neuroscience; week 5; emotional and relational needs

why does experience matter here?

• understand the diversity of experience across individuals

  • Beware of stereotypes

• Need to get away from stigmatising representations, e.g.:

  • Dangerous”

  • “Wilful”

  • “Self-obsessed”

Diagnosis can be a paradoxical experience in this field

• Being diagnosed can feel like you are being written off as:

  • A problem person

  • Having no prospect of change

• Being diagnosed can be an enormous relief

  • Recognition that there is a problem

  • Access to therapy

• But the lack of clarity about diagnosis and treatment can be frustrating too

Defining personality

• Personality is our tendency towards patterns of behaviour, emotion, cognition, and interaction that show through regardless of the situation we are in

  • i.e., trait rather than state

• For example,

  • Anxious before an exam – STATE

  • Anxious all the time – TRAIT

  • Wanting to do an important job well – STATE

  • Wanting to do everything perfectly - TRAIT

• So, personality can be something that has positive implications if it fits the demands of the world

• But it can be a negative influence if it does not fit the world around us or its rules

Personality disorder: Socio-political perspectives

• A way of saying ‘that person is weird’

  • how good are we at agreeing on that?

• A way of saying ‘that person is not acceptable’

  • and we know people disagree on that...

• A way of saying ‘that person is not within social bounds’

  • e.g., detained in Soviet Gulags due to being defined as ‘antisocial’ for having non-fitting views

• A way of saying ‘that person is not diagnosable, but is pretty close and probably will have a problem soon, so let’s something about it now’

  • e.g., early definitions of borderline personality disorders were about being borderline of experiencing psychosis

Personality disorder: Medico-legal perspective

• are we entitled to jail/detain people on the basis of what we believe they might do?

• what if we do not and they go on to offend?

• levels of caution and politics can still get in the way

Categories vs dimensions

• Personality varies along dimensions

• so, are personality disorders just extremes on those dimensions?

  • if so, how to establish a cut-off?

  • e.g., is the top 0.5% of impulsivity qualitatively different to the top 1.0%?

• Big five- openness extraversion (defined in a dimensional way – high or low)

• Are personality disorders distinct ‘clumps’ at either extreme

  • e.g., extreme introversion or extraversion could be seen as a problem

• Or a distinct clump at just one end of the dimension?

  • e.g., we might see extreme neuroticism as a problem, but not extreme stability

Definition of personality disorder under the DSM-IV (1994)

• “An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture”

  • note that this is a very vague definition

  • could encompass unusual belief systems (e.g., flat earthers), that might have been quite normal at some points in history

• But things got a lot more complex after the DSM-5 taskforce met…

  • lots of plans for change, based on problems with DSM-IV

  • but lots of debate

  • so we still have the same categories – somewhat…

DSM-5 definition of personality disorder (2013)

• •“The essential features are impairments in personality (self and interpersonal) functioning and pathological personality traits”.

• Diagnosis of a personality disorder requires:

  • significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning

  • ”pathological” personality trait domains or trait facets

  • impairments in personality functioning and personality trait expression are relatively stable across time and situations

• impairments in personality functioning and the individual’s personality trait expression are not better understood as normative and are not due to the direct physiological effects of a substance or a general medical condition

What are problems with the DSM-5 definition of personality disorder (2013)? How did it allow for future changes in diagnosis?

• define ‘significant’ and ‘normative’

• clinicians tend to use diagnosis regardless of substance use, nutrition issues, injury, etc

The other differences in the DSMs

• DSM-5 included research proposals to allow for future potential change in diagnosis

  • Level of personality functioning

  • Personality trait domains and facets

  • Personality disorder types

Summary of changes to DSM-4/5

• DSM-5 maintains diagnostic criteria from DSM-4 and continues to define personality disorders on categorical basis

• But it discusses a dimensional approach to the diagnosis of personality disorders and encourages further research on these

Key issues in reaching a diagnosis

• Long-term presentations

• Independent of biological factors

  • e.g., drug use; starvation; actual threat

• Diagnoses cannot be made at a single clinical meeting

• Yet each of these gets ignored by clinicians...so please remember that an element of cynicism is pretty reasonable

• usually do not diagnose in childhood and adolescence

Personality disorders clusters

Cluster A:

