see the person in personality disorder civil or forensic 22 june 2006 john d mcginley

1. 1 �See the PERSON in PERSONality Disorder� Civil or Forensic22 June 2006John D McGinley/Lindsay Johnson The State Hospital/Caledonian University

2. 2 See the person in personality disordercivil and forensic Losing the person Attitudes Legal issues Clinical issues Political issues Finding the person User focus Traumatic experiences Emotional intelligence Moral maturity Clinical governance

3. 3 ICD 10 DSM IV Paranoid Paranoid Schizoid Schizoid Cluster A Schizotypal Dissocial Antisocial Emotionally unstable/borderline Borderline Histrionic Histrionic Cluster B Narcisistic Anxious(avoidant) Avoidant Dependent Dependent Cluster C Anankastic OCD __________________________________________________________ Emotionally unstable/impulsive Passive-aggressive Depressive Mental retardation

4. 4 DSM IV TR - Personality Disorder �Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself, that are exhibited in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause functional impairment or subjective distress do they constitute Personality Disorders�. (APA, 2000, p. 686)

5. 5 DSM IV TR - Diagnostic Criteria An enduring pattern of inner experience that deviates markedly from the expectations of the individual�s culture. This pattern is manifested in two (or more) of the following areas: Cognition - i.e., ways of perceiving and interpreting self, other people and events Affectivity - i.e., the range, intensity, lability and appropriateness of emotional responses Interpersonal functioning Impulse control

6. 6 DSM IV TR - Diagnostic Criteria The enduring pattern is inflexible and pervasive across a broad range of personal and social situations The enduring pattern leads to clinically significant distress or impairment in social, occupational, or important areas of functioning The pattern is stable and or long duration and its onset can be traced back at least to adolescence or early childhood The enduring pattern is not accounted for as a manifestational consequence of another mental disorder

7. 7 Clinicians Attitudes to Personality Disorder Those patients viewed as �not really ill� tend to be ignored (MacIIwaine, 1981) �Few psychiatric staff prefer to care for this patient group and tend to dislike this population� (Moran & Mason, 1996) �..plentiful evidence exists that staff become alienated from disliked patients.� (Bowers, 2002) �..therapeutic pessimism about PD is widespread among psychiatric professionals, adding to profoundly negative attitudes towards PD patients..� (Bowers, 2002) � Recommend no change to current psychiatric practice regarding compulsory detention� (Personality Disorder Report, Forensic Network 2005) Those patients viewed as �not really ill� tend to be ignored (MacIIwaine, 1981) �� and encourages rejection. Most seriously, it leads to pejorative attitudes.� (Lewis & Appleby, 1986) �few psychiatric nurses prefer to care for this patient group and tend to dislike this population� (Moran & Mason, 1996) �plentiful evidence exists that nurses become alienated from disliked patients.� (Bowers, 2002) Those patients viewed as �not really ill� tend to be ignored (MacIIwaine, 1981) �� and encourages rejection. Most seriously, it leads to pejorative attitudes.� (Lewis & Appleby, 1986) �few psychiatric nurses prefer to care for this patient group and tend to dislike this population� (Moran & Mason, 1996) �plentiful evidence exists that nurses become alienated from disliked patients.� (Bowers, 2002)

8. 8 Personality Disorders: legal and clinical issuesMH (Care and Treatment) (S) Act 2003 Criteria

9. 9 Personality disorders: political issue DSPD Criteria: England and Wales Criterion 1. Severe PD: Significant disorder of personality Criterion 2. High risk: More likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find difficult or impossible to recover Criterion 3. Functional link: The risk presented appears to be functionally linked to the personality disorder

10. 10 Personality disorders: political and clinical issue DSPD Criterion 1: Severity of personality disorder Very high psychopathy: PCL-R score 30+ High psychopathy: PCL-R score 25-29 DSM IV-TR PD x 1 (Not APD Comorbid PD: DSM IV-TR PD x 2

11. 11 Personality disorders: clinical and political issue DSPD criterion 2: level of risk More likely than not Personality disorder: IPDE SCID-1 Actuarial risk instruments VRAG violence risk Static 99 sexual risk Structured clinical judgement HCR 20 Risk Matrix 2000 Dynamic risk VRS SARN

12. 12 Personality disorders: political and clinical issue DSPD criterion 3: functional link Clinical formulation Functional analysis Patterns of past offending Risk type Presence of risk related behaviours

13. 13 Personality disorders: clinical issues co morbidity �the co morbidity of Axis II diagnoses and the degree of heterogeneity within diagnostic groups raise as yet unresolved questions concerning the validity of a diagnostic approach� (Roth and Fonagy, 1996) �Both clinical practice and available research suggest strongly that an individual can suffer from both Axis I condition as well as personality disorder simultaneously� (Lenzenweger & Clarkin, 2005)

