Personality Disorder in Primary Care Dr Graham Ingram Consultant Psychiatrist
Epidemiology Prevalence 6-13 % ECA etc Primary care surgery consults 24 % (Moran) Borderline PD community 1-2 % Borderline PD Primary care 6.4 % (Gross)
Personality Many and varied definitions Patterns of thoughts, feelings and behaviours (individual) Flexible across social situations
OCEAN 5 Factor analysis (dimensional) Openness to experience/intellect Conscientiousness Extraversion (sociability) Agreeableness (attachment) Neuroticism/emotional stability
What is Personality Disorder IC10/DSM 5 are reasonable guide Enduring patterns of perceiving, relating to and thinking about the outside world which is inflexible and deviates from cultural norms Present from adolescence onwards Distress is a key feature either to individual themselves or others or often both Essentially an impairment of social functioning and relating to others across a wide range of contexts
Behaviour beware That which is observable Behaviour most evident part of presentation of PD Underlying cause not necessarily evident Inherent presumptions about behaviour may not be accurate and often arn t
Categorical or Dimensional DSM V stuck essentially with trait theory- ie describe a number of cognitive/perceptual/emotional and behavioural TRAITS which a person may have or have not In reality there is a dimensional aspect to personality traits in that there is a continuum over which different traits may be evident to different degrees with an arbitrary cut off Extrovert-----------------------^----------------------Introvert dimensional
Subtypes 10 subtypes in DSMV /ICD10 Today we will be mainly concerned about the particular type Emotionally unstable (borderline/impulsive type) PD In reality 60% mixed picture including dependant,
Cluster A The odd & eccentric Cluster B The dramatic & erratic Cluster C The anxious & fearful DSM V Paranoid Distrust and suspiciousness Schizoid Socially and emotionally detached Schizotypal :difficulty in establishing and maintaining close relationships with others. Antisocial Violation of the rights of others Borderline Instability of relationship, self-image and mood Histrionic Excessive emotionality and attention-seeking Narcissistic Grandiose, lack of empathy, need for admiration Avoidant Socially inhibited, feelings of inadequacy, hypersensitivity Dependent Clinging and submissive Obsessive compulsive Perfectionist and inflexible ICD-10 Paranoid Distrust and sensitivity Schizoid Emotionally cold and detached No equivalent Dissocial Callous disregard of others, irresponsibility and irritability Emotionally Unstable A) Borderline type: unclear self-image and intense unstable relationships B) Impulsive type: inability to control anger, quarrelsome and unpredictable Histrionic Dramatic, egocentric and manipulative No equivalent Avoidant Tense, self-conscious and hypersensitive Dependent Subordinates, personal need, seeking constant reassurance Anankastic Indecisive, pedantic and rigid
The skeptics Legitimate questions about validity and reliability of diagnosis Essentially a social construct Medicalising bad behaviour HOWEVER the general idea of disordered personality disorder has some clinical usefulness and can inform better management and SAVE time
Emotionally unstable PD International classification IC10/DSMV Disturbance and uncertainty about self image Liability to become involved in intense and unstable relationships often leading to emotional crisis Excessive efforts to avoid abandonment Recurrent threats or acts of self harm Mood unpredictable, unstable Chronic feelings of emptiness Impulsive Fear of abandonment
Aetiology PD /BPD Genetic ~ 50% inheritability. Double dosing Environmental childhood emotional, physical and sexual abuse leading to attachment problems.abuse as child as high as 80% of BPD patients Invalidating environments Dysfunctional attachment
Aetiology
Diagnosis in primary care Demanding Difficult Manipulative Disruptive Aggressive Psychologically challenging to physician
Diagnosis in Primary Care Self harm (eg cutting,o.d. ) Suicidal ideation Treatment resistant (comorbidity) Somatisation Comorbidity with depression anxiety,alcohol and substance misuse, eating disorders common
SCENE 1
Management- general Calm and none threatening attitude VALIDATION- understand the problem from the patients perspective rather than your own standards Be reliable accessable and CONSISTENT Assess RISK
SCENE 2a
Management continued Explore reasons for distress. Focus on CURRENT problem and try to enhance coping skills Stimulate reflection Avoid minimising reasons for crisis Instil hope and optimism Ask about previous coping strategies EXPECT Misinterpretation, misunderstanding and anger
SCENE 2b
Management -medication Treat comorbid illness such as depression Avoid prescribing for symptoms of BPD itself Benzodiazepines during a crisis can be helpful if patient not likely to abuse
Management- refer on to secondary care Increasing risk (remember 10% mortality rate in young often female population) Failure to respond to resources available (psychology, counselling etc)
Management secondary care Structured Case management DBT Mindfulness Increasing evidence base for efficacy
SCM Structured Clinical Management (SCM) enables an increase in the persons understanding of their own internal states of mind, development of skills to manage emotions/impulses/relationships more effectively & encourages the development of interests outside of services. It uses individual & group work psychoeducation, identification of short & long term goals, crisis plans, & collaborative car e plans
DBT in PD Dialectical Behaviour Therapy (DBT) aims (through individual, group based & telephone based skills coaching), to help people develop a range of Distress Tolerance, Emotion Regulation & Interpersonal Effectiveness Skills. It uses behavioural chain analysis to help people work out more effective solutions to problems they experience
Mindfulness Often distress and other overwhelming emotions result from focussing upon circumstances, people, and events that have happened in the past or might happen in the future. It tends to be our judgements and thoughts about these circumstances & events that influence our emotions and determine our actions and responses.
Livesley 1. Safety and managing crisis 2. Containment 3. Impulse control and regulation 4. Exploration and change 5. Integration & synthesis
NHS services for PD (EUPD) Very slow to develop when consider comparison with Early Intervention in Psychosis Online resources/self help eg Emergence No specialist none forensic team until last year Personality Disorder Hub Team who will Manage about 80 challenging and risky patients Knowledge and Understanding Framework for personality Disorder (National)
So Remember no longer a diagnosis of exclusion DOH 2003 GPs manage the majority of PD patients with milder symptoms
Patient resources www.emergenceplus.org.uk www.mind.org.uk/information.../borderline -personality-disorder www.nhs.uk/.../borderline-personalitydisorder/pages/introduction https://www.personalitydisorderkuf.org.uk