Dr Glenys Dore, Senior Staff Specialist Psychiatrist, NSCCAHS
In this seminar Dr Dore introduced us to what is sometimes a "no go zone" for health professionals involved in addiction treatment: Personality Disorders (PDs).
People with Personality Disorders are "The Patients Psychiatrists Dislike" (Lewis & Appleby Br J Psych 1988), and workers in drug and alcohol will recognise these feelings: these patients are seen as difficult to manage, unlikely to arouse sympathy, annoying, not deserving of health resources, noncompliant, not accepting advice, having poor prognosis, their suicide attempts as "attention-seeking' rather than genuine, their requests for admission as manipulative.
Therefore, a Personality Disorder diagnosis may be seen as derogatory, pejorative and stigmatising. "What is conveyed.. is that the patient is difficult and probably unpleasant" (Gunn &Robertson Psychological Medicine 1976), with their symptoms seen as less genuine (Slavney &McHugh 1974; Thompson &Goldberg 1987).
Before focusing on Antisocial PD and Borderline PD, the most common diagnoses in substance using populations, Dr Dore traced some of the development of ideas about what we now call personality.
Hippocrates identified four elements in nature with four corresponding substances in human beings: Air, with Blood; Water, with Phlegm; Fire, with Yellow bile; Earth with Black bile. Galen later identified four corresponding "temperaments": from blood, the Sanguine (confident, hopeful); from Phlegm, the phlegmatic (dull, sluggish); from bile, the Choleric (passionate) and from Black bile, Melancholic.
Eysenck neatly resolved Galen's four temperaments into two dimensions: introversion-extroversion along one axis and stable-unstable along the other. In this model, the "sanguine" person was extroverted and stable; the "phlegmatic" person stable but introverted; the "choleric" person extraverted and unstable; the "melancholic" person introverted and unstable (the psychotic person emerged out of this combination).
Others have suggested a three or four dimensional approach. Cloninger's model of personality, has four distinct "traits" of Temperament (Harm avoidance, Novelty seeking, Reward dependence and Persistence) and three "traits" of Character (Self-directedness, Cooperativeness, Self-transcendence). Temperament comprises basic emotions, the emotional core of personality, early emotional and behavioural dispositions whereas Character "mental self government", "what a person makes of himself or herself intentionally".
For example, one of your correspondents is by temperament harm avoiding, novelty shy, aloof (not needing cuddles) and persistent..another almost the opposite. Both, of course, have Self-directed, Cooperative and Self-transcendent characters!
DSM-IV is concerned less with theories and more with practical empirical descriptions. Thus, it uses a categorical rather than Dimensional approach, with 3 clusters - Cluster A, Odd or Eccentric; Cluster B, Dramatic, Erratic or Emotional and Cluster C, Anxious or Fearful - comprising a total of ten personality disorders (and a rag-bag category, as always in DSM, "not otherwise specified").
Personality Disorders are common in the general population (Antisocial PD = ASPD 4%, Borderline PD = BPD ~ 2%), and especially so in psychiatric populations and people with substance use disorders. Among people with a current alcohol use disorder: 30% have at least 1 PD; people with a current drug use disorder, 50% at least 1 PD. The ATOS study reported 80% of current heroin users with a PD, 33% Antisocial PD, 7% Borderline PD, 38% ASPD + BPD. In this study BPD was strongly related to suicide attempts, needle sharing, overdose risk, polydrug use, depression, psychological distress and poorer treatment outcomes (Darke et al. Drug &Alcohol Dependence 2004). Antisocial PD is associated with earlier onset drug use &IDU, more polydrug use, higher levels HIV risk-taking and poorer social functioning in patients on MMT (Henderson et al 2002 NDARC Monograph No. 49).
Before labelling someone with a personality disorder (like "narcissistic" or "borderline") it is essential to be sure that they meet the general criteria of a personality disorder. Under the mnemonic PPAIIN, the pattern of inner experience &behaviour must be Persistent, Pervasive (with a broad range of personal &social impacts), from Adolescence onwards, causing Impairment, be Inflexible &maladaptive and Not due to mental disorder, medical condition, or substance use.
Before concentrating on ASPD and BPD, Dr Dore introduced us to all the DSM PDs, for which ingenious psychiatry candidates have developed helpful mnemonics (listed in the Supplement to this summary on the Redfern Clinic Website, with some case examples).
In Cluster A, the Odd or Eccentric group, are the Paranoid (Suspicious, Jealous, but not Psychotic or Unlawful); the Schizoid (Unemotional, Cold, Indifferent) and Schizotypal (Odd + Magical Beliefs, Behaviors, not Paranoid) types.
