Dr. Janet Feigenbaum, Senior Lecturer UCL
Consultant Clinical Psychologist
Strategic and Clinical Lead for Personality Disorder, NELFT
Email: [email protected]; [email protected]
Appleby and Lewis (1988)
‘Personality Disorder: the Patients Psychiatrists Dislike’
Adshead (2001)
‘Murmurs of Discontent: Treatment and Treatability of
Personality Disorder’
What is personality disorder?
(Livesley, 2003)
‘…failure to achieve adaptive solutions to life tasks…’
Life Tasks
 integrated representations of self and others
 capacity for intimacy
 capacity for affiliation
 adaptive social functioning
prosocial behaviour
cooperative relationships
‘The overall goal in treating personality disorder is to improve adaptation’
Manipulative
Selfish
Attention
seeking
Demanding
Miserable
Creative
Courageous
Lonely
Biosocial Theory of Borderline Personality Disorder
Emotional
Vulnerability
Invalidating
Environment
Emotional
Dysregulation
Emotional
Dysregulation
Cognitive Dysregulation
information processing
problem solving
Affective Dysregulation
Physiological arousal
attention to emotion
Behavioural dysregulation
direct response to emotion
attempts to control emotions
Lack of skills to manage
emotions
Failure to label emotions
accurately
Invalidating
Environment
Ease of solving life’s
problems
Self
Invalidation
DBT Model
Cue or
Trigger
Emotional
Dysregulation
Solution:
Avoid or
reduce
Self
Invalidation
Problem
Behaviour
Temporary
Relief
Four Ways for the individual to Change
 Solve the problem/cue/trigger
 Change one’s emotional reaction to
the problem/cue/trigger
 Tolerate the distress that arises from
the problem/cue/trigger
 Stay miserable
So how do I interact with someone with BPD?
BE GENUINE
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Recognize that they are experiencing strong emotions
Keep information simple and clear – write it down
Clear boundaries – let them know the rules/expectations
Their behaviour is the problem not the person
Spend some time listening
Contingency Management
A reinforcer increases the likelihood of a behaviour
A punisher decreases the likelihood of a behaviour
Positive Reinforcer: reward
Negative Reinforcer: remove adversity
Positive Punishment: apply adversity
Negative Punishment: remove reward
Histrionic Personality Disorder
pattern of excessive emotionality and attention seeking
Feels invisible and alone
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Active listening, but
Set limits on descriptions/time
Stick to facts not emotionality
Encourage social support not medical
Narcissistic Personality Disorder
pattern of grandiosity, need for admiration, lack
Feels inferior
• Allow them to come up with ideas (socratic questioning)
• Allow them to be ‘experts’ in their care
• Document all decisions with rationale to avoid anxiety
about complaints
• Notice when feeling angry, seek supervision/peer support
Antisocial (Dissocial) Personality Disorder
pervasive disregard for the and violation of the rights of
others
Finds it difficult to wait, quick to take offence
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Be ‘extra’ respectful of their views
Be clear on the ‘gains’ for the individual
Set clear guidelines on acceptable behaviour
If controversial information, consider colleague attend
Document all information well
Avoidant Personality Disorder
pattern of social inhibition, feelings of inadequacy,
hypersensitivity to negative evaluation
Extreme social anxiety, avoids conflict
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Warm, welcoming stance
Find the merit in their actions
Highlight strengths
State differences of opinion as choices
Anticipate DNAs
Highlight drug/alcohol use as avoidance
Dependent Personality Disorder
pattern of excessive need to be taken care of that
leads to submissive behaviours and fears of separation
Extreme generalized anxiety, fearful of making mistakes
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Encourage/expect them to make decisions
Cautiously- encourage social network involvement
Try not to admit to wards where possible
Allow to attach, but set limits
Obsessive Compulsive (Anakastic) Personality Disorder
pattern of preoccupation with orderliness, perfectionism, and
mental and interpersonal control at the expense of flexibility,
openness and efficiency
Fears being out of control
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Document and give copies of all letters/reports
Give them opportunities to ask questions/raise concerns
Set standard appointments, regular practitioner
Recognize self harm as need to punish self
Schizoid Personality Disorder
detachment in relationships, restricted range of
emotional expression in interpersonal situations
Terror of interpersonal closeness
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Keep an emotional distance
Avoid touch as far as possible
Don’t push a therapeutic alliance/relationship
Be very matter of fact
Schizotypal Personality Disorder
a pattern of acute discomfort in close relationships and
cognitive or perceptual distortions or eccentricities in
behaviour
Fearful of interpersonal closeness
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Eccentricities are protection
Challenge coping strategies not beliefs
Encourage social network building
Don’t push therapeutic relationship, allow to happen
Paranoid Personality Disorder
pervasive distrust and suspiciousness of others who are
regarded as malevolent
Fear of harm from others
• Open about all communication
• Allow them to see all letters/reports and comment
• Clear about purpose of actions
• Avoid speaking to others without them present
NICE Guidelines n = 2
BPD - DBT for self harming women
MBT and CBT – up and coming
ASPD – Stop and Think, Interpersonal Problem Solving
both group based CBT interventions
DBT in Emergency Care
Sneed et al. (2003) – DBT enhances readiness to change
use validation and change strategies
McQuillan et al. (2005) – Intensive DBT outpatient treatment
3-4 weeks; 4 days a week;
4 hours per day; group format
Results: good treatment retention
reduced depression and hopelessness
Types of validation:
explicit verbal
implicit functional
Functions of validation:
to strengthen clinical progress
as acceptance to balance change
to strengthen self-validation
as feedback
to strengthen the therapeutic relationship
Levels of validation:
staying awake: unbiased listening and observing
accurate reflection
articulating the unverbalized emotions, thoughts or behaviours
validation in terms of learning or biological dysfunction
validation in terms of present context or normative functioning
radical genuineness
Dialectical Change
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Attend to the bigger picture - look for what is left out
Embrace conflict as opportunity to move to truth
The truth is found in the synthesis of different views
Enter the paradox
Irreverent style
Making lemonade out of lemons
Metaphors