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right. Um Okay. Um hello, everyone. So my name is Alex Thomas. I'm a consultant psychiatrist in forensic psychiatry based in Wales. Um, and I'm I've, uh, I suppose, honored to to be involved in, in sort of trying to, uh, provide some teaching in the circumstances. Um, I just like to start by, I suppose, um, saying I hope you're as as well as as can kind of be expected. Uh, I'm going to talk today about personality disorder, which is quite a but from the from the perspective of I suppose people, I don't know how much experience people who've got in in in psychiatry and thinking about mental illness. Um, but it it's quite a a different way of thinking about things to a lot of the kind of typical medal medical model of physical illness. So my talk today I was I want to mainly, um, kind of cover the the difference between what we think of as severe mental illness and personality disorder. Uh, talk to a little bit about how the theory is of personality development And what person? That what you mean by personality, Um, the role of adverse childhood experiences in abnormal development of personality. Um, and how we how we classify and how we group together different personality disorders. Um, and then how? How, how sort of how they're treated and what kind of life sort of looks like for people with personality disorder. Um, now, in, um, in in psychiatry, generally in sort of certainly an adult psychiatry. Most of the time, we kind of, um most of our problems that we deal with can be broadly categorized into a couple of different categories. And I thought it was helpful in how we think about personality disorder, too, to kind of compare it with, um, severe mental illnesses. So, essentially, I think of personality disorders in terms of learning. Um so personality, uh, which I'll come onto in a in a minute is your sort of patterns of thinking, feeling and behaving that you develop as you as you could go through your childhood adolescence and ultimately the rest of your life. But childhood and adolescence have a very, uh, central part in the formation of of your development of your personality. Um, quite a lot can sort of go wrong with it, unfortunately, um, but it's quite different from the idea of of of mental illness. Um, but in terms of the sort of technical the, um, wording, we use the the they're all mental disorders. When we talk about mental illness, we're thinking of things like severe depressive disorder, schizophrenia, bipolar effective disorder, um, schizoaffective disorder, that sort of thing. Um, and I suppose kind of looking going through the kind of the different columns that we've got here. Um, they all have a bit of a genetic component and a bit of a sort of inherent biological component, and they also are affected by someone's psychosocial circumstances. So, um, by that I mean, you know, do you know whether they've grown up experiencing, um, abuse of some kind or extreme poverty, or or indeed, any kind of trauma? Really? Um, uh, essentially to do with kind of their environment and and the people around them, um, in mental illness, Uh, we kind of tend to think of it as being a a something that is inherently kind of biological and chemical, and to do with perhaps, structural changes in the brain. Um, and that the, you know, things like, um, adverse childhood experiences can be a bit of a trigger can perhaps be a risk factor, but they don't in order to sort of causative if you like, Whereas in personality disorder, um, the psychosocial side of it is much more important and kind of causative. So it's to do with what people go through as they develop. But there is a bit of a biological, uh, predisposition so that we know that, for example, twin studies where twins are separated at birth if one twin develops personality disorder, the other trend trend is likely to as well, even if they've been raised in different circumstances. Um, but it generally kind of it's you can almost always sort of link, uh, personality disorder to add various experiences growing up. Um, mental illness is generally something that's kind of there and is sort of stable in how it's there through the lifespan. And you have kind of episodes of, uh, of relapse, and then it it goes into remission. And then you might have and rather relapse. Um, p d. Sort of personality disorder. I put P. D. I don't like saying PD because P. D is is kind of almost a pejorative term. Sometimes where people want to be can be quite dismissive of people with personality disorder. And they say, for example, they quote just p d. I put P d down as a as a sort of abbreviation written form, but I'll try and say Personality disorder. Um, personality disorder is pervasive over the lifespan but tends to improve with time, so you don't tend to see as many people in their kind of sixties seventies eighties with personality disorder. And I don't think that's particularly due to the fact that their experiences will have been very different. Um, what we do know is that somebody who's diagnosed with, for example, borderline personality disorder in their twenties, um, might not meet the criteria for borderline personality disorder by the time they're about 50 or 60. Um, but I suppose our job in psychiatry and mental health services is to try and help people get there quicker, so to sort of recover from, um, you know. So I suppose the idea being that generally schizophrenia, um, you know that sort of, uh, severe mental illness people will will need to kind of rain on medication, Probably lifelong. Um um, and medication is coming to the next step medication is is the main treatment. Really? Um, in most conventional, uh, psychiatry, Um, and psychotherapy, You know, there are there. Are you know, there's cognitive behavioral therapy for, um, for psychotic symptoms, for example? Um, but they just may improve the symptoms, and they're not going to really make it go away. Um, medication doesn't really make it go away either. But it is sort of the main way in which I suppose people do get control over the illness. Um, whereas in contrast, in personality disorder, the main treatment should be psychotherapy. Um, people do end up on medication, and medication can be helpful. It does have a place. Um, it can help with, um uh, some of the symptoms of personality disorder. Um, it can help with, uh, improving someone's, um, emotional, uh, lability. How how