Psychotherapy and personality Disorder

Dr Linda TrelivingConsultant Psychiatrist in psychotherapy

NHS Grampian

linda.treliving@nhs.net

DSM IV CLUSTER CLASSIFICATION

• Cluster A, including paranoid, schizoid, and schizotypal PDs, which may manifest in cognitive distortions and an interpersonal style that is odd, eccentric, or detached.

• Cluster B, consisting of antisocial, borderline, histrionic, and narcissistic PDs, which often involve behaviour that appears dramatic, erratic, impulsive, aggressive, or affectively dysregulated.

• Cluster C, which includes avoidant, dependent, and obsessive-

compulsive PDs that tend to involve fear, anxiety, apprehension, or perceived avoidance of harm.

Epidemiology

• Approximate prevalence of PD in;• Community 10 %•General practice 20 %• Psychiatric outpatients 30%• Psychiatric inpatients 40%• Prison 20-80 %

“The distinction between personality disorder and mental illness”

• …… it is commonplace for a diagnosis of personality disorder to be used to justify a decision not to admit someone to a psychiatric ward, or even to accept them for treatment……

B.J.Psych. Volume 180,February 2002,pp 110-115 KENDELL, R. E.

Are personality disorders treatable?• Lewis & Appleby (1988) 2 case vignettes , one with a history of PD. - pd was an enduring pejorative label - distinct from genuine illness - attribution of responsibility and control - less deserving of treatment - treatment unlikely to work

Treatment utilization by patients with personality disorders

PD more extensive usage than major depression of – • Psychiatric outpatient• Psychiatric inpatient• Psychopharmacologic treatment

Bender et al (2001). American Journal of Psychiatry, 158, 295–302.

Malcolm Pines, Group analyst

• “…..those attending personality disordered patients feel impelled to conform to a pattern imposed by the patient, so that we begin to feel provoked, hostile, persecuted and have to behave exactly as the patients need us to, becoming rejecting and hostile…..”

• Group Analysis, (1978), 11, 115-126

DSM IV diagnosis of BPD

•A pervasive pattern of instability• of interpersonal relationships• self-image• affects

•marked impulsivity• beginning by early adulthood • present in a variety of contexts, • as indicated by five (or more) of the following:

BPD = 5 or more of the following

1.Frantic efforts to avoid real or imagined abandonment

2.Unstable and intense interpersonal relationships.

3.Identity disturbance:

4.Impulsivity.

5.Recurrent suicidal behavior

6.Affective instability

7.Chronic feelings of emptiness

8.Inappropriate, intense anger

9.Transient, stress-related paranoid ideation or severe dissociative symptoms

The biopsychosocial model of BPD

PDQ IV scores for 129 prisoners in Cornton Vale, 2011

Cornton Vale audit 2011

• 53% Borderline PD

• 52% Antisocial PD

• 35% Borderline PD and Antisocial PD

Cornton Vale audit, Childhood trauma questionaire

Secure attachment

....... should engender a positive, coherent, and consistent self-image and a sense of being worthy of love, combined with a positive expectation that significant others will be generally accepting and responsive.

The hyperactivation ofattachment in BPD

• The attachment system in BPD is hypersensitive and triggered too readily• Indications of attachment hyperactivity in core

symptoms of BPD• Frantic efforts to avoid abandonment• Pattern of unstable and intense interpersonal relationships• Rapidly escalating tempo moving from acquaintance to

great intimacy

Attachment Disorganisation in relationship to practitioner

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Mild Distress/Anxiety

Emotional Challenge

Proximity seeking

Activation of attachment

The ‘hyperactivation’ of the attachment system

Emotionally Challenging Experience in Relation to the practitioner

Attachment provocation

• In the ward• Stimulation of attachment system in admission• Changing shifts• Negotiating levels of observation, • Discussing discharge• Managing incidents• Negotiating availability – “in 5 minutes”

Attachment provocation

At interview• Clinician lowering voice• Increasing intimacy• Responding to demands• Refusing to respond to demands• Boundary violation however small

Attachment theory and the psychiatrist–patient relationship• An empathic response on the part of the doctor, with accurate verbal

identification of emotion, produces assuagement of attachment behaviours, triggering ‘vitality affects’ and the beginnings of ‘companionable exploration’ – the reasons for coming and history of presenting symptoms.• Jeremy Holmes, BJPsych (2008)193, 377

Attachment theory and the psychiatrist–patient relationshipPeople with insecure attachment histories find this process

problematic, typically deactivating’ or ‘hyperactivating’ affect, or producing incoherence.

