“Management of Personality Disorders in Acute Hospital Care and Liaison” Dr. Andrea Tocca Consultant Psychiatrist Northumberland CRHT Assistant Medical Director Community – Inpatient Services North CBU Structure of the Session:

• Classification of Personality Disorders • Theories about Personality Disorders • Management of Personality Disorders • Group Exercise • Discussion DSM V

• Cluster A Personality Disorders: • Paranoid Personality Disorder 301.0 (F60.0) • Schizoid Personality Disorder 301.20 (F60.1) • Schizotypal Personality Disorder 301.22 (F21) DSM V

• Cluster B Personality Disorders: • Antisocial Personality Disorder 301.7 (F60.2) • Borderline Personality Disorder 301.83 (F60.3) • Histrionic Personality Disorder 301.50 (F60.4) • Narcissistic Personality Disorder 301.81 (F60.81) DSM V

• Cluster C Personality Disorders: • Avoidant Personality Disorder 301.82 (F60.6) • Dependent Personality Disorder 301.6 (F60.7) • Obsessive – Compulsive Personality Disorder 301.4 (F60.5) DSM V

• Other Personality Disorders: • Personality Disorders due to Another Medical Condition 310.1 (F07.0) • Other Specified Personality Disorder 301.89 (F60.89) • Unspecified Personality Disorder 301.9 (F60.9) Theories (Verywell Mind)

• Biological Theories

• Biological Theories • Biological approaches suggest that genetics are responsible for personality. In the classic nature versus nurture debate, the biological theories of personality side with nature. • Research on heritability suggests that there is a link between genetics and personality traits. Twin studies are often used to investigate which traits might be linked to genetics versus those that might be linked to environmental variables. For example, researchers might look at differences and similarities in the personalities of twins reared together versus those who are raised apart. • One of the best known biological theorists was Hans Eysenck, who linked aspects of personality to biological processes. For example, Eysenck argued that introverts had high cortical arousal, leading them to avoid stimulation. On the other hand, Eysenck believed extroverts had low cortical arousal, causing them to seek out stimulating experiences. • Behavioral Theories • Behavioral theorists include B. F. Skinner and John B. Watson. Behavioral theories suggest that personality is a result of interaction between the individual and the environment. Behavioral theorists study observable and measurable behaviors, rejecting theories that take internal thoughts and feelings into account. • Psychodynamic Theories • Psychodynamic theories of personality are heavily influenced by the work of Sigmund Freud and emphasize the influence of the unconscious mind and childhood experiences on personality. Psychodynamic theories include Sigmund Freud's psychosexual stage theory and Erik Erikson's stages of psychosocial development. • Freud believed the three components of personality were the id, the ego, and the superego. The id is responsible for all needs and urges, while the superego for ideals and morals. The ego moderates between the demands of the id, the superego, and reality. Freud suggested that children progress through a series of stages in which the id's energy is focused on different erogenous zones. • Erikson also believed that personality progressed through a series of stages, with certain conflicts arising at each stage. Success in any stage depends on successfully overcoming these conflicts. • Humanist Theories • Humanist theories emphasize the importance of free will and individual experience in the development of personality. • Humanist theorists also focused on the concept of self-actualization, which is an innate need for personal growth that motivates behavior. Humanist theorists include Carl Rogers and Abraham Maslow. • Trait Theories • The trait theory approach is one of the most prominent areas within personality psychology. According to these theories, personality is made up of a number of broad traits. • A trait is basically a relatively stable characteristic that causes an individual to behave in certain ways. Some of the best-known trait theories include Eysenck's three-dimension theory and the five-factor theory of personality. • Eysenck utilized personality questionnaires to collect data from participants and then employed a statistical technique known as factor analysis to analyze the results. Eysenck concluded that there were three major dimensions of personality: extroversion, neuroticism, and psychoticism. • During his initial examination, he described two major dimensions of personality which he referred to as Introversion/ Extroversion and Neuroticism/Stability. Extroversion and introversion related to how people tend to interact with the world while neuroticism and stability related to emotionality. • Eysenck believed that these dimensions then combine in different ways to form an individual's unique personality. Later, Eysenck added the third dimension known as psychoticism, which related to things such as aggression, empathy, and sociability. • Later researchers suggested that there are five broad dimensions that make up people's personalities. Often referred to as the Big 5 theory of personality, this theory suggests that the five major personality dimensions are Openness, Conscientiousness, Extroversion, Agreeableness, and Neuroticism, sometimes identified with the useful acronym OCEAN. Management •Focus: Borderline Personality Disorder (Leonard Fagin – Advances in Psychiatric Treatment 2004 vol. 10, 93-99) Management principles in the treatment of personality disorders (after Bateman & Tyrer, 2002) • Staff should devote effort to achieving adherence to the treatment, which should: • be well structured • have a clear focus • have a theoretical basis that is coherent to both staff and patient • be relatively long-term be well integrated with other services available to the patient, using the care programme approach as a main means of networking, communicating and reviewing plans between different elements of the service involve a clear treatment alliance between staff and patient Indicators for admission of patients with a personality disorder

