Download - Relationships and mental illness
Mental illness and relationships
Dr. Nick Stafford, Consultant PsychiatristNHS & Private Practiceclinical-partners.co.uk
Seminar & discussion withRELATE Leicester July 2013
DisclosuresPharmaceuticalsAstra Zeneca LtdOtsuka LtdBristol Myers Squibb LtdGlaxo Smith Kline LtdPfizer LtdEli Lilly LtdLundbeck LtdServier Laboratories LtdGW Pharma Ltd
Private PracticeClinical Partners LtdNuffield HealthBMI HealthcareClinics in:London, Leicester, Sutton Coldfield
Previously Vice Chair Bipolar UK
Contents of talk
• Fundamentals
– Self, Attachment, Development, Social cognition
• Personality & disorder
• Bipolar disorder as a model
• Families
• Services and health care professionals
• Film examples
Summary – systemic model
Individuals
Illness
Response to stress
Treatment
Education / Knowledge
The brain is our lens of the world
Perception determines relation
Mental illness / Relationship System
Mental illness
Relationship
Protective factorsIndividual style
Attachment styleCommunication
Expressed emotion
NatureDegree
TreatmentsImpairmentsPersonality
What makes the self?
Self
Others
World
Bio
Psycho
Past
RelationshipsSpouse
Children
Friends
Colleagues
Neighborhood
BRIEF ENDURING
Social sciences
Psychology Social Work
Sociology Anthropology
Doctor
Insight
Regulations
Law Custom
Agreement Groups
Society
Attachment
Me
ATTACHMENT
Mummy
The World
Self
Dev
elo
pm
ent
Ad
ult
Lif
e
Attachment style (childhood)
Attachment styles
Secure
Insecure
Anxious avoidant
Ambivalent
Disorganised
Theory of mind
Development
Acquaintance
Build Up
Continuation
Deterioration
Termination
BEGINNING
ENDING
Adult attachment
SecureAnxious-
preoccupied
Dismissive-avoidant
Fearful-avoidant
Some forms of psychological maladjustment and clinical disorders are attributable in part to the effects of insecure working models and attachment styles.
Security based strategyof affect regulation
SecureAnxious-
preoccupied
Dismissive-avoidant
Fearful-avoidant
Self-esteem thoughts about the selfSo
ciab
ility
th
ou
ghts
ab
ou
t o
ther
s
Positive Negative
Positive
Negative
Security based strategy
Attachment avoidance strategy
Hyper-activation strategy
BIPOLAR DISORDERAn example mental disorder
Relationships in bipolar
• Key relationships– Divorce is twice as common– Loss of employment is twice as common
• Deficits in social cognition underpin these disabilities
• Treatments for these principal deficits– Psychoeducation– Functional remediation– DBT
• Things that don’t work– CBT– Counselling
Bipolar disorder comorbidities
• Anxiety disorders
• Eating disorders
• Alcohol and substance misuse disorders
• Impulse control disorders
• Behavioural addictions
• Personality disorders (esp. Cluster B)
• Medical problems – CVS, CVA, Cancer, etc.
• Psychosocial problems
COGNITION
Social cognition - Bandura
Social mirroring neurons
The Root – Cognitive deficits
PERSONALITY
Personality (the study of)
• Changes
• Development
• Disorder
• Genetics
• Pathology
• Psychology
• Style
• Systematics
• Tests
• Type
• Traits
• Measuring
Personality types & disorder
Personality type
• Hippocrates four temperaments– Yellow bile, Black bile
– Phlegm, Blood
• Eysenck– Extraversion / Neuroticism
• Myers-Briggs– Extraversion / Introversion
– Sensing / Intuition
– Thinking / Feeling
– Judging / Perception
Personality disorder (Type A,B,C)
• Paranoid
• Schizoid
• Schizotypal
• Antisocial
• Borderline
• Histrionic
• Narcissistic
• Avoidant
• Dependent
• Obsessive-Compulsive
Paul Abbott
COMMUNICATION
Communication styles
Passive
Aggressive
Passive-aggressive
Assertive
Communication
• How is this impacted on by the illness?
• Bipolar
– Mood state affects style of communication
• Depression predominates – Passive
• Mania disinhibited – Aggressive & Passive aggressive
– Thinking style can be different (social cognition)
– Relating styles affected by cognitive deficits (facial emotional recognition …)
MOOD AND EMOTION
Emotions
• What are they?
• Why have they evolved?
• How can they be helpful?
• How can they be unhelpful?
Moods – Depression
Why do people with bipolar have relationship problems?
• The impact of mania and depression
• Subsyndromal symptoms– Irritability– Depression
• Comorbid axis I disorders
• Personality traits and disorders
• Sleep disorders
• Treatments
Moods – Mania
Irritability
• Negatively affects ability to moderate emotions during social interaction
• Easily argumentative
• Evokes negative emotions in others
• Difficult for sufferer to distinguish their own irritableness
• Unpleasant to be around
• This is a predominant mood state in mania, depression and sub-syndromal states
OTHER PROBLEMS
Social anxiety disorder
• More than 80% of bipolars suffer with this
• Disabling anxiety in the context of mixing with others
• Avoidance of social contact leads to increased social anxiety
Alcohol and substance misuse
• 60% of bipolars suffer alcohol dependence at some point in their lives
– Worsens illness prognosis
– Increases other comorbidities
– Reduces interpersonal functioning
– Reduces occupational functioning
– Cost
– Domestic violence
Impulse control disorders
• Varied and can be pervasive
• Impulsive behaviour causes the person to lack judgment
• Consequential damage to self, others and relationships
Behavioural addictions
• Sex
– Could be a problem even if kept within a faithful relationship
• Gambling
– Amounts of money wasted can be staggering
• Spending
– Typically when high but also when low
Medication impact on a relationship?
• Overall improvements due to the treatment and improvement of the illness
• Side effects
– Impact on communication (sedation)
– Libido, impotence, delayed ejaculation
FAMILY FACTORS
Families - High expressed emotionFA
MIL
Y
PATI
ENT
HOSTILITY
EMOTIONAL OVER-INVOLVEMENT
CRITICAL COMMENTS
STRESS
ILLNESS
Families - Low expressed emotionFA
MIL
Y
PATI
ENT
MORE EDUCATEDFAMILY DON’T HAVE TO PUT UP WITH THE
ILLNESS
FEEL PATIENT DOES NOT HAVE CONTROL
OVER ILLNESS
MORE RESERVED WITH CRITICISM
STRESS
ILLNESS
TREATMENTS, SERVICES, RESOURCES
DBT
• Dialectical behavioural therapy
• Training yourself to become more aware of your emotions and how they impact on you
• Form of psychotherapy
• Marsha M. Linehan
• Original use EUPD
• Mindfulness
• Distress tolerance
• Emotion regulation
• Interpersonal effectiveness
Services for Relationships
• Generic psychiatric services
• GP counselling
• Rethink (carers)
• Relate (couples)
• All services to some degree assist
• Community institutions
Impact of health professionals
• All health care professionals should play a key role in a patient’s relationships– Assessment and identification
– Education
– Treatment
– Therapy
• ‘Negative’ impact of HCPs on relationships– Changes lead to relationship revaluations
– Discovery of abuse
Summary – systemic model
Individuals
Illness
Response to stress
Treatment
Education / Knowledge
Overcoming
Resources
Resources
THANK YOU