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Personality Disorders in High Risk Offenders: Treatment and Prevention

46 important questions on Personality Disorders in High Risk Offenders: Treatment and Prevention

What possible treatments would help a patient with borderline personality disorder? What treatment would not be beneficial?

- Dialectical Behavior Therapy (DBT)
- CBT

May not go into psychoanalytical therapy because this would be too intensive for individuals with extensive trauma especially if it is short term

How would you treat someone with Skizoid Personality Disorder?

Avoid becoming too involved; a lot of treatment is reassuring the family that the individual is going to be okay (a lot of the time the family can negatively impact the individual because of the way they behave)

How does Schizotypal Personality Disorder differ from schizophrenia?

People with Schizotypal Personality Disorder don't have hallucinations - they more have delusional thinking

Describe Antisocial Personality Disorder (cluster B).

A pervasive pattern of disregard for and violation of the rights of others

repeated acts that are grounds for arrest
deceitful, impulsive, irritable and aggressive
reckless
irresponsible
lack remorse (not a complete absence of remorse)
lack empathy (not complete absence of empathy e.g. they may get in a fight to protect someone) – not incapable of love like a psychopath
easily provoked - have high levels of hostile attributional bias
they don’t claim responsibility for their actions
they tell lies
conduct disorder before age 15

Those with antisocial personality disorder have to have been diagnosed with conduct disorder before 15. Why has this caused controversy? What is a way around this?

The individual may not have had access to mental health services

We can rely on school/educational records and parents' account of pervasive, conduct disorder behaviour - this can substitute for the conduct disorder diagnosis

Describe Borderline Personality Disorder (cluster B).

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity

abandonment issues/ fear of abandonment
unstable and intense relationships
identity disturbance- self image problems
incongruent affect
high levels of impulsivity = typically to do with risk-taking behaviours

emotionally unstable at times --> people with BPD are not always like this, they do not always display the symptoms - they can act and live normally but sometimes they have episodes and this is when it becomes maladaptive to their lives
black and white thinking - either something is fantastic or terrible
Suicidal behaviour
Chronic feelings of emptiness
Affective instability

What treatment is not effective for borderline personality disorder?

SSRI's
--> mood regulator but can have negative effects which can reinforce belief systems of someone with BPD e.g. feelings of restlessness, increase weight gain
--> reinforces symptoms of BPD

What is transference-based psychotherapy?

Old-school therapy
Psychoanalytical
= difficult for therapist to maintain boundaries which is very negative

What is mentalization-based psychotherapy?

More integrated than transference-based psychotherapy
It employs psychodynamics
About problem solving

What is schema-focussed therapy?

Stems from the idea that maladaptive/dysfunctional emotions and behaviours are learned - we learn these early on and we reinforce them with age and they just become part of us
- this focuses on things like attachment styles etc.
- these maladaptive/dysfunctional emotions have been established at a young age and reinforced over time to the point where they are pathological

What are the general principles of psychotherapy?

focus on patient-therapist relationship in the here and now (what challenges they are facing right now)
key principle of all psychotherapy - the individual needs to have active engagement and willingness to change
utilise countertransference to explore relationship
educate patients to recognise the affective reactions and what triggers them
connect actions with thoughts and feelings (i.e. thoughts generate behaviours), both their own and others (Kernberg, 2009)

The patient-therapist relationship needs to be strong - it's the only relationship where they have a therapist who is there for them and their well-being - strong supporting relationships

Describe narcissistic personality disorder (cluster B).

Excessive emotionality and attention seeking:

grandiosity, need for admiration, lack of empathy
self important
fantasies of unlimited success, unrealistic goals
believes is special
require excessive admiration
sense of entitlement
arrogant and exploitative

Narcissistic personality disorder can turn very nasty when these individuals do not get a lot of admiration

Describe avoidant personality disorder (cluster C).

feels "left out"
completely avoid all social relationships - this can impact their work and health
don't like to take risks (they see going to the store as a risk)
feel like they are inept, like they are not capable of great or even mediocre things, there is always someone better than them
immense fear of being rejected/preoccupied with rejection = social inhibition
hypersensitivity to criticism --> avoids people, relationships, exposure, risks

What are treatments for avoidant personality disorder?

Psychotropic medication are effective for these individuals (SSRI's, SNRI and RIMA's)

CBT is really helpful

In CBT, what is the client's role and the therapist's role?

Client's role:
define goals
express concerns
learn & implement learning

Therapist's role:
help client define goals
listen
teach
encourage

What did Pratt et al. (2015) find? What does this show?

