Talk on Personality Disorders by Dr Chess Denman, Medical Director of CPFT

Author: Cambridgeshire & Peterborough NHS Foundation Trust

I'm going to talk to you about personal disorder but I'm going to start in a slightly different place, which is to talk to you first of all about the function of emotion. What is emotion for - because until you understand what emotion is for its very very difficult to understand what goes wrong with it and the ways in which it can go wrong in personality disorder. So emotion has all sorts of different functions but one of the principal things it's for is to impel action. We do things because we have feelings. We know what to do because we have thoughts but if we just had thought and no feelings, then we wouldn't really ever be impelled to do anything. So when we're in the grip of an emotion it feels like the right thing to do whatever that emotion impels us to do. So we might be in the grip of a loving emotion and we therefore we're impelled to find the person that we love be close to them.

We might be in the grip of an angry feeling in which case we feel angry, we want to go discharge that anger or maybe angry about something we'll go and seek that individual and be aggressive towards them. Now we know that emotions are very very basic, and one of the ways in which we know that emotions a very basic is that if you travel across the world, across linguistic barriers, and across cultural barriers, you find that almost universally, in fact pretty much universally, emotions are represented by characteristic contours. And I am going to take advantage of this, to show you the characteristic contours - I am literally going to show you the contours but not label them and you can guess before I say. So here's the characteristic contours of one emotion, here's the characteristic contour of another emotion and here's a slightly more difficult one to identify. So that first one is the characteristic contour of anger, so if you ask somebody, press a button in an angry way that's what the pressing will look like. And if you show most people that - they will identify that as the case - that's the contour of an emotion they'll say that's anger. The second one is sadness and that last one is actually a different characteristic contour and until I voice it for you you won't know what that one is. We all know what that is because every child we've every been with has produced it frequently especially when presented with nourishing wholesome vegetables.

So that tells us that these emotions are very very very very basic within us because they're very very cross-cultural of course how we express them, what we do about the context in which we can express them vary very widely, but what's the point of anger, what's it about ... It's about dominance in a social group, it's about fighting off aggressors but it's also about getting one over on others. Similarly what's the function sadness? why bother why did evolution leave sadness to us? Well it's probably linked with not getting killed if a stronger animal comes to get you.

If a stronger animal in your tribe comes to square up to you and you definitely going to lose your antlers are a bit smaller than the other guys antlers so there's got to be a system the causes you to retreat because if you go on fighting you're going to die and your jeans aren't going to be transmitted and that is about withdrawal, it's about defeat, it's about humiliation - all of these rather unpleasant feelings actually are there to stop your tribe from tearing itself to bits in a sort of aggressive way. And what about this one - well that's because when you live in a group of people it becomes all of a sudden very very important how you manage waste. Animals they'll tread through poo anyhow they like but once you're living in a social group it's really quite important to manage to mix waste and make food and so building on the very very basic understanding that we have that we were given as it were as even lower animals but what tastes nice on what tastes nasty we have this thing called disgust "it's disgusting... Wanna get away from it... It's really nasty" So those are some other basic emotions and I've picked the ones I want to talk about. As you might imagine I've picked all the nasty ones because those are ones which we're going to see are very important later on. Now, each of those sets of feelings is embedded in a system but one of the kind of core systems underneath, if you like, is an even more basic system which is a system which says wake up pay attention something important is happening and we call that system vigilance or anxiety or arousal - it's what tells us what the most important thing in the room is - so if I didn't have that vigilance I wouldn't know to paying attention to you to make sure you're not asleep or whispering to one another about what crap talk this is or anything like that and you wouldn't know to pay attention to me that's what vigilance does it focuses you it tells you what is salient. And that pay attention is also a deeper function of emotion - it tells you again it accompany's emotion it tells you what the emotion producing stimulus is.

