Personality Disorder Positive Outcomes Programme

Personality Disorder Training For General Practice Teams

Skills and Concepts

PDPOP training is built around core skills and concepts that give all staff a common language to be able to understand and describe the interactions and challenges that crop up when communicating with patients with personality disorder.

 What is Personality Disorder?

WWe all have a personality. A way of thinking and behaving and relating to world that is unique to us. Think about what someone with the most 'average' personality might be like. Probably fairly unremarkable. But most of us have some quirks or traits that are different to the average. Perhaps we're more prone to anxiety, more conscientious, more moody or more indecisive than the average. These character traits that can work for us or against us depending on the circumstances. If these start to cause us a problem in our day to day lives we might use the term Personality Difficulties. And if our character traits are at the extreme end of the spectrum AND causing us so many problems that life has become unmanageable these might be best described by the term Personality Disorder.   challenges!

  The Internal world

People with Personality Disorder are unique individuals - just like everyone else. However there are some common themes that can help understand what is going on for these individuals. Most have difficulty regulating emotions, thinking coherently or mentalising (we use the term 'mentalisation' to describe the ability to think about your thoughts). Their capacity to self soothe is compromised. Self awareness and empathy are reduced. Threat perception may be very high and they are likely to seek poor lifestyle choices to relieve stress.

We all can probably relate to some of this if we think about times when we are very stressed. But with personality disorder this is often how things are the majority of the time. with the very best solutions for your challenges!

  Types of Personality Disorder

Personality disorders may be grouped into subtypes or 'styles'.  There is some controversy surrounding this - people do not generally fit into one neat box. There is also some confusing or inconsistent terminology between different diagnostic manuals. However many front-line staff often find it useful to recognise what main style(s) a patient may exhibit. This can help predict behaviour and what skills may be most useful. It can also help patients understand their issues better and access appropriate resources.

Five of the most relevant subtypes are:
1. Emotionally unstable (also known as borderline): Characterised by emotional instability and impulsivity. Feelings of abandonment often trigger self harm and crisis presentations
2. Antisocial (also known as dissocial): Characterised by a fragile self esteem dependent on establishing superiority over others. Threats to self esteem can trigger angry or violent outbursts. Risk taking behaviour is driven by core beliefs that usual rules and consequences do not apply to them.
3. Paranoid: Characterised by a pervasive distrust of others, or organisations. Associated with frequent or vexatious complaints, and severe difficulty in establishing a therapeutic alliance
4. Dependent: Strong external locus of control, with the feeling of not being an actor in ones own life. Associated with medically unexplained symptoms and frequent presentations.
5. Avoident: Best understood as character based 'hard wired' anxiety (as opposed to episodic anxiety). Horizons can march inwards e.g. periods of sick leave leading to loss of job, to not leaving the house, the room, the bed. Associated with strong feelings of shame.
 with the very best solutions for your challenges!

  Unmet Need

Many people with personality disorder can be best understood as having an unmet emotional need. This is commonly experienced as a chronic feeling of emptyness and intense fear of abandonment. This can often result in frequent attendances to NHS services, often in emotional crisis. The 'hidden agenda' is often a wish for a health care professional to 'fix' them and/or validate the distress that they are in.

Disordered Attachment

WAnother recurring theme is difficulties in forming stable relationships. In some individuals this can involve idealising others only to dismiss them when they are unable to live up to their expectations. This can result in increasing attendances to health professionals or attempts to create a special or dependent relationship with one individual staff member.  

Triggers

WTriggers are events that cause an intense emotional reaction. We all have things that trigger us, for example being cut up by another driver is a common trigger for many people to experience anger. People with personality disorder are no different. However they are often much more sensitive to triggers and find it more difficult to self sooth and avoid a catastrophic emotional reaction. Sometimes triggers may appear inconsequential (to us) or may not have been recognised by the patient. Being aware of triggers can assist you to prevent, manage and help patients recognise these incidents

Emotional Thermometer

WWhen distressed and agitated we all find it difficult to think. The emotional thermometer is a way of visualising our thinking zone. When triggered we may zoom out of our 'yellow' thinking zone and into the 'red' emoting zone. Individuals with personality disorder have a reduced or narrower thinking zone. When they enter the red zone they may in turn trigger others around them to leave their own thinking zone. Keeping the thermometer in mind can help you stay thinking and help land the patient back into their own yellow zone.

Rescue - Blame Seesaw

W People with personality disorder often evoke strong reactions in others. Sometimes this can be experienced as overwhelming feelings of sympathy and a desire to help fix the persons problems ('rescuing'). Other presentations can evoke very negative feelings ('blaming'). Neither tends to be helpful for a patient, as rescuing tends to further reduce their ability to solve and work on their own issues (we use the term 'personal agency'). Blaming makes a therapeutic alliance very difficult. Both tend to be hugely draining for health professionals. We suggest it is most helpful to keep an awareness of when you may be pulled in one direction on the seesaw and aim to stay balanced in the neutral professional centre.

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