Grace under Duress Morbidity, assessment and management principles

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Grace under Duress Morbidity, assessment and
management principles

• October 2005
• Steve Pearce, TVI Oxfordshire

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• 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)

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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

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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?

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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

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Epidemiology

• Community 4.5 (10-13), age 25-44, malefemale
  
• Primary care 24 of attendees. Cluster C.
  (Moran 2000)
• Psychiatric outpatients 59-81
• Psychiatric inpatients 36 - 67

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Prevalence

• Inpatients with addictions 78 alcohol and 91
  polydrug addiction
• 69 Eating Disorder Unit inpatients
• 41 of completed suicides suffered from EUPD

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Prevalence of personality disorder in prison
  Male Male Female  
  Remand Sentenced All  
  Per cent Per cent 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
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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

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Classification

• 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)

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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 (very variable)

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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)

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

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Aetiology

• social structure breakdown?
• Loss of secure attachments -gt affective
  instability
• General risks for all PD
• parental psychopathology
• family breakdown
• traumatic events
• Diathesis - stress model (temperament may
  determine category)

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

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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

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Aetiology ASPD

• Antisocial behaviour in parent -gt 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)

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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

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Morbidity

• Excessive consumption of psychotropic medication
• Frequent attenders at GP, emergencies
• difficult consulting behaviour
• Revolving door syndrome/repeated psychiatric
  hospitalisation

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Comorbidity

• Cluster A - psychosis (non affective)
• Cluster B - psychosis, anxiety, ED, substance
  misuse
• Cluster C - psychosis, mood disorder, anxiety,
  ED, somatoform

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Compared to depression, greater use of

• psychiatric medication
• hospitalisation
• psychotherapy
• day care
• social care

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Assessment

• often missed
• four domains
• symptoms
• interpersonal function
• social function including work history
• inner experience
• interview an informant

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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

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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

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Trajectory

• J shaped curve for clusters B and C (traits not
  disorders)
• Antisocial personality disorder falls off gt45

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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

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Management principles

• 2 - pay close attention to countertransference
• blaming
• the assumption that unconscious processes are
  conscious
• understanding past and present dynamics, avoiding
  falling into same roles
• supervision

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Management principles

• 3 avoid reinforcing unhelpful behaviours
• attachment rather than rule based
• contingency management
• 4 encourage reflection and agency in decisions,
  explaining rationale
• 5 management tailored to the individual
• 6 - constancy
• avoid staffing changes. Esp in BPD, problems of
  loss and despair get re-enacted

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Management principles

• 7 Medication

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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

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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

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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/mentalhealthimplowgraph
  ics.pdf

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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

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4. ASSERTIVE OUTREACH

• 4.1 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, more
• than 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