14. 14 Personality Disorders: clinical issues Assessment Case and file review Categorical model: DSM IV:TR: Axis II: SCID-1 Dimensional model: DSM V? Self report: IPDE Statistical: Neo-Pi-R (5 factor model) Clinical: Psychopathy Checklist (PCL-R) Emotional intelligence Intelligence quotient Moral reasoning Trauma assessment Risk assessment Baseline measures (e.g. addictions: anger) Overall formulation Outcome measures

15. 15 See the PERSON Inner self Consciousness Subjective experience Spiritual Mindfulness Consistency of thoughts (schema), feelings (emotions), behaviours (expression) More than sum of traits

16. 16 Personality disorders: clinical issues Treatment: idiopathic Multiple domains of psychopathology Requires combination of interventions tailored to individual needs. Common Factors in all cases � different manifestations Require general and individually tailored strategies within all treatments Complex psychological and biological etiology Psychological and biological treatment; aim to enhance adaptation Psychosocial adversity influences the contents, processes and organisation of the personality system. Address all consequences of adversity Livesley 2001

17. 17 Personality disorders: clinical issues Treatment: effectiveness Best conceptualised in integrative and biopsychosocial perspective. Assessing treatability or amenability to treatment is critical to maximizing treatment planning and outcomes. Effective treatment of personality disorders is tailored treatment. The lower the level of treatability, the more combining and integrating of treatment modalities and approaches is needed. The basic goal of treatment is to facilitate movement from personality-disorder functioning to personality-style functioning. Sperry 2003

18. 18 Personality disorders: clinical issues Psychotherapeutic models Supportive therapy Psycho-educational Psychodynamic CBT/CAT/DBT Milieu therapy Community Pharmacological

19. 19 Maladaptive and inflexible thinking: Schema Focused Therapy EMAs � develop from toxic childhood experiences. Wider definition than Beck � memories, emotions, cognitions & bodily sensations re relationship between you and another Dysfunctional behaviour develops as a response to schemas. Mode is those schemas or schema operations currently active for an individual ie clusters of active schemas Currently identified 10 modes in 4 general categories: Child Maladaptive coping Maladaptive parent Healthy adult EMAs � develop from toxic childhood experiences. Wider definition than Beck � memories, emotions, cognitions & bodily sensations re relationship between you and another Dysfunctional behaviour develops as a response to schemas. Mode is those schemas or schema operations currently active for an individual ie clusters of active schemas Currently identified 10 modes in 4 general categories: Child Maladaptive coping Maladaptive parent Healthy adult

20. 20 Personality disorders: clinical issues Treatment: Difficulty in Engaging

21. 21 Personality disorders: clinical issues Personality and risk

22. 22 needs of the PERSON � holistic restore self respect contract, cooperation, engagement match needs with treatment adapt to suit PERSON system of integration of person experience develop new treatments evaluate effectiveness right place, right time, right treatment

23. 23 Emotional Impairment and psychopathy Psychopathy identifies one form of pathology associated with high levels of antisocial behaviour: individuals who present with a particular form of emotional impairment The Psychopath: emotion and brain James Blair et al (2005)

24. 24 Emotional intelligence Self awareness Motivation Self regulation Empathy Social skills Goleman 1998

25. 25 Emotional competence framework Self awareness Emotional awareness Accurate self assessment Self confidence

26. 26 Emotional competence framework Self regulation Self control Trustworthiness Conscientiousness Adaptability Innovation

27. 27 Emotional competence framework Motivation Achievement drive Commitment Initiative Optimism

28. 28 Emotional competence framework Empathy Understanding others Developing others Service orientation Leveraging diversity Political awareness

29. 29 Emotional competence framework Social skills Influence Communication Conflict management Leadership Change catalyst Building bonds Collaboration and cooperation Team capabilities

30. 30 Person and moral maturity: 1. Stages Pre-conventional stage State 1 Punishment/obedience State 2 Instrumental relativist Conventional stage State 3 Good boy-Nice girl State 4 Law and order Autonomous stage State 5 Social contract State 6 Universal ethical principle Kolberg

31. 31 Person and moral maturity: 2.Qualities Stage development is invariant Cannot comprehend beyond next stage Cognitive attraction to next stage Development depends on cognitive disequilibrium

32. 32 Personality Disorders: Clinical GovernanceUnderstanding Personality Disorder: BPS June 2006  Treatment: core services in mental health and forensic settings Access to specialist multi-disciplinary personality disorder teams Multi-agency collaboration Clinical and forensic psychologists: clinical leaders Training of team and agencies essential: awareness of specialisms Structured assessments Focus on formulating person�s needs User views, user research and user involvement

33. 33 It is the responsibility of psychiatrists to offer treatment where ever possible Improve teaching of psychiatry trainees Prioritise limited capacity of psychiatric services Develop preventive interventions in child and adolescent services Develop clearer definition of treatment goals Ensure multidisciplinary cooperation

