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Management of Severe Personality Disorders


Management of Severe Personality Disorders Dr. J. S. Parker OPD Lentegeur Hospital and UCT Dept of Psychiatry and Mental Health – PowerPoint PPT presentation

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Title: Management of Severe Personality Disorders

Management of Severe Personality Disorders
  • Dr. J. S. Parker
  • OPD
  • Lentegeur Hospital and UCT Dept of Psychiatry and
    Mental Health

Some General Principles
  • Recognition is Key
  • Managing oneself - mindfulness
  • Developing the therapeutic alliance
  • Exploring diagnosis
  • Implications and risks
  • MI and PST
  • Metaphor
  • Setting and securing the boundaries
  • Playing the long game

Personality Disorder
  • Defn Patterns of inflexible and maladaptive
    traits that cause subjective distress or
    significant impairment in social or occupational
    functioning or both.
  • Foster vicious cycles
  • Deviate markedly from cultural norms
  • Generally safer to talk about traits than a
    personality disorder
  • Considered enduring and pervasive rather than
  • DSM IV Axis II but DSM V mono-axial system

  • Attempt at hybrid dimensional/categorical
    approach abandoned at the last minute as too
    complicated, but retained in section III for
  • New approach retained 6 types Borderline,
    Antisocial, Narcissistic, Avoidant, O-C and
  • New Personality Disorder -Trait Specified,
    allows for recognition of mixed traits

DSM V (cont)
  • Reliability studies done on clinical populations
    rather than general population
  • Borderline PD criteria found to be highly
    reliable, OCPD and ASPD found to be of
    questionable reliability, insufficient numbers
    for other studies
  • Single axis

ICD 10
  • Specific Paranoid Schizoid Dissocial
    Emotionally Unstable (impulsive borderline
    types) Histrionic Anankastic Anxious
    (avoidant) Dependent Other
  • Mixed disorders
  • Enduring personality changes

DSM Personality Disorder Clusters
  • A. odd and eccentric- Paranoid Schizoid
  • B. dramatic emotional and egocentric-
    Antisocial Borderline Histrionic Narcissistic
  • C. anxious and fearful- Avoidant Dependant

  • A pervasive mistrust and suspiciousness of others
  • Suspects others are exploiting them.
  • Doubts the loyalty of friends.
  • Reluctant to confide in others.
  • Bears grudges
  • Feels attacked by others and reacts to this
  • Suspects partner of unfaithfulness.

Paranoid PD
  • NB to establish a trusting and non-threatening
    relationship formal, honest and professional
  • Caution! Avoid being too friendly, too warm or
    too humorous, expect accusations and belittling
  • Avoid direct confrontation, MI and problem
    solving techniques very useful
  • CBT and Schema-based therapy

Schizoid PD
  • Detachment from relationships
  • Restricted range of affect
  • Few close friends
  • Little sexual interest
  • Loner by choice
  • Allow space
  • Avoid over-involvement
  • Relatives often need reassurance
  • Exclude schizophrenia

Schizotypal PD
  • Acute discomfort with close relationships
  • Cognitive or perceptual distortions or
    eccentricities of behaviour
  • Ideas of reference
  • Odd beliefs, thinking, speech and affect
  • Eccentric appearance opr behaviour
  • Differentiate from schizophrenia
  • Relatives may need advice and reassurance
  • NB! Cultural context

Antisocial PD
  • A pervasive pattern of disregard for and
    violation of the rights of others.
  • Repeated acts that are grounds for arrest
  • Deceitful, impulsive, irritable and aggressive
  • Reckless
  • Irresponsible
  • Lack remorse
  • Conduct disorder before age 15

Antisocial PD
  • Psychopath charm intelligence egocentric
    exploitative lack remorse
  • Malingering substance abuse
  • NB! Identify early focus on parenting skills,
    problem solving, emotional awareness, improved
    self-concept, control of arousal and emotions
  • Caution! Firm boundaries.

Borderline PD
  • A pervasive pattern of instability of
    interpersonal relationships, self-image and
    affects, and marked impulsivity
  • Abandonment issues
  • Unstable and intense relationships
  • Identity disturbance
  • Impulsivity
  • Suicidal behavior
  • Affective instability
  • Chronic feelings of emptiness
  • Inappropriate anger
  • Transient paranoia or dissociation under stress
    (micropsychotic episodes)

Borderline PD
Borderline PD Management
  • Beware of idealization, be realistic about
    treatment targets as well as risks and side
  • A cautious, structured approach, maximising
    collaboration is key.
  • Treat presenting pathology
  • BUT Know what you are dealing with, avoid red
    herrings eg. depression voices in the head
  • Be honest, consistent and non-judgmental
  • Long-term perspective NO QUICK FIXES