Talk on Personality Disorders by Dr Chess Denman, Medical Director of CPFT

What I am going to suggest is that personality disorder, which is a horrible name it's a horrible stigmatizing name, but it's the one we've got is a disorder if you like of some of those basic emotional systems. And before I tell you what sort of disorder we have to ask ourselves why might those emotional systems be disordered. And the answer is we don't know. It might be that what we're looking at when we talk about personality disorder is just natural variations - so some people have more of this one characteristic than others, so for example the predisposition to disgust is distributed through the population, some people a very low sense of disgust, some people have a very high sense of disgust. And one of the rather spooky facts about disgust is that the higher your sense of disgust the more likely you are to vote conservative. Or it might be that we actually have a disordered system, that actually some people are born with an inborn disorder of the system, either an inborn disorder in which they become very irritable or likely to become abnormally aroused or inborn disorder of the disgust system. And I've spent some time trying to unpick that and I'm no closer than anyone else but it was great fun. So I think therefore that what we're talking about when we talk about personality disorders is disorders of emotion or disorders of emotional regulation.

And there are really two broad groups of disorder emotion & emotional regulation. One is a sort of fixed or ridged disorder which you get somebody who's basically stuck, always in one main emotional pattern or emotional regulatory pattern. So an example of that might be somebody whose always miserable or somebody who's always anxious and aroused, or another one which I love is somebody's always focused on doing things for others as in the expression "she lives for others you can tell the others by their harassed looks". So that's one group, the fixed or rigid group but then there's another group who are just what would be called in the old days as hyperbolic, so they're just very variable, they're very variable and very twitchy and their feelings change rapidly from one state to another and that second group is the group that we think of as having, either we call them having Cluster B personality disorders, that's one term you'll find used or we talk about them having borderline personality disorder, again, it's a lovely term but it doesn't convey anything useful, except why do we keep using it because if we want to find out anything about it that's what you've got to type in the the Internet, if you like it's a station that everyone can visit. If we change the name then lots of people wouldn't be able to find the right place on the Internet. So let's just work our way then through how basic emotions might be disordered in a number of personality disorders and the first one I've picked is not borderline personality disorder it's another one, which gets an even worse press than borderline personality disorder and that's so-called narcissistic personality disorder. If you want to abuse somebody even more than calling them borderline you say all "she's very narcissistic" but let's just think about what that means, that's somebody who's extremely sensitive to being humiliated, that's what it is, so imagine the worst dressing down that you've ever had, say you're in front to the class and you've done something terrible, you've been haled up you be caught gouging your name with a compass point under the desk and in front everybody your dressed down and you're publicly humiliated and you feel that feeling of cringing and withdrawal and it's extraordinarily unpleasant it's that powerful retreat from a socially dominant position.

People who are very very sensitive, whose system just turns on with a hair trigger so you just walk into a room and you happen not to spot them so you don't so smile and nod at them and they think they've been dissed. They think that they've been rejected and they've been humiliated and then depends a bit which way they go, so people that have that sensitivity some of them got "what!!! I'm not putting up with this" and they get into rage about the whole business whereas other people think "ooh I knew would I never come too much" that's a narcissistic personality disorder and I've just used it as an easy example to see how emotional regulation is damaged. What about borderline personality disorder what's gone wrong in that condition? Well, first of all we need to understand what people with that condition do, what causes the trouble in it and if you go and look at the classification of diseases, the Diagnostic Statistical Manual it's called, then what you find is enormous long, it's like trying to order a Chinese meal of symptoms. You'll have a number 31 and have a bit of a bit anger and a bit of impulsivity. In fact it was one of my personal humiliations as an expert in personality disorder is that I can never remember any of the list of systems, they went in and they went out again, no matter how many times I tried to learn them because they're so various, but maybe once you've cottoned-on to the fact that the listed symptoms is very various, you've begun to understand what's really going on here. This is a group of people who are displaying a huge wide range of behaviors so they're impulsive they do things that are very very ill-considered and are very very poor judges of what would be a good idea, so lots of people I saw, lost of man with personality disorder traits, borderline traits, would get into fights okay but what don't you do if you're going to get into a fight? You definitely don't choose to get into a fight with a group of five people who are much bigger than you. That's not a good way to get into a fight and also they will get into fights with the police, that's also not a good idea and invariably if they got into fights in the health system they tend to fight with their consultant - never hit a consultant very bad idea. So they get into fights but they're poor judges of what fights to get into.

