Personality Disorder: An update for Primary Care Dr Pardeep Dhillon With inputs from Dr Chris Bench and Dr Neelima Reddi(Consultant Psychiatrists)
Contents Diagnostic criteria Relation to Clustering Typical presentation Management Resources
What are the essential components of personality disorder?
ICD-10 Ingrained patterns of behaviour indicated by inflexible and disabling responses that significantly differ from how the average person in the culture perceives, thinks and feels, particularly in relating to others
DSM-IV An enduring pattern of psychological experience and behaviour that differs predominantly from cultural expectations, as shown in two or more of: Cognition (ie perceiving and interpreting the self, other people or events) Affect (ie the range, intensity, lability and appropriateness of emotional response Interpersonal functioning Impulse control
Additional Criteria: ICD-10 Markedly disharmoniousattitudes and behaviour, involving usually several areas of functioning, eg affectivity, arousal, impulse control, ways of perceiving and thinking, and style of relating to others. The abnormal behaviour pattern is enduring, of long standing, and not limited to episodes of mental illness. The abnormal behaviour pattern is pervasive and clearly maladaptive to a broad range of personal and social situations. The above manifestations always appear during childhood or adolescence and continue into adulthood. The disorder leads to considerable personal distressbut this may only become apparent late in its course. The disorder is usually,but not invariably, associated with significant problems in occupational and social performance.
Additional Criteria: DSM-IV The pattern must appear inflexible and pervasiveacross a wide range of situations, and lead to clinically significant distress or impairment in important areas of functioning. The pattern must be stableand long-lasting, have started as early as at least adolescence or early adulthood. The pattern must not be better accounted for as a manifestation of another mental disorder, or to the direct physiological effects of a substance (eg a drug or medication) or a general medical condition (eg head trauma).
ICD-10 and DSM identify 11 Personality Disorders ICD-10 Paranoid Schizoid Dissocial Emotionally unstable Impulsive type Borderline type Histrionic Anankastic Anxious (avoidant) Dependent DSM-IV Cluster A Paranoid Schizoid Schizotypal Cluster B Antisocial Borderline Histrionic Narcissistic Cluster C Avoidant Dependent Obsessive -compulsive
In practice Cluster A: Odd and eccentric Paranoid Schizoid Schizotypal Cluster B: Dramatic / erratic Borderline / emotionally unstable / impulsive Antisocial Histrionic Narcissistic Cluster C: Anxious / avoidant Avoidant Dependent Anankastic / obsessional
Can we do better in terms of classification? Criteria for the current 11 PDs are not supported by good empirical evidence They are committee diagnoses May be better to regard them as risk factors and complicating factors for a wide range of mental disorders (like obesity is risk factor for DM, IHD, Breast cancer etc) Distinction between personality traits(part of normal functioning) and symptomswhich are unpleasant and alien and undesirable
ICD-11 Abolish individual categories of PD Do not include borderline PD Replace with 5 levels of severity No personality disturbance Personality difficulty Personality disorder Complex personality disorder Severe personality disorder Severity qualified by trait domains Schizoid domain Anankastic domain Externalising domain (sociopathic) Internalising domain (neurotic)
ICD-11 Severity determined by: Number of domains involved (more = greater severity) The degree of social dysfunction Risk to the individual and to others
DSM -5 Current Edition has abolished axis 2, Infact it has abolished the first three axis There are a lot of issues with the current edition National Institute for mental health has withdrawn support The proposal was similar to ICD11 a with move towards six personality hybrids and further categorisation based on severity American psychiatric association has decided to retain the use of DSM4 for the time being The hybrid methodology retains six personality disorder types: Borderline Personality Disorder Obsessive-Compulsive Personality Disorder Avoidant Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Narcissistic Personality Disorder
Parking lot of the Personality Disordered
Parking lot of the Personality Disordered Paranoid cornered again!
Parking lot of the Personality Disordered Narcissistic largest car, big hood ornament
Parking lot of the Personality Disordered Dependent relies on being close to other cars
Parking lot of the Personality Disordered Passive aggressive parks car to take up two spaces
Parking lot of the Personality Disordered Borderline rams into car of ex-lover
Parking lot of the Personality Disordered Antisocial deliberately obstrusts other cars
Parking lot of the Personality Disordered Histrionic parks dramatically in centre look at me
Parking lot of the Personality Disordered Histrionic parks dramatically in centre look at me
Parking lot of the Personality Disordered Obsessional perfect alignment in parking
Parking lot of the Personality Disordered Avoidant parks in corner
Parking lot of the Personality Disordered Schizoid cannot tolerate being close to other cars
Parking lot of the Personality Disordered Schizotypal intergalactic parking
Personality Disorder and Clustering
Clustering in mental health Now There is a move to PBR in Secondary care, based on HoNoS The HoNoS PBR or Clustering Assessment 13 current items rate symptoms and need in the last 2 weeks 5 historical items consider problems which occur in episodic or unpredictable ways.