unstable someone's mood is. For example, unfortunately, quite a lot of people, uh, I suppose in my in my anecdotal experience, but I think this is back to violence as well. End up on quite a lot of medication because, unfortunately, the psychotherapy that would help them is is not really available or not as widely available as it should be, um, perhaps that that may be improving, but that's sort of the general kind of principles. Um, the way they're kind of similar is that they're both quite sensitive to stress. So people who've got schizophrenia, for example um uh, quite, you know, they they can be sort of, uh, significant life events that may precipitate a relapse or precipitate the first episode. Um, and in personality disorder, where we have where someone might go into a period of crisis and may also be precipitated by stress. Um, and both of them have quite often got come orbit substance and seriously. So what do we mean when we talk about personality and psychology and psychiatry? So if you think of someone in a sort of from it in in lay terms, um, and you think of you know what someone's personality is like you might think, or that person is a funny person or that might that person is a kind person, or that person is a mean person. But in in, um, in in our field, we were thinking about essentially how somebody developed there, uh, patterns of, as I put there, patterns of thinking, feeling and behaving which is the sort of usual terminology that they that that gets, gets used. Um, some parts of personality are inherited or inheritable or or are, you know, genetic in origin. But a lot of it is to do with, you know, your upbringing and your experiences and the people that are around you, Um, as you grow up. Um, and the point of a personality of being human, I suppose, is it helps us to navigate the world and to, um, to deal with other people and to know what to do in different situations. Um, and And I suppose it's not something, you know, when we talk about personality, even though we're talking about there are some things that you might be sensitive to, and certain situations make things worse. The sensitivity to that to that situation is consistent. It's the It's the, um you know, the underlying baseline level of you know of baseline patterns and baseline thoughts and baseline behaviors across situations. So, for example, if somebody is, um, yeah, one of their personality traits is that they find it difficult to trust people. Um or, you know, they're not very trusting. Then they're probably not going to be very trusting in work. They're probably not gonna be very trusting in their private relationships. They're probably not going to be very trusting in the, you know, going out in the cinema and things. Um, and in the in different, you know, it's It's not that, um, you know, these are things traits that kind of stick with people as they go through life and how it sort of develops. There's a lot of different if you, you know, read psychology. And there's a There's a lot of different theories of of how personality develops. And I think really they they sort of look at different things. Um, and there's there's loads and loads of these, and I'm not going to really go into them sort of in too much detail today. But, um, broadly speaking, and this is I suppose my, uh, simplified model of it, Um, as as you, you know, from A from being a baby, you know, you you explore the world, but you have, um, in a sort of typical, uh, normal, stable. Um, so, you know, for for in in inverted commas, normal personality development, you need a stable base which is typically, um, your your family and and more specifically, probably usually, uh, the mother. Um, but but oftenly a primary caregiver, whoever that may be, um and I suppose, normal levels of adversity. Now, by that I mean, I suppose in normal times, someone's normal level of adversity might be that they go to school and there's a bit of bullying, but nothing to severe. Um, they might have the odd illness, you know, a bit of childhood flu, um, chicken pox, or, you know, things like that. But but nothing out of the ordinary. Um, and they sort of develop, uh, their ideas of of how to be, how to be with themselves and how to be with other people. And you learn what's socially acceptable and what's normal and what's you know, what's what. To be weird. Um, and that should in theory, produced a well adjusted adults who can deal with stress essentially, um, psychoanalytic theory and originated with fried and then developed further by, You know, his sort of students and people and young and respite. But, uh, the the basic. There's a different ways of thinking about that. There's, uh, the idea, you know, for I proposed the idea of consciousness and the conscious and unconscious brain. So the conscious is what I'm aware of, right here. And now, Um, the pre conscious is what I can remember, but I have to really think about it, and I have to have to deliberately bring it to mind. And the unconscious is sort of the all the things in our personality that we're not aware of. So, for example, maybe unconsciously, um very, um, I don't know, very mistrusting of people who look like someone that was very nice to you when you're young. Um, there's also the idea of the structural model of personality. So when we're born, um, we have an ID, which is the part of our personality of, uh, I think of a newborn baby. It's It's all about pleasure and perhaps of pleasure principle. Um, and then you developed the ego, which is sort of starting to become aware of of other people and and things. But when you do things, it's more about how you get your needs met. But you appreciate how other people feed into that, and then you're super ego is more about your kind of conscience as they were and your idea of fairness and and that other people have needs as well. Um, and you know, that's some sort of disordered. If people get sort of stack, I suppose that perhaps an ego stage and don't develop much of a super ego because their childhood personality development has been a bit stunted. Then you know they may struggle with, you know, they may. Everything is about meeting their own needs, and they they struggle to, then meet it in other people. Uh, and then he also talks about the psycho sexual stages, which are kind of chunks of a person's daily life, Really, that, uh, that are based on these sort of observations. I think we've kind