Grace under Duress Morbidity, assessment and management

principles

February 2007

Steve Pearce, TVI Oxfordshire

• ‘Personality disorder is a device for attaching the scientific prestige associated with health with what are essentially judgements of value’.

• Barbara Wootton (1956)

• ‘Personality disorder is a concept like body odour…. indubitably affected by constitution and environment, a source of distress to both sufferer and society, yet imbued with ideas of degeneracy so that its possession is also a personal criticism’.

• Peter Tyrer & Brian Fergusson (1988)

The origins of PD categories

• Borderline – psychoanalytic understandings

• Psychopathic disorder – degeneration theory, criminality

• Anxious PD - social phobia

• Schizotypal PD - adoption studies of schizophrenia spectrum disorder

Grace under Duress

• How much is out there? (aka epidemiology)• What problems are associated? (morbidity)• How can you tell? (assessment and

diagnosis)• What causes it? (aetiology)• What can one do about it (management

principles, and why this is a problematic concept)

• …and what is the problem with all of the above?

Presentations

• recurrent deliberate self harm• symptoms of depression and anxiety• eating disturbances• interpersonal problems, which may include

violence• parenting problems• substance abuse • behavioural difficulties, including criminal

offences.• somatic symptoms without physical pathology• high level of use of services

Epidemiology

• Community – 4.5% (10-13%), age 25-44, male=female

• Primary care – 24% of attendees. Cluster C. (Moran 2000)

• Psychiatric outpatients – 59-81%

• Psychiatric inpatients – 36% - 67%

Epidemiology II

• Inpatients with addictions: 78% alcohol and 91% polydrug addiction

• 69% Eating Disorder Unit inpatients

• 41% of completed suicides suffered from EUPD

Prevalence of personality disorder in prison

  Male Male Female  

  Remand Sentenced All  

  Per cent  

Type of personality disorder        

Antisocial 63 49 31  

Paranoid 29 20 16  

Borderline 23 14 20  

Avoidant 14 7 11  

Obsessive-compulsive 7 10 10  

Narcissistic 8 7 6  

Schizoid 8 6 4  

Dependent 4 1 5  

Schizotypal 2 2 4  

Histrionic 1 2 1  

         

Any personality disorder 78 64 50

General features

• Enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individuals culture

• Inflexible and pervasive• Leading to clinically significant distress

or impairment in social, occupational, or other important areas

Cluster A: ‘odd, eccentric’

• Schizoid – detachment from emotional engagement and restricted emotional expression (0.5-1%)

• Paranoid – distrust and suspiciousness, others motives are interpreted as malevolent (1-2%)

Cluster B ‘flamboyant, dramatic, emotional, erratic’– Borderline – instability in interpersonal

relationships, affect and self image, and impulsivity (women, 1%)

– Impulsive – dominated by emotional instability and lack of impulse control

– Histrionic – excessive emotionality and attention seeking (women, 1-3%)

– Dissocial/antisocial – disregard for and violation of the rights of others (men, 1-3%)

– Narcissistic – grandiosity, need for admiration, lack of empathy (variable)

Cluster C ‘anxious, fearful’

– Obsessive-compulsive – preoccupation with orderliness, perfectionism and control (2-7%)

– Dependent – submissive and clinging behaviour related to an excessive need to be taken care of (women, 1-5%)

– Avoidant – social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation (1-4%)

Aetiology

• Where have all the antisocial Taiwanese gone? (Hwu 1989)

• Schizotypal PD commoner in Scandinavia• ASPD and probably BPD becoming more

common in USA (Robins 1991, Millon 1993) (criminality/depr/parasuicide)

• Higher rates of parental separation in Axis II (Paris 1994)

Aetiology

• Social structure breakdown?• Lack of secure attachments -> affective

instability• General risks for all PD:

– parental psychopathology– family breakdown– traumatic events

• Diathesis - stress model (temperament may determine category)

Is BPD caused by childhood abuse?

