Jonathon Rosen
Thinking Clearly About Personality Disorders
Excerpts, for the whole article visit here.
For years they have lived as orphans and outliers, a colony of misfit
characters on their own island: the bizarre one and the needy one, the
untrusting and the crooked, the grandiose and the cowardly.
But when full-blown, the disorders are difficult to characterize and
treat, and doctors seldom do careful evaluations, missing or downplaying
behavior patterns that underlie problems like
depression and anxiety in millions of people.
The new proposal — part of the psychiatric association’s effort of many
years to update its influential diagnostic manual — is intended to
clarify these diagnoses and better integrate them into clinical
practice, to extend and improve treatment. But the effort has run into
so much opposition that it will probably be relegated to the back of the
manual, if it’s allowed in at all.
Personality problems aren’t exactly new or hidden. They play out in
Greek mythology, from Narcissus to the sadistic Ares. They percolate
through biblical stories of madmen, compulsives and charismatics. They
are writ large across the 20th century, with its rogues’ gallery of
vainglorious, murderous dictators.
Yet it turns out that
producing precise, lasting definitions of extreme
behavior patterns is exhausting work. It took more than a decade of
observing patients before the German psychiatrist Emil Kraepelin could
draw a clear line between
psychotic disorders, like
schizophrenia, and mood problems, like depression or
bipolar disorder.
Likewise, Freud spent years formulating his theories on the origins of
neurotic syndromes. And Freudian analysts were largely the ones who, in
the early decades of the last century, described people with the sort of
“confounded identities” that are now considered personality disorders.
Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were.
In the late 1970s, Ted Millon,
scientific director of the Institute for Advanced Studies in
Personology and Psychopathology, pulled together the bulk of the work on
personality disorders, most of it descriptive, and turned it into a set
of 10 standardized types for the American Psychiatric Association’s
third diagnostic manual. Published in 1980, it is a best seller among
mental health workers worldwide.
These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder.
Borderline is characterized by an extreme neediness and urges to harm
oneself, often including thoughts of suicide. Many who seek help for
depression also turn out to have borderline patterns, making their mood
problems resistant to the usual therapies, like antidepressant drugs.
Today there are several approaches that can relieve borderline symptoms
and one that, in numerous studies, has reduced hospitalizations and
helped aid recovery: dialectical behavior therapy.
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A
pioneering approach to treating parents with personality disorders is
achieving excellent results and, potentially, saving councils thousands
of pounds. Judy Cooper investigates.
Wednesday 12 December 2012 17:51
On
a suburban street in Holloway, behind a shopping centre, sits a small
building that resembles a nursery with its clean, light rooms and
abundant toys, photos and cots.
In fact, that’s exactly what it used to be, but the building is now
the focus of a new way of working between mental health services and
social workers in Islington.
Minna Daum, one of the project leads and a family therapist with the
Anna Freud Centre in London, says social workers often become paralysed
when faced with parents who are hostile or intimidating – or, in
clinical speak, show signs of personality disorder.
“It’s hard to see the child and what the risks are because they are
having to deal with the immediate problem of the parents and their
anger,” Daum says. “The system becomes paralysed because there's a lack
of services for these parents, so social workers are faced with closing
the case or escalating it into a child protection issue.”
Co-project lead Dr Duncan McLean, a psychiatrist, worked with adults
in mental health services at the Maudsley Hospital day centre and became
keenly aware that services for parents with mental health problems were
minimal.
“Adult services don’t cater for those with children but if you have a
child under five what are you supposed to do with them while you go for
treatment? It’s a massive gap and effective transitions between child
and adult mental health services are non-existent,” he says.
Shadowing social workers
The pair’s belief that parental problems could be resolved much
earlier in the process prompted them to apply for government funding to
set up the Early Years Parenting Unit (EYPU) under a service level
agreement with Islington’s children’s social care.
The EYPU only takes referrals from social workers who believe
children are at risk of being taken into care. Anna Freud therapists
were allocated to social work teams after shadowing them and undergoing
IT and data-sharing training so they could have (read-only) access to
files.
Psychologist Nicola Labuschagne says the team still work closely with
social workers and will go out on joint visits with them, “so we know
what the social worker's concerns are and what needs to happen or change
for their concerns to be reduced”.
In the year since the unit opened 15 families have entered the
programme. In four of the families the risks have reduced to the point
where children who were about to be taken into care have instead been
placed on the child-in-need register.
Labuschagne admits the commitment - two days a week for 18 months -
feels overwhelming for many parents, but says once they start most
understand the need for it and enjoy the visits.
What makes the EYPU
unique, according to McLean, is that the same staff deal with all three
presenting issues in one place – the parent’s own problems and mental
health, their parenting and the child’s developmental problems.
However, the unit's funding will come to an end in April 2013. The
team is applying for more, but there are concerns for its future with
cash-strapped local authorities reluctant to take on extra spending.
Read about the perspective of a parent in the program, a SW and the cost effectiveness here.