of sort of best. It's behind largely. Perhaps, um, it's not something that in psychiatry events, and we tend to really think about much as much. But all of these different stages where, for example, will stage a newborn baby, um explores the world through his mouth. Um, the anal stage is sort of where you get toilet training and people and, you know, Children, um, develop, you know, experiencing their prices through through that and through elimination. Um um and then and so on. Um and then, quite quite, I think perhaps more in line with what I was saying earlier about the sort of ST stable base is is the idea of attachment theory. So this was primarily, um, sort of proposed by Bowlby, Also others following him. Um, that you you need an attachment to a primary caregiver to explore the world. Um, and you kind of have this sort of base, which is again, typically, mother, and then in the in the wild is as well, though we I come in through this door be actually. But there was there were experiments above, um I think it was recess monkeys that they gave the them a cloth mother and the and the lawyer mother. And you know how have the monkeys developed attachment? But but it's important for for everyone that you have. You developed attachments early on. And you you learn how to, um what you know, You learn your attachment styles. So if you know that you can trust your primary caregiver and and that they look after you, but they support you to develop your, uh, your own ability to um uh, to, you know, explore the world. You'll probably develop what they call a secure. If there's a problem with that, if something gets in the way, Um, then you may develop one of these, uh, insecure attachments And in increasing severity, I suppose the sort of the first level of of severity, of of insecure attachment is actually some different. Where, um, you know, you you've perhaps you're you're able to form quite, you know, significant attachments. But you are constantly anxious that they might be abandoned or that they might break down or that they're going to disappear or all sorts of things. Avoidant would be that sort of the next where where you probably don't reform many attachments. But, you know, you still have some and then the probably the most severe, Um uh, sort of, uh, from from severe deprivation. So people, Children who who have a neglected and things in times that might might develop a fear for a disorganized attachment style where they can't really form very much attachment to to, uh, people that are important in their life. I haven't so we talked about kind of normal development, and then, unfortunately, if you either have a lack of a stable base and or the adverse events the the the difficulties that you have to deal with our outside of what we're normally expected to do. And in terms of personality disorder, um, it's primarily to do with forms of abuse. Um, and different, um, types of abuse may, um, lead to different sort of personality traits developing, um, neglect Or, you know, sometimes other. There are other forms of trauma, so there's kind of, like areas trauma where you you kind of have to experience other other people's, uh, you know, there's different types of sexual abuse, Unfortunately, where it doesn't have to be contact with the person, um that can, you know, have a significant effect on a person's appreciation of, you know, development of their sense of self and and the development of relationship to other people. And that kind of can precipitate then quite of what we call maladaptive behavior. So instead of being, um, sort of behaviors that are healthy and pro social, um, they are they get you through, they help you survive, but unfortunately they're unhealthy. So things like self harm, for example, is seen as a maladaptive behavior or maladaptive coping skill because some people might employ it in very stressful situations or as a as a method of communication. But ultimately it's it's not sustainable. It's not a sort of safe, healthy way of dealing with stress. Uh, and ultimately, if this has enough of, uh of an effect on your life, then it can It can develop into personality disorder. So personality disorder is, um, a, um, sort of maladaptive set of, you know, patterns of, of thinking, feeling and behaving. Um, that persists through different from childhood through different sort of situations in your life, um, and cause either you or other people very significant distress. Um, and there's there's a couple of different ways that they've kind of come to be thought about. So when I was doing my training, um, and I and being in the UK based psychiatrist and you replaced psychiatrist, we tend to go with I C. D, which is the international classification of disease. Uh, this is effectively a sort of coding and classification system for all health problems, But there's a section on mental illness. Um, and this is how we sort of would do things, um, then and think about personality disorder. Um, and we would think about whether someone has a specific personality disorder where there are kind of Gen generic criteria. For example, you know that the the problem has been, you know, present since childhood, and it's stable across different situation things. But then there are different, uh, difficulties and different symptoms and different atomic. The traits that define each one. Um and they've been grouped into three what they call clusters second block, um, where each type, um, shares similar features, but they're they're slightly totally different. Um, Cluster a, uh, is, uh, three purse three types of personality disorder that essentially the people things that people get sort of the struggle with all the things that they focused on our to do with, how they think about and how they present themselves to the world. So, para not someone with paranoid personality disorder, it would typically be convinced that everyone is is against them, but not to the level of someone with the delusion. So if I don't know how much you've, if you've done about kind of delusional beliefs and psychotic symptoms, But if someone's delusional, essentially, it's like trying to tell somebody that sky is brown. You know the sky is purple. Um, you all know that the sky is blue But if you're delusional If you had a delusion about the color of the sky it would be a bit like somebody trying to convince you, You know, that if you were delusional that the sky is