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You are so warmly, welcome to this middle primary care session. Uh, we are really honored to have the wonderful doctor Mavi Capanna back with us, er, this evening. Um, as many of you will know, Doctor Capanna is a psychiatrist in London and a current darts fellow and she's going to be talking to us today about personality disorder and I know there's some really big updates that have happened in the, the last couple of years and, er, Doctor Kana is going to, er, share some of those with us and they're actually quite important. So I hope you find this, uh, a really helpful session and, um, if you have any questions, please pop them into the chat and we'll have some time for questions at the end. Um, we're gonna have some polls as well. They'll pop up in the chat, please answer them. It would be really helpful and allows us to, uh, just to kind of see where you're at and make this, er, really interactive and we also get questions about, um, er, certificates and on demand content and the best way to access that is via the app and I've pasted the links to the IOS and Android app in the chat. Um, or you can, er, er, get them in any of the app stores and that'll allow you to get your certificate after the event. And we'll also be able to let you know when the on demand content is available. So I hope you find this really helpful, um, and it's really good to have you and it's really great to have, er, Doctor Kana here with us this evening. Who I am gonna hand straight over to Mavi. Thanks. So, um yeah, so welcome everyone today. We're gonna be talking about personality disorders um and the diagnosis treatment options and the comorbidity considerations. Um We're gonna start off with a poll whilst I also put the learning objectives on the screen. Um So for the first poll, I'm just wanting to understand how confident um the audiences just to get an idea of where we're starting from. So how confident are you in treating and assessing personality disorder while people reply, I'm just going to cover what we're gonna be talking about. So we're gonna be defining personality disorders. Um This includes some major changes that are in the new ICD 11 compared to ICD 10, which came out in January 2022 which has changed the way we diagnose personality disorders. Uh We're gonna talk about the treatment for personality disorders um uh med medicine as well as therapeutic options and then we'll have to look at comorbidities and how that interacts um with how we manage these patients. So looking on the poor, it seems like the majority of people are not confident in treating or assessing. So that's good. It means you're in the the right place, hopefully um to get some more information and then some people are confident in assessing but not treating it. So we'll definitely cover that. So how do we diagnose personality disorder? So the main changes I'm gonna talk about as well. Uh But until the ICD 11, you might all remember that we used to classify personality disorder based on these categories and prototypes like borderline PD, antisocial PD. Um whereas this has now gone because it kind of aims to acknowledge the fact that there's a fundamentally dimensional nature to personality and it's not just one disorder in a specific category and it requires clinicians to kind of make rather than categorical decisions, overview decisions about that person's functioning, which is more representative of how personality disorder can present. Um And it kind of asks us to look on a spectrum rather than a presence or absence of a full disorder. So we'll talk about mild, moderate and severe levels of personality disorder as well as personality difficulties. There's also this connection between a normal personality and the personality disorder. Um and how there can be five different trait domains that can present. So we'll also talk about those. Um and that kind of fits into. So first you do the mild, moderate, severe and then there are some of these traits, um, disturbances that we'll talk about and there's five main ones. Um, and this kind of covers the five main personality traits that were in the previous categories. So there's things like negative affectivity, detachment to social behavior. Um this inhibition and an an Caia which will also cover the other main key difference is that it used to be that you couldn't diagnose personality disorder up until the age of 16 plus because of the nature that personality changes and how teenagers can also present, which we'll touch on later as well. Whereas now it's all ages are included. So the main things we're looking at when we're starting is these required elements. So there has to be problems in functioning in aspect of the self and interpersonal dysfunction, causing distress and impairment in personal family, social, educational and occupational functioning. So by the self, they mean our self identity. So things like self-worth, how much people know who they are, the accuracy of their self view and kind of giving themselves self direction. So things like in the past borderline personality disorder, so it was called would say, you know, I feel like I'm not really sure who I am, the sense of emptiness within myself. And that is the sense of self that they're talking about in that first bullet point. Then the what they mean by the interpersonal dysfunction is things like the ability to develop and maintain close mutual relationships that are satisfying to both sides and the ability to understand others perspectives and to