• paranoid personality disorder

• schizoid personality disorder

• schizotypal personality disorder

Cluster B

• antisocial personality disorder

• histrionic personality

• narcissistic personality disorder

• borderline personality disorder

Cluster C

• avoidant personality disorder

• obsessive compulsive disorder

• dependent personality disorder

Cluster A: odd/eccentric

• Personality disorders (PD) with some schizophrenia-like features

  • lacking active symptoms, such as hallucinations

• Paranoid PD

  • pattern of distrust and suspiciousness

  • resistant to challenge by others

• Schizoid PD

  • pattern of separation from social relationships

  • limited emotional expression and experience

• Schizotypal PD

  • pattern of eccentric ideas, magical thinking

Cluster B: dramatic/ erratic

• Personality disorders characterised by impulsive/erratic and/or self-centred behaviours, emotions and thinking

• Antisocial PD

  –pattern of disregard of other’s rights

  –strong links to conduct disorders and criminality

  –selfishness and lack of empathy

• Borderline PD (Emotionally Unstable PD – ICD)

  –pattern of unstable relationships, mood, and behaviour

  –efforts to control emotion (e.g., drink; self-harm) and avoid rejection

• •Narcissistic PD

  –pattern of overestimation of own abilities and accomplishments

  –pervasive need for admiration, while not caring about others

  –anger when not recognised for their ‘specialness’

  –fragility of self-esteem

• Histrionic PD

  –attention-seeking, need to be the centre of attention

  –dramatic behaviour, undue emotional expression

  –exaggerated presentation

Cluster C: anxious/ fearful

• Personality disorders characterised by anxiety that is lifelong

  • –not related to any trigger

• Avoidant PD

  • pattern of social avoidance

  • inadequacy, and sensitivity to others’ views of them

• Dependent PD

  • pattern of dependence on others’ care

  • submissive, clinging, seek others’ approval/support

• Obsessive-compulsive PD

  • excessive perfectionism (focus on doing the task: forget the goal)

  • need for order, patterns and control

Summary of diagnostic clusters

• three broad clusters with ten diagnoses: odd/ eccentric, dramatic/ erratic and anxious/ fearful

• big overlap across clusters and diagnoses

  • it is rare for a person to only meet one personality disorder criteria

  • if one meets the criteria for one PD, on average they meet the criteria for 4.5

• expected to identify which cluster a diagnosis belongs to but not the criteria for each personality disorder

Personality disorder: prevalence

• No clear onset, so focus on prevalence rather than incidence

• The rate depends on how thorough the assessment is

  –many studies use weak measures, and overestimate prevalence

  –gender bias in diagnosis? (Women Cluster B & C; Men Cluster A)

• The most reliable studies suggest 10-15% for all personality disorders

  –most common: borderline, schizotypal, antisocial, obsessive-compulsive

• But the figures really vary

Personality disorder: co-morbidity

• High rate of co-occurring personality disorders

• High rate of comorbidity with:

  • depression

  • substance misuse

  • panic disorder

  • PTSD

  • social phobia

  • eating disorders

  • neurodiversity

• Co-occurance – afraid of abandonment (BPD) – dependent PD

Is a personality disorder for life?

Old viewpoint:

• yes, but the symptoms tend to fade after 40 years of age

• it is ‘untreatable’

Current View

• no, as a large number of cases are not diagnosable a few years later

• treatment for some personality disorders is effective in some cases

Factors underpinning Cluster A PDs:

biological/ neurological factors

• enlarged ventricles

• enhanced startle response

• cognitive deficits

• lack of link to specific PDs

environmental factors:

• parental relationships

• rejection

• abuse

Factors underpinning Cluster B PDs

biological/ neurological factors:

• antisocial:

  • childhood conduct disorder

  • genetics

  • low anxiety

  • weak fear conditioning

• borderline

  • genetics

  • limbic system dysfunction

Environmental factors

• antisocial

  • modelling

• borderline

  • trauma/ emotional

  • invalidation

• narcissistic

  • doting parents?

• general

  • experience driving

  • schema developing: angry and impulsive child

Factors underpinning Cluster C PDs

biological/ neurological factors

• avoidant

  • genetics

• general

  • physiological predisposition to anxiety → more fearful anxiety

Environmental factors

• avoidant

  • childhood negative experiences

• dependent

  • fear of rejection

• general

  • experience driving

  • schema development

what type of interventions are recommended for personality disorder?