blue Everyone else tries to convince you that sky is purple, but you just know, you know, it's 100%. It's a fact and paranoid personality disorder probably doesn't quite meet that threshold where, you know, they have suspicions about everyone. But ultimately they can probably be persuaded that things are things are okay, um schizoid and schizotypal, uh, sort of slightly different. They're kind of again, possibly a bit like schizophrenia and how they present. So I must be honest. I probably should have checkpoint really have time before, just before the talk. But I was mixed up which one they are. But, um, I so schizoid personality disorder would be somebody who becomes who's very indifferent to the world is very kind of quite alone in how they how they are and how they think about things. Um, and I think schizotypal is is sort of to do with quite bizarre beliefs about things, but again, not quite the extent of a delusional belief. And and frank, hallucinatory, uh, experiences. Plus, to be, um, this tends to be What I do with as a sort of forensic psychiatrist, um, is is personality disorders where things are much more to do with kind of emotions and how you manage stress. And I'll go into antisocial borderline, um, in in a bit more detail because they're quite prominent, very common, histrionic. Mean is somebody who I suppose is overly dramatic and and kind of has really extreme reactions to everything is the worst thing that could possibly happen. Or, um, you know, very extreme reactions to to every everyday stress or, um, and then narcissistic personality disorder. This is where somebody's, you know, but self worth is very inflated. Um, they can be very, um, very sensitive to perceived criticism. So if somebody if you're, uh, somebody with narcissistic personality disorder, you might find it very difficult to kind of receive any sort of criticism. And you think everyone else is wrong? You're you're you're right. Can lead to a lot of conflict. Um, and then just to see is to do with essentially anxiety states, but not they rooted in personality. Not in a in a specific anxiety disorder. Um, an avoidant personality disorder. You know, independent personality disorder is sort of to do with, um things. You know, You've always always got things that can, uh, well, avoidant personality disorder. You've you've kind of always got things that stress you out, and you voted for extreme lengths to avoid things. But again, it's rooted in personality, Not in, for example, of ct um, dependent personality disorder you feel would feel that you know, you you need other people too, to function, um, sort of people who kind of cannot be on their own at all, or not very good at that. Um, obsessive compulsive personality disorder, uh, is sort of a again a sort of similar to obsessive compulsive disorder. But it's not something that's arisen as a new phenomenon. It's just sort of part of, you know, that someone is just chronically worries about lots of things and has lots of quite obsession, obsessional thoughts, but it doesn't quite meet that doesn't meet the criteria for obsessive compulsive disorder. I need something that's, you know, rooted in personality and it and it's just sort of present through through most of their life. It doesn't really respond to typical treatment for, um o c d. Now I say I used that for I see 10. The new D S M, which is the American version, is the Diagnostic and statistical manual of mental disorder. Um, when I was training, it was D M D S M four, and they've more recently, uh, come up with the S M five. But there's not really been a huge change in how personality disorder is classified in the S M five. However, there has been a huge change in how it's personality disorder is sort of in I c t 11. So I suppose kind of if people are staying around Europe, you'll probably have more to do with I c. D. 11. If you go into psychiatry and instead of having these sort of specific personality disorders, you know you don't in I c t 11. They don't really talk about an are Castaic personality disorder or um or dependent personality disorder. You just have personality disorder as a diagnosis. So any of them as long as you kind of meet sit in kind of criteria. Um, which would be that you've got, You know, these persistent patterns of thinking, feeling and behaving that are at odds with, you know, your, um your cultural development and, uh, distressing and have been present since you were a child or through, you know, kind of had lessons into adulthood. Um, you just get a diagnosis amount of personality disorder, and then it's been graded by severity mild, moderate and severe. Unless you don't quite meet the criteria for personality disorder. But you have lots of personality difficulties. Um, is another separate sort of thing, and then you can qualify with different traits. Now, they've sort of reworded some of the previous categories of personality traits. Um, so negative affectivity is to do with, um in kind of antisocial, um, and schizoid personalities. You you end up with, you know, your you've got quite a flat mood effective or affect, um, and and you know, you you a bit sort of flat and not motivated. And those sorts of things, um, detachment. Similarly, dis social itty is another way of saying antisocial. So when people have, uh, prominent, uh, rule breaking and behavior and and difficulty in empathizing with other people's suffering, that's dis sociology and so on. So they did include a separate borderline pattern for what would historically have been described as borderline personality disorder because that is really quite, um, its own sort of thing. So I'll just describe for a second statements of my water. Yeah, um, the the kind of current terminology. I mean, apart from the, um in in I c t 11, the new terminology of of, um, borderline pattern of personality disorder you'll still hear borderline personality disorder talked about. And I think in I c. D 10 and in D S m. It's sort of also referred to as emotionally unstable personality disorder, which is the kind of core feature Um, it's extremely rare, I would say, to see somebody who who has personality disorder, who has not experienced quite significant, um, childhood address experiences and typically abuse and typically sexual abuse and and maybe sort of more sadistic emotional abuse rather than physical abuse, because that tends to precipitate antisocial personality traits. Um, but