They're very very sensitive to rejection I used to say to all the people I trained "imagine when you're talking to somebody with one of these problems that it's them listening to you but also behind their eyes there's a little animal and that animal isn't listening to what you're saying, their listening to whether you like them or not, whether they think you like them or not and for that little animal "listen I'm going to be away on holiday" doesn't mean "listen I'm going to be away on holiday" it means "I don't like you enough to stay here next week" it's an animal, it's not thinking the same way as you or I might think in a calmer moment. So they're very very sensitive to rejection but they're also thrill-seeking, so one of the things that you find in patients with borderline personality disorder is that they will do thrill-seeking type of things. What sort of things? well one of the first things I discovered was that patients of this group read horror novels and that they were swapping horror novels, especially true crime stories and those of them who where younger and had opportunities were often trying out drugs, just lots of different ones just for the go of it.

They're also impulsively suicidal, so you'll be having a conversation with them, settle a few matters and they'll say they're feeling okay and 10 minutes later they'll be cutting themselves or take an overdose now that's not quite thrill-seeking but it is something very impulsive and very, in a way, like thrill-seeking its very activating. So I began to feel, thinking about that, there was something going on in this group of people that wasn't easy to pin down but was all kinda irritable and itchy/scratchy and the person who actually finally brought it home to me and she knows that I talk about this was a patient who said to me "well its like your sitting down and there's big horrible hairy spider next to you, only you are the spider. So it's like horrible disgusting feeling inside you which you just can't get away from.

We've all seen that horrible disgusting feeling, I saw it in a little boy who drew a picture of a dinosaur and coloured it in and then mum said all that's a lovely dinosaur and the child looked the dinosaur and you could see in its mine figuring it wasn't like the picture the dinosaur in the book that it was copying and he could suddenly see that wave of horrible irritable crossness come over the child. Rip rip rip because it didn't live up to expectations so that triggered that and we've all had it, that feeling of suddenly everything is horrible, gone to dust in your month. Now I think that is a feature of the disgust system, I think that that is the disgust system turning on - all of a sudden dramatically BAM it's on and you just can't get away from the feeling. And in fact if you talk to patients what they'll say is that it comes on in great big waves so that they'll have days and days of just being unable to settle and if you think about it if you think about that horrible feeling, which I sometimes inducing people by telling them disgusting things, but I won't do today in this public setting but you think about that horrible feeling just not being able to get away from it and not being able to locate it. I mean what do we do with disgusting things, well we go and clean them up that's what we do, we make ourselves feel better by cleaning it up or cleaning the kitchen so some of these patients will just go and clean and clean and clean.

But we also aroused and irritated and when you're in in that state, and if you can imagine that state you can sort of see that it might be quite enticing to cut yourself because it just does something to drown out the basic feeling or you might think actually I'll have a joint - I'll feel better if I have a joint and you do they feel better - they have a joint, well I'll have some ecstasy, and, of course, I talk about these pleasures, these thrill seeking behaviours as a sort of golden handcuffs really because they all work really really well, the problem is the consequences of doing them. If we had safe cannabis or safe self-harm, that didn't build up on you and make people look at you strangely when you go swimming, then we'd all be doing a lot better with it because it's really very effective. So those are the key features that impulsivity, suicidal behaviour which really is partly about, it's just a ghastly condition some people just feel miserable with it and just you know feel suicidal but it's also sometimes about I just want to get away myself - I am the spider and there is only one way I can think to get away from myself. It's the rejection sensitivity because if you feel that you are disgusting then you're anticipating other people rejecting you. It kinda stands to reason really. One of the best experiences you can have in that regard, I'm looking for my group therapists around the room, is to put a group of people with this condition together and have them all stoutly claim that they are disgusting and that everyone else in the group is alright. Literally they will all be saying "I'm disgusting I just know I am - but you're not disgusting" and then the next one will say "I'm disgusting you're not".

They've never actually started a fight but even within that context where, if you like, the most dramatic demonstration that everybody is perfectly accepting of everyone else but they're not accepting it themselves. It still doesn't ring past that very very visceral feeling of disgust. What to do about it? So the first horrible piece of news that doctors have to convey to patients with these conditions is "we don't know" we haven't got a cure, we don't have any easy treatment and for two reasons, first of all biological treatments for anxiety which is one of the powerful things that people want taken away to make them feel better all have the same effect, they all work brilliantly until you stop them. And the very best one is actually free (well not on prescription). The very best anti-anxiety drug out there on the market is alcohol by a long shot and it works great until it stops. Then you have to have another drink and the problem doesn't quite stop there because you have to have another big drink and then another big one and then it's the same with all the other anti-anxiety pills and it doesn't matter what they're called really they could be called and they keep bringing new ones out in the hope but actually they're all the same, they all worked brilliantly until you stop and you always need more and more of them and anxiety comes back, breaks through. And we've get no pills that hit the disgust system as yet, maybe we will discover them, and if we did I'd be handing them out like Smarties.