Making the Diagnosis May be better made by GP Longitudinal perspective Often better able to distinguish between new, transient and enduring patterns of behaviour GP less likely to make specific PD diagnosis Other than borderline (BPD) and antisocial (ASPD)
Borderline personality (BPD) People with BPD are likely to: Feel they do not have a strong sense of who they really are, and others may describe them as very changeable Suffer from mood swings, switching from one intense emotion to another very quickly, often with angry outbursts Have brief psychotic episodes, hearing voices or seeing things that others don t Do things on impulse which they later regret Have episodes of self harm, and suicidal thoughts Have a history of stormy or broke relationships Have a tendency to cling on to damaging relationships, because they are terrified of being alone
Borderline personality (BPD) Does not mean it s borderline whether there is a personality disorder or not Does refer to the borderline between being neurotic and psychotic Somepatients do flip alarmingly into a (brief) psychotic mental state
Antisocial personality People with ASPD are likely to: Act impulsively and recklessly, often without considering the consequences for themselves or others Behave dangerously and sometimes illegally Behave in ways that are unpleasant for others Do things even though they may hurt people to get what they want, putting their needs above others Feel no sense of guilt in they have mistreated others Blame others and offer plausible rationalisations for their behaviour Be irritable and aggressive and get into fights easily Be very easily bored and may find it difficult to hold down a job for long Have a criminal record Have had a diagnosis of conduct disorder before age 15 Say now look what you made me do
Epidemiology Prevalence: Community: 3 10% (~1 in 20 of these has severe PD) Primary Care: 10 30% Secondary Care: Inpatients: 50% Outpatients: 50% Substance Use services: 70% Prison populations: Male remand: 78% Female remand 50% Completed suicide: 57%
BPD - Clues from the assessment Disruptions / adversity in personal history History of self harm Difficulty in initiating or sustaining intimate relationships Repeated history destructive relationships Poor work history / sickness Difficulty in sustaining working relationships Substance use Forensic history Splitting within / between teams you re the best doctor I ve ever seen, not like that one I saw here last week
BPD -Clues from the assessment How are they in the room with you? Strong emotional reactions Transference / counter-transference Heartsinks and favourites Rescue fantasies Do you find yourself behaving atypically Marked variation in colleagues reactions Difficulty in engaging patient in addressing health care Boundary violations
Re-enactments Imagine a patient with an early experience of neglect or abuse Their underlying expectations will persist largely unconsciously but become more active when seeking help They will tend towards acting in a way that is designed to meet those expectations Their approach encourages those around them to act in a way that complements that This can lead to a re-creation of the initial caring failure
Illness Behaviour In primary care the re-enactments often manifest through abnormal illness behaviour: Medically unexplained symptoms Frequent attending Unpredictable use of healthcare (DNAs then requests for emergency appts) High use of psychotropics / medication Self harm Complaints It can be hard to remember that PD patients are asking for help it s just in a way that confuses (and disturbs) us
Management in Primary Care The consistent relationship is the key Keep to task in the consultation Keep to time in the consultation Keep to your normal structure If you are doing something very different from normal it s probably not the right thing Continue to manage the Physical and Mental health needs in the face of whatever challenge they bring (wherever possible)
What can help in Primary Care? Sharing the burden / experience Informal discussions Formal complex cases reviews Foster climate of openness with all staff in surgery Be curious about range of experiences they are valid and help in understanding Buy time tell the patient you want to consider things carefully Be frank with the patient the most burning thing to say is probably the most important Seek specialist opinion/ advice where appropriate
When to refer Threatening patients Assessment of diagnosis Assessment of level of risk Formulation of management plan Repeat deliberate self harm Common feature of borderline personality Risk factor for future self harm and increased risk suicide Co-morbidity Depression, anxiety, somatization, substance misuse Marked impairment of psychosocial functioning Vulnerability of self / dependents
Treatment Making the diagnosis Being honest with patient about this The relationship with the patient Some specific treatments Treat co-morbidities Depression (if fulfills criteria for depressive episode) Anxiety Substance use
Drug Treatments Most randomised trials in the last 20 years are in BPD Most trials are judged to be of low quality by NICE NICE (2009) antipsychotic drugs should not be used for the medium and long term treatment of borderline personality disorder in general drug treatment should be avoided except in an emergency
Drug Treatments Lieb et al (2010): British Journal of Psychiatry 196, 4-12 Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Suggested that mood stabilisers and second generation antipsychotics may be effective for treating a number of core symptoms Evidence does not support effectiveness for overall severity of borderline PD Pharmacotherapy should be targeted at specific symptoms
Psychological Treatments More likely to be effective in those patients who can: Think about and monitor their own thoughts, feelings and behaviour Be honest with themselves about their problems and imperfections Accept responsibility for solving their problems, even if they did not cause them Be open to change and stay motivated Or in short, patients with a reasonable insight