it's it's still it's pretty common, so in the UK the estimated prevalence is somewhere between one and 6% and it does tend to the sort of female to male ratio is its effects. About women are diagnosed with borderline personality disorder about three times more commonly than men. Um, and the kind of core features of Of, um, emotionally unstable personality disorder are, um, that your emotions are basically all over the place, so you get quite severe mood swings, and one minute you can be, you know, in quite a good mood. And then something sets you off, and then you feel the worst you've ever felt, and then that recovers quite quickly. That's in comparison when we talk about differential diagnosis later on, um, mood disorders tend to last for quite a long time. So if you've got bipolar disorder, you would tend to be elated. Mood for, you know, weeks or months, um, or depressed for weeks or months. Um, whereas with emotional, stable personality disorder, it's within a day have multiple sort of emotional states. Um, I suppose partly to try and meet, you know to to correct how people feel. They can be, quite, um, prone to very impulsive behavior without really thinking things through, Um, they were contend to have, um, really intense but short lived and unstable interpersonal relationship. And there's a phenomenon called splitting, Uh, which is where? Um, it's quite hard sometimes for people to see different sort of shades of gray of a person. So someone is either, um, put up on a pedestal that they're the best person ever. You know, you you are. You've saved me. You are. You're my hero. You're you know, you're you're you're such a good person. And then as soon as that person isn't that there's no in between there just the worst person you know. You you. So you that's called idealizing when you think someone is is the best thing ever and denigrating when they are, you know they've they've let you down. You can't trust them. They're horrible people. So, um, there's a lot of debate about whether or not it's it's the person who you know. It's the person with personality who causes splitting, or it's the personalities of people around them that interact too, cause splitting, um, people who can also really have a distorted sense of theirselves of who they are, what kind of person they are who they want to be, you know, they just feel can be that can feel quite empty and quite, quite alone. And I'm quite unsure of what what to do. Um, and particularly in terms of where people come into contact with health services, people with borderline personality disorder. Um, quite often, one of the sort of typical patterns that people fall into of managing their emotions is with self harm and self harm is very, um, is a very complicated, uh, phenomenon where people people do lots of different things to self harm. Um, and people self harm for lots of different reasons. So if you you know, some people kind of cut themselves frequently, um, which is quite clearly self harm. But then I suppose some people might deliberately miss some medication that they need. Or they might overeat so that they become overweight deliberately because they sort of feel that they deserve to feel bad. And that could be a potentially a type of self harm. And people do have different reasons as well. So some people can will self harm entirely in private, and they will be would be absolutely mortified if somebody was to find out that that's what they have been doing And that is, uh will be a way of of managing emotions. So when you've got very strong, very complicated emotions, sometimes people don't know how to how to feel. They don't know how to what to do with that with that feeling. So they if they can feel sort of transform it into physical pain. You can kind of make sense of that, Um, and sometimes feel. Sometimes people feel that they have to self harm to get a release from, you know, different from really horrible feelings. Um, and then Paris suicide. It's along the same. Um well, well, well, the other. The other type of. I suppose the main reason that people self harm is a way of is a way of communicating their distress through their bodies rather than if they don't necessarily have the words or people don't listen. So you may find as a as a child that when you tell somebody that you're struggling, they don't listen to you, but they take notice. If you start cutting yourself and you tell them that you've been or show them that you've been cutting yourself, Um, so essentially, it's a way of kind of getting their needs met. Whatever those needs are at the time, Clara suicide is kind of a more extreme version of that where people either threaten or attempt suicide as a means of communicating distress. So the intentions in in taking the overdose, for example, is not to die but because, you know, they people don't listen to me when I say or when I ask for help, they maybe stop listening when I self harms. But they do take notice. If I say I'm going to kill myself or if I present in a and E uh, any, you know, um, the emergency department. And again, it's quite a complicated thing. And it's difficult to know because sometimes people with personality disorder do a very real suicidal ideation, suicidal thoughts, and they do mean to really sort of end their lives. So, um, you know, it's it's difficult, and I suppose you've got to got to take each each situation as it comes ready. Um, and then people with borderline personality disorder typically have quite an extreme fear of abandonment, and I'd be extreme. I just mean there are very prominent, very strong fear of abandonment, whether it's real or or or not. You know, they people, uh, tend to can contend to really struggle is if they sort of feel someone is leaving them. Um, and that can prompt, you know, self harm para suicide. Another kind of dysfunctional ways of communicating your distress. Um, and then the other thing that people with borderline personality disorder experience And this is where the term borderline historically came from is that this disorder is is on the borderline between psychosis and what they would call neurosis. So anxiety and, you know, personality type symptoms. So people with who have been abused might quite quite often on a chronic chronic basis. They might then start hearing voices saying nasty things about them, and it's kind of felt to be perhaps there, um, an expression of sort of their own. Um, you