manage conflict in that relationship. And this is the things that we see where there can be maladaptive responses. So people that are really inflexible or people who are really poorly regulated. So when there is conflict, there's this really poor emotional regulation and we'll talk about that in, in the next few bits as well about the extent of that. Then the second bit is about personal family, social education also. So it cannot just be that there's a specific relationship or role where this dysfunction presents, it needs to be throughout the individual's social and interpersonal interactions with other people, then it needs to be persistent. So it cannot just be that they're having a really stressful time. And in that time, there's a really um uh dysregulated period of emotional instability. It has to be persistent over an extended period of time, which is usually two plus years. And you can also ask that in terms of getting a collateral and getting their family input to get that historical timeline. This usually presents in patterns of cognition, emotional experience, emotional expression and maladaptive behavior. So we've covered that. Um And it manifests across this range of emotion uh of, of, of situations. The really important bit here is the word cultural. So it needs to be not explained by cultural or social factors. So it doesn't, it isn't something that maybe is not appropriate emotionally in the UK, but is emotionally appropriate somewhere else. So this can be seen in like people's response to stress or grief or loss. Um And that needs to be seen in the context culturally of that person. And as well, here is, it talks about developmentally appropriate, which is important when we think about the fact that there's now no age limit. So there is available evidence that indicates some gender distribution in personality disorder that I'm just gonna call PD from now on for brevity. And it's usually a gender distribution that's equal. However, there's significant differences between the genders and then their behavioral expression of personality disorder and also some of the trait domains. So the ones we talked about that we'll, and we'll look at more closely. So specifically, there's worse dissociality and disinhibition in men with PD. And there's greater amounts of neg negative affectivity in, in women with PD. And it's important to see as well that some of these do change with age and we'll look at the progression of personality disorder in a few slides, but the impulsivity associated does decrease with age as well in both sexes. So once you've had those main criteria satisfied, you're then gonna look at the severity. So we're not looking at individual categories anymore. We're looking at a pattern of malfunction and a pattern of personality that is across social contexts and that is a prolonged over two years. And now we're looking at how severe is this PD. So they, in the ICD, it's split up into emotional behavioral and cognitive manifestations of the personality disorder. So, emotional manifestations is range appropriateness and recognition. The range and appropriateness is how are they expressing their emotional experience? So, we touched on this a bit before. Is there a variation, is there a strong expression, a fluctuation? Is there a tendency to be emotionally over or under active, both kind of to be considered? Because both are a sign of kind of maladaptive coping strategies in response to emotional experiences. Is there an ability for the person to recognize and acknowledge emotions that are difficult or wanted? So when they are angry, when they are sad, when there's something that isn't suiting their narrative of that situation, how are they able to recognize and acknowledge that emotion that they're feeling uncomfortable? Angry, sad, uh abandoned. And how does that sit with them? The behavioral manifestations, we're, what we're looking at there is their ability to control their impulses and modulate their own behavior. So, when they are feeling angry or sad, how are they modulating that? How are they responding to the impulses that come with that? And how appropriate is that especially in response to stress? So how does stress lead to dysfunction or malfunction? What is that response in them? And how does that impact their overall functioning? There's a level of flexibility in controlling these impulses. And we need to see that they're giving due consideration to the consequences as well. They're not just active impulsively on that emotion. Um, and behaving in a way that could then have risky impacts on themselves or others. And we're looking at kind of how prone are they to having inappropriate responses to stressful situation. Does it lead to a propensity to self harm to suicide to violence? And I think, you know, if you've worked clinically, you've got, you, you do get that with some personality disorders that when they're under stress, like they have been kicked out of their house or they're having an argument with their family member, they will present in a suicidal acute state that actually if they then have time to process that and self regulate or helped in regulating, that will go down. So this also has a good consideration in terms of risk. So risk to others, not only risk to self. So people with what used to be called antisocial or dissocial personality disorder that have that this level of dissociality when they don't get their way. So for, for example, on a forensic ward, when I had a patient who didn't believe that when he went out to on his