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Personality disorder (continued...) |
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AXIS I AND AXIS II DISORDERS CONTRASTED Much of the confusion in mental health services about how to manage personality disorder may come from the general ignorance of the separate classification of PD. Clients with PD are often pejoratively labelled as "not genuinely mentally ill" by professionals in a way which is neither accurate nor helpful. What is true is that PD is not a mental disorder of the same sort as schizophrenia, depression or anxiety. These occupy a separate part of the classifications of mental disorder - both the DSM (Diagnostic and Statistical Manual) used in the USA and the ICD (International Classification of Diseases) produced by the World Health Organisation. In both classifications, common mental disorders mentioned above are grouped in Axis I, while personality disorders are grouped in Axis II, being recognised as very different entities. The problem arises when a client is correctly diagnosed with an Axis II PD, but given treatments based on for similarly presenting complaints from Axis I. For example, a referral may arise because a patient is expressing suicidal thoughts. If these arise in a depressive (Axis I) illness, then we assume that the patient wants their symptoms relieved and will be happy for this to be achieved and for their discharge from the mental health system. Thus patient and professionals have the same end in sight - symptom reduction - and use their relationship as the means to arrive at that end. On the other hand, some patients with a PD may present suicidal symptoms to professionals because the system has taught them that this is the way to attract professionals' attention. We suggest that for a person with PD, the desired end is almost always going to be a relationship. They will do whatever is necessary to establish and maintain a relationship with a mental health professional, and producing a symptom is the very best means to that end. This is not to suggest that this is done deliberately or even consciously. Nor is it to suggest that patients are to blame for this dynamic; in fact we are suggesting that it is professionals and the services they work in who are equally responsible for the dynamic. When faced with a range of patients to see, whom does the psychiatrist put at the top of their list? The person exhibiting the riskiest behaviour. Unfortunately, for a patient with a PD this can be seen as a straightforward rewarding of the very behaviour we are supposed to be discouraging. The first step to a better understanding of the problem is to establish whether we are in a linear (Axis I) or a more circular (Axis II) situation. Getting the two confused means that patient and professionals are at odds about means and ends and unaware of their own confusion. WELL-RESEARCHED TREATMENTS FOR PERSONALITY DISORDER PD has been seen as untreatable in the past - in fact the two concepts were seen as interchangeable in a kind of circular definition. If a range of treatments had been tried (drugs, ECT, behavioural therapy) and all had failed, the patient could be diagnosed as personality disordered because personality disorder was, by definition, untreatable. Anyone whom you did successfully treat was obviously not personality disordered in the first place&ldots;. Lately two psychological treatments, one developed in the USA and one in the UK, have been well researched with randomised controlled trials to test their effectiveness. DIALECTICAL BEHAVIOUR THERAPY (DBT)
1) Individual therapy 2) Group skills training
3) Telephone contact 4) Therapist consultation The approach has been the subject of RCT with admittedly small numbers, but results of clinical and statistical significance. It is being trialled with other problems involving impulse control such as violent behaviour, eating disorders and substance misuse. · Time-limited psychotherapy with fixed number of sessions (between 4-24, usually about 16) agreed in advance. · Cognitive - because it uses clients' capacity to observe and consider themselves, their thoughts, feelings and behaviour. · Analytic - because it acknowledges unconscious factors which must be explored and worked with, and makes explicit use of the client-therapist relationship (eg counter-transference phenomena. · Makes extensive use of written and diagrammatic material - eg the written formulation at an early stage, client and therapist 'goodbye' letters at termination. · Integrates theory and practice from a range of sources: · Psychoanalysis - concepts of defence, object relations and countertransference. · Kelly's Personal Construct Theory - focus on how people make sense of their world, common sense and co-operation with the client as expert on their own world. · Cognitive-Behavioural approaches - step-by-step planning and measurement of change, self-observation by the client of moods, thoughts, symptoms, behaviour. · Developmental Psychology and Artificial Intelligence - information processing model for the organisation of sequences of internal (mental) events and external (behavioural) actions. · CAT was developed as a psychotherapy for a range of mental health problems, not only personality disorder. Has been the subject of RCTs with borderline patients, also with one-off self-harmers in A&E departments. REFERENCES Benjamin, L.S. (1996), Interpersonal Diagnosis and Treatment of Personality Disorders (2nd edition), New York: The Guilford Press. British Journal of Medical Psychology Volume 73 Part 2, June 2000. (Special edition on CAT) Gabbard, G.O. (2000), Psychotherapy of Personality Disorders, Journal of Psychotherapy Practice and Research, Vol 9, No 1, pp 1-6. Linehan, M.M. (1993), Cognitive Behavioural Treatment of Borderline Personality Disorder, New York: The Guilford Press. Ryle, A. (Ed) (1997), Cognitive Analytic Therapy and Borderline Personality Disorder-, Chichester: Wiley. Back to Specialist Therapies Service Continue to personality disorder links
Page last updated 19 April 2001 |
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