Within 6 months, CBT reduced suicidal ideation and self-harm behaviours, psychiatric symptomatology, personality dysfunction

--> shows that CBT doesn't just effect one area of the individual, such as suicidality and self injurious behaviour but also negative symptoms associated with these behaviour

What did Chen et al. (2014) find?

Within a 9 week period, CBT reduced physical aggression, verbal aggression, autoaggression (a self destructive form of aggression)

This study was conducted in China = CBT is widely applicable

How can dialectical behavioural therapy (DBT) be used as a treatment?

The therapist has to accept the individual for who they are --> once acceptance is established, building change can start

Purpose of DBT - To learn and refine skills in changing behavioural, emotional, and thinking patterns associated with problems in living that are causing misery and distress

Dialectic = when an individual has two thoughts and feelings at opposing ends and you believe in both at the same time

How can DBT be used to treat people with borderline personality disorder?

BPD patients typically have "All or nothing" thinking e.g. they're either a slob or tidy, they can't be in between --> DBT says that they don’t need to be at one end of the spectrum, they can be somewhere in the middle, you can compromise

BPD = no evidence to their thoughts or beliefs – it’s a hyperreaction to a situation

How does DBT allow the client to understand what their thinking style is? (i.e. what is maladaptive and what is not)

DBT looks at the:
- the rational mind (thinks logically and intellectual)
- the emotional mind (driven by emotions)
- the wise mind (a mix of the rational and emotional minds to get the best of both i.e. dialectic; balancing the the rational and emotional mind)

What are the 4 stages of DBT?

1. Severe behavioural dyscontrol
.2 Quiet Desperation (focuses on emotional experience)
3. Problem in Living
4. Incompleteness

Describe stage 1 of DBT.

1. Severe Behavioural Dyscontrol
The client is miserable and their behaviour is out of control: they may be trying to kill themselves, self-harming, using drugs and alcohol, and/or engaging in other types of self-destructive behaviours

The goal of stage 1 is for the client to move from being out of control to achieving behavioural control - addressing their life-threatening behaviours, therapy interfering behaviours, and factors affecting their quality of life (e.g. are they losing their house; expelled from school) --> i.e. addressing the contributing factors to their current behaviour discontrol

Describe stage 3 of DBT.

3. Problem in Living
The challenge is to learn to live: to define life goals, build self-respect, and find peace and happiness.
--> looking at the "here and now", solving problems in everyday life
--> getting the client to own their behaviour and have self value

The goal is that the client leads a life of ordinary happinesses and unhappiness

Describe stage 4 of DBT.

4. Incompleteness
For some a 4th stage is needed: finding a deeper meaning through a spiritual existence
- the therapist is not just trying to reduce symptoms, they are also trying to help the client make their life better so they get enjoyment out of it - if the client has enjoyment and happiness, it's hard to feel hopeless and depressed

The goal is for the client to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom

What is one of the biggest risk factors for self harm and suicidality?

Hopelessness

What are the 4 DBT skills?

Core mindfulness: decrease cognitive dysregulation
Interpersonal effectiveness: decrease interpersonal chaos i.e. gaining stability in relationships
Emotion regulation: decrease affective lability; not losing control
Distress tolerance: decrease impulsivity and mood-dependent behaviours; coping strategies to bring stress levels down

What are the goals of interpersonal effectiveness?

Ultimate goal = make interpersonal relationships better

decrease interpersonal chaos
ask for what you want
say "no" and be taken seriously
build relationship & end destructive ones
sustain or increase self-respect
walk the "middle path", balance acceptance & change, wants & needs in relationships

What are the goals of emotion regulation?

Gain control over their emotions

accept that emotions are just part of life, but strive for some control
understand why we have emotions
reduce emotional vulnerability
decrease emotional suffering
increase positive emotional experiences
learn to act in ways opposite to the emotion

What are the goals of distress tolerance?

survive the crisis
have a "first aid kit" for tough situations
learn how to get through a difficult situation without making it worse and without harming yourself or anyone else

What is an added benefit of DBT?

The cost reduction as the individuals are not assaulting staff = staff don't have to take time off, not having to house the offenders in maximum security or solitary confinement

What was Shelton et al's. (2011) study?

18 weeks of DBT on 38 adolescent males in a correctional facility

Outcome: significant reduction in physical aggression and overall misconduct; the correlational officers observed improved prosocial behaviour

Note: working with adolescents, it is difficult for adolescents not to be delinquent

What are the differences between CBT and DBT?

CBT = Focuses on addressing maladaptive behaviours
DBT = Addressing maladaptive behaviours + incorporates acceptance of the self and non judgment attitudes + more of an emotional understanding

DBT is not heavily critically like CBT --> DBT you accept thoughts etc. and are willing to change it (you don't criticise yourself for thinking a certain way)

(especially with women DBT is more effective than CBT)

What did Nee and Farman (2005) study?

