Norman Swan: It's on a spectrum.

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1 Norman Swan: Peter Tyrer, who's Professor of Community Psychiatry at Imperial College London. I'm Norman Swan and this is the Health Report here on RN. Peter Tyrer has an international reputation for his work on what are called personality disorders, not so much mental illnesses as dysfunctional ways of being in the world, which Peter claims are much misunderstood and wrongly believed by many doctors to be fixed and untreatable. Peter Tyrer: Well, first of all, disorder refers to your ability to make good relationships. It's an interpersonal social function, to put it into its rather jargon terminology. And it's an interesting point of course, if you are on a desert island and don't interact with anybody then you haven't got a personality disorder. But it s the people who have difficulty in all sorts of ways of making good relationships and maintaining them, and as a consequence creating problems in other people's relationships, these are the people who have some degree of personality dysfunction. I use the word 'dysfunction' because Norman Swan: It's on a spectrum. Peter Tyrer: It's on a spectrum. We have now got a new classification which is not a bizarre classification that doesn't mean anything Norman Swan: And let's talk about that because there are people who might have heard the phrase 'borderline trait' describing a certain type of dependent self-obsessed person who's needy. They've certainly heard of psychopaths, sociopaths, narcissists for whom the world revolves around them, and you believe that those are rather artificial terms describing personality disorders which don't really make sense. Peter Tyrer: Yes, they're artificial because they've been derived, first of all, from a German psychiatrist, Kurt Schneider, who was a very good writer and impressed everyone with his writing about abnormal personalities, and it has been developed further by committees. And committees in psychiatric classification for years have sat around tables with no evidence. And of course if you sit around with no evidence the dogmatic views of one or two or three dominate, and unfortunately that's what's happened with personality disorder, when in fact the evidence, and this has mainly come from psychologists who are not working in personality disorder but working with normal personality variation, it has shown clearly that there are no fundamental distinctions between personality disorder in patients and personality variation in normal people. It's just a range. And to actually label someone as borderline or narcissistic, first of all it's artificial because we all have some of those features anyway. Secondly it's actually wrong because very few people have just one slab of personality characteristics which don't overlap with others. And in fact we haven't done a service to patients by becoming obsessed by these labels. Norman Swan: When you read descriptions of borderline trait, people who are dependent, clingy, needy, often abused as children themselves, sometimes sexually abused, who often turn quickly from love to anger and hatred, you kind of meet people who are exactly like that. Peter Tyrer: There's no doubt that there are groups of people like that. Personality disorder is something which we know develops in childhood or adolescence, and we know that half of

2 the features of personality disorder are genetically determined, the other half are environmental, and obviously we know that quite often people have very poor environments in abusive situations when they are young and this can account for a great deal of personality pathology. But it's not an all-or-none thing, and the thing that we've found repeatedly is that the people with borderline personality disorder in the current classification are grossly heterogeneous. You have people who extend from people in prison who in fact are really dangerous and can cause all sorts of problems and need to be locked up because they are so dangerous, because they are so impulsive and can react, right through to people who in fact are perfectly capable of functioning in the community and working, and yet they've all got borderline personality disorder. So I think the real problem has been that we haven't got a diagnostic system that allows us to identify people well and to identify what treatment they should need. It has tended to be a neglected area because people have almost said, well, if you've got a personality disorder Norman Swan: You might as well give up because there s no treatment. Peter Tyrer: Yes. Norman Swan: But in Australia there is an industry of psychotherapists who believe that they can treat personality disorder or borderline trait, and give them extended two-year courses of psychotherapy. Peter Tyrer: It is difficult to interpret the evidence because some of these people have got serious pathology, other people have got a much more minor pathology and we don't know which group is which because you can satisfy the diagnosis of borderline personality disorder on very little. You only need to get four out of seven symptoms, it's almost like a sort of lottery. You say, well, you've got seven of these but someone can have the top four and the other can have the bottom four. They've still got borderline personality disorder. So the evidence is really not all that impressive. It really shows that if in fact you receive a form of structured psychotherapy, it doesn't matter what it is, it just needs to make sense to the patient and be internally coherent, and you give it in a consistent way, then you'll do pretty well, whether it's called psychotransference, focused psychotherapy, cognitive behavioural therapy, cognitive analytical therapy. There are about 10 different types of treatment, all of which have a guru promoting them. They are all basically the same, and if in fact they compare their treatment with someone else's, if the person leading the treatment is the guru for that treatment you know it will come out better. So in fact we are not at all impressed by the results of these studies. But I don't want to blame the treatment here so much, I'm blaming the diagnostic system. Norman Swan: Let's now try and make it tangible. Describe the problem spectrum and how not coming to a specific diagnosis helps in terms of finding the right treatment. Peter Tyrer: Well, in the case of mental health the average person with a mental health problem presents with symptoms which they want treated. Now, what we fail to do is to assess their personalities. This is not easy, to assess people's personalities, and therefore I can understand why in a short consultation you don't actually do it very well. But in fact GPs actually do it better than the average because they see people more than once. And if you see

