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REFLECTIONS ON THE MANAGEMENT OF PERSONALITY DISORDER IN SECURE SETTINGS

Character/Personality Types/Disorder . Descriptions from ancient world eg body fluids and humourBody typePsychodynamic theoriesTrait theorySocial learning theory. . Current descriptions of Personality Disorder are not particularly helpful in planning clinical interventionsCircular causality Legal vs clinical descriptionsOverlap between disorders/clusters.

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REFLECTIONS ON THE MANAGEMENT OF PERSONALITY DISORDER IN SECURE SETTINGS

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    1. REFLECTIONS ON THE MANAGEMENT OF PERSONALITY DISORDER IN SECURE SETTINGS G Krishnan Rampton Hospital

    3. Current descriptions of Personality Disorder are not particularly helpful in planning clinical interventions Circular causality Legal vs clinical descriptions Overlap between disorders/clusters

    7. Treatability Who When By whom

    8. Epidemiology - Community Surveys Personality Disorder Antisocial Borderline Narcissistic Histrionic Paranoid Schizoid Schizotypal Avoidant Dependent Compulsive Any % 2.0 - 3.0 1.7.-2.0 0.4 2.1 2.0 0.4-0.9 0.6-5.6 1.1-1.3 1.6-1.7 1.7-2.2 5.9-13.0 Reich & De Girolamo (1997) & Moran (1999)

    9. Epidemiology - Prison Antisocial Personality Disorder Male Remand - 63% Male Sentenced - 49% Female - 31% Singleton et al (1998)

    10. Epidemiology - Special Hospitals Borderline Personality Commonest Amongst Men And Women (55% & 91%) Higher Prevalence Of Narcissistic PD Higher Prevalence Of Hares Psychopathy Sex Offenders, Arsonists Over Represented Highly Selected Population Coid (1992)

    11. Comorbidity Dolan et al (1995) - Severity of Disorder ? Multiplicity Of Diagnosis Hogue et al (1998) - Prevalence Of Axis I Pathology Coid et al (1999) - Significant Axis I & II Comorbidity - ASPD/BPD - Comorbid Substance Misuse in 60% Sainsbury (in progress) - Range Of Psychopathy

    13. Common Themes In PD Deprivation, Abuse, Family Breakdown Lack Of Experience Of Success Self Esteem Emotional Under/Over Control Maladaptive Coping Interpersonal Relationship Difficulties

    15. Treatment: What When By Whom

    16. Treatment Models Attachment Interpersonal Trauma Disability Emotional Regulation Cognitive Schema

    17. Evidence Base Norton et al - Therapeutic Communities Linehan -Dialectical Behaviour Therapy Bateman, Fonagy - Pschoanlytically based partial hospitalisation in Borderline PD Gendreau,, - Cognitive Behavioural, Offence Andrews Related Relapse Prevention Progs

    18. Rampton Programme PD Service Development 42 Beds - 2 Consultants Patients - All Male Multidisciplinary Team Incremental Development - Assessment, Rehabilitation Wards Added In A Staged Way

    19. Comprehensive Multidisciplinary Assessment Biopsychosocial, Includes Risk/Offending ICD/DSM Diagnosis Dynamic Formulation Psychometrics/Psychological Testing Single Case Recording, Treatment Plan

    20. Treatment Package Eclectic But Primarily Cognitive Behavioural Individual - Nursing, Psychology Group Work - Nursing, Psychology, Social Work, OT, Medics Medication Management Role Of Key Worker/Primary Therapist

    21. Groups Community Meetings Introductory, Motivation Core Groups e.g. Thinking Skills, DBT Specific Groups e.g. SOTP, VOTP Range Of Educational,Vocational, ADL, Leisure Maintenance, Relapse Prevention

    22. Case Example - 1 24 year old white male Mother of borderline/low IQ, promiscuous Pakistani stepfather, several relationships with vulnerable women Several step siblings Extreme abuse Education, vocation, relationships - disastrous

    25. Case Example - 2 61 year old caucasian male Mother died early, father remarried Father - harsh discipline Stepmother - detached, mocking School - unremarkable Difficulty sustaining relationship, number of acquaintances, no friends Married - interest in teenage stepdaughter

    28. Readiness For Treatment ? Treatability DBT Hierarchy Stages Of Change

    29. Culture Multidisciplinary Managing Defensive Reactions Structure & Flexibility Staff Support, Supervision Communication

    30. Does It Work Problems Of Research Recidivism And/Or Institutional Behaviour Measuring Change - Pre/Post Intervention - Individual Monitoring Anecdotal Evidence Of Change

    31. The Future Uncertainty But Guarded Optimism Gradual Emergence Of Knowledge Base Resources To Translate Knowledge Into Clinical Practice Flexible Movement Between Health & Penal Settings ?? DSPD

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