Psychiatrists need to identify and understand this sequence of relational expectations and behaviours in themselves and their clients.

Jeremy Holmes, BJPsych (2008)193, 377

Mentalization

• the capacity to recognise and understand the existence of minds, both one’s own and those of others.

• The normal ability to ascribe intentions and meaning to human behaviour

• to recognize that human behavior is motivated by mental states–by things like thoughts, beliefs, feelings, and desires.

Mentalization

• Shapes our understanding of others and ourselves

• Central to human communication and relationships

• Underpins clinical understanding, the therapeutic relationship and therapeutic change regardless of modality of therapy

What does good mentalizing looklike?• Perception of own mental functioning• Appreciation of changeability• Developmental perspective• Realistic scepticism• Awareness of impact of affect

• Self-presentation e.g. autobiographical continuity• General values and attitudes e.g. tentativeness and moderation

What does non-mentalizing look like?

• Excessive detail to the exclusion of motivations, feelings or thoughts.• Focus on external social factors, such as the school, the council,

the neighbours.• Focus on physical or structural labels.• Preoccupation with rules, responsibilities.• Denial of involvement in problem.• Blaming or fault-finding.• Expressions of certainty about thoughts or feelings of others.

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Mentalization

• Everybody will struggle to mentalize at times.

• People with borderline PD and other diagnoses have more consistent difficulty especially under high arousal.

• Underpins clinical understanding, the therapeutic relationship and therapeutic change regardless of modality of therapy

Mentalization based therapy

• Aims to strengthen patients capacity to understand their own and others mental states in attachment contexts in order to address difficulties with –

• Affect regulation• Impulse regulation• Interpersonal functioning

All of which contribute to suicide and self harm. Bateman and Fonagy 2009

Why mentalization based therapy?

• Evidence based• Psychodynamic treatment• Rooted in attachment and cognitive therapy• Requires limited training with moderate levels of supervision • Implemented by generic mental health professionals.

Mentalization based therapy – what does it look like?• Therapist adopts a stance of inquisitive, not knowing – Columbo vs

Poirot• Alert to patients mentalizing and level of arousal in session • Intervenes to restore mentalizing• Maintains arousal at optimal level • Collaborative therapeutic relationship

MBT Skills

• Any situation involving contact with person with Borderline PD is opportunity to use MBT skills• A&E, outpatients, inpatients, substance misuse, eating disorders, forensic etc

• Aim is to facilitate the patients capacity to mentalize in the setting whilst being aware of factors which may be jeopardising capacity

MBT Skills

• Things to avoid!• Metaphors• Interpretations• Promises that can’t be kept• Behaviour that over stimulates attachment

• Lowering voice, special relationship, boundary violation however small or apparently insignificant.

The hyperactivation ofattachment in BPD

• Suicide attempts are often aimed atforestalling the possibility of abandonment:they seem to be a last-ditch attempt atreestablishing a relationship• only something extreme would bring aboutchanges in the adults behavior and thecaregiver used similarly coercive measure

MBT skills - Self harm

• Means of staff conceptualising incident from different perspective – e.g to avoid abandonment, • Responding with indication of concern for actions rather than “ignoring or

minimising for fear of reinforcing bad behaviour”• MBT skills to consider the incident and underlying affect

Effective ingredients of treatment (Bateman and Tyrer)1. to be well structured; 2. to devote considerable effort to enhancing compliance; 3. to have a clear focus, 4. to be theoretically highly coherent to both therapist and patient, 5. to be relatively long term; 6. to encourage a powerful attachment relationship between therapist and patient,7. to be well integrated with other services available to the patient.