Personality as the Outer Layer of Defense Against Psychic Stressors

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Stop Think Looking Backwards in order to Move
Forwards!
Conor Duggan, University of Nottingham Arnold
Lodge, RSU Leicester.
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Looking BackwardSome significant Achievements
over the past 8 years

• Treatment of Personality Disorder at Arnold
  Lodge.
• Providing an evidence base for what we do (i.e
  The LANDSCAPE Project).
• The extension of treatments for those with
  personality disorder into the Community (i.e. the
  Nottinghamshire Community Personality Disorder
  Service at the Mandala Centre).
• The Systematic Review into the Effectiveness of
  Pharmacological and Psychological Treatments for
  those with Personality Disorder.

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THE EAST MIDLANDS CENTRE FOR FORENSIC MENTAL
HEALTH
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THE EAST MIDLANDS CENTRE FOR FORENSIC MENTAL
HEALTH

• When the Unit opened in 1998, there was a lack of
  a treatment rationale and few to deliver
  treatments for those with a history of both
  offending and a personality disorder.
• Those with personality disorder who were
  initially admitted were found to have a range of
  disturbances including impulsive behaviour,
  controlling their anger, dealing with substance
  misuse etc.
• Through working with Professor McMurran, we were
  able to develop and train front line staff to
  deliver such programmes the center of which was
  Stop Think.

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But, Looking forward, not all is Sweetness and
Light - SPS at Arnold Lodge!

• Social Problem Solving is a generic intervention
  appropriate to a range of disabilities - both
  physical and psychological -so that there is no a
  priori reason as to why it has an especial
  relevance to those with PD unless
• Social Problem Solving is generally delivered as
  a short-term intervention (c. 6 months) but, on
  the PDU, it continues weekly for as long as the
  individual is on the Unit.
• Hence, there is a need to extend SPS to meet the
  needs of the individual - especially as regards
  the aetiology of his difficulties.

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Looking BackwardSome significant Achievements
over the past 8 years

• Treatment of Personality Disorder at Arnold
  Lodge.
• Providing an evidence base for what we do (i.e
  The LANDSCAPE Project).

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Rationale of the LANDSCAPE Project.

• Had the approach on the PDU using psychoeducation
  and SPS any generalisability outside the Unit?
• How did professionals outside of mental health
  (esp. those in Housing, A E, Probation, A E)
  view those with PD?
• Was it possible to encourage those who managed
  such services in the community to get involved in
  supporting a rigorous evaluation?

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Treatment-control comparisons
Adj diff 2.09 t 4.40 p lt.001 d0.58
Adj diff -1.05 t 1.06 p .031 d-0.25
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But, Looking forward, not all is Sweetness and
Light the LANDSCAPE Project !

• The LANDSCAPE Trial compared a composite
  intervention (i.e. Psychoeducation SPS) versus
  TAU. Hence, it is unclear as to what was the
  active component. This requires further
  evaluation.
• Social Problem Solving was compared with a
  Treatment as
• Usual (TAU). This is not the best comparison
  and is now frowned upon in drug trials where the
  desired comparison is between the experimental
  treatment versus the best current alternative.
• There was no attempt at an economic analysis.

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Looking BackwardSome significant Achievements
over the past 8 years

• Treatment of Personality Disorder at Arnold
  Lodge.
• Providing an evidence base for what we do (i.e.
  The LANDSCAPE Project).
• The extension of treatments for those with
  personality disorder into the Community (i.e. the
  Nottinghamshire Community Personality Disorder
  Service at the Mandala Centre).

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The Nottinghamshire Community PD Project the
Achievements

• This was one of the projects that achieved tha
  largest amount of funding within a competitive
  funding bid.
• It offers three tiers of interventions in which
  the LANDSCAPE (incl. Social Problem Solving) was
  a significant component.
• The addition of a research component will provide
  information from a significant number of
  individuals in a clinical setting that will be
  very informative when such data are analysed.

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The Nottinghamshire Community PD Project not
all is sweetness and light!

• There have been difficulties in the integration
  of the different levels of provision.
• Some critical appointments have not been made so
  that the original aspiration of developing a
  Managed Care Network has not been realised.
• Drop-outs need to be considered.

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Drop-Outs from Treatment are important as

• They are Common.
• They lead to an Uneconomical Use of a limited
  resource.
• They may have a Detrimental Effect on both
  patient and therapist.