leave, he wasn't smoking, he came back and completely smashed the ward and smashed the nurse's station, that's not an appropriate response to feeling you're not being believed. But it's that lack of regulation that that leads to escalation and risk. So to which extent do these dysfunctions affect functioning and the response to a situation? The cognitive manifestation is how like, how well are they appraising accurately the situation? Not only the situation, but also the interpersonal appraisals, especially under stress. So this keeps coming up. It's especially under stress. How are they reacting when they feel they're under stress or there's a, they feel abandoned or they're having an emotional discussion with a family member or a personal relation? How are they assessing that situation? Are they jumping to conclusions? Are they immediately thinking everybody hates them? Everybody wants to abandon them and they're a failure? Are they thinking that everybody's out to get them? And are they able to then based on that assumption, make appropriate decisions when there is uncertainty and what we see in personality disorders, a lot of the time they jump to conclusions, make an incorrect appraisal under stress and then make a very either risky or inappropriate decision based on that. And based on the level of that uncertainty of what they're feeling. And this links in well with the fact that there is an inability to kind of have that flexibility in understanding other people's point of view or shaking that narrative. And there's, there isn't that stability in their belief system? So they're not able to think, oh, maybe it isn't that this nurse doesn't believe me because I smell smoke and there's, you know, I can explain the situation. They'll immediately think no, everybody in my life has let me down. Everybody in my life thinks I'm a liar. Therefore, this nurse thinks I'm a liar. Therefore, they're out to get me. And it's a very, it's, it's a pattern of response based on previous narratives which we'll discuss later on, based on the etiology of PD. So here I've just put a table, um looking at the differences in the domains that we've just discussed. Um and the different categories of mild, moderate and severe and how you would rate that. So we've covered these already. But mo just as a quick summary, it's usually a spectrum of self harm or harm to others are not present, um are not usually associated with mild PD and then it gets increasing in um likelihood as you get to more severe, um the level of impairment gets worse uh in all areas of life and the functionality in those there's and the level of interpersonal functioning also gets worse and the disturbance in that sense of self we discussed also gets worse. There's also another category that they discuss in the ICD 11, which is around personality difficulty and it's not classified as a mental disorder, but it's listed in the grouping of kind of problems associated with interpersonal interactions. And it's the risk isn't there and it comes out usually in times of great stress or lack of coping strategies but it's not as persistent um and doesn't affect functioning as much as PD so onto the domain descriptions. So these are the ones we discussed. So you've gotten the basic criteria of the ICD 11 and that's been met, you've decided they're mild, moderate or severe and now for, to make kind of a greater understanding of the difficulties that person is having and to describe the characteristics of the individual's personality that are most prominent and that can contribute to the personality disturbance. They've come up with these five trait domains. Um And these are kind of resembling the previous diagnoses that we had borderline and acas to social. Um and it covers the main types. So the trait domains are not diagnostic categories in themselves, but they're kind of a set of dimensions that correspond to the underlying structure of that person's personality. And as many trait domains can be used to describe that person's functioning and personality and people with more severe personality disorder will probably have more than one of these. And this is this kind of shows why there is a benefit in taking away those categories and diagnoses of PD because a lot of the severe, moderate to severe, but mostly the severe cases have a lot of different comorbid personality traits. And so this way of actually coming up with the diagnosis shows that fluidity of people having a bit of borderline traits, a bit of a of just social traits. And this can all summarize it. Um So moving, I'm gonna move through each one of them. Um And there's quite a lot to talk about. So I'm gonna try and keep it as to the point as possible. Um So negative affectivity, so broad, this sounds like a, a lot of word with affectivity but mostly about mood. So it's a broad, broad range of negative emotions which occur frequently and more intensely than other than others would judge as normal functioning and is out of proportion to the situation. It makes sense to the person. So the person with PD, this isn't an inappropriate response. It makes sense to their own narrative and their own learned experience. So for example, I had a patient in one of the high secure hospitals and every time that he became more aggressive, they used to put him in a seclusion room, which is an an isolation room in that in that ward. And he would then, rather than calm down, which we saw with a lot of our other patients because they want to get out of seclusion and there's nothing to do there. He would