know, their own internal thoughts and their own beliefs about themselves. Or it could be a sort of almost a flashback type thing from if somebody was saying, you know, bad, bad things to you. Um, so people can end up being treated for psychosis when it's more actually rooted in personality. Um, but that said sometimes antipsychotic medication that we would use for schizophrenia and for mania, and things like that can actually be quite beneficial. Um, but I think it's important to know what you're treating. Uh, and then the other specific one that I'm going to talk about is antisocial or sometimes called dis social personality disorder. Um, which is, uh, slightly less common, but still pretty common, and especially in a prison setting about there's estimated up to about half of all people in prisons in the UK Um, Katima would would meet, you know, the the criteria for antisocial personality disorder. And I suppose this if you think about, you know, a child growing up, who's who experiences a lot of physical abuse and a lot of nastiness and perhaps neglect, they may not develop much empathy for other people because they personal needs have not really been thought about. So why should they learn to, you know, be nice or two to do nice things for other people? Um, and you tend to find that, uh, there's there's actually quite a strong genetic components been found for antisocial personality disorder. So again, twin studies have shown, uh, if you get twins who who grow up separately, one of them develops, Um, antisocial personality disorder is more likely that the other twin will also develop antisocial personality disorder, even if they are very different experiences growing up. So, uh, you may. They may find that they meet quite interior of something called conduct disorder, which is probably something that you recover in child and adolescent, um, psychiatry lectures. But that's sort of to do with basically difficulties in Children following rules. And they get two fights and they can be quite nasty, and they get pleasure from hurting other people. And that's the thing. Um, but antisocial personality disorder in adults is a pattern of really not either not caring or deliberately violating the rights of of other people. Um, but there's a complete lack of empathy for being able to, um, you know, understand or care about what other people are going through very, very high rates of substance use and addiction to, um, alcohol and drugs. Um, and people can be prone to quite impulsive and sort of aggressive behavior. So there's quite poor um uh, what should we say? Regulation of of there, uh, you know about their emotions, Um, and then kind of, Well, it's It's quite, um, uh, it's It's a little controversial about psychopathy, whether someone can be a psychopath. Um, there's also there's different thoughts about sociopaths and whether they're a different thing and and it it's all you know, it's it's all people Trying to make sense is I mean, it's really, really complicated and and not so easily visualized, I suppose. Um, so is psychopathy a very severe form of antisocial personality disorder? Or is it effectively just how someone is kind of wired? And it's a basically a different form of perhaps autism or something along? So I'm not saying for a second, of course, that people with autism are psychopaths, But But in terms of autism, we kind of think of autism as something that that's just who somebody is. Um, that, you know, there's you can't always do about. You don't necessarily treat autism. You you kind of modulate the environment to suit the person rather than the other way around. And perhaps psychopathy is sort of in a similar the similar concept of that. Just how someone is kind of wired that they don't have the capabilities, physiologically or psychologically, to to feel, um, empathy and emotion for other people. Um, and then it's It's kind of it's been the subject of a lot of research. And there's this chap called, um, this gentleman called Hair, who came up with a psychopathy checklist. Um, and in the revised version that's called the PCL are and the PCL are has got all these different items. There's 20 different items. I think you can score 40 is the maximum, Um, and it's to do so. We just kind of go through some of them someone who is quite superficially charming. It's got a bit of a grandiose sense of their self worth. Um, they find it very easy to lie because they don't feel bad about what they're doing. Um, um, no feelings of guilt or about, you know, don't take responsibility Very impulsive and irresponsible. Um, you know, and these sorts of things now, interestingly, if you, um can, uh, you score it up, you you If you do the PCL out some when you do it, you do a score. And I think it's 25 in the UK, makes you a psychopath and 30 in the U. S. Makes you a psychopath. So maybe that says something about I suppose our, uh, received, uh, you know, goals. And I suppose in in in the UK with very sort of funny social animals and and that, you know, we've all these kind of rules and things, and we we don't seem to maybe put up with with with breaking those rules as much as, um, the Americans do. But for some reason, they've got different cuts off. What makes us like that? Um, there's a lot of debate over whether psychopathy is actually exists. Um, is it severe? Antisocial P D. Is it treatable? Does it get any better or is it just who someone is? I can't say I really know the answer. I would probably probably come down on the idea that it's a separate entity myself. That it is sort of essentially how someone is kind of wired, and it's very, very difficult to do very much back. So just to to round off, I suppose. Like how you actually go about diagnosing personality disorder, um, in in a hospital setting where you might have, you know, good access to psychologists. Um, they can do psychological testing. So there are different kind of psychological sort of psychometric tests that people can do to to say how, How much how, you know, identify that and quantify the different parts of their personality. So somebody might come out of that with, you know, very strong. Um, strongly, uh, endorsed, um, antisocial traits or dependent rates or whatever, but typically in in a in psychiatry, the diagnosis of of personality disorder is from from a full assessment of of kind of the person's history, and you would tend to want to sort of get quite a