So we haven't got any pills, Psychotherapy, like talking to people, quite good evidence that that improves things. My very strong feeling about it, personally, is that what it's doing is it's building on the rest to the person If you can make the rest to the person bigger and stronger then they'll cope with the horrible deck of cards they've been dealt with on the emotional front better. My feeling is that what therapy is about is about making the good bits of people stronger better, more confident, giving them an ally, not really about taking away the core problem and if people say I won't be better until I don't feel this - you have to say - well you won't be better - maybe I can't help you not feel this but maybe I can help you not totally muck up your life as well or maybe I can help you feel some other good things sometimes at least So formal therapies, limited but more valuable than pills but most of all what helps is what I've given different names at different times but what day I decided I call it "containing environment".

So what's that about? well if you're somebody who leads a completely irregular life because your emotions are completely irregular, you can't predict things from one day to the next then what then what you need, or one idea that we have about what would help is that you need to put that regularity back sort of by force if you like, so by personal force, so think about, those of you that did it, the difference between school and university school had that regularity imposed on you, there were bells, you did things, everyone did them together, it was all very regular and then you go to university and you can lie in bed all day well certainly you could at my universe, I don't know about yours. That regularity is taken away and you could see in that environment some people who hated the regularity of school really blossomed and other people just fell apart. So what I say is that, in borderline personality disorder in particular, having that regularity, finding a way to order life and to structure it, is really critical and that people with that kind of condition cannot really afford to lead a disorderly life by which I don't mean disorderly conduct like the police, just one that is different every day, each try and persuade people to do the same thing every day. The second thing is to try and persuade people to find pleasure in things which I call slow pleasures - there is this whole thing called slow food which is about taking time to cook and I talk a bit about slow pleasures. Slow pleasures aren't like having a drink or cutting yourself or going and jumping out of an air-plane with a parachutes strapped to your back getting that big thrill, they pay back slowly but when they do pay back the tend to pay back over a longer period of time. So it depends what floats your boat. Lots and lots and lots of people I've worked with over the years a really important slow pleasure for them has been an animal, really helpful to care for an animal takes time, there are chores involved and it pays back lots over a long period of time, that's one. A skill, life drawing, playing the flute, whatever, again it takes time but it's pretty reliable.

And those slow pleasures are important and they help to bring down the hyperbolic nature of things but they also give you something stable to which you know you can return to in times of not trouble, in times when when the rest of life begins to the come to the fall. Because one of the things about this illnesses is quite destructive of people's lives, so they tend not to have a normal attainments that keep people going you know even when it's pretty bad our stuff to put food on the table for my family so I'd better get up and go to work even if I'm not looking forward to it but if your jobs been taken away from you because you punched your boss and you haven't got any kids because you haven't been able to form a stable relationship or you've got that disaster characteristic of always going for the wrong guy or the wrong girl, then, what's there to get up for? So those slow pleasures put that "what's there to get up for" back if you can get them. And then a third thing which don't get on so well I and it's what I call social obligation and and it goes like this really, if you're ill for any reason at all in our culture over an extended period of time society slowly starts to get you. It slowly starts to reject you so there's all kinds of ways in which it's obvious that society starts to reject you if you, for example are in a wheelchair, if you're in a wheelchair and just attempt normally to get about, I don't know how you would have got here for example and don't know how you get on and off the train, it's very very difficult and you can only go on and off certain tube stops in London so how you can get from A to B is very difficult and people talk to the person who is wheeling the wheelchair rather than talking to you which is very embarrassing and difficult. If you are not working people look at you because you tend to be out during the middle of the day when everybody else is working and when you go to Tesco then they're only mums with children and senior citizens and they all look at you a bit strange - what's that young healthy person doing walking around in Tesco. And then you don't have any money so you have to go to a benefits office where..