34. 34 Personality Disorders: ethical issuesChallenge assumptions Harder to engage Higher attrition rates Poorer outcome More clever psychopath! Service �abusers� rather than �users� Untreatable Alienation: disliked patients Split the team! PD patients are frequently seen as more difficult to engage in treatment. They are sporadic attendees and difficult to engage in long-term treatment plans. Self-damaging, suicidal and violent behaviours often interrupt treatment (Warren & Dolan, 1996). Requiring higher dosage and having higher attrition rates. Skodol 1983 found there is a high dropout rate for people with personality disorders, 44-66% within hospital based treatment (Blackburn, 2000; Goldstein, Powers, McCusker, Lewis, Bigelow & Mundt, 1998; Lipsey, 1995). Presence of PD predicts poor outcome for most psychological interventions (Diguer, Barber & Luborsky, 1993; Hardy, Barkham, Shapiro, Stiles, Rees & Reynolds, 1995; Hoglend, 1993; Reich & Green, 1991; Reich & Vasile, 1993). Same in forensic settings (Blackburn, 2000; Dolan, 1998; Goldstein, Powers, McCusker, Lewis, Bigelow & Mundt, 1998; Lipsey, 1995). Harris et al (1994) and Rice (1997) concluded that patients with BPD, not only failed to respond to treatment, but their maladaptive behaviours were often amplified by their involvement in treatment, simply because of the fundamental characteristics of BPD. Can get worse for several reasons Retraumatisation / Arousal / excitement; Offending / detection evasion repertoire; Confrontation can lead toexacerbation of symptoms eg paranoid thinking, abandonment, more entrenched views; Failure in therapy can make them worse ieStigmatisation � �PDs can�t change� / �I can�t change� (Safran & Muran 1996; Jones,2002) Such negative opinions have led to patients with BPD being considered by many as �sucking in services in response to a crisis� and as �abusers� of the mental health services, rather than �users� (Warren & Dolan, 1996). Last 10 years growing body of evidence PD can respond to therapy suggesting that treatments can reduce the symptomatic behaviours and accompanying emotional problems characterising BPD (Dolan, 1998; Gabbard, 1997; Monsen, Odland, Faugli, Daae & Eilertsein 1995; Sanislow & McGlashan, 1998). PD patients are frequently seen as more difficult to engage in treatment. They are sporadic attendees and difficult to engage in long-term treatment plans. Self-damaging, suicidal and violent behaviours often interrupt treatment (Warren & Dolan, 1996). Requiring higher dosage and having higher attrition rates. Skodol 1983 found there is a high dropout rate for people with personality disorders, 44-66% within hospital based treatment (Blackburn, 2000; Goldstein, Powers, McCusker, Lewis, Bigelow & Mundt, 1998; Lipsey, 1995). Presence of PD predicts poor outcome for most psychological interventions (Diguer, Barber & Luborsky, 1993; Hardy, Barkham, Shapiro, Stiles, Rees & Reynolds, 1995; Hoglend, 1993; Reich & Green, 1991; Reich & Vasile, 1993). Same in forensic settings (Blackburn, 2000; Dolan, 1998; Goldstein, Powers, McCusker, Lewis, Bigelow & Mundt, 1998; Lipsey, 1995). Harris et al (1994) and Rice (1997) concluded that patients with BPD, not only failed to respond to treatment, but their maladaptive behaviours were often amplified by their involvement in treatment, simply because of the fundamental characteristics of BPD. Can get worse for several reasons Retraumatisation / Arousal / excitement; Offending / detection evasion repertoire; Confrontation can lead toexacerbation of symptoms eg paranoid thinking, abandonment, more entrenched views; Failure in therapy can make them worse ieStigmatisation � �PDs can�t change� / �I can�t change� (Safran & Muran 1996; Jones,2002) Such negative opinions have led to patients with BPD being considered by many as �sucking in services in response to a crisis� and as �abusers� of the mental health services, rather than �users� (Warren & Dolan, 1996). Last 10 years growing body of evidence PD can respond to therapy suggesting that treatments can reduce the symptomatic behaviours and accompanying emotional problems characterising BPD (Dolan, 1998; Gabbard, 1997; Monsen, Odland, Faugli, Daae & Eilertsein 1995; Sanislow & McGlashan, 1998).

35. 35 Hope and developments Service users stories of hope New century re-birth of hope and raising expectations Hearing voices networks See me Proud of our experience Improving alliance with service users Improved assessment procedures Developing effective treatment paradigms Collaborative relationships � practitioner (the expert by training) and service user (the expert by experience)

36. 36 ConclusionsPerson distressed by a personality disorder deserves consideration under mental health legislation for care and treatmentWhen assessing the impact of a mental disorder, in all circumstances, all persons being assessed should be screened for personality disorder

37. 37 WORKSHOP 2 Covert versus Overt Personality Disorder diagnosis? What are the barriers to the effective involvement of service users and staff? Lindsay Johnston and John McGinley

38. 38 �See the PERSON in PERSONality Disorder� Civil or Forensic22 June 2006John D McGinley/Lindsay Johnson The State Hospital/Caledonian University