thorough, detailed and longitudinal assessment. So you wouldn't really make a diagnosis of personality disorder just meeting someone you might well have very strong suspicion. Um, but it wouldn't really be right to say, you know, So I guess you would want to kind of see them over over a period of time, maybe get some collateral information from other people. Um, and you would want to know about their childhood. What was their childhood like? Was it a happy childhood? Was it very difficult was their poverty? Um, and you know what would did anything happen that they would consider to be traumatic? Would they? Were they Did anything happen that they think of as being abused? Um, well, their relationships, like with their important, you know, primary caregivers, mother, father, brothers and sisters. Do they have any friends? Um, what do they do when they get stressed? How do they manage? You know, different things, and then look at different symptoms. So, you know, somebody might come to you, and they they say that, you know, I can't, um I can't go to bed without without checking, Um, my gassed cooker many times or something like that. And then you look at it kind of Is that CT, or is that a CD personal disorder or obsessive compulsive personality disorder? Um, and again, you kind of look at to to look at Is it personality disorder? Is it a different psychiatric entity? You sort of think. Is there someone that has kind of always been there throughout most of this person's life? Or is it something that kind of comes on in? Episodes can really get episodes of personality disorder. Everyone saying, um, it is possible to have, you know, typically a head injury or some sort of brain injury that you know, perhaps meningitis or a stroke or something that that changes, fundamentally changes your behavior and changes and can look like personality disorder. And we think of that as acquired personality disorder. That's pretty rare. Um, differential diagnosis. I think you would sort of look at whether or not, um, you know, if somebody has has odd beliefs, you have to quantify. Is this person delusion? Uh, visit is delusional disorder? Or does it Do they have other psychotic symptoms? And maybe they have schizophrenia? Or is it something that they just kind of have quite weird ideas about things? But they're not fixed. They're just, you know, um, they can be called one or the other, and they're always a bit like that. It's not something that's developed in this person's late teens. Early twenties, um, just to be, you know, particularly historically it's been bipolar disorder gets kind of diagnosed or personal Polanco Italian disorder, getting diagnosed as bipolar disorder. And then people end up on huge doses of mood stabilizers, another cycle fix that maybe they don't need. Maybe they What they need is psychotherapy. Um, and substance misuse disorder. I suppose if you are addicted to heroin or two something along those lines, you will do a lot of things to get to meet your need of the of the substance that can look a bit antisocial so you don't send People find that they start stealing and they start whatever because they need to get the effects of the drug. And actually, they wouldn't necessarily meet the IPD criteria. It's not that. And if you can manage the substance misuse disorder, the problem kind of goes away. Um, so that's why it's important to kind of think about that. And then just to see their anxious sort of episodic anxiety versus someone who's just an anxious person other where I've done that one twice and then to finish, How do we treat it? So historically, there was, uh, and I suppose, unfortunately, it's a lot of people do still believe this. That personality disorder is untreatable. It's just who that person is, and they can. There's no role for psychiatry, and maybe, you know, you might get better with. You might get some benefit from some some sedative medication, but that's it. But there is a lot of research that personality disorder does respond to treatment. So borderline personality disorder, emotionally unstable personality disorder. Um, they do. There is a specific treatment, a specific psychotherapeutic treatment, um called DBT dialectic behavioural therapy, which is a sort of a course, almost sort of sort of, a program of treatment that looks at basically, there's different symptoms of personality disorder. And it helps you with each of those things, because it's all effectively things that people have either not learned to do or learned maladaptive ways of doing it. So it's, uh, the different sections are things like looking at your distress tolerance is one your interpersonal skills. Um, your regulation of your emotions. Emotional regulation? Uh, and there's one other one which doesn't which has escaped me for a minute. Um, I put their adult life so you personality disorder. A lot of the time forms as a way of surviving adverse childhood experiences. If you're being quite routinely abused or neglected or anything, then you can develop these ways to sort of survive that situation to me, get your needs met, and then you go into the other world and you don't need to do those things anymore. But old habits die hard, actually, and you find that you're kind of stuck doing those things. But eventually people do learn are actually I'm pushing everyone away. If I you know, if I act like this, I'm not due bringing people closer. I'm actually pushing them away, or you find other things that work for you. So if again with coming back to board like this are disorder if we did nothing. The sort of natural history of borderline personality disorder is that it tends to get better or gradually, very slowly over someone's life because they have different situations that they have to deal with. They have different people in their lives. They get used to people coming and going, um, and that sort of thing, Um and then medication can have a role. As I say, you know, schizophrenia. The standard treatment at the moment is antipsychotic medication, probably for life, or and, you know, you can you can try, and some people won't need lifelong, but lots of people will, um and we don't really have anything that will make it go away. Um, however, personality disorder could go away eventually, but medication can help just, you know, keep you keep you a bit. Keep the person a bit. Um Well, keep them going. Help the symptoms. Um, some people do very