“See the PERSON in PERSON ality Disorder” Civil or Forensic 22 June 2006 John D McGinley/Lindsay Johnson The State Ho

1. “See the PERSON in PERSONality Disorder”Civil or Forensic22 June 2006John D McGinley/Lindsay JohnsonThe State Hospital/Caledonian University

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

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 PERSONALITY DISORDERS

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. 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. 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. 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)

8. Personality Disorders: legal and clinical issuesMH (Care and Treatment) (S) Act 2003Criteria • Mental disorder • mental illness • personality disorder • learning disability • 2. Medicaltreatment • prevent worsening • alleviate symptoms • available • 3. Significant risk to person or safety of others • Compulsion necessary • 5. Impairment of ability to make decisions about treatment (civil application only)

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. Personality disorders: political and clinical issueDSPD 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. 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. 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. 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. 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. See the PERSON Inner self Consciousness Subjective experience Spiritual Mindfulness Consistency of thoughts (schema), feelings (emotions), behaviours (expression) More than sum of traits

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. 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. Supportive therapy Psycho-educational Psychodynamic CBT/CAT/DBT Milieu therapy Community Pharmacological Personality disorders: clinical issues Psychotherapeutic models Fit treatment to uniqueness of the person: relationships, integration, combinations, environmental control, staff consistency multidisciplinary collaboration

19. Personality disorders: Clinical Issues Psychotherapeutic eclecticism Maladaptive and inflexible thinking: Schema Focused Therapy Poor integration of concept of self or others: Psychodynamic Therapy Attachment and emotional developments: Psychodynamic Therapy Reformulation in collaboration: Cognitive Analytic Therapy Skills training: Cognitive Beh. Therapy Therapeutic alliance and validation: Dialectical Beh. Therapy Motivational engagement: Cognitive Beh. Therapy

20. Personality disorders: clinical issues Treatment: Difficulty in Engaging • Enduring and relatively stable patterns • Maladaptive interpersonal behaviour • Persistent over time • Label and stigma attached to experience and distress • Difficult to motivate into engaging in treatment • Resistant to therapeutic change. • Previous failed attempts at change. • Excluded by low motivation and ‘untreatability’ • Progress requires coordinated clinical and social support • Progress requires immersion: suitable milieu • Maintenance requires social integration • Maintenance requires extended support

21. Personality disorders: clinical issues Personality and risk PD: Dynamic Risk Factor Maintain Clinically relevant behaviours Sustained Integrated care pathway Motivate Engage Learning Change Functional relevance Formulation Risk assessment-----risk management-----risk reduction-----public safety Person engagement-----treatment progress-----community re-integration

22. PERSONALITY DISORDERS: CLINICAL ISSUES PERSON Focused (PFPI) 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. 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. Emotional intelligence Self awareness Motivation Self regulation Empathy Social skills Goleman 1998

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

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

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

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

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

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. 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. 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 Personality Disorders: Clinical GovernanceUnderstanding Personality Disorder: BPS June 2006

33. Personality Disorders: Clinical Governance Royal College of Psychiatrists Council Report CR 71, February 1999 • 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. 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!

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. 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. 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. “See the PERSON in PERSONality Disorder”Civil or Forensic22 June 2006John D McGinley/Lindsay JohnsonThe State Hospital/Caledonian University