Mental Health theory and local perspectives

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Mental Health theory and local perspectives

• Dr Steve Pearce
• 23 May 2006

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Consequences of childhood abuse (Silverman,
Reinherz, Giaconia, 1996).

• 375 young adults aet 21, longitudinal study
• 10 reported physical or sexual abuse before age
  18
• 80 of the abused young adults met criteria for
  at least one psychiatric disorder at age 21
• more
• depressive symptoms
• anxiety
• psychiatric disorders
• suicidal ideation and suicide attempts
• poorer general functioning

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Abused women in primary care a survey (Coid 2001)

• Domestic violence demonstrated strong
  associations with most mental health measures.
• CSA associated with domestic violence and rape in
  adulthood
• Sexual assault in adulthood was associated with
  substance misuse rape with anxiety, depression,
  and PTSD, but not substance misuse.

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Later problems associated with childhood abuse
and neglect

• panic and anxiety disorders
• depression
• post-traumatic stress disorder
• alcohol and substance misuse
• suicidality and deliberate self harm
• eating disorders
• somatisation
• personality disorders

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Consequences of childhood abuse and neglectLuntz
Widom (1994)

• Followup of 416 abused children vs. 283 non
  abused children.
• Abuse/neglect doubled risk of having antisocial
  personality disorder
• Cycle of violence

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Personality disorder (PD)

• An enduring pattern of inner experience and
  behaviour that deviates markedly from the
  individuals culture, is pervasive and
  inflexible.
• Affecting thoughts, emotions, interpersonal
  functioning, impulse control

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Antisocial PD

• Pervasive pattern of disregard for and violation
  of the rights of others occurring since the age
  of 15
• Features
• failure to plan ahead
• irritability or aggressiveness, repeated physical
  fights or assaults
• failure to sustain consistent work behaviour or
  honour financial obligations
• reckless disregard for safety of self or others
• repeatedly performing acts that are grounds for
  arrest
• lying, use of aliases, or conning others for
  personal profit or pleasure
• lack of remorse, indifference to or rationalising
  having hurt, mistreated, or stolen from another

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Mortality and disability in PD

• Increased likelihood of depression and anxiety
• Increased chance of accidental death, suicide,
  homicide
• Relationship difficulties
• Housing problems
• Long term unemployment
• Poverty, victimhood

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Personality disorder

• repeated self-harm
• drug and alcohol misuse
• violence
• high level of use of mental health services
• excessive consumption of psychotropic medication
• parenting problems
• somatic symptoms without physical pathology

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Compared to depression(Bender 2001)

• Greater use of
• psychiatric medication
• hospitalisation
• psychotherapy
• day care
• social care

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People with personality disorder

• Inpatients with addictions 78 alcohol and 91
  polydrug addiction
• 69 eating disorder unit inpatients
• 41 of completed suicides suffered from PD
• Prisons

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Prevalence of personality disorder in
prisonSingleton et al 1998
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Community 5
General practice 20-30
Psychiatric patients 30-60
Personality Disorder
Prisons gt 70
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• 70000 men 49000
• 4000 women 2000
• Population
• 59m
• 1.8m diagnosable with PD

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Personality disorder

• Antisocial PD and probably Borderline PD becoming
  more common in USA (Robins 1991, Millon 1993)
• Higher rates of parental separation (Paris 1994)
• Loss of secure attachments -gt affective
  instability
• General risks for all PD
• parental psychopathology
• family breakdown
• traumatic events

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Aetiology ASPD

• antisocial behaviour in parent -gt ASPD in child
  independent of other risk factors
• capricious and violent parenting, physical abuse
  (Pollock 1990)
• coercive child training, failure to monitor
  child's behaviour (Patterson 1982,1986)
• large family, low IQ (Farringdon 1988)

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ASPD

• institutional care and early parental loss
• parental discord and hostility parent - child -gt
  conduct disorder

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The effects of neglect and abuse (Johnson 1999)

• prospective study
• PDs increased in children grossly neglected or
  abused
• physical or sexual
• all personality disorders but particularly
  borderline PD

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Borderline personality disorder (BPD)

• Frantic efforts to avoid real or imagined
  abandonment
• Pattern of unstable and intense relationships
  alternating between idealisation and devaluation
• Identity disturbance unstable sense of self or
  self-image
• Self damaging impulsivity (spending, sex,
  substance misuse, driving, eating)
• Recurrent suicidal behaviour, gestures or threats
  or self mutilating behaviour
• Emotional instability
• Chronic feelings of emptiness
• Inappropriate intense anger or difficulties
  controlling anger
• Transient stress related paranoid ideation or
  severe dissociative symptoms

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Is BPD caused by childhood abuse?