• 50-70% CSA in BPD

• BUT also associated with other PDs

• 30% severe CSA trauma, 30% less severe CSA, 30% none

• Independent assoc. CSA-BPD (Paris 1994, Links 1993)

BPD

• describe parenting as neglectful or overprotective

• greater temperamental needs, historically all nurturance perceived as inadequate

• Prospective study (Johnson 1999)– PDs up in children grossly neglected or abused– physical or sexual– cluster B

Aetiology ASPD

• Antisocial behaviour in parent -> ASPD in child independent of other risk factors

• Capricious and violent parenting, physical abuse (Pollock 1990) (?independent of parental psychopathy)

• coercive child training, failure to monitor child's behaviour (Patterson 1982,1986)

• large family, low IQ (Farringdon 1988)

Mortality and disability

• Comorbid alcohol and drug use• Increased likelihood of depression and

anxiety• Increased chance of accidental death,

suicide, homicide• Relationship difficulties• Housing problems• Long term unemployment

Bullying

• psychopathologic behaviour– social problems (v)– Aggression (p)(vp)– externalizing behavioral problems (vp)

• a consequence rather than a cause of bullying experiences

• perpetrator or victim

Kim 2006

Morbidity

• Excessive consumption of psychotropic medication

• Frequent attenders at GP, emergencies

• ‘difficult consulting behaviour’

• Revolving door syndrome/repeated psychiatric hospitalisation

Comorbidity

• Cluster A - psychosis (non affective)• Cluster B - psychosis, anxiety, ED,

substance misuse• Cluster C - psychosis, mood disorder,

anxiety, ED, somatoform

Compared to depression, greater use of:

• psychiatric medication

• hospitalisation

• psychotherapy

• day care

• social care

• Bender 2001

Assessment

• often ‘missed’

• four domains– symptoms– interpersonal function– social function including work history– inner experience

• interview an informant

BPD– symptoms

• Self damaging impulsivity (spending, sex, substance misuse, driving, eating• Recurrent suicidal behaviour, gestures or threats or self mutilating behaviour• Transient stress related paranoid ideation or severe dissociative symptoms

– interpersonal function• Pattern of unstable and intense relationships alternating between idealisation and

devaluation • Frantic efforts to avoid real or imagined abandonment

– inner experience • Identity disturbance: unstable sense of self or self-image• Affective instability due to marked reactivity of mood• Chronic feelings of emptiness• Inappropriate intense anger or difficulties controlling anger

– social function including work history

Assessment

• Problems should be long term – since late adolescence/early adulthood

• Problems should be pervasive – generalised across situations

• Problems should be disabling – produce suffering in patient or those around them

• Problems will usually affect social, occupational and personal spheres

Trajectory

• J shaped curve for clusters B and C (traits not disorders)

• Antisocial personality disorder falls off >45

• Recent controversies (Fonagy 2006)

Management principles

1. consistency– all team members substantially involved should

maintain close contact to reduce potential of ‘splitting’ and maintain a consistent approach

– restrict those involved in management to those with a clear role and task

– ‘core team’– likely to be optimal in a specialist team approach

Management principles

2 - pay close attention to countertransference

ie reflective practice• blaming• the assumption that unconscious processes are

conscious • understanding past and present dynamics,

avoiding falling into same roles• supervision

Management principles

3 – avoid reinforcing unhelpful behavioursattachment rather than rule basedcontingency management

4 – encourage reflection and agency in decisions, explaining rationale

5 – management tailored to the individual6 - constancy

avoid staffing changes. Esp in BPD, problems of loss and despair get re-enacted

Management principles

7: Medication

8: Meanings of behaviour eg cutting

9: Impact of environment eg L, no shoelaces, able to be with knives, goes back to ward and tries to hang herself.

