Transcript Personality Disorder Food for thought

Personality Disorder
Food for thought
Geoff Searle
BUT
When I say personality disorder I
mean Emotionally Unstable/
Borderline Personality Disorder
Learning Objectives
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To learn about clinical features of different
personality disorders
To understand issues relating to comorbidity and difficulties in diagnosis
To learn about different management
options of specific personality disorders
Expectation
• You will read, or will have read your
textbook chapter on this topic
• The material from this session is extra
• And so is the work……
Menu
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Referral
History
Differential Diagnosis
Reality in OPD
Problems
Management
Exit
The Memorial Care
Plan
Spring 1994
Referral
• Co-morbidity is essential
Referral
• Co-morbidity is essential
• “May be suffering from a PD…… “
History
• What’s the story? Change or discovery?
History
• What’s the story? Change or discovery?
• Why now?
History
• What’s the story? Change or discovery?
• Why now?
• Why this person?
History
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What’s the story? Change or discovery?
Why now?
Why this person?
It’s a “social” condition
History
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What’s the story? Change or discovery?
Why now?
Why this person?
It’s a “social” condition
Asking about abuse – Mind F**k
History
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What’s the story? Change or discovery?
Why now?
Why this person?
It’s a “social” condition
Asking about abuse – Mind F**k
“False memory”
History
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What’s the story? Change or discovery?
Why now?
Why this person?
It’s a “social” condition
Asking about abuse – Mind F**k
“False memory”
Prosecution/ Risk to others/ Child protection
The Great Deceiver?
The Great Deceiver?
• Autism/ emotional ~ social incompetence
The Great Deceiver?
• Autism/ emotional ~ social incompetence
• Long High Dive vs Psychoticisation
The Great Deceiver?
• Autism/ emotional ~ social incompetence
• Long High Dive vs Psychoticisation
• Ultra Rapid Cycling – how fast before it’s
not bipolar?
The Great Deceiver?
• Autism/ emotional ~ social incompetence
• Long High Dive vs Psychoticisation
• Ultra Rapid Cycling – how fast before it’s
not bipolar?
• Obsessional coping
The Great Deceiver?
• Autism/ emotional ~ social incompetence
• Long High Dive vs Psychoticisation
• Ultra Rapid Cycling – how fast before it’s
not bipolar?
• Obsessional coping
• Depression ~ Somatisation
How Long?
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Can personality change?
Long term problem/ illness or PD revealed?
Would you be different?
Is everybody aggravating & unresponsive to
treatment personality disordered?
SNAP!
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Blokes are Psychopaths
Girls are Victims
Needy
Aggravating
Withdrawn
Embittered
Franklin’s error
That’s Ben Franklin the well
known human lightning conductor
Outpatients
Why you really need experience of
analytical therapy
(and it’s not for the sake of the patient
you “treat”)
Black Hat/ White Hat
Why are you always OK when I’m
here?
Out of your depth in
OPD
• Engagement – no safe distance – no safe
carer role available
• Aiming for rejection
• Dropping in & out
• Ultra sensitive
• Special
Where are they?
Anxiety
Autonomy
Abuse
Problems
• Nihilism
• Who’s responsible for keeping the patient
safe?
• Reciprocal roles/ acting out
I love you, you don’t love
me, I’m going to kill
myself….
With the pills you just prescribed
Are you managing the patient ?
Or is the anxiety & transference
within you & your team driving
you?
Problems 2
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Splitting
Labelling
Mislabelling
“Manipulative”
“Anxious and dependant”
Re-Re-Re-Re-Re-Labelling
Schizo-affective
Special relationship…….
Managing
Good enough parenting
Think about it
Think about it
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Uncritical positive regard
Supportive
Tolerant
Firm/ fair
Strong
Calm
Reliable
Being a good enough parent
Of a difficult teenager
RAID
• Reinforce
• Adaptive
• Ignore
• Dysfunctional
Problems/ Solutions
Problems/ Solutions
• Focusing only on the negatives/ problems
Problems/ Solutions
• Focusing only on the negatives/ problems
• Boundaries
Problems/ Solutions
• Focusing only on the negatives/ problems
• Boundaries
• Acting the transference
Problems/ Solutions
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Focusing only on the negatives/ problems
Boundaries
Acting the transference
Too close or too far?
Problems/ Solutions
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Focusing only on the negatives/ problems
Boundaries
Acting the transferance
Too close or too far?
“Largam”
“He who has a why to live for can bear
almost any how”
Finding a why
Is the only cure for chronic
suicidality
Medication
• Lets be realistic about this….
Medication
• Lets be realistic about this….
• Only biological symptoms of depression
Medication
• Lets be realistic about this….
• Only biological symptoms of depression
• Why SSRI?
Medication
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Lets be realistic about this….
Only biological symptoms of depression
Why SSRI?
Don’t treat your anxiety with another
compound
Medication
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Lets be realistic about this….
Only biological symptoms of depression
Why SSRI?
Don’t treat your anxiety with another
compound
• Why promethazine?
• Why not depot?
EXIT
• Gatefever ~ “flash”
• Getting the rejection in first
• Parting Shot
So…
• Discuss
• Discuss
• Prepare
• Discuss
• Prepare
• Courage
• Discuss
• Prepare
• Courage
• and
• Discuss
• Prepare
• Courage
• and
• Hope
Questions from you?
Questions to you?
Task 1
• How common is personality disorder are there real differences over and
between cultures?
• References from NICE guidelines… pick
one each
Task 2
• What are the strengths and weaknesses
of diagnosis based on archetypes and
clusters of traits? How have they
changed through history?
• Papers provided – looking backwards &
forwards
Task 3
• Do treatments of personality disorder
work if you judge them like drug trials?
Are any effective or superior?
• The Lancet or Zannarini paper – pick a
reference each but avoid meta-analyses…..
Task 4
• Is the prognosis of personality disorder
changing? Is treatment cost effective?
• Pick the references from Bateman &
Fonaghy – or if you are keen do a citation
search…
Leading too
• A handout summary for your colleagues
• A presentation of 5 minutes with…..
• No more than 2 powerpoint slides
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And this is not an invitation to use a small typeface
• Time for discussion
THE END
Now “Get weaving”