• 50-70 CSA in BPD
• BUT also associated with other PDs
• 30 severe CSA trauma, 30 less severe CSA, 30
  none
• independent assoc. CSA-BPD (Paris 1994, Links
  1993)

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• Overprotective parenting -gt anxious children
  (Kagan 1994)
• Dependent PD report intrusive parenting (Head
  1991)

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• Those of us with personality disorder can
  elicit a negative response and a kind of
  aloofness from professionals and carers, probably
  because we are a mass of churning emotions and,
  unintentionally, this is threatening to others,
  or stirs up their own deep-seated emotions.

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Local services

• Mental health
• Community mental health teams
• Psychological therapies services
• Specialist services
• Addictions
• Eating disorders
• Self harm/liaison
• Personality disorder services
• National
• Local

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Mild moderate PD

• psychological therapies
• CMHTs
• inpatient units
• specialist teams

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Principles governing the service design

• Emphasis on engagement
• Gradual
• Committed
• Flexible
• Accessible settings
• Emphasis on group working
• Best evidence
• Staff effectiveness and morale
• Safe practice
• Boundary violation
• Communication and miscommunication

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Multiagency involvement

• Multiagency steering group
• Agencies involved in feedback
• User groups
• Probation
• Primary care
• Housing departments
• Police
• Voluntary sector

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Univ College health counselling
Samaritans
Occupational health
NHS Direct
Self-referral
Liaison psychiatry
Prisons
SHs
CAMHS eg parents with PD
AE
HV
MAPPPs
SSDs
Young offender services
PC
GP
Court divert schemes
Adult mental health CMHTs, IP, crisis services,
assertive outreach
Probation
Forensic stepdown
Homeless services
Drugs Alcohol units
Housing
RF , MIND etc
Referral to more suitable services occasionally
to out-of-area residential units (eg Henderson
or Cassel Hospitals) or for suitable patients to
outpatient psychology or psychotherapy.
For those with specific issues, geographical or
time limitations, or not suitable for daily
programme
For those able to take sufficient degree of
responsibility for themselves
For those able and willing to go on to a more
intensive treatment programme
Planned discharge
Planned discharge
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PD service modelcoordination between local
services
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end

• www.psox.org/ocns
• www.tva2i.net

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• Bender D, Dolan R, Skodol A, Sanislow C, Dyck I,
  McGlasgan T et al. Treatment utilization by
  patients with personality disorders. Am J
  Psychiatry 2001 158(2)295-302.
• Coid J. (2001). A Survey of Women Receiving
  Primary Care Who Have Been Abused. The Research
  Findings Register. Summary number 625. 2001.
  http//www.ReFeR.nhs.uk/ViewRecord.asp?ID625.
  Ref Type Generic
• Green B, Krupnick J, Stockton P, Goodman L,
  Corcoran C, Petty R. Effects of Adolescent Trauma
  Exposure on Risky Behavior in College Women.
  Psychiatry Interpersonal and Biological
  Processes 2005 68(4)363-378.
• Johnson J, Cohen P, Brown J, Smailes E, Bernstein
  D. Childhood maltreatment increases risk for
  personality disorders during early adulthood.
  Arch Gen Psychiatry 1999 56(7)600-606.
• Luntz B, Widom C. Antisocial personality disorder
  in abused and neglected children grown up. Am J
  Psychiatry 1994 151(5)670-674.
• Parker G. Parental 'affectionless control' as an
  antecedent to adult depression. A risk factor
  delineated. Archives of General Psychiatry 40,
  956-960. 1983. Ref Type Generic
• Silverman A, Reinherz H, Giaconia R. The
  long-term sequelae of child and adolescent abuse
  A longitudinal community study. Child Abuse
  Neglect 1996 20(8)709-723.
• Van B, Runtz M, Kadlec H. Sexual Revictimization
  The Role of Sexual Self-Esteem and Dysfunctional
  Sexual Behaviors. Child Maltreatment Journal of
  the American Professional Society on the Abuse of
  Children 2006 11(2)131-145.