well on antipsychotics. There's a trial going on at the moment of closet pain, which is a very, very strong if you like, very effective antipsychotic with a lot of side effects and a lot of problems. Um, but of clozapine for, um, actually unstable personality disorder because people have found tried it and they're on egrets. It's very it can be quite effective to help people's mood become a little bit more stable. But it's not really a long term, you know, it's not meant to be. A long term solution is to help people get to a stage where they can sort of do the work that they need to do. And that's sort of it for my talk today. So I I it's it's been it's not perhaps got into as much detail as as I could have done, but I think because it's so different from you know, if you're looking at types of fracture and things, you look at the X ray and you I mean that's a bit naive for me, but you would look at an X ray and you see what the fracture is. And it can be classified, and they would look the same to different people. Um, in psychiatry, you know, we we think about things perhaps slightly differently. And because you can't see what's going on, you have to observe someone's behavior in someone's symptoms and and, you know, try and make sense of it that way. So because it's as a, you know, a bit of a different. But I just wanted to kind of give a little bit of an introduction to it. Really? So I would be happy to take any questions. Um, if anybody has any, um, yes. May, uh, I have a question. Uh, okay. Thank you. So, um, I heard and thought that for our brain, Um, the idea is that we have the stable personality during the whole our life. It's like like base. It's, like stable, um, stable thing. Uh, it's just interesting for me. What if, uh, they think wouldn't be stable for our brain? What if our brain just thought that one day we just woke up and we will be the other people. The other woman, I think so what? What would be with us? What would be with our brain and what we go? Go on. Or so, um, I'm not I'm not sure I fully understand the question, but I think in terms of, um, like if you if you were to wake up one day and be suddenly really quite different in in a certain in a particular way, Um, then I think it's probably not personality disorder that is going on. So I think sometimes you know you can Sometimes people can have, I suppose, short term, uh, you know, short term, uh, modification to their personality. So, for example, if you go into a romantic relationship and that person cheats on you, and then you might for quite some years after that find it very difficult to trust new people and trust new, um, uh, you know, trust new new partners, Um, and that you know, that that can be based on a on a particular single significant event. Um, but generally, I mean, it's not to say that you're someone's personality is exactly the same all the way through their life, but just generally day today, Um, that, you know, that person will tend to react to a situation in a similar way. Um, you know, if if you have a situation that comes up today is a I I don't know, Um, you know, in in in a different in A In A. So, Okay, so say I'm in work and I have an idea or I say something that I say. I think I I think a patient has, um, has got personality disorder. And one of the other staff members laughs at me because they think Oh, well, of course, this is not personality disorder. You're stupid, Doctor. Um, they just, you know, they just this is just drugs or they're actually ill or whatever their their opinion is different from mine. And they say they laugh at me and they belittle me and things like that. My personality depend shows, you know, kind of affect how I will respond to that. So I could get quite defensive. And I could perhaps, you know, go on the offensive to to belittle that person back to make myself feel better. I could stay quiet and go off and be very sad and be very affected by it, or I could not really respond to it and just think, Well, that doesn't matter or, you know, But the idea of personality is that I will probably. If that happens again in 23 years' time, I would probably feel the same way as I do now. I will probably respond to it in a similar way, whereas if I was, if I was somebody who you know whenever somebody, uh you know, similarly say, um, I don't know. Somebody took my took my sandwich in the fridge. I brought my sandwich to work and I was looking forward to my sandwich and somebody took it and they ate it. And I found out I could be someone who would go and hit that person and say, You know, you can't do that and I'd get very angry and I would go in and and hit that person, or I would be very, very nasty to them. And if I was that sort of person, then whether that happens now or in three years' time, I'll probably react in the same or similar way. If it was happens in 25 years' time, I might have changed a bit by then. But the idea of the of personality of personality is that that it's it's reasonably stable. Whereas, like a mood disorder. You know, somebody could, um, say to me now or you've, um you know, you you you've lost a bit of weight, and I would. And if I'm not depressed, I might think, Oh, that's that's a nice thing that you know, uh, and then, uh, if I, you know, in two months time, if I'm depressed, I'm I fundamentally changed. Like how I think about things for, you know, uh, my brain chemistry has changed How I think about things. And if somebody says the same thing to me, they might say you've lost weight. They I would think, Oh, no. They think I look terrible or they think I'm able. They think I you know? Well, maybe I'm you know, So you think about things very differently in different states of episodes of illness, for example, does that make sense? Yes, I see. So the idea is that the personality is kind of flexible and depends on the situation. Depends on the condition of a person, etcetera. Yes. Yeah, within within that person. Yeah. Okay, so I see it. Thank you very much. No problem. Um, and any other questions? Okay. Are we happy to, um, um to end it there? Um, I think, Yeah, we're also a bit over the designated time, but thank you very much, Doctor Thomas. That was a really fascinating lecture. Really interesting. Well, thank you all for coming, and I hope it was use of some use. Um, And I hope you, um we'll think about psychiatry because it's a really good job. Thank you. Well, and the recorder.