Emotionally Unstable Personality Disorder Brighton & Hove GP Seminar Series 15 th July 2013

1. Emotionally Unstable Personality DisorderBrighton & Hove GP Seminar Series15th July 2013 Dr Graham Campbell Consultant Inpatient Psychiatrist Regency Ward, Mill View Hospital Sussex Partnership NHS Foundation Trust

2. GP Seminar • Introductions • Focus of Session • Brief Tutorial with discussion • Introduction to Lighthouse Recovery Support • Questions/Discussion

3. Personality Disorder • Severe disturbance associated with considerable personal and social disruption/distress • Appears in late childhood/adolescence and continues into adulthood • Enduring and longstanding • Markedly disharmonious attitudes & behaviour • Affectivity, arousal, impulse control, ways of perceiving & thinking or relating to others • Pervasive & clearly maladaptive to a broad range of personal and social situations • Significant problems in occupational & social performance

4. Prevalence • General population 10% • MH presentations to GP 5-8% (primary diagnosis) • Psychiatric outpatient 30-40% (not primary) • Psychiatric inpatient 40-50% (not primary) • “ “ 5-15% (primary) • Prison population 25-75%

5. EUPD/EID • Also known as Emotional Intensity Disorder (EID) – disorder of emotional/behavioural regulation • Likely biological/genetic vulnerability (traits/temperament) • Possible familial relationship with EUPD and affective disorder • Often inconsistent emotional support, invalidating emotional environment, neglect or abuse in the person’s history • Range of partially dissociated ‘self-states’ – response to unmanageable external threats and reinforced through repeated trauma

6. EUPD – ICD-10 • Impulsive type • Emotional instability • Marked tendency to act impulsively without consideration of the consequences (lack of self-control) • Reduced ability to plan ahead • Intense anger which can lead to violence and “behavioural explosions”

7. EUPD – ICD-10 • Borderline type • Emotional instability • Disturbance of self-image, aims and preferences (including sexual) • Chronic feelings of emptiness • Intense & unstable relationships • Repeated emotional crises • Excessive efforts to avoid abandonment • Recurrent suicidal threats or acts of self-harm

8. Understanding the Challenges

9. Understanding the Challenges • Limit-setting / boundaries • Medication • Splitting • Idealisation & denigration • Pre-reflective ways of thinking • Psychic equivalence • ‘Pretend mode’ • Projection & Projective identification

10. Understanding the Challenges Need for continuity, consistency and connectedness from services

11. Interpersonal Challenges • Behaving out of the ordinary? • Overly worried? • Angry with the patient? • Angry with MH services? • Being taken out of role? • Loss of time boundaries • Talk to a colleague or MH worker involved with the patient

12. Interpersonal Challenges • Narrow repertoire of intense emotions expressed • Managing panic/crisis • Staying calm, listening and neutral • Helping patient to see some situations as part of life and not reinforcing idea that all pain is to be avoided, distracted from or medicated • Managing limitations of professionals & services

13. Managing Self-Harm • Deal with urgent health crisis • Listen • Explore the stressor to allow problem-solving and consideration of alternative coping strategies • Encourage awareness of triggers • Help the individual stay “grounded” and try and stay grounded yourself! • Sometimes positive-risk management required

14. ‘Staging’ • Stage 1 • First/early presentation – diagnosis to be verified • Short-term previous contact with services • Admissions ideally under 2/52 • Allows for full assessment and risk management • Consideration of other MH diagnoses (eg. Substances/Depression) • Liaise with community re: future management • Plan to limit further admission frequency and duration • Consider community treatment, eg. STEPPS, PD service (Dr Connie Meijer, DoP)

15. ‘Staging’ • Stage 2 • Known to MH service with confirmed diagnosis • Admissions 1-2 times in 12-month period • Presenting in crisis • Admission ideally < 1 week • Length of stay discussed on admission • Voluntary treatment at earliest opportunity • Review meds with community (reduce polypharmacy/benzo use) • Liaise with community team in MDT review to update risk & management plan • Review benefit of admission if self-harm on the ward (Dr Connie Meijer, DoP)

16. ‘Staging’ • Stage 3 • Long-term MH contact • Repeated presentation for admission • Admissions more than twice in 12-month period • Usually psychosocial stressors • Admission ideally around 72 hours • Length of stay discussed on admission • Voluntary treatment at earliest opportunity (lift section on admission?) • No major change to medication • Involvement of care coordinator re: discharge plan • Review benefit of admission if self-harm on the ward (Dr Connie Meijer, DoP)

17. Positive Risk Management (DoH 2007) • Being aware that risk can never be completely eliminated • Management plans inevitably have to include decisions that carry some risk • Positive risk-taking “balances QoL & safety needs of SU, carers and the public…considers benefits vs harm of one action over another” • Emphasises the positive aspects of what can be achieved through risk management rather than simply the avoidance of undesirable consequences

18. The Role of Medication • NICE recommends that medication is not used for BPD or specific associated symptoms • Aim to reduce and stop chronic treatments • Only short-term (< 1/52) sedative medication • Medication role only for co-morbid diagnoses

19. STEPPSSystems Training for Emotional Predictability and Problem-Solving • Group sessions • Psychoeducational • Emotional Management • distancing, communicating, challenging, distracting, and problem management • Behavioural Management • goal setting, healthy eating behaviors, sleep hygiene, regular exercise, leisure activities, health monitoring (e.g., medication adherence), avoiding self-harm, and interpersonal effectiveness • Two facilitators • Manualised 2 hour sessions • Systems-based • Sessions for family member, carer & professionals

20. Recovery & Hope • STEPPS and specialist services have been shown to help people manage the more destructive and distressing aspects of their personality • Important to maintain hope when making therapeutic and risk management decisions