yet unresolved questions concerning the validity of a diagnostic approach” “ the co morbidity of Axis II diagnoses and the degree of heterogeneity within diagnostic groups raise as yet unresolved questions concerning the validity of a diagnostic approach” (Roth and Fonagy, 1996) “Both clinical practice and available research suggest strongly that an individual can suffer from both Axis I condition as well as personality disorder simultaneously” “Both clinical practice and available research suggest strongly that an individual can suffer from both Axis I condition as well as personality disorder simultaneously” (Lenzenweger & Clarkin, 2005) (Lenzenweger & Clarkin, 2005)

14. 14 Personality Disorders: clinical issues Assessment Case and file review Case and file review Categorical model: DSM IV:TR: Axis II: SCID-1 Categorical model: DSM IV:TR: Axis II: SCID-1 Dimensional model: DSM V? Dimensional model: DSM V? Self report: IPDE Self report: IPDE Statistical: Neo-Pi-R (5 factor model) Statistical: Neo-Pi-R (5 factor model) Clinical: Psychopathy Checklist (PCL-R) Clinical: Psychopathy Checklist (PCL-R) Emotional intelligence Emotional intelligence Intelligence quotient Intelligence quotient Moral reasoning Moral reasoning Trauma assessment Trauma assessment Risk assessment Risk assessment Baseline measures (e.g. addictions: anger) Baseline measures (e.g. addictions: anger) Overall formulation Overall formulation Outcome measures Outcome measures

15. 15 See the PERSON Inner self Consciousness Subjective experience SpiritualMindfulness Consistency of thoughts (schema), feelings (emotions), behaviours (expression) More than sum of traits

16. 16 Personality disorders: clinical issues Treatment: idiopathic Multiple domains of psychopathology Multiple domains of psychopathology – Requires combination of interventions tailored to individual needs. Common Factors in all cases – different manifestations Common Factors in all cases – different manifestations – Require general and individually tailored strategies within all treatments Complex psychological and biological etiology Complex psychological and biological etiology – Psychological and biological treatment; aim to enhance adaptation Psychosocial adversity influences the contents, processes and organisation of the personality system. Psychosocial adversity influences the contents, processes and organisation of the personality system. – Address all consequences of adversity Livesley 2001 Livesley 2001

17. 17 Personality disorders: clinical issues Treatment: effectiveness 1. Best conceptualised in integrative and biopsychosocial perspective. 2. Assessing treatability or amenability to treatment is critical to maximizing treatment planning and outcomes. 3. Effective treatment of personality disorders is tailored treatment. 4. The lower the level of treatability, the more combining and integrating of treatment modalities and approaches is needed. 5. The basic goal of treatment is to facilitate movement from personality-disorder functioning to personality-style functioning. Sperry 2003

18. 18 Personality disorders: clinical issues Psychotherapeutic models Supportive therapy Supportive therapy Psycho-educational Psycho-educational Psychodynamic Psychodynamic CBT/CAT/DBT CBT/CAT/DBT Milieu therapy Milieu therapy Community Community Pharmacological Pharmacological Fit treatment to uniqueness of the person: relationships, integration, combinations, environmental control, staff consistency multidisciplinary collaboration

19. 19 Maladaptive and inflexible thinking : Schema Focused Therapy Poor integration of concept of self or others: Psychodynamic Therapy Reformulation in collaboration: Cognitive Analytic Therapy Skills training: Cognitive Beh. Therapy Personality disorders: Clinical Issues Psychotherapeutic eclecticism Attachment and emotional developments: Psychodynamic Therapy Motivational engagement: Cognitive Beh. Therapy Therapeutic alliance and validation: Dialectical Beh. Therapy

20. 20 Personality disorders: clinical issues Treatment: Difficulty in Engaging Enduring and relatively stable patterns Maladaptive interpersonal behaviour Persistent over time Label and stigma attached to experience and distress Difficult to motivate into engaging in treatment Resistant to therapeutic change. Previous failed attempts at change. Excluded by low motivation and ‘untreatability’ Progress requires coordinated clinical and social support Progress requires immersion: suitable milieu Maintenance requires social integration Maintenance requires extended support

21. 21 Personality disorders: clinical issues Personality and risk PD:DynamicRiskFactor Functional relevance relevanceFormulation MaintainClinically relevant relevant behaviours behaviours MotivateEngageLearningChange SustainedIntegrated care care pathway pathway Risk assessment-----risk management-----risk reduction-----public safety Person engagement-----treatment progress-----community re-integration

22. 22 needs of the PERSON – holistic needs of the PERSON – holistic restore self respect restore self respect contract, cooperation, engagement contract, cooperation, engagement match needs with treatment match needs with treatment adapt to suit PERSON adapt to suit PERSON system of integration of person experience system of integration of person experience develop new treatments develop new treatments evaluate effectiveness evaluate effectiveness right place, right time, right treatment right place, right time, right treatment PERSONALITY DISORDERS: CLINICAL ISSUES PERSON Focused (PFPI)