3 someone three or four times you actually get a much better feel for their personalities then when you see them only once. But so many of the people we see who have these symptoms actually have got personality dysfunction. The thing which we really want to get over, although I have to say we need more research on the subject, is the notion that if in fact you assess people properly from the personality aspect when you first see them, you are much more likely to give them appropriate treatment. Norman Swan: So just play that out. So somebody comes in and says: I'm depressed and I'm anxious, I feel unmotivated, I don't enjoy the things I used to enjoy, I don't want to get out, I just feel unable and I've lost my appetite or my appetite has gone up hugely and I'm just generally anxious, I'm fearful of everything. Peter Tyrer: The first thing to establish is if that is a recurrent phenomenon. Again, people tend to probably overstate the fact that it isn't a recurrent phenomenon because they want to emphasise their present symptoms. But if it is a recurrent phenomenon, almost certainly it's linked to personality aspects as well. If in fact it is related to a major stress or something like that, the first thing I would suggest, I don't want to be too strong about this in the case of depression because depression of course can lead to much more major problems such as people being suicidal, but if someone isn't suicidal and they are depressed and anxious and have these symptoms and they have no evidence of personality pathology, I would say and I'd say this to all the patients, I'd say, 'My assessment of you is that you are stable person with no significant problems in your personality. These symptoms are going to get better. And therefore I don't want to do anything very much for the next two weeks or three weeks because I think you're going to get better anyway.' And there may be a bit of self-help and other things that I may offer at that point, but I don't want to get involved with heavy treatment at that point because the evidence we've got from our research is that those people will get better without much intervention. Norman Swan: And what is a systematic way and people who are listening to this will be thinking about themselves in this what is a systematic way of quickly finding out whether there is something with your personality going on? What sort of questions do you ask, or is it just a feel you get across the room? Peter Tyrer: Well, you're really asking the difficult question now because the questionnaires that you give to people with personality problems, no one has found a good one yet. We have one or two which are good screening ones. They can certainly pick people up. There is a very well-known old one which is the Eysenck Personality Questionnaire Norman Swan: Back to neurosis. Peter Tyrer: Yes, back to neurosis, which in fact certainly identifies a lot of the people with previous personality problems. Norman Swan: That's describing, if you like, the worrywart or the person who doesn't express themselves outwardly and I m oversimplifying the Eysenck scale. But there are other things with personality which you talked about earlier which is about not caring about other people, only caring about yourself, being callous.

4 Peter Tyrer: One of the important things we are taught as psychiatrists which I think everyone can do is to get a feel of the person when you first assess them, and if you find someone has had an unstable work record, even though they should have coped all right, and they moved around the country a lot, they've had all sorts of different relationships and none of them have lasted very long, this is a very strong indication of personality pathology. Interestingly enough in our own research based on national surveys people with personality disorder also consult doctors and health services much more than people without personality disorder. Again, they aren't consulting with their personality problems but their personality problems mean they have more difficulties and they tend to consult. So you can get a feel fairly easily from someone by asking those questions. And I saw someone only last week who has got a major illness, schizophrenia, and has actually got, in my view, a completely stable personality. And I've said to her, 'You've got a stable personality and your prognosis is going to be good, because even though you've got quite marked symptoms of schizophrenia now, there are all sorts of reasons which make me feel that you're going to have a good outcome.' So it helps you to plan the prognosis. People with personality disorder and depression and anxiety, it's been shown by one of my colleagues, Dr Newton-Howes, who is in New Zealand, that those people who have depression and some form of personality disturbance have more than a twice as much risk of a poor outcome than those with no personality disorder. Norman Swan: So what you're implying then is that if you treat the depression without recognising the personality dysfunction, you're not going to be as successful with your depression treatment, which still begs the question how do you help people with their personality dysfunction? Peter Tyrer: Well, you have to be aware of that. So, for example, when I'm seeing a depressed person and I know that they've got some personality dysfunction and we've established that and they admit it, I say, 'Look, the treatment for your depression is this, you've got several options. You're going to have problems if you go onto antidepressants, not with getting better, you're going to have problems in stopping them, because in fact you're more likely to have withdrawal problems when you stop and you're also going to probably need them for a lot longer than someone with no personality problems.' Therefore by putting that option to the patient they can decide. And if someone says, 'Well, I don't care what you say, Doctor, these symptoms are terrible and if you can get rid of these symptoms I don't mind if I have to stay on these tablets for the rest of my life, but I just want to get rid of them, so please move now' if in fact they choose to have psychological treatment then in fact the same applies, 'Although this will probably help, you're likely to have relapses in the future and therefore in some ways you need to be aware of the fact that your lifestyle ought to be adjusted to some extent because under pressure you are likely to relapse.' So it's helping people to actually structure their lives more effectively rather than just saying, 'I've treated your symptoms, you are now cured,' which is one of the things we do very unwisely in our field.

