why we need to offer wiser care for personality disorder...

Why we need to offer wiser care for personality disorder?

structured community care to alternative to admissions

Dr Mark Sampson Consultant Clinical Psychologist Lead Clinician in personality

disorder 5bp

Personality Disorder in the offending population

• Public Health and Criminal Justice (Prevalence) Prisoners 16+ Population 16-64 Psychosis 8% 0.4% Dep/ Anx 45% 17.6% Drugs 45% 3.4% Alcohol 30% 5.9% Personality Disorder 66% 4.4%

Prevalence • High use of healthcare services was

confounded by comorbid mental disorder and substance misuse.

• Cluster B disorders were associated with early institutional care and criminality.

• British Journal of Psychiarty 2006 May;188:423-31. • Prevalence and correlates of personality disorder in Great Britain. • Coid J1, Yang M, Tyrer P, Roberts A, Ullrich S.

What is Personality Disorder? Personality Disorder is a medical label Although not a very good label evidence suggest if

used sensitively it is outcomes better for service user. It is when somebody has long standing

difficulties coping Persistent, pervasive and problematic

However: – It is different from a mental illness?

Personality Disorder What is a Personality Disorder?

– Personality Disorders in their current form first emerged in DSM III when they utilized a multi-axial diagnostic system- Multi-axial Assessment

– Axis I Clinical Disorders – Axis II Personality Disorders – Axis III General Medical Conditions – Axis IV Psychosocial and Environmental Problems – Axis V Global Assessment of Functioning

D.S.M. I.C.D. Cluster A paranoid schizoid schizotypal

Cluster B antisocial borderline narcissistic histrionic

Cluster C avoidant dependent obsessive compulsive

paranoid schizoid

dissocial emotionally unstable - impulsive - borderline histrionic

anxious dependent anankastic

What to work on? • Co-existing mental health problems not uncommon (i.e.

Depression, Eating Disorders, Anxiety, Poly drug use)

• Therapy/Treatment Options 1. Address the clinical disorder only e.g.

depression/anxiety, psychosis, eating disorder etc 2. Address the clinical disorder but modify the treatment to

account for personality disorder 3. Personality disorder seen as primary problem and

therapy/treatment aimed to address this.

What Works

Personality Disorder Recovery

DBT

MBT

CAT

Structured Care

Predictive Recovery by Axis II Pathology

What is helpful? • Attachment • Secure attachment facilitates recovery • But how?

Recovery • Reliability • Consistency • Coherency • Mirroring emotions internal states

Why is this difficult? • System

– Wrong model of care • Fixing rather than mirroring • Passing on rather than containing • Lack of a coherent model

• Practitioner • Lack of appropriate training e.g. managing internal states • Practitioner capacity for tolerating emotions

• Client communication of internal state of confusion

Clear Coherent Approach

Affect Regulation Clear theoretically driven

Protocols on risk management

Have a clear Identity

(theory –goals) Have a clear

coherent way of Interacting

What do we do in 5bp CHOICE

Cluster A Cluster B Cluster C

DBT

MBT

SCM

Myths to working with Personality Disorder

• Being drawn into the ‘Fantasy Elsewhere’

Medication • Over prescribing

Myths to working with Personality Disorder

• Hospitalisation – Doing more is NOT always helpful?

Proposal

Alternative To Admission

CRISIS CRISIS BEDRecovery

TeamHome

TreatmentHome

Treatment

In patientadmission

Banked bed days self referral

Training Opportunities Skill based training

(SCM)

Nationally Recognised KUF Programme

3 day Training course

1 Day CJ focussed Workshop PDiM

E Learning

Any Questions

• mark.sampson@5bp.nhs.uk • 01744 626741