actually escalate and attack any staff that went to open the door. And a while later years later in therapy, it came out that his mom used to lock him in a small cupboard when he was small and misbehaved. And so his narrative and that attachment style was kind of lit up when he was put in seclusion because it reminded him of his mother's neglect and his mother's abuse of him. And so it escalated his behavior. So to him getting more aggressive when he was reminded of that situation makes perfect sense. But to us from the outside, it seems like an overreaction to a situation that's already inflamed. So all these emotions, anxiety, worry, sadness, fear, guilt, hostility, everything gets more enraged, everything gets more pronounced. There's a higher fluctuation of the moods. There's a higher changeability to them. The emotional liability, liability of it comes and goes very quickly. If you laughing, presenting as manic and crying, then being really angry. And there's a real difficulty in these people and a real distress in regulating these emotions. And it takes a much longer time to return to their baseline emotional states. So the reactions, a lot of the time match the intensity of the emotion. And once there's a bit of a cool off period, these tend to come down, but it takes a longer time than the average person. Um And this can come with a lot of feelings like we talked about before of hopelessness, low self esteem, low confidence, which links in with some of the comorbid conditions that come with personality disorder like ad HD, depression, anxiety, detached. So next trait domain detachment, this can be social or emotional. Uh a lot of these people present with isolation, they avoid intimacy of all kinds. There's a limited emotional expression. There's an unreactive or kind of whether it's positive or negative, negative emotional occurrence. People tend to distance themselves from that or tend to actively avoid it dissociality. Next trait domain. So this is um, one that we see where people is commonly seen in people that end up in the criminal justice system or in the forensic services. Um, and it also is linked when Children have conduct disorder, this can later develop into, into adults with the social traits. So they have a disregard for others, feelings and rights. They have a attitude of self-centeredness and lack of empathy that the rules are for everybody else and not for them, this entitlement towards others and expect and thrive off admiration. Um And if these, if the responses of others aren't what they expect, then there can be really dramatic displays of dissatisfaction. And this is when the criminality aspect comes out. Um And this, as I said, is kind of linked with people that end up in prison or in the forensic services. And it's the personality disorder that the media likes to kind of label as psychopaths or sociopaths, which isn't a diagnosis in psychiatry. But the, the, the one that it resembles is what used to be antisocial personality disorder than the social personality disorder. And now this is the trait domain that links with that. Um So the next one is um this inhibition. So this is the one linked with impulsivity again, the risky two to have together, I mean, they all come with their own risks. But the social um and disinhibition can come with a risk because you have the impulsivity of the disinhibition with the A and, and its link with kind of self harm and harm to others. And then with the dose, uh if you have someone that has also the dissocial trait, it can lead to more criminal behavior. Whereas if you have a disinhibition with impulsivity, um and with some negative affectivity, it can also lead to more self harm um and substance use. So this lack of consideration of consequences and actions, putting themselves and others at risks impulsively and a lot of difficulty with delayed gratification, becoming easily bored with routine and needing to be distracted again, kind of links with AD HD as well and why a lot of the time there is a um dual diagnosis or it can get confused with each other. So the last one, an Caia which I always struggle pronouncing. Um So this is people who are very clear and detailed with their personal sense of perfection. Um Some, it sometimes gets misdiagnosed or co diagnosed with OCD. And there's a level of intense obsession with, with perfection and imperfection and it extends beyond this usual standard. So this, it keeps coming up, this, this thing of it, it, it extends beyond the norm, it beyond what's usually expected, what you would consider normal and that's why it's really important to keep in mind the cultural aspect because what's considered normal in the UK is vastly different to what can be considered normal in other places. So these people are very stuck to rules and that the rules should be followed. Exactly. And obligations strictly met, they will end up redoing the work of others. So I'm sure you, we've all had colleagues that have traits of this personality disorder where no matter how much we do something, it is never quite good enough and they have to do it and do it and do it and micromanage uh to the nth degree um to a perfectionist standards. And this usually comes with a high wish for control and a clear sense of what is right or wrong to the point of really black and white, rigid thinking. So those are the main, uh those are the trade domains, not the main ones. Um As an addition to this, uh there is a specific borderline pattern that they've added in and it's called a borderline pattern specifier. And