5 Norman Swan: I'm still not sure how you help people with their relationship issues, with the fact they don't necessarily recognise or even want to recognise emotional reactions in other people, that other people are as important as they are in life et cetera. Peter Tyrer: You're bringing me over to another subject which I've talked about on ABC before which is nidotherapy which is the treatment whereby you adjust the environment to suit the person. Norman Swan: What could be more narcissistic than that? Peter Tyrer: Well, if you've got personality problems it's often a good idea. And one of the big advantages of being an Australian is that your option for environmental change is much greater than we have in the UK. And I couldn't help noticing that when I was last in Australia that a well-known rancher who managed to round up all his animals by helicopter and introduced a new method of looking after cattle, he was a delinquent youth who in fact would have probably been in prison repeatedly in the UK, but in fact people realised he had abilities and he became a rather high-risk-taking rancher and did very well. So I think one of the things we do in our clinical practice is to say, well, you've got personality difficulties, this is your problem, we've got to try and minimise that by getting the environment right. I've had academic colleagues who have been referred to me as having problems like Asperger's syndrome, which is a condition where people have difficulty relating to others and which is linked to the autistic spectrum. Well, these people didn't have Asperger's syndrome, they were people who were promoted because of their work in labs and other areas where they weren't working with people and they were promoted to people-supervision jobs where in fact they couldn't deal with people, and that was the reason why they seemed to have a condition like Asperger's, they weren't able to deal with people. And the answer was very straightforward; well, there's no need for this person to be a people manager, send them back to the lab, they're doing really well there, that's what they want to do, do not try and put them in an environment where they are going to have further problems. Norman Swan: So it comes back to your metaphor earlier, that you don't have a personality disorder on a desert island where nobody else is around. Peter Tyrer: No, you don't, it's one of the things that I often say to people with personality disorders. You can actually cope perfectly well if you didn't have to interact with other people, and if you do have to interact with other people it's got to be the people who are ones that you can relate to well. So there are all sorts of ways of adjusting the personality to the environment which makes people more successful. And I think one of the big negatives of current mental health practice is that we are too obsessed with treating symptoms. And if we are not obsessed with treating symptoms we go back to treating something which is some sort of amorphous core developmental problem. In fact it is not a core developmental problem, it's there right in front of you in the personality, that can be dealt with in practice quite well, and there are very few people who I come across in my clinical practice that I would ever say, well sorry, your problems are too difficult for me to deal with because they are beyond my abilities, because most of the people who reject patients on the grounds that they are untreatable are actually saying 'I am incompetent at dealing with personality problems, that is why you are untreatable, not because you are really untreatable.

6 Norman Swan: What's your answer then for the person who is callous and uncaring and ends up in jail? Is jail the right environment for them? Peter Tyrer: Oddly enough in some cases it is. We've been evaluating the dangerous and severe personality disorder program in England which is a somewhat curious and rather expensive way of identifying people who are dangerous and have personality disorders. And quite a few of the people we saw there, even though they were having quite complex treatment, told us, 'Well, I don't want to go out of prison, I'm actually quite happy in prison.' The interesting thing that we still haven't got a good explanation for of course is the people who are callous and antisocial and extremely dangerous in many ways, many of these do improve over the course of time. And that's one of the other things that we want to emphasise in our personality disorder research, is that the notion that once you've got a personality problem it is immutable, it will follow you the rest of your life, is totally untrue. Norman Swan: Peter Tyrer, who is Professor of Community Psychiatry at Imperial College London. References: Tyrer P et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. The Lancet 2014;383: Chris Williams, Allan House, Cognitive behaviour therapy for health anxiety. (Comment) The Lancet 2014;383: Guests Professor Peter Tyrer Community Psychiatry Centre for Mental Health Dept. of Medicine Imperial College London Further Information Professor Peter Tyrer, Imperial College London, with links to articles The Lancet (medical journal) Credits Presenter Dr Norman Swan Producer Brigitte Seega

Section 4 Decision-making

Section 4 Decision-making Decision-making : Decision-making Summary Conversations about treatments Participants were asked to describe the conversation that they had with the clinician about treatment at diagnosis. The most common