Do you know what really upsets me about benefits offices is that they screw the chairs down to the floor so you have to be seen somewhere where they screw the chairs down to the floor. That's what I mean by society getting you and the people who look after you, the people who were putting all that health service, it moves doesn't it imperceptibly moves from "oh yes we'll make you better" smiles and smiles, to "hello" fixed grin "arh its you again" and sometimes bit more than that to frank abuse or "what are you doing cluttering up my casualty department.. Again". That's what I call society getting you and I think that's very very destructive to anybody with any illness, but particularly destructive if you're illness doesn't declare itself on the surface. So if nobody can tell what's wrong with and I think actually and it's very very unpleasant, I think there is actually only one way out of that which is that people who are ill, even though that they are ill, have to pay their dues to society and I talk about that in terms of social obligations, that actually society will get you unless you're giving something back. And that's unpleasant because people who are ill should be cut some slack but actually in truth it's easier, it's better if we can persuade people who are ill to work if they possibly can not necessarily because it's "good to work" but because in our culture if you don't we have all sorts of ways of being mean to you.

They are very polite, because we're British, but boy are we mean to you. So those are things over the years that basically in a nutshell is what I've ended up relying on everything else is sort of smoke-and-mirrors or a bit of this and a bit of at that but really that's the core of it. Now, of course, there is an incredibly important group in the lives of patients with this illness and that's those who love them and care for them and so I want to move over gently now into thinking a little bit about carers and I want I just try to encapsulate because we're going to hear about it from the carers perspective and I can't do that for you but I can tell you what I now, whenever I do a consultation, which is sadly rarely because I am Medical Director now, but means I make paper better and boy do I make paper better. You just don't get the same quality borderline paper these days though.

So what is it what's the main advice I would give to carers? The first piece for advice I would give to carers and relatives is actually an odd one and goes a bit like this, when I'm in a social group what's the function of feeling, here I am I'm standing up I'm up regulating I'm smiling, I'm looking up, i'm looking around at you, what am I doing I'm making you pay attention to me. You'd look distinctly odd if one of you was looking out and I'd be worried if one of you was looking out over there. What I've done is I've roped you in, sure I'm playing my audience that's what it's called but the mechanism by which that happens is because emotions have to go between two people - there social events. So if you are the carer of somebody's whose emotions are all over the place, where are you gonna be? All over the place because one minute you'll be comforting somebody whose sad, the next minute you're being being a bit frightened of somebody whose angry, the next minute you'll be told you've rejected them and you be like "what me?" so bewildered and themselves now not very well so that's the first thing that happens carers is that they get no very well themselves, they get a bit of the illness themselves not because they have it but because that's the in training functional of emotions does to people. So the first piece of advice I have for carers is self-protection.

Pay attention to your own mental health - know that you will need some time on your own, sometime with other people, don't fall into the trap of it being all-consuming. And then the second piece of advice that I have is a harder a piece of advice because it's very hard to take, in practice and that is that probably this is one of those conditions where you have to balance risk a bit. We can't always go for the safest option. Why can't we go for the safest option? Because some of the options that doctors offer like, I will see you again in clinic in a week's time, I'll give you an extra long appointment, tell you what come to the day hospital maybe you need to come into hospital, I'll admit use an inpatient, oh dear you're not very safe maybe I'll use the Mental Health Act to detain you, oh dear this locked ward, isn't quite containing enough for you maybe put you on more observations. What's each of those interventions doing actually for everybody? It's reducing anxiety. And what do we know about things that reduce anxiety? Why's it any different from the pills? It always stops working after a while so the natural progression, if you just reduce anxiety and pick the safest option is up into more and more and more sick, ill places because actually where should everybody not want to be? a psychiatric ward. And what's worse than a psychiatric ward? a more severe psychiatric ward so it's about beginning to tumble that frightening thing were we've got to take a bit of a risk and then, of course, it's getting the balance right what's the right amount of risk, what's too much risk, what's too little risk and so one of the things I talk to parents about lots is how can we all together work through what the right level of risk is and how can we accept that sometimes we'll call it wrong. Sometimes we'll get that decision wrong, both ways, it's quiet the damage that happens when you are too risk-averse nothing dreadful obviously happens just the person goes downhill.

Of course its dramatic when you're not not risk-averse enough and the person does something dramatic because they don't feel protected enough but again it's about balancing those risks and someone who's done that in spades is Mike ....

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