23. 23 Emotional Impairment and psychopathy Psychopathy identifies one form of pathology associated with high levels of antisocial behaviour: individuals who present with a particular form of emotional impairment Psychopathy identifies one form of pathology associated with high levels of antisocial behaviour: individuals who present with a particular form of emotional impairment The Psychopath: emotion and brain James Blair et al (2005)

24. 24 Emotional intelligence Self awareness Motivation Self regulation Empathy Social skills Goleman 1998 Goleman 1998

25. 25 Emotional competence framework Self awareness Self awareness – Emotional awareness – Accurate self assessment – Self confidence

26. 26 Emotional competence framework Self regulation Self regulation Self control Self control Trustworthiness Trustworthiness Conscientiousness Conscientiousness Adaptability Adaptability Innovation Innovation

27. 27 Emotional competence framework Motivation Motivation Achievement drive Achievement drive Commitment Commitment Initiative Initiative Optimism Optimism

28. 28 Emotional competence framework Empathy Empathy Understanding others Understanding others Developing others Developing others Service orientation Service orientation Leveraging diversity Leveraging diversity Political awareness Political awareness

29. 29 Emotional competence framework Social skills Social skills Influence Influence Communication Communication Conflict management Conflict management Leadership Leadership Change catalyst Change catalyst Building bonds Building bonds Collaboration and cooperation Collaboration and cooperation Team capabilities Team capabilities

30. 30 Person and moral maturity: 1. Stages Pre-conventional stage Pre-conventional stage State 1 Punishment/obedience State 1 Punishment/obedience State 2 Instrumental relativist State 2 Instrumental relativist Conventional stage Conventional stage State 3 Good boy-Nice girl State 4 Law and order Autonomous stage Autonomous stage State 5 Social contract State 6 Universal ethical principle Kolberg

31. 31 Person and moral maturity: 2.Qualities Stage development is invariant Stage development is invariant Cannot comprehend beyond next stage Cannot comprehend beyond next stage Cognitive attraction to next stage Cognitive attraction to next stage Development depends on cognitive disequilibrium Development depends on cognitive disequilibrium

32. 32 Personality Disorders : Clinical Governance Understanding Personality Disorder: BPS June 2006 Treatment: core services in mental health and forensic settings Treatment: core services in mental health and forensic settings Access to specialist multi-disciplinary personality disorder teams Access to specialist multi-disciplinary personality disorder teams Multi-agency collaboration Multi-agency collaboration Clinical and forensic psychologists: clinical leaders Clinical and forensic psychologists: clinical leaders Training of team and agencies essential: awareness of specialisms Training of team and agencies essential: awareness of specialisms Structured assessments Structured assessments Focus on formulating person’s needs Focus on formulating person’s needs User views, user research and user involvement User views, user research and user involvement

33. 33 It is the responsibility of psychiatrists to offer treatment where ever possible It is the responsibility of psychiatrists to offer treatment where ever possible Improve teaching of psychiatry trainees Improve teaching of psychiatry trainees Prioritise limited capacity of psychiatric services Prioritise limited capacity of psychiatric services Develop preventive interventions in child and adolescent services Develop preventive interventions in child and adolescent services Develop clearer definition of treatment goals Develop clearer definition of treatment goals Ensure multidisciplinary cooperation Ensure multidisciplinary cooperation Personality Disorders: Clinical Governance Royal College of Psychiatrists Council Report CR 71, February 1999

34. 34 Personality Disorders: ethical issues Challenge assumptions Harder to engage Harder to engage Higher attrition rates Higher attrition rates Poorer outcome Poorer outcome More clever psychopath! More clever psychopath! Service “abusers” rather than “users” Service “abusers” rather than “users” Untreatable Untreatable Alienation: disliked patients Alienation: disliked patients Split the team! Split the team!

35. 35 Hope and developments Service users stories of hope Service users stories of hope New century re-birth of hope and raising expectations New century re-birth of hope and raising expectations Hearing voices networks Hearing voices networks See me See me Proud of our experience Proud of our experience Improving alliance with service users Improving alliance with service users Improved assessment procedures Improved assessment procedures Developing effective treatment paradigms Developing effective treatment paradigms Collaborative relationships – practitioner (the expert by training) and service user (the expert by experience) Collaborative relationships – practitioner (the expert by training) and service user (the expert by experience)

36. 36 Conclusions Person distressed by a personality disorder deserves consideration under mental health legislation for care and treatment When assessing the impact of a mental disorder, in all circumstances, all persons being assessed should be screened for personality disorder

37. 37 WORKSHOP 2 Covert versus Overt Personality Disorder diagnosis? What are the barriers to the effective involvement of service users and staff? Lindsay Johnston and John McGinley

38. 38 “See the PERSON in PERSONality Disorder” Civil or Forensic 22 June 2006 John D McGinley/Lindsay Johnson The State Hospital/Caledonian University