Cluster A PDs have a higher incidence in families of schizophrenia patients, and are often antecedent for Psychotic disorders, including schizophrenia, delusional disorders and schizophreniform disorder. In these people, stress may trigger Brief Reactive Psychosis.
Treatment options for cluster A include low dose antipsychotics and supportive psychotherapy, with openness, consistency, emphasising reality (paranoid), and social skills development (schizoid), and education on the interaction between substance use & psychiatric vulnerability.
In Cluster C, the Anxious or Fearful group, are the Avoidant (Needs People But Fears Relationships); Dependent (Needs Relationships, Indecisive, Fears Abandonment) and Obsessive-Compulsive (Rigid, Perfectionist + Inefficient) types. The Passive-Aggressive PD (Negative Attitudes with Passive Resistance to Demands) was dropped from DSM-IV.
Remember that Cluster C PD are not the same as anxiety disorders, although these may co-exist. Anxiety disorders may respond to specific therapies.
In Cluster B, the Dramatic, Erratic or Emotional group, are the ASPD (Aggressive, Unlawful, Impulsive); Borderline (Unstable, Chaotic, Impulsive, not Aggressive or Unlawful), Narcissistic (Self-Centered, Entitled, Lacks Empathy But Not Unlawful or Chaotic), and Histrionic (Dramatic, Seductive But not Chaotic) types.
Many people will recognise the "narcissistic rage" of a person typically fragile at their core, the demands of specialness and entitlement belying a sense of inner inferiority. It was asked without irony how common Narcissistic PD is among CEOs. Sadly few people with Narcissistic PD go into psychotherapy, few improve over time. Histrionic PD might present as almost hypomanic.
Briefly the DSM criteria for ASPD are: the individual is at least age 18 years, with evidence of Conduct Disorder with onset before age 15 years, and a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, not exclusively during the course of Schizophrenia or a Manic Episode.
As a general exclusion, the behaviours should not be better explained by another disorder, including a substance use disorder. ASPD may be over-diagnosed in SUD populations, because drug seeking behaviours, especially for illegal drugs, are likely to be considered "antisocial".
ASPD is more common in 1st-degree relatives of ASPD individuals, is associated with ADHD; the related Conduct Disorder is associated with erratic or inconsistent parenting and neglect. After 30 years of age there tends to be reduced antisocial behaviour (crime, promiscuity) and reduced substance use.
Dr Dore gave the example of a man who had a history of fights, truancy, theft, near expulsion from school, drug use and dealing, addiction to heroin, benzodiazepines, cannabis, with alcohol use, and by age 19, three counts of murder. When seen at age 36 yrs, he was married, with a child, and much settled.
Heroin users with ASPD respond as well as other heroin users to opioid pharmacotherapy (similar retention in treatment, methadone dosage, improvement in heroin use) however with poorer social functioning (Darke et al 1996; Darke et al 1994; Gill et al 1992; Rouser et al 1994)
Spot the diagnosis: "On return from your last holiday, your patient informed you that she smashed up her goldfish bowl and flushed her much-loved goldfish down the toilet, killing them. She has since replaced them."
Marsha Linehan (1993), the guru of Dialectical Behavior Therapy, gives us an unforgettable image:
"Borderline individuals are the psychological equivalent of the 3rd-degree burn patient. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering.."
Briefly the DSM criteria for Borderline PD are: A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood, which may include: frantic efforts to avoid real or imagined abandonment; unstable and intense interpersonal relationships alternating between extremes of idealization and devaluation; impulsiveness in spending, sex, substance abuse, shoplifting, reckless driving, binge eating ; recurrent suicidal threats, gestures, or behaviour, or self-mutilating behaviour; intense episodic dysphoria, irritability, or anxiety; chronic feelings of emptiness; inappropriate, intense anger or lack of control of anger; transient, stress-related severe dissociative symptoms or paranoid ideation. (see supplement for full criteria).
People with BPD may suffer from an almost murderous rage. Does "cutting" serve as emotional release or self punishment? Their feelings may swing pendulum like between love and hate, the pedestal and resentment. There is a poor sense of identity, of who/what they are.
