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Update on the current status of international research and treatment of personality disorders and future trends

in the field

Brin Grenyer grenyer@uow.edu.au

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Key themes 600 published studies per year on Borderline Personality Disorder alone

1.  Diagnosis – DSM-5 and ICD-11 2.  Increased interest in narcissism - higher prevalence of

people diagnosed by psychiatrists with narcissistic disorder 3.  New findings on emotions in personality disorder 4.  Mentalisation and the neurobiology of trust 5.  DBT unpacking studies 6.  Early intervention – working with adolescents 7.  Families and carers

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DSM-5 and ICD-11

•  DSM-5 May 2013 – retained DSM-IV Personality disorders but no longer on separate axis

•  DSM-5 Research Criteria: Disorder of Self and Disorder of Relationships + 6 types: Borderline, Obsessive-Compulsive, Avoidant, Schizotypal, Antisocial, Narcissistic

•  ICD-11 – Due in 2015. Two steps: 1. Severity, 2. Subtype.

•  Likely to be: asocial/schizoid, dyssocial/antisocial, obsessional/anankastic, anxious/dependent, and emotionally unstable

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NHMRC Clinical Practice

Guideline – Released 15 March 2013

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8 Key Recommendations

1.  BPD is legitimate diagnosis for healthcare services

2.  Structured psychological therapies should be provided

3.  Medicines should not be used as primary therapy

4.  Treatment should occur mostly in the community

5.  Adolescents should get structured psychological therapies

6.  Consumers should be offered a choice of psychological therapies

7.  Families and carers should be offered support

8.  Young people with emerging symptoms should be assessed for possible BPD

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www.projectairstrategy.org

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Emotional dysregulation •  Higher amygdala activation (peak and slower to return to

baseline): Borderline PD > Schizotypal PD – Control = greater emotional reactivity

•  Problems in labelling emotions – physiological response vs blunted self-report experience to unpleasant stimuli = reported unpleasant pictures as less unpleasant !

•  Unlike schizotypal personality disorder, there was no habituation to repeated presentations of unpleasant pictures

•  Psychotherapy should facilitate emotion recognition – such as in transference-focussed and DBT approaches

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Mentalising and Epistemic Trust

Peter Fonagy

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Reflective Functioning

•  The capacity to view yourself and others as separate beings, each with his or her own mind

•  Perceive and understand oneself and others in

terms of psychological states that include feelings, beliefs, intentions, and desires

•  Childs develops internal control or more mature

forms of emotional expression

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Sensitivity and Responsive Caregiver

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Shorter DBT studies

•  McMain – 2013

conference •  20 weeks DBT skills

alone vs waitlist •  Outcomes of skills

alone = Outcomes of full year of DBT skills+individual

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Future implications

•  Shorter DBT (20 weeks) may be as effective as longer (1 year) treatment

•  Skills training alone, or individual therapy alone compares favourably to full group+individual DBT treatment

•  Challenge to the field – does the format matter as long as effective ingredients such as emotional processing and reflection on self and other in relationships happens?

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Why focus on families and carers? •  “With the shift from hospital to community-based

treatment, the responsibility for the care of personality disordered patients has fallen on families and carers, who can be enlisted as allies in treatment” (Gunderson, Berkowitz & Ruiz-Sancho, 1997).

•  “the families and carers of people [with Borderline Personality Disorder] may also feel unsupported in their role by healthcare professionals and excluded from the service user’s treatment and care” (NICE guidelines p. 35).

Harvard Review of Psychiatry Vol 21 – 2013

Systematic Review

METHOD The PRISMA systematic review method was used with predetermined terms and inclusion criteria with three search phases. MAIN RESULTS •  6 studies were included, 5 of which focused on carers of persons with BPD. •  Data on 465 carers of persons with Borderline Personality Disorder (mainly mothers of female

patients) was aggregated and compared to previous literature with the same measures. •  Carers scored significantly higher on measures of burden, grief, and significantly lower on

empowerment than carers of persons with other serious mental illnesses (including inpatients with mood, substance, neurotic and psychotic disorders).

•  Carers also reported experiencing symptoms consistent with depression and anxiety. CONCLUSIONS •  Carers of persons with BPD are significantly burdened and grieving. •  Further research is needed to understand the experience of carers of persons with other

personality disorders. •  The study outlines the need for effective means to support these carers.

Journal of Personality Disorders Vol 28 – 2014

Carer Burden and Wellbeing

METHOD 287 carers of persons with any personality disorder completed measures of burden and wellbeing and were compared to convenience comparison groups. MAIN RESULTS •  Carers of persons with any personality disorder were not significantly different to carers of

persons with Borderline Personality Disorder on a measure of carer burden. •  Burden and grief was significantly higher than reported by carers of persons with other serious

mental illnesses (including inpatients with mood, substance, neurotic and psychotic disorders). •  Carers endorsed symptoms consistent with mood, anxiety, and Post Traumatic Stress

disorders. CONCLUSIONS •  Carers of persons with personality disorder report grieving their change in life. •  Carers report significant burden compared to carers of persons with other mental illnesses. •  The experience of PTSD symptoms was hypothesised to indicate secondary trauma. •  The results highlight the need for interventions to support carers.

Personality and Mental Health E-view ahead of print – 2014

The Interactional Environment for BPD

METHOD 280 carers of persons with Borderline Personality Disorder completed measures of the interactional environment – including levels of emotional overinvolvement and criticism. MAIN RESULTS •  Carers reported elevated criticism and emotional overinvolvement. •  Elevated emotional overinvolvement was correlated with higher burden and mental health

problems for the carer. •  Parents were not significantly different to partners/spouses on the measures. CONCLUSIONS •  Elevated criticism and emotional overinvolvement in family environments represent a dynamic

involving extreme conflict yet high emotional closeness. This likely represents a difficulty in the carer balancing their own needs (self-care) and the needs of the person with BPD.

•  The findings represent an intriguing dilemma: previous research has found elevated emotional overinvolvement as beneficial for patient clinical outcome, yet we report that it is also associated with impaired carer wellbeing.

•  It is likely that a balanced and collaborative treatment approach, where possible, may be most beneficial to clinical outcome for the patient and carer.

Thankyou to the Project Air Strategy for Personality Disorders Team – includes: Rachel Bailey (PhD Clinical Psychology Candidate), Dr Marianne Bourke (Research Fellow), Dr Annemaree Bickerton (Psychiatrist), Toni Garretty (Family and Carer Team), Kate Lewis (Research Fellow), Alex McCarthy (Research Assistant), Heidi Jarman (Clinical Psychologist), Kye McCarthy (Research Fellow), Liesl Radloff (Project Administrator)

grenyer@uow.edu.au