• Crisis intervention, particularly to reduce risk of suicide or violence to others • Comorbid psychiatric disorder such as depression or a brief psychotic episode • Chaotic behaviour endangering the patient and the treatment alliance • To stabilise existing medication regimens review of the diagnosis and the treatment plan • Full risk assessment • Above all, the unit must have the capacity, in terms of skills, staffing and clinical pressures, to manage the admission The main elements of psychiatric intervention in an acute in-patient setting • Informality • Careful assessments by experienced staff, focusing on the present crisis and need for containment • Involvement of significant others, carers, relatives and other agencies in the assessment • Early care plan with specified goals agreed and communicated to all staff and the patient, paying special attention to perceived or real inconsistencies. Anticipation of crises, especially about impulsive discharge, self harm, drug use, sexual promiscuity or aggression, and establishment an agreed multidisciplinary response • A focus on immediate needs, mostly of a practical nature • Clear boundaries regarding tolerable behaviour, including aggression, suicidal gestures, use of illicit substances or alcohol and absconsions • Effective use of in-patient groups • Treatment of psychiatric symptoms with medication when necessary • Staff support groups and supervision looking at countertransference reactions, particularly of junior staff, who may become overinvolved • Early discharge arrangements when crisis has been overcome • Readiness to discharge if goals are not met • Referral to community or specialist services on discharge, with close and careful handovers through the CPA • Short duration of admissions • Consideration of comorbidity of a personality disorder if treatment for an Axis I disorder does not meet with the predictable response Principles of management of patients with borderline personality disorder in inpatient units • Maintain flexibility • Establish conditions to make the patient safe • Tolerate intense anger, aggression and hate • Promote reflection • Set necessary limits • Establish and maintain the therapeutic alliance • Avoid splitting between psychotherapy and pharmacotherapy • Avoid or understand splitting between different members of staff, either in hospital or in the community • Monitor countertransference feelings Borderline personality disorder: recognition and management Clinical guideline [CG78] Published date: January 2009

• 1.3.5 The role of drug treatment • 1.3.5.1Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk- taking behaviour and transient psychotic symptoms). • 1.3.5.2Antipsychotic drugs should not be used for the medium- and long-term treatment of borderline personality disorder. • 1.3.5.3Drug treatment may be considered in the overall treatment of comorbid conditions (see section 1.3.6). • 1.3.5.4Short-term use of sedative medication may be considered cautiously as part of the overall treatment plan for people with borderline personality disorder in a crisis.[3] The duration of treatment should be agreed with them, but should be no longer than 1 week (see section 1.3.7). • 1.3.5.5When considering drug treatment for any reason for a person with borderline personality disorder, provide the person with written material about the drug being considered. This should include evidence for the drug's effectiveness in the treatment of borderline personality disorder and for any comorbid condition, and potential harm. For people who have reading difficulties, alternative means of presenting the information should be considered, such as video or DVD. So that the person can make an informed choice, there should be an opportunity for the person to discuss the material. • 1.3.5.6Review the treatment of people with borderline personality disorder who do not have a diagnosed comorbid mental or physical illness and who are currently being prescribed drugs, with the aim of reducing and stopping unnecessary drug treatment. Group Exercise