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Drop-outs from Treatment are common

• For BPD and psychodynamic therapy, rates of 67
  at 3 months, (Skodol et al. (1983)), 52 at 6
  months (Gunderson (1989) 46 at 6 months
  (Waldinger Gunderson, 1984).
• However, lower rates have also been reported for
  other approaches DBT 17 at 1 year (Linehan et
  al,1991) Day Hospital 16 at 3 months
  (Stephenson Meares 17 1992) Bateman
  Fonaghy,
• Generally, however, figures of drop-out
  approaching 50 are common and are higher in
  those with PD!

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What predicts Drop-Out?

• Socio-economic factors (i.e. low educational
  attainment, poor social support and young age).
• Symptomatology the more severe the pathology,
  the higher the rate of drop-out (generally).
  (e.g. more personality disordered traits, higher
  PCL-R scores, the higher the drop out).
• High levels of anger and hostility (
  sociopathic traits)
• A lack of capacity to work collaboratively
  leading to poor therapeutic engagement.

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Sample frame Completers vs. Non Completers Feb
1999-Dec 2005
Patients discharged from the PDU n50
Patients completed treatment n17
Patients failed to complete treatment n33
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Looking BackwardSome significant Achievements
over the past 8 years

• Treatment of Personality Disorder at Arnold
  Lodge.
• Providing an evidence base for what we do (i.e
  The LANDSCAPE Project).
• The extension of treatments for those with
  personality disorder into the Community (i.e. the
  Nottinghamshire Community Personality Disorder
  Service at the Mandala Centre).
• The Systematic Review into the Effectiveness of
  Pharmacological and Psychological Treatments for
  those with Personality Disorder.

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A Systematic Review of the Effectiveness of the
Pharmacological and Psychological Treatments for
those with Personality Disorder
Conor Duggan, Clive Adams, Lucy McCarthy etc etc.
Soon to be on the Nat. Forensic R D web site.
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Included RCTs 29 Excluded RCTs
27 Quasi-Experimental 2 Control Cohort
4 Case Control 14 Non-case-control cohort, case
series etc 113
Onion Ring diagram of study quality ratings all
PDs
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Included RCTs 17 Excluded RCTs
7 Quasi-Experimental 0 Control Cohort 3 Case
Control 6 Non-case-control cohort, case series
etc 71
Onion Ring diagram of study quality ratings BPD
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Included RCTs 3 Excluded RCTs
6 Quasi-Experimental 0 Control Cohort 1 Case
Control 3 Non-case-control cohort, case series
etc 14
Onion Ring diagram of study quality ratings ASPD
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The Systematic Review into the Treatment of
Personality Disorder not all is sweetness and
light!

• There is an urgent need to continuously update
  systematic reviews.
• There is a significant problem in personality
  disorder reviews in that (a) a significant number
  of practitioners believe that personality
  disorder as an entity does not exist (or should
  not exist) a disorder without a name.
• The outcome measures of the interventions are not
  agreed. For instance,

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Hence, for this area to advance scientifically,
there is a need to agree on

• Entry criteria of PD for inclusion in trials.
• A similar agreement on outcome measures so that
  what constitutes a significant improvement (or a
  failure to improve) is determined from the
  outset.
• In this respect, it is no different from other
  scientific enterprises.
• For instance,

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Why is it difficult for the talking therapists
to talk to one another?

• It is difficult as the fundamentals from either
  camp are so different from one another that
  dialogue is impeded.
• This arises for a number of reasons including
  the definition of the field, initial training,
  what constitutes proper practice through
  supervision, professional affiliations etc.

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Hence, SPS has to evolve if it is to survive!

• Should it continue without modification as an
  on-going treatment after 6-12 months?
• Drop-outs (and the reasons for them) need to be
  investigated (and reduced).
• The relationship between Emotions (i.e. Bad
  Feelings) and Behaviour (i.e. impulsiveness)
  needs to be further elucidated. Here, the
  Enhanced Social Problem Solving being developed
  at A.L . and the incorporation of Schema
  Focussed Therapy at Mandala is encouraging.

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Why is it difficult for service providers within
this Trust to talk to one another when we could
have two vehicles to do so?

• The National Personality Disorder Institute!
• A Managed Care Network for PD in the East
  Midlands?