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