Today's Theme: Personality Disorders ;-}

Jonathon Rosen

Thinking Clearly About Personality Disorders

BENEDICT CAREY, November 26, 2012, New York Times. 

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. 

This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders. 

Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities. 

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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Social workers pioneer new approach to personality disorders

A pioneering approach to treating parents with personality disorders is achieving excellent results and, potentially, saving councils thousands of pounds. Judy Cooper investigates.

Judy Cooper

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.