Limited evidence for most personality disorders

• A range of clinical suggestions indicate psychological interventions, rather than neurological

• Beck et al. (2016) provide a range of clinical guidance based on CBT

• Some evidence for other, more integrative therapies

  –Cognitive analytic therapy (Ryle)

  –Mentalization-based treatment (Bateman)

Psychotherapy for BPD- Oud et al (2018)

Oud et al (2018)

• systematic review and meta-analysis

• 20 studies

• 1374 participants

• Objective:

• BPD affects up to 2% of the population and is associated with poor functioning, low QOL and increased mortality. Psychotherapy is the treatment of choice, but it is unclear whether specialized

  psychotherapies are most effective, so we investigate the effectiveness of psychotherapies.

• Methods: Randomized controlled trials were assessed and outcomes were meta-analyzed. The review has been reported following Systematic Reviews and Meta-Analyses guidelines.

• Results: Specialized psychotherapies had a medium effect based on moderate quality evidence on overall BPD severity, and dialectical behaviour therapy, with a small to medium effect on self-injury.

• Conclusion: There is moderate quality evidence that specialized psychotherapies are effective in reducing overall borderline personality disorder severity. However, further research should identify which patient groups profit most of the specialized therapies.

Best treatment evidence

Schema Therapy

Integrative Model – cognitive, behavioural, gestalt, attachment theory,

object relations

Three ways of changing schemas:

• Behavioural (Doing)

• Feeling (Experiential)

• Thinking (Cognitive)

Greater focus on:

• Therapeutic relationship (rapport)

• Using mental imagery techniques

• Using Chairwork in therapy

Arntz et al (2022)

• largest trial in CERN/PD to date

• the combined individual and group schema therapy group had significantly reduced BPDSI (Borderline Personality Disorder Severity Index) score compared to the treatment as usual and predominantly group schema therapy groups (which did not significantly differ from one another).

Good treatment evidence

• Behaviourally-based programme

• Managing impulsive behaviours and thought processes in BPD

• Elements of contingency management, operant conditioning, mindfulness, etc.

• Very resource intensive

• Designed to manage symptoms effectively, but not to remove the cognitions But main outcome measure is suicidality

Reading- personality disorder

4-12% of the adult population have a formal diagnosis of personality disorder; if milder degrees of personality difficulty are taken into account this is much higher.

reading- What is personality disorder?

The definition of personality disorder differs between the ICD and DSM.

People with personality disorder have a persistent pervasive abnormality in social relationships and social functioning.

People with personality disorder have a limited range of emotions, attitudes, and behaviours to cope with the stresses of everyday life.

Personality disorder is different from mental illness because it is persistent throughout adult life, whereas mental illness results from a morbid process, with a recognisable onset and time course.

A cohort study found good rates of remission in people with borderline personality disorder (78-99% at 16 year follow-up), but remission took longer than in other personality disorders and recurrence was more common.

Evidence suggests that most people with BPD will show persistent impairment of social functioning even after specialist treatment.

Reading- Why is personality disorder important?

People with PD experience distress, suffering, and stigma, but can also cause distress to those around them.

Comorbid mental health problems are more common in people with personality disorder, more difficult to treat, and have worse outcomes.

In depression, personality disorder is an important risk factor for chronicity.

Personality disorder is associated with higher use of medical services, suicidal behaviour and completed suicide, and excess medical morbidity and mortality, especially in relation to cardiovascular disease.

Categorical Vs dimensional approach

There has been growing criticism of a purely categorical approach of a person meeting criteria for paranoid, borderline, or antisocial personality disorder.

Considerable overlap exists between categories, which do not take into account the wide variation in impairment seen in everyday practice, and reinforce the stigma associated with the diagnosis.

The DSM-5 has the categorical classification, although an alternative, more complex, classification that was rejected is also included.

The ICD-11 is still in preparation, but publications propose a dimensional approach using 5 levels of severity.

A criticism of this approach is that the diagnosis of BPD, which has considerable clinical utility, is lost.

The diagnosis is a misnomer because the primary category was thought to be borderline was schizophrenia, and this is no longer the case.

What do we know about the causes of personality disorder?

Personality disorders are probably the result of multiple interacting genetic and environmental factors.

Twin studies suggest heritability of personality traits and personality disorders ranging from 30%-60%.

Epidemiological studies also suggests that family and early childhood experiences are important, including experiencing abuse (emotional, physical, and sexual), neglect, and bullying

Do people with PDs seek treatments? are treatments effective?