BPD is characterised by recurrent suicidal threats, gestures, or behaviour, or self-mutilating behaviour, and although 90% improve despite multiple suicidal episodes, the stark reality is that 10% will complete suicide. Like ASPD, BPD tends to improve with age: by age 35 - 40 years: 75% have close to normal function, with less impulsivity (suicidality, self mutilation), better interpersonal relationships (less stormy relationships, less devaluation/sadism/manipulation) and people learn how to avoid emotional triggers. (Paris J. Canadian Medical Association Journal 2005)
In managing patients with PDs, especially BPD, it is important to bear in mind the concept of Transference, whereby unresolved feelings about important figures from the patient's past are revealed in the patient's transference towards the therapist.
Common defense mechanisms allow the person to defend against threatening or anxiety-provoking situations: splitting, idealisation, denigration, externalisation, projection, denial, acting out, repression.
If this seems too high falutin, we can at least identify the tactics. The person may stone- wall (allows no choice other than his/her position), attack ("You're not the caring doctor I thought"...."I'll take you to HCCC"...."I'll kill myself") or trick (manipulating the facts, making surprise demands) (from Ury William. Getting Past No: Negotiating With Difficult People).
The therapist's counterpart to transference is "Countertransference". They may themselves fall into the role of victim (feeling helpless, worthless, distant, withdrawn), of abuser (getting angry, retaliating, rejecting, cancelling appointments, "throw off program") or the role of rescuer ("only I understand"; unfair criticism of colleagues, extra appointments, late night calls, inappropriate prescribing, even sexual relationship).
In balancing Countertransference, remember there is a "zone of helpfulness" between overinvolvement and underinvolvement.
In managing your reactions, remember people are often trying to provoke reaction - they know your hot buttons. It is tempting to strike back, to break off the relationship, or to give in - the latter rewards bad behaviour, encourages same tactics in future, damages your reputation (weak, soft touch) and may compromise safety
. Try not to react, remain empathic and nonjudgmental,
. "Go to the balcony", either actually or mentally.
. "Step to their side" (you can't reason with a non-receptive patient, give a full respectful hearing
. Acknowledge (don't dismiss patient as irrational, acknowledge his/her point &feelings, if appropriate offer an apology)
. Use active listening (eye contact, empathic, reflective listening, paraphrase, seek clarification
. Buy time to think (pause &say nothing, "rewind the tape, ask for clarification, take time out, delay the decision)
. Try to understand transference-countertransference issues.
. Debrief with colleagues
Some rules for yourself:
. Acknowledge their position, even if don't agree with it (agree wherever you can)
. Express your views clearly without provoking (acknowledge negative impacts of your decision, acknowledge your differences, speak about your responsibilities, mention duty of care, Guidelines, Dept of Health etc)
. Negotiate a way forward (treatment contracts can help)
The focus of treatment for BPD may be the BPD itself, or comorbid Axis I, II disorders, and should include safety assessment and risk management.
A suicide/violence risk assessment distinguishes between plan and intention. Watch out for a recent mental state change. Management includes a crisis plan in collaboration with other (clinicians and family), increasing patient responsibility (exploring alternatives to self harm, self soothing techniques), consulting with colleagues if high risk, with medication and/or hospitalisation if needed. It is crucial to document your assessment and plan: remember the pain of writing a "Dear Coroner" letter.
Pharmacotherapies for BPD may be used with the aim of symptomatic relief: for affective dysregulation, impulsive-behavioural dyscontrol, or cognitive perceptual symptoms (suspiciousness, referential thinking, paranoid ideation, illusions, derealisation, depersonalisation, hallucinations). Treatments may include SSRIs or venlafaxine, low dose antipsychotics (higher doses if psychotic), Mood Stabilisers. ECT may be used if there is comorbid severe axis I depression.
Dialectical Behaviour Therapy is a three pronged approach
. Accepting patients just as they are within a context of trying to teach them to change
. Supportive acceptance; validation
. Confrontation &change strategies (individual or group work towards emotion regulation, improved interpersonal effectiveness, distress tolerance, core mindfulness, self-management skills) (Linehan M. CBT of Borderline PD 1993)
Principles of work with BPD (After Gabard 1994) are
. Establish a stable framework/structure predictable (eg frequency, length sessions)
. Take an active stance: validate, affirm
. Contain the anger &self destructing behaviours (soothe, validate, risk assessment, limit behaviour; problem solve)
. Establish the connection between feeling &actions
. Set limits on problem behaviours
. Maintain a "here &now" focus
. Monitor countertransference feelings
. Risk Management
Dr Dore highly recommended "Getting Past No: Negotiating With Difficult People", a book by Ury William.
Summary by Richard Hallinan based on the Concord presentation by Dr Glenys Dore.
Note there is also a supplement to this seminar available.