See the PERSON in PERSONality Disorder Civil or Forensic 22 June 2006 John D McGinley/Lindsay Johnson The State Hospital/Caledonian University

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

• 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-aggressiv
  e
• Depressive
• Mental retardation

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
  individuals 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 2003
Criteria

• Mental disorder
• mental illness
• personality disorder
• learning disability
• 2. Medical treatment
• 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
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
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 IVTR 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
Personality disorders clinical issues
Psychotherapeutic models

• Supportive therapy
• Psycho-educational
• Psychodynamic
• CBT/CAT/DBT
• Milieu therapy
• Community
• Pharmacological

Fit treatment to uniqueness of the
person relationships, integration,
combinations, environmental control, staff
consistency multidisciplinary collaboration
19
Maladaptive and inflexible thinking
Schema Focused Therapy
Personality disorders Clinical Issues
Psychotherapeutic eclecticism
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
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 persons needs
• User views, user research and user involvement

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
Johnson The State Hospital/Caledonian University