Feedback loops and autonomy

Inpatient backup

• Difficult to discharge• More antisocial behaviour when assertive

community based treatment is used (Gandhi et al, 2001)

• Depression and social functioning improved more with hospital based treatment than community based treatment for psychiatric emergencies (Tyrer 1994)

Inpatient backup

• Fewer attachment and support figures – CMHTs unlikely to be able to provide support necessary when function deteriorates

• Early evidence that centres favouring hospitalisation may have increased frequency of repeat DSH (Bennewith 2001)

Indications for admission?

• Crisis intervention, particularly to reduce risk of suicide or violence to others

• Comorbid psychiatric disorder such as depression or brief psychotic episode

• Chaotic behaviour endangering the patient and the treatment alliance

• Stabilising medication• Reviewing the diagnosis and treatment plan• Full risk assessment

Admission should be

• Informal with patient-determined admission and discharge

• Organised around specific goals agreed between patient, psychiatric staff and nursing staff

• Arranged with the clear agreement of nursing staff

• Brief, time limited, and goal determined – patient may be discharged if the goals of admission are not met

Risk assessment

• Possible triggers• Emotional antecedents• Continual or temporary nature• Use of drugs and/or alcohol• Towards whom – general or specific• Intensity e.g. delusional or not• Plans• Reaction of interviewer/team e.g. fear

Practitioner characteristics

• practitioners find it difficult to implement treatment plans consistently for patients with personality disorder

• capacity to be steady, skilful and competent despite provocation, anxiety, and pressure to transgress boundaries

• ability to be pragmatic rather than dogmatic• personality of therapist may have an effect• ‘toughness and tolerance’ - feeling that

worker is indestructible and engaged

General principles

• experience of being the subject of reliable, coherent and rational thinking

• correlates of the level of seriousness and the degree of commitment with which teams of professionals approach the problem of caring for this group

• have been deprived of exactly such consideration and commitment during their early development and quite frequently throughout their later life

New NSF Psychiatric Services

• Early intervention for Psychosis• Assertive outreach• Home treatment teams (crisis resolution)

• The Mental Health Policy Implementation Guide http://www.doh.gov.uk/pdfs/mentalhealthimplowgraphics.pdf

CRISIS RESOLUTION/HOME TREATMENT TEAMS

• Commonly adults (16 to 65 years old) with severe mental illness (e.g. schizophrenia, manic depressive disorders, severe depressive disorder) with an acute psychiatric crisis of such severity that, without the involvement of a crisis resolution/home treatment team, hospitalisation would be necessary. (NB) In every locality there should be flexibility to decide to treat those who fall outside this age group where appropriate.

This service is not usually appropriate for individuals with:• Mild anxiety disorders• Primary diagnosis of alcohol or other substance misuse• Brain damage or other organic disorders including dementia• Learning disabilities

• Exclusive diagnosis of personality disorder• Recent history of self harm but not suffering from a psychotic illness or severe depressive illness• Crisis related solely to relationship issues

4. ASSERTIVE OUTREACH4.1 Who is the service for?

Adults aged between 18 and approximately 65 with the following:2. A history of high use of inpatient or intensive home based care (for example, morethan two admissions or more than 6 months inpatient care in the past two years)3. Difficulty in maintaining lasting and consenting contact with services

4. Multiple, complex needs including a number of the following:• History of violence or persistent offending• Significant risk of persistent self-harm or neglect• Poor response to previous treatment• Dual diagnosis of substance misuse and serious mental illness• Detained under Mental Health Act (1983) on at least one occasion in the past 2 yrs• Unstable accommodation or homelessness

1. A severe and persistent mental disorder (e.g. schizophrenia, major affective disorders) associated with a high level of disability

Mental Health Bill

• Currently in the Lords

• Amendments:– Adding exclusions to the definition of

mental disorder. – Introducing a concept of impaired decision-

making to part 2 of the Act. – Probing amendment to examine the

Government's thinking on treatability.

end