Psychological Treatments No evidence for any one mode of treatment being more effective than an other Ideally have menu of options available Common treatment programmes include: STEPPS / CBT Mentalisation Dialectical Behaviour Therapy Psychodynamic programmes / transference focussed Rx Therapeutic communities Treatments tend to be long (1 2 yrs), often tiered and much preparation Structured team approach is required for BPD Cognitive therapeutic approach (group work) for ASPD In ASPD interventions that reward are better than those that punish
Mentalisation based therapy (MBT) People with BPD may have a poor capacity to mentalise. Mentalisation is the ability to think about thinking. Examining thoughts and beliefs Assessing whether they are useful, realistic and based on reality Recognising that others have thoughts, emotions etc and that your interpretation of these may not necessarily be correct Being aware of the potential impact your actions will have on other people s mental states MBT aims to improve ability to recognise your own and others mental states, and learn to step back from your thoughts about yourself and others and examine them to see if they are valid. Individual and groups sessions; usually up to 18 months
Dialectical Behaviour Therapy (DBT) DBT suggests that in order to overcome these problems you need to learn how to control your emotions, and that the first step in doing so is to experience, recognise and accept your emotions. You can then start to reduce their intensity and let them go quicker. Marsha Linehan developed DBT from CBT for use in BPD CBT traditionally focuses on helping change unhelpful ways of thinking and behaving DBT also helps change but focuses on accepting who you are at the same time DBT uses a balance of change techniques and acceptance techniques Uses individual and group sessions, out of hours contact, and a team approach Evidence in particular in women with BPD who self harm
Role of Peer Support Increasingly core feature of treatment programmes Learn through lived experience Expert patients Makes for a normalising process Focusses on people s strengths Challenges hopelessness Interventions are very powerful
Where treatment works Reduction in destructive behaviours Self harm Substance use Improved social and occupational function Reduction in GP attendance A&E attendance Psychotropic prescriptions Crisis presentations In patient admissions
Prognosis Variable May improve over time Higher incidence of death by violence and suicide. Between 30 and 60% of completed suicides retrospectively show evidence of a personality disorder. People with obsessional personality disorders are at a high risk of progression to depressive illness. Borderline PD carries a relatively favourable prognosis with clinical recovery in over 50% at 10 to 25 year follow up. People with paranoid and schizotypal PD may progress to persistent delusional disorder, but those with schizoid PD do not. The prognosis for personality disorders is improved if the person establishes a stable relationship with another person.
What to expect from secondary care For all those referred Assessment / formulation / diagnosis Assessment of risk Liaison with other agencies where necessary Local authority / safeguarding Substance use services Criminal justice system Some indication of current treatability Advice on what to do and what not to do
How Can the GPs help the patient? Recognise the use of immature defence mechanisms and the negative coping mechanisms used by patients with certain types of personality disorder. Be supportive and try to establish a good rapport. Provide support for improving social situation, for eg help with social housing, benefits etc. Try to be non judgemental Understand that a lot of emotions that we feel could be due to transference and counter transference and it is important to sometimes take and objective impersonal view. Seek advice and Support from both primary care and secondary care colleagues Patients illness will also create difficulties in providing care for physical health, perhaps create physical health care plans for patients and ensure they are aware of the plans or perhaps have written copies
Referrals 1.Initial referrals should be done to CMHRS for care coordination and initial assessment 2.Initial stability is important, so referral are not generally done directly to psychotherapy 3.After initial stabilisation, the referrals are then done to local psychotherapy group within North-West surrey
Future of local services Personality disorder strategy is being discussed in the Trust and if approved, it will be launched towards latter part of the year following an implementation plan. It will offer: Good, early, comprehensive assessment with stabilisation of social factors; Good clinical care with co-morbid physical and mental health problems; Offering help with drug and alcohol issues and then a tailored treatment plan according to the needs of the patient across the Trust. This is to ensure uniformity and parity of care across the Trust. Structured clinical care; User networks will be developed as well as carer support as well as tele-health initiatives.
Local Psychotherapy team Dr Neelima Reddi: (offers individual, group therapy and MBT in the department) Dr Elaine Alves - offers DBT, CAT, ACT; Rebecca Isherwood-Smith from Transitions Services offer STEPPS, ACT, OT for PD Richard Whitaker who offers Art Therapy and is part of the MBT team.
Support available General resources Choice and Medication website: http://www.choiceandmedication.org/wlmht/ WLMHT website pages for GPs: http://www.wlmht.nhs.uk/how-we-canhelp/gp-information/ Royal College of General Practitioners: http://www.rcgp.org.uk/clinicaland-research/clinical-resources/mental-health.aspx Royal College of Psychiatrists: http://www.rcpsych.ac.uk/healthadvice/atozindex.aspx
Support available Specific PD resources NHS Choices http://www.nhs.uk/conditions/borderline-personality-disorder/pages/treatment.aspx Royal College of Psychiatrists http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/personalitydisordersfacts.aspx Mind: http://www.mind.org.uk/media/42894/understanding_bpd_2012.pdf http://www.mind.org.uk/information-support/drugs-and-treatments/dialectical-behaviour-therapy Mental Health Foundation: http://www.mentalhealth.org.uk/help-information/mental-health-a-z/p/personality-disorders/ Everyman (anger management and related for men): http://www.everymanproject.co.uk BPD World: http://www.bpdworld.org/