There is little evidence for what treatments are helpful.

An exception is borderline personality disorder, for which there is now a growing evidence base, and kind of antisocial personality disorder.

NICE guidelines have now been produced for both of these.

Those with a borderline diagnosis tend to seek treatment, whereas those with antisocial personality disorder and other categories are reluctant to commit to treatment.

What are the basic principles of managing personality disorders?

Explore treatment options in an atmosphere of optimism, building a trusting relationship with an open non-judgmental manner.

Services should be accessible, consistent, and reliable, especially as many people will have had experiences of trauma and abuse.

Consideration should be given to working in partnership, helping people to develop autonomy, and encouraging those in treatment to be actively involved in finding solutions to their problems.

Managing borderline personality disorder

Consider BPD in a person presenting to primary care who has repeatedly self harmed and shown persistent risk taking behaviour or marked emotional instability.

Primary care doctors should help manage patients’ anxiety by enhancing coping skills and help patients to focus on the current problems.

Techniques for this include looking at what has worked previously, helping patients to identify manageable changes to deal with the current problems, and offering follow-up appointments.

When a patient with BPD presents to primary care in crisis, assess the current level of risk to self and others. If the risk of harm or levels of distress are increasing, consider referral to specialists.

People with this disorder require special attention when managing transitions (like changes to and endings of treatment) given intense emotional reactions to any perceived rejection or abandonment.

Specialist treatment

Dialectical behaviour therapy:

• is a modified version of CBT

• uses the concept of “mindfulness” from Buddhist philosophy.

Trials focusing on women who repeatedly self harm have shown reductions in anger, self harm, and attempts at suicide.

mentalisation based treatment:

• focuses on improving mentalising capacity,

• reduces suicidal behaviour and hospital admissions.

Other therapies reducing borderline symptoms are:

schema focused therapy

• Improving core symptoms,

• improved psychological functioning and quality of life;

transference focused therapy:

• improved psychosocial functioning

• reduced inpatient admissions

cognitive analytic therapy

• improved interpersonal functioning and wellbeing

• reduced dissociation (splitting of the personality).

randomised trials identified two other treatments:

Problem solving for BPD

• combines cognitive behavioural elements, skills training, and intervention with family members.

  • reduces borderline symptoms and improve impulsivity.

Manual assisted cognitive treatment,

• aimed at reducing deliberate self harm,

Psychological treatments with the current best evidence for borderline personality disorder- Dialectical behaviour therapy

• a modified version of CBT

• incorporates the concept of “mindfulness” drawn from Buddhist philosophy.

• focuses on:

  • emotional regulation,

  • distress tolerance,

  • interpersonal effectiveness

• through individual therapy, group skills training, and telephone coaching.

Psychological treatments with the current best evidence for borderline personality disorder- Mentalisation based treatment

An adaption of psychodynamic psychotherapy grounded in attachment theory,

emphasises improving patients’ ability to “mentalise”— to understand their own and other people’s mental states and intentions.

The treatment is delivered in a twice weekly individual and group therapy format or as part of daily attendance at a treatment centre.

Psychological treatments with the current best evidence for borderline personality disorder- Transference focused therapy

A form of psychodynamic psychotherapy

derived from Kernberg’s theory of object relations, which describes contradictory internalised representations of self and others.

It focuses intensely on the therapy relationship

is delivered as twice weekly individual sessions aimed at the integration of split off aspects of the personality.

Psychological treatments with the current best evidence for borderline personality disorder- Cognitive analytic therapy

Brief focused and collaborative therapy

integrates ideas from object relations theory and CBT.

uses diagrams and letters to help people to recognise and revise confusing patterns and mental states

delivered individually over 24 weeks with follow-ups.

Psychological treatments with the current best evidence for borderline personality disorder- Schema focused therapy

A development of cognitive behaviour therapy founded by Jeffrey Young, which blends elements of Gestalt therapy, object relations, and constructivist therapies. It identifies and modifies dysfunctional patterns (schemata) made up of patients’ memories, feelings, and thoughts about themselves and others. It is usually delivered as once or twice weekly individual therapy.

Psychological treatments with the current best evidence for borderline personality disorder- Effective management and care coordination: general management therapies

Specialist treatments are not generally available in the community, and people struggling with unstable support systems may not engage with them.

