Carers4PD Personality Disorders Empowerment Guide A Guide For Those Who Meet The Diagnostic Criteria And For Their Family And Friends Kevin Emry Dennis Lines Carers4PD 1 Introduction This comprehensive empowerment guide, may help people to overcome some of the difficult relationship dynamics that often arise in connection with Personality Disorders (PD) and are a fundamental part of a Personality Disorder diagnosis, given the fact that; by diagnostic definition; Personality Disorders consist of “inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others,” (DSM IV). The guide is intended equally for the benefit of people that meet the personality disorder diagnostic criteria and for people that are involved in a close personal relationship with them, partners, parents, siblings, children etc. Although the guide is divided into sections aimed primarily at one or the other of each of those two groups of people it is highly recommended that all users of the guide; irrespective of if they meet the diagnostic criteria themselves or have a close personal relationship with someone else that does; read all sections People that meet the personality disorder diagnostic criteria will gain immense benefit by looking at things from the perspective of someone that doesn’t meet the diagnostic criteria but cares deeply about someone that does and people that don’t meet the diagnostic criteria but are involved in a close personal relationship with someone that does, will also benefit by reading the section aimed primarily for people that do meet the diagnostic criteria. Historically, individuals with any sort of mental health problems have automatically been treated as invalids of some kind, someone that needs looking after. The language and structure of mental health services reflects this concept with a “Duty of Care,” “Support Workers,” “Care Pathways,” “Care Plans,” etc. The emphasis is placed firmly on the concept of taking care of, looking after and providing support, invalid care, as opposed to placing the emphasis on the concepts of providing treatment, making well and empowering. It is inevitable that as a result, the relatives of people with a PD diagnosis tend to fall into the trap of treating the individuals concerned as invalids of some kind, assuming responsibility for them and making allowances for their behaviour.This effectively dis-empowers everyone, encourages dependency and reinforces the problems in the long run. Difficulties Associated with Personality Disorders Some of the most potentially destructive problematic factors associated with a personality disorder diagnosis include: - Limited Affect Control (Difficulty processing and/or containing overwhelming feelings and emotions). Irresponsible Impulsivity, Emotional Dependency, Self-Harm, Suicidality, Substance Misuse, Domestic Violence. All of which potentially entail extremely volatile interpersonal relationships. Supporting someone with personality disorder can lead to a decline in a carer’s own mental health, personal relationships and employment status (Briggs & Fisher 2000). Family members often on ‘front line’ serving as case managers and crisis intervention teams , thrust into roles that cause them to feel ill prepared, too traumatised and dis-empowered to be of help to their relative. (Hoffman, Penney and Woodward, 2002) 2 Family members are at high risk of depression and suffer from feelings of burden, grief and isolation (Hoffman, Fruzzetti, Buteau, 2007) The feelings of being traumatised and dis-empowered together with feelings of burden, grief isolation and depression are also features of many diagnostic categories of Personality Disorder of course. It is widely recognised that the lives of people that meet the criteria for a diagnosable personality disorder often consist of crises after crises. What is usually not recognised or acknowledged, is the fact that if that person happens to be someone that you deeply care about, your son, daughter, parent, sibling, or your partner, your life consists of crises after crises as well. How long can it be before the trauma and stress results in the individual, the “carer,” concerned having some sort of breakdown themselves and the “carer” relationship developing into a co-dependent relationship in which both parties have diagnosable mental health or “stress related” problems of some kind? This guide is not simply about empowering individuals that meet the Personality Disorder diagnostic criteria. It is also about establishing healthy, collaborative, mutually supportive relationships in which everyone’s needs are met, everyone is validated and everyone is empowered. Psychological diagnoses are made in five different categories called Axis. • Axis 1: Clinical Disorders • Common mental illness. Things like schizophrenia, phobias, neurosis, the sort of things that most people think of in relation to mental illness. • • Axis II: Developmental Conditions • Things like Autism, Asperger’s syndrome, Learning Disabilities, Personality Disorders. • • Axis III: General Medical Conditions • Including malfunction of the endocrine system and other physical problems that may affect mental health. Being physically disabled for example. • • Axis IV: Psychosocial and Environmental Problems • Things like bereavement, divorce, redundancy, homelessness, substance use and other life events that can contribute to psychological problems, shock, Post-Traumatic Stress Disorder. • • Axis V: Global Level of Functioning • The individual’s overall level of functioning. Their general ability to look after themselves under normal circumstances. Personality disorder is an Axis II psychological developmental condition and not an Axis 1 mental illness. It is the way that an individual has become, how they relate to themselves, others and life in general, their view of the world and the way they function within it, not something that keeps going wrong with the way that they function. In order to be given a personality disorder diagnosis the individual has to be at least eighteen years old, cognitively as well as chronologically. In other words, everyone that meets the Personality Disorder diagnostic criteria has full adult capacity. 3 Definitions of Personality Disorders Enduring patterns of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture is pervasive and inflexible, has an onset in adolescence or early adulthood. International Statistical Classification of Diseases (ICD 10) Deeply ingrained and enduring patterns manifesting themselves as inflexible responses to a broad range of personal and social situations; they represent either extreme or significant deviations from the way the average individual in a given culture perceives, thinks, feels and particularly relates to others and are developmental conditions which appear in childhood or adolescence and continue into adult life. Diagnostic and Statistical Manual of Mental Disorders (DSM IV) Personality disorders are divided into three broad classifications that are called Clusters. Cluster A: Odd/Eccentric: - Cognitive disorders (Psychosis) Cluster B: Dramatic/Flamboyant: - Affective (Mood) disorders Cluster C: Anxious/Fearful: - Anxiety disorders (Neurosis) Other than problems that have an organic or biological cause, Personality Disorders encompass the full range of psychiatric difficulties. There are two different diagnostic classification indexes that are used, the European International Statistical Classification of Diseases (ICD 10) and the American Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Although they agree entirely on diagnostic definitions ,some of the names of the diagnostic categories differ. In practice an individual might be given a formal diagnosis from either index depending entirely on the preference of the clinician making the diagnosis. The differences are simply in terminology and are as follows. DSM IV Cluster A Paranoid, Schizoid, Schizotypal Cluster B Antisocial, Borderline, Narcissistic, Histrionic. Cluster C Obsessive-Compulsive, Avoidant, Dependent ICD 10 Cluster A Paranoid, Schizoid (Schizotypal does not appear in ICD10) Cluster B Dissocial, Emotionally Unstable Impulsive Type, Emotionally Unstable Borderline Type, Histrionic. Cluster C Anankastic, Anxious (Avoidant), Dependant. Cluster A, the odd or eccentric group are characterised by perceptual distortions although not necessarily delusional in the definitive sense, eccentricity of thought if you like, similar to psychosis. 4 Psychotic symptoms fall into two classifications, the positive symptoms and the negative symptoms. Positive symptoms of psychosis consist of perceptual distortions, delusional perceptions of reality, hearing voices, hallucinations etc. The negative symptoms consist of withdrawal and apathy. There are three diagnostic categories in cluster A. Paranoid, Schizoid and Schizotypal. Paranoid Personality disorders are pervasive and affect all levels of functioning. Essentially a diagnosable paranoid personality disorder consists of an extreme overwhelming mistrust of others and a pervasive sense of persecution. Schizoid A schizoid personality disorder is characterised by marked detachment. People with a schizoid personality have little or no interest in close personal relationships and/or social interaction with others, they are indifferent. Indifference