2.  What is a Personality Disorder?  Management & Containment  There’s no “I” in “Team”

3.  A Personality Disorder is a mental illness  A person with a personality disorder is unable to control their actions  The most effective intervention for DSH is a psychiatric admission  Personality disorders are attention seeking  The purpose of a diagnosis is to refer to statutory services  Its normal to feel annoyed when working with someone with a personality disorder

4.  ‘personality’ refers to the collection of characteristics/traits developed  By our late teens we have developed our own personality (thinking, feeling and behaving).  These stay pretty much the same for the rest of our life. Usually, our personality allows us to get on reasonably well with other people.

5.  For some of us, this doesn't happen, personality can develop in ways that make it difficult to live with self &/or other people.  The capacity to self reflect & learn is limited and there’s difficulty changing personality (traits) that cause the problems.  A personality disorder is an enduring pattern of inner experience and behavior that deviates from the norm.  The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.  The pattern is stable and of long duration, and its onset can be traced back to early adulthood or adolescence.

6.  Most experts agree that there is no single cause of personality disorder It is likely to be caused by a combination of factors.  genetics – genes inherited may make people more vulnerable, given certain environmental factors (see below)  neurotransmitters –neurotransmitters can have a significant effect on mood and behaviour  neurobiology –  environmental factors – events that happened in a person’s past, i.e. relationship with your family, abuse, lack of validation,

7.  People with a diagnosis of personality disorder have not, in the past, had enough help from mental health services.  These services have been more focussed on mental illnesses like schizophrenia, bipolar disorder.  There have been arguments about whether mental health services can offer anything useful to people with personality disorders.  Some Personality Disorders are more receptive to treatment.  Harm minimisation approach

8.  Yes.  There is evidence that they tend to improve slowly with age.  Antisocial behaviour and impulsiveness, in particular, seem to reduce in your 30s and 40s  Why?

9.  Research suggests that personality disorders tend to fall into three groups.  As you read through the descriptions of each type, you may well recognise some aspects of your own personality.  TraitsDisorder

10.  There are different ways to describe mental disorders, and to put them into categories.  The first step is to see if there are patterns, or collections of personality traits that are shared by a number of people.  Research suggests that personality disorders tend to fall into three groups, according to their emotional 'flavour':

11. Cluster A: 'Odd or Eccentric  Paranoid Personality Disorder: long standing pattern of pervasive distrust/suspiciousness  Schizoid Personality Disorder: long standing pattern of detachment from social relationships and exhibit difficulty expressing emotions to others  Schizotypal Personality Disorder: eccentricity & great difficultly in maintaining close relationships Cluster B: 'Dramatic, Emotional, or Erratic'  Antisocial Personality Disorder: long standing patterned disregard for other people's rights, often crossing the line and violating those rights. It usually begins in childhood or in teens and continues into their adult lives.  Borderline, or Emotionally Unstable Personality Disorder: exhibits a pervasive partner of instability interpersonal relationships, self image and emotions.  Histrionic Personality Disorder: long standing pattern of attention seeking behaviour and extreme emotionality  Narcissistic Personality Disorder: long standing pattern of grandiosity, an overwhelming need for admiration and usually a complete lack of empathy toward others Cluster C: 'Anxious and Fearful'  Obsessive-Compulsive Personality Disorder: preoccupation with orderliness, perfectionism  Avoidant Personality Disorder: long standing feelings of inadequacy, lead to social inhibition and isolation which in turn are associated with avoidance of school, work etc  Dependent Personality Disorder: long standing need to be taken care of and fear of being abandoned or separated. This leads to dependence, submission and clinging behaviours

12.  long-standing pattern of a disregard for other people’s rights, often begins in childhood.  a person’s pattern of antisocial behavior has occurred since age 15.  lack empathy, callous, cynical, superficial charm, arrogant self appraisal, contemptuous of the feelings, rights, and sufferings of others.  Aggression and violence is often behaviours associated with this diagnosis

13.  Failure to conform to social (lawful) norms, repeatedly performing acts that are grounds for arrest  Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure  Impulsivity or failure to plan ahead  Irritability and aggressiveness, as indicated by repeated physical fights or assaults  Reckless disregard for safety of self or others  Consistent irresponsibility, repeated failure to sustain work behaviour or honour financial obligations  Lack of remorse, as indicated by being indifferent or to rationalizing having hurt, mistreated, stolen from another

14. TRAITS & VULNERABILITIESANTI SOCIAL  Identityarrogant self appraisal  Challenging Behaviourrepeated actions that lead to arrest Impulsivityfailure to plan ahead  Self Reflectionlack of remorse  Emotional Responseirritability & aggressiveness  Relationshipsdeceitfulness/conning others  Safetydisregard for safety of self & others

15.  The main feature of BPD is a pervasive pattern of instability in interpersonal relationships, self-image and emotions. An impulsivity often times demonstrating self-injurious behaviors (cutting, suicide attempts).  Fear of Abandonment: perception of impending abandonment or rejection. Intence abandonment fears and inappropriate anger, make frantic efforts to avoid real or imagined abandonment.  Unstable & Intense Relationships: switch quickly from idealizing people to devaluing them, feeling that the other person does not care enough, does not give enough, is not “there” enough.  Unstable Sense of Self: persistent unstable self-image or sense of self. There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends.