Well structured general psychiatric management can be as effective as specialised treatments when delivered under research conditions.

It involves case management and weekly individual sessions using a psychodynamic approach that focused on management of symptom targeting drugs.

Management should be systematic and preferably manualised (guided by a “manual” with prescribed goals and techniques for each phase of treatment) to provide a clear model to work with.

This helps to deal with common clinical problems, such as risk of suicide, by talking with the patient about any unmanageable feelings, giving basic psychoeducation about managing mood states, encouraging problem solving and the sharing of risk and responsibility.

In addition, pay close attention to emerging problems in the therapeutic alliance.

Are there any drug treatments available for borderline personality disorder?

There is no evidence for the efficacy of drugs for core borderline symptoms of chronic feelings of emptiness, identity disturbance, and abandonment.

Some trials showed benefits with second generation antipsychotics, mood stabilisers, and dietary supplements of omega-3 fatty acids, but these are single studies with small sample sizes and are not recommended by NICE.

Antidepressants may be helpful in the presence of coexisting depression or anxiety.

Managing antisocial personality disorder- services and primary care

The treatment work within a clear care pathway with a range of services.

The pathways should specify helpful interventions at each point and enable communication between clinicians and organisations.

Locally agreed criteria should be established for transfer between services with shared objectives and a comprehensive assessment of risk.

Services should establish multiagency APD networks for central training, provision of support and supervision to staff, and the maintenance of standards.

GPs may need to offer treatment too and should be aware that poor adherence, misuse of drugs, and drug interactions with alcohol is increased in this group.

Assessment of risk in primary care should include history of violence and its precipitants; comorbid mental disorders; use of drugs and the potential for drug interactions; misuse of prescribed drugs; current life stressors; and accounts from carers.

treatments NICE suggests and what people with PD often require surrounding treatment

NICE guidelines suggests group based cognitive and behavioural interventions that focus on the reduction of offending and other antisocial behaviour.

Particular care is needed in assessing the level of risk and adjusting the duration of programmes accordingly.

Participants will need to be encouraged to attend and complete programmes.

People with severe personality disorder often come through the criminal justice system and will require forensic psychiatry services. Treatments include violence reduction programmes. Staff involved in such programmes require close support and supervision.

Other treatments- therapeutic communities, nidotherapy

Therapeutic communities, which provide a longer, group based, and often residential approach to therapy, are in the treatment of PD, but have no evidence for effectiveness.

In the UK, the Department of Health set up pilot projects for management of personality disorder in 2004-05.

One was the Service User Network model: offers community support groups for people with PD, with individuals involved in the design and delivery of the service.

• Routine data and a cross sectional survey, showed that the service attracted many people with health and social problems and was associated with improved social functioning and reduced use of other services.

Nidotherapy (nest therapy) is a new treatment approach. It involves manipulation of the environment to create a better fit between the person and their surroundings, rather than trying to change a person’s behaviour.

• A review (only one study met inclusion criteria though) showed an improvement in social functioning and engagement with non-inpatient services.

What are the problems in everyday practice?

Personality disorder affects the doctor-patient relationship. Misunderstandings and angry reactions are not uncommon and consistency, clarity, and forward planning are all important in managing the relationship.

The diagnosis of PD should never be given to a patient that the doctor simply finds “difficult”, but there is a disparity between a formal diagnosis of personality disorder achieved using a research interview and the diagnoses made by GPs.

However, a diagnosis of comorbid personality disorder is a possibility in patients who do not respond to treatment or seem particularly difficult to manage. A simple eight item screening interview is useful for this.

People with comorbid substance misuse may face problems accessing psychological therapies (some services do not offer them to these people), specialist therapies may not be locally available, and barriers persist in accessing mental healthcare for people with PD in the UK.

Tips for non-specialists

Consider personality disorder in people who are difficult to engage and do not respond to treatment—for example, those who do not respond to treatment for depression. Try to maintain a consistent and non-judgmental approach even when “underfire” from a person who is emotionally aroused or wound up It is more important to recognise the general problem of an enduring pattern of difficulty in a wide variety of social contexts, and a limited repertoire of coping skills, than to diagnose a particular subtype of personality disorder. Make plans for crisis management, especially recurrent crises, such as repeated self harm or threats of self harm. Explore possible therapeutic avenues with specialist care; don’t let the label be a reason for not referring.