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Definitions of abuseDepartment of Health.
Working together to safeguard children a guide
to inter-agency working to safeguard and promote
the welfare of children. Norwich TSO, 1999 5-6.

• Child abuse and neglect
• serious physical and sexual assaults
• standard of care does not adequately support the
  childs health or development.
• through the direct infliction of harm
• through the failure to prevent harm occurring.
• Emotional, physical, sexual abuse and neglect

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Physical abuse

• Physical abuse may involve hitting, shaking,
  throwing, poisoning, burning or scalding,
  drowning, suffocating, or otherwise causing
  physical harm to a child. Physical harm may also
  be caused when a parent or carer feigns the
  symptoms of, or deliberately causes ill health to
  a child whom they are looking after. This
  situation is commonly described using terms such
  as factitious illness by proxy or Munchausen
  syndrome by proxy.

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Emotional abuse

• Emotional abuse is the persistent emotional
  ill-treatment of a child such as to cause severe
  and persistent adverse effects on the childs
  emotional development. It may involve conveying
  to children that they are worthless or unloved,
  inadequate or valued only in so far as they meet
  the needs of another person. It may feature age
  or developmentally inappropriate expectations
  being imposed on children. It may involve causing
  children frequently to feel frightened or in
  danger, or the exploitation or corruption of
  children. Some level of emotional abuse is
  involved in all types of ill-treatment of a
  child, though it may occur alone.

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Sexual abuse

• Sexual abuse involves forcing or enticing a child
  or young person to take part in sexual
  activities, whether or not the child is aware of
  what is happening. The activities may involve
  physical contact, including penetrative or
  non-penetrative acts. They may include
  non-contact activities, such as involving
  children in looking at, or in the production of,
  pornographic material or watching sexual
  activities, or encouraging children to behave in
  sexually inappropriate ways.

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Neglect

• Neglect is the persistent failure to meet a
  childs basic physical or psychological needs,
  likely to result in the serious impairment of the
  childs health or development. It may involve a
  parent or carer failing to provide adequate food,
  shelter and clothing, failing to protect a child
  from physical harm or danger, or the failure to
  ensure access to appropriate medical care or
  treatment. It may also include neglect of, or
  unresponsiveness to, a childs basic emotional
  needs.

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Tier 1 Assertive engagement and active assessment
Numerous activities in different settings, one
common weekly drop-in engagement group for
informal meeting and information sharingn25
t12 months. Shared care with referrers
Various combinations of different days for
different referral groups, iin different
locations

• Tier 1 is similar to assertive outreach in AMI
  services.
• Organised with numerous agencies at locality
  level.
• Individual and joint consultations
• Includes a weekly non-exploratory group
• Shared care

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Tier 2 Outreach, inreach and access to therapy
Could include weekend programmes for those in
full time work or education
Different activities at different times in the
week, for different populations, in different
locationsn54 (with 3 projects) t12-18 months

• Tier 2 will be located close to patients market
  towns.
• Mixture of individual and group therapies

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• Tier 3 requires larger geographical coverage for
  formation of appropriate groups
• Group or individual and group in a therapeutic
  community format
• Opportunities for staff training in tiers 2 and
  3.

Tier 3 Day programme definitive treatment
Whole-time daily programme as service base, with
different activities, therapies and
groups. Considerable user-involvement. Also
training base.n24 t18 months
Mon
Tue
Wed
Thu
Fri
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• Tier 4 primarily group, but with specific
  consultations for particular individuals
  according to each persons needs.
• Could also be designed to include therapy with
  families and carers

Tier 4 Leaving process graded disengagement
Half day per week (or less), with overlap into
last weeks/months of tier 2 or tier 3 programme.
In liaison with other agencies (eg college,
employment). Normally back to GP care only.n25
t6 months