16.  Impulsivity: that is self-damaging, ie gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex.  Parasuicidal Behaviour: recurrent suicidal behavior, gestures, or threats, self-mutilating behaviour (e.g., cutting or burning). Recurrent suicidality is often the reason that these individuals present for help.  Emotional Dysregulation: affective instability due to a marked reactivity of mood (hours). The basic dysphoric mood disrupted by anger, panic, or despair, rarely relieved by well- being or satisfaction - extreme reactivity to interpersonal stresses.  Chronic feelings of emptiness.  Intense anger or have difficulty controlling their anger.

17. ■Frantic efforts to avoid real or imagined abandonment ■A pattern of unstable and intense interpersonal relationships, alternating between extremes of idealization and devaluation ■Identity disturbance, significant and persistent unstable self-image ■Impulsivity in at least two areas that are potentially self-damaging (spending, sex, substance abuse, reckless driving, binge eating) ■Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior ■Emotional instability due to significant reactivity of mood (e.g., intense episodic dysphoria, irritability, anxiety lasting a few hours and no more than a few days) ■Chronic feelings of emptiness ■Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) ■Transient, stress-related paranoid thoughts or severe dissociative symptoms

18. TRAITS & VULNERABILITIESBORDERLINE  Identitypoor sense of self  Challenging Behavioursuicidal & deliberate self harm Impulsivitylinked to challenging behaviours Self Reflectionlimited  Emotional Responseemotional dysregulation  Relationshipsfear of abandonment/rejection/instability  Safety parasuicidal behaviour

19.  TRAITS/VULNERABILITIESBORDERLINE ANTI SOCIAL  Identitypoor sense of selfarrogant self appraisal  Challenging behavioursuicidal & DSHrepeated actions/arrest Impulsivitychallenging behavioursfailure to plan ahead  Self Reflectionlimitedlack of remorse  Emotional responseemotional dysregulationirritability/aggressiveness  Relationshipsfear abandonmentdeceitfulness  Safetyparasuicidal behaviourdisregard for safety/others

20.  Motivation  Self reflection  Substance misuse  Post code lottery of Services  Gender bias??

21.  Take some time to reflect on our expectations when working with people with personality disorders?  Change behaviour?  Establish consistent therapeutic rapport?  Prevent risk?  Being mindful of our expectations can assist s to have amore confident and consistent professional therapeutic relationship

22.  Minimise risk  Shape behaviour  Encourage self reflection  Encourage self efficacy

23. TRAITS & VULNERABILITIESANTI SOCIAL  Identityarrogant self appraisal  Challengingrepeated actions that lead to arrest Behaviour  Impulsivityfailure to plan ahead  Self Reflectionlack of remorse  Emotionalirritability & aggressiveness Response  Relationshipsdeceitfulness/conning others  Safetydisregard for safety of self & others

24.  Identify risk incl historical  Risk management plan (as well as support plan) - consistency - clear boundaries - mindful of reinforcements i.e. negative & positive reinforcement, - immediate consequences i.e. temporary exclusions

25. TRAITS & VULNERABILITIESBORDERLINE  Identitypoor sense of self  Challengingsuicidal & deliberate self harm Behaviour Impulsivitylinked to challenging behaviours  Self Reflectionlimited  Emotionalemotional dysregulation Response  Relationshipsfear of abandonment/rejection instability  Safetyparasuicidal behaviour

26.  Accountable for factors included in risk assessment  History – good predictor of future  Plan & Lethality  Intent

27.  Types of Self Injury  Function of DSH Self Injury Dance with Death Suicidal Intent  Harm Minimization  Chronic  Acute

28.  History is a predictor of future behavior  Collaborative  Shared responsibility  Clear expectations & boundaries  Positive risk taking when appropriate  Share & escalate management plan

29. “I cant control myself” “I just react”

30.  i.e. substance misuse, DSH  Linked to impulsivity  Work in the short term – reinforcement  Often formed at early age – survival  Continue into adult hood when no longer required  No other tools in tool box

31.  Therapeutic relationship  Transference and counter transference issues & most importantly lashings of  Validation & Empathy

32. DEAL WITH DISTRESS FIRST - Remove from situation - Strategies to reduce distress i.e. distractions ONCE DISTRESS REDUCES THEN DISCUSS ISSUE REFLECTIVE PRAXIS ABC

33. When I feel [EMOTION] and feel like [BEHAVIOUR], I will try [INTENSE SENSATIONS] & [DISTRACTIONS] & then I will talk with a staff member. If I still feel very unsafe I will call [EMERGENCY #]

34.  Consistency  Risk sharing  Reflective practice & supervision