12 months of DBT in female prisoners

Outcome: reduced BPD symptoms; reduction in impulsivity and emotion control problems; prisoners stopped blaming others for their mistakes and acknowledging when they were at fault
--> they are starting to see the middle of the dialectic and using better judgement

Still effective 6 months post DBT – BPD symptoms dropped by half immediately with DBT and they’ve been able to maintain it
- this shows the skills they adopted through DBT have become part of them and are very functional

What are the possible treatments for borderline personality disorder? What is the best treatment?

Psychotherapy:

dialectical behavioural therapy (DBT)
transference-based psychotherapy
mentalization-based psychotherapy
schema-focussed therapy

DBT = REALLY GOOD CHOICE OF TREATMENT FOR BPT - one of the most empirically valid treatments for BPD in offender populations - focuses on suicide and self-injury prevention and emotion dysregulation (know this for exam)

Is change possible for individuals with borderline personality disorder? If so, which BPD symptoms change the quickest and which are more resistant to change? Who is this according to?

YES
- while some aspects of BPD change, others are more resistant to change

A number of acute symptoms in BPD e.g. self-mutilation, help-seeking behaviour and suicidal threats resolve rapidly

Other symptoms that are not specific to BPD e.g. chronic feelings of intense anger, resolve much more slowly, if at all

(Zanarini et al. 2005)

(p. 318 textbook)

High drop out rates are seen especially for which personality disorder undergoing which treatment? According to which study?

Individuals with borderline personality disorder undergoing psychodynamic therapy (Gunderson et al. 1989)

(p. 320 textbook)

Why is dropping out of therapy such an issue? According to which study?

Those offered treatment who then drop out are more likely to reoffend compared with those left untreated (McMurran & Theodosi, 2007)

What statistics did Rizvi et al. (2013) state?

In individuals with BPD

rates of non-suicidal self injury range from 69-80%
up to 75% attempt suicide at least once
8-10% die by suicide

(own reading)

What did Linehan et al. (2006) study?

Participants: 101 clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria. They received 1 year of DBT

Results: Subjects receiving DBT were half as likely to make a suicide attempt compared with non–behavioral therapy by experts, required less hospitalization for suicide ideation. Subjects receiving DBT were less likely to drop out of treatment (25% dropout rate in DBT compared with 59% in CTBE)

= suggests that DBT is the superior treatment for BPD compared with CTBE

(own reading)

What can be said about BPD and gender?

The majority of BPD research has been conducted with entirely or primarily female populations. The gender bias is largely due to the disproportionality higher rates of BPD diagnosis in females compared to males

Why is DBT especially useful for prison populations?

BPD is diagnosed in higher rates in prison populations and DBT directly aims to reduce impulsive, aggressive, or life-threatening behaviours (McCann et al. 2007)

Why is the evidence base for DBT's effectiveness on BPD insufficient? Who argued this?

Most of the existing evidence is limited by the small sample sizes and short follow-up in clinical trials

(Bateman et al. 2015 - own reading)

What can be said about Ms B's mindfulness?

Ms B had long-standing dysfunctional thoughts (e.g. perceived negative judgements and negative self-perceptions) and maladaptive coping strategies, such as self-harm and substance misuse and dissociation. Core mindfulness skills were used to calm her down during urges to self-harm or periods of anger; and helped her decrease the frequency of her dissociative experiences. ‘Wise mind’ was useful in helping her take control (A therapist will communicate and explain the rational mind, the emotional mind, and the wise mind (Lynch et al. 2006)).

(Nee & Farman, 2007)

What can be said about Ms A's interpersonal effectiveness ?

Ms A had continual difficulties with interpersonal relationships. Through DBT, she showed an improvement in interpersonal interactions and increased control of relationships with individuals inside and outside of the prison environment.

(Nee & Farman, 2007)

What can be said about Ms B's interpersonal effectiveness?

History of relationship difficulties e.g. victim of domestic violence. Ms B depended heavily on the affirmation of others, having little sense of her own self-worth. Interpersonal effectiveness skills through DBT helped her understand the development and maintenance of relationships. DBT also helped her develop self-worth.

(Nee & Farman, 2007)

What can be said about Ms A's emotion regulation skills?

Exhibited strong emotion dysregulation, high impulsiveness and state anger. Towards the end of DBT, she showed a decrease in self-invalidation and mood dependency behaviour through the daily use of emotion regulation skills.

(Nee & Farman, 2007)

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Forensic Psychology

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