Borderline PD Treatment
  • Pharmacotherapy (adjunct)
  • Cochrane Review (2010)SSRIs not recommended for
    as first choice for affective dysregulation
    impulsivity, nor low dose antipsychotics for
    cognitive-perceptual symptoms
  • SSRI only for MDD
  • Affective dysregulation topiramate, valproate,
    lamotrigine, aripiprazole, olanzapine
  • Impulsive-behavioural lamotrigine topiramate,
    omega-3 fats, flupenthixol aripiprazole
  • Cognitive-perceptual olanzapine, aripiprazole
  • Self mutilation and suicidal behaviour none.
    Olanzapine unfavourable effect

Borderline PD Treatment
  • Psychotherapy (Mainstay)
  • DBT suicide and affective dysregulation
  • Transference-based psychotherapy
  • Mentalization-based psychotherapy
  • Schema-focussed therapy
  • General Principles
  • Focus on patient-therapist relationship in the
    here and now
  • Utilize countertransference to explore
  • Educate patients to recognise their affective
    reactions and what triggers them
  • Connect actions with thoughts and feelings, both
    their own and others (Kernberg 2009)

Histrionic PD
  • Excessive emotionality and attention seeking
  • Needs to be the center of attention
  • Seductive or provocative
  • Rapidly shifting, shallow expressed emotions
  • Uses physical appearance to draw attention to
  • Impressionistic style of speech
  • Exaggerates emotions
  • Exaggerates intimacy of relationships
  • Need long-term consistent support
  • NB when relationships lost
  • Vulnerable to abuse

Narcissistic PD
  • Grandiosity, need for admiration and lack of
  • Self important
  • Fantasies of unlimited success
  • Believes is special
  • Requires excessive admiration
  • Sense of entitlement
  • Arrogant and exploitative
  • Lacks empathy

Narcissistic PD
  • Persona a shield for internal vulnerability and
    dysregulation. Can be powerfully expressed or a
    more muted perfectionism.
  • Relationship problems
  • Substance abuse
  • Mid-later life crises when no longer able to
    satisfy inflated sense of self
  • Depression
  • Suicide
  • Psychotherapy may be helpful but need to be

Narcissistic PD
  • Alliance building early on is key - Flexible!
  • Attention to motivational focus, clarification of
    experiences and formulation of difficulties
  • Must accommodate difficulty with self-reflection,
    affect tolerance and regulation of self-esteem

Dependent PD
  • Need to be taken care of
  • Excessive need for support/nurturance
  • Submissive and clingy
  • Struggles to take initiative, responsibility or
    to disagree
  • Uncomfortable alone
  • Preoccupied with fear of being left alone
  • Anxiety disorders and depression common,
    especially after separation
  • Vulnerable to abusive relationships
  • Common pathology in stalkers
  • Need long term support and structure
  • CBT

Avoidant PD
  • Left out
  • Social inhibition, feelings of inadequacy
    hypersensitivity to criticism
  • Avoids people, relationships, exposure, risks
  • Views self as inept, unappealing or inferior
  • Preoccupied with rejection/ridicule
  • Probably on a spectrum with social phobia.
  • CBT
  • SSRIs, SNRI and RIMAs

Obsessive-compulsive PD
  • Order, perfection and control at the expense of
    flexibility, openness and efficiency
  • Preoccupied with rules and lists
  • Inflexible moralists
  • Cannot discard objects
  • Excessively devoted to work
  • Can be rigid and stubborn
  • Thorough approach but NB to avoid focus on
    uncertainties and variables
  • Treat anxiety psychotherapy SSRI

Motivational Interviewing
  1. Ask for permission to discuss the problem raise
  2. Elicit talk about change. Evoke ideas of
    advantages and disadvantages of change
    possibilities and taking the first step.
  3. Importance check - rate readiness to change
    (scale 1-10). (Reinforces talk about change)
  4. Ability check (1-10) (assess pts confidence in
    ability to change and elicits possible barriers.)
  5. End with summary of discussion points, what has
    been agreed and what remains uncertain.

Problem Solving
  1. Identify the problem. Specify and define.
  2. Consider multiple solutions brainstorm all
    possible alternatives
  3. Look at pros and cons and choose most suitable
  4. Seek commitment with specific details (eg By
  5. Summarise and schedule follow up, acknowledging
    that further barriers may be encountered and that
    solutions for these will also be found.

  • Valkenberg Hospital OPD Tel 021 4403100
  • Valkenberg Ward 1 Tel 021 4403100
  • Lentegeur Hospital OPD 0213701430
  • Lentegeur Hospital Pathways (Wd 15) 0213701132
  • Stikland Hospital 0219404400