it's been included to enhance the clinical utility of the classification um for personality disorder for clinicians. Um And it specifically is used to facilitate the individual um who may respond to certain psychotherapeutic treatments, which we will discuss in the next few slides. So, so that's how you diagnose and figure out the severity, the trait domains for people that you think have personality disorder. So then um I know there's some questions but I think we'll save them till the end. I can see them popping up. Um Unless there's any burning ones that um Phil wants me to touch on, but otherwise I'm going to move on. So why some, a bit of etiology for personality disorder? Why does it happen? So, personality disorder tends to arise when individuals experience really hard life circumstances and there's inadequate support from for typical personality development. This is usually because of the person's attachment to their primary caregiver. Um And there's typically elements of abuse in either one or numerous modalities. Um and that the the aspect of the person's temperament um that needs that support is not able to develop fully. So early life adversity is a huge risk factor for later development of personality disorder. And it a as it is for many other per uh mental health disorders, but it's not determinative. So you don't have to develop PD not everyone who has aces adverse childhood experiences, develops personality disorders or other mental health disorders. And it, it is that some individuals temperament or attachment to other people in their life can allow typical development of their personality despite extremely adverse early environment. But nonetheless, if you have someone that has some traits of personality disorder with the context of early adversity in their life with ongoing behavioral emotional cognitive difficulties, interpersonal problems, then you should consider this and especially in people with borderline. Um subtype. Um looking at the attachment and early rejection and abuse is typically a very good determinant of personality disorder in that context of that borderline subtype. So the person, the the thing to bear in mind as well that we'll talk about a bit more is that personality disorder often complicates and lengthens treatment of other clinical syndromes. So as I've already touched upon, sometimes it oc ad HD depression, it gets misdiagnosed and missed. Um And there can be kind of poor or incomplete response to certain standard treatments. And when that happens, we always need to question if there is some personality disorder, when there is consistent lack of response to treatment and it might be good in these cases to always kind of have an idea of the history as well. So there's often kind of considerable variability in the degree to which the individual knows around them agree that the behavior is due to response or the personality or a particular trait. And there's a usually a big disc, a discrepancy between their own self description and the self, the description of people around them. So it's usually a very good idea to get a collateral as well. So gonna talk about progression. So there's another poll here. Um Does P do you think personality disorder PD get better or worse with time? I'm just going to wait for some people to vote and then we don't wanna give the answer away. So pretty equal split slightly more than the. Yes, uh which is correct. Um So does PD get better with time in some ways it does. So the manifestations of personality disturbance tend to appear in childhood and then they increase during adolescence and continue to, to manifest during adulthood. Um And although individuals might not come to attention of services for, for some time in later life misdiagnosis or because they um don't want to be in touch with services. There still should be some caution throughout that period of time and especially in Children and adolescents where their personality is still developing. Um And in teenagers where some of the some of the development of teenage years when you're exploring your own personality and your own self might come across as disinhibition and increased impulsivity. So there should be some caution there. Um And that those some of those might settle down even in teenagers who are having a slightly harder time, but usually the overt behavioral manifestations. So the dissocial and the disinhibition tend to decline over the course of adulthood. Whereas other traits like the detachment and the anesthesia are less likely to do so, um both in kind of how much they impact the function but also them themselves because impulsivity tends to go down with older age as well. And especially after young adulthood, these do remain relatively stable with, I mean, there are slight decreases and slight in the social inhibition, but overall it's pretty stable but they may change also because the person changes and the person finds coping strategies and coping and, or either because they're going to the treatment or because they are just decreasing in their impulsivity and they're just social or they found other ways of coping whether healthy or not. Some people end up drinking. Some people end up substance using substances and some people unfortunately can end up in a cycle of going in and out of hospital or end up within um long term units. But much less commonly, people can have an emergence of a personality disorder in their older age. And usually when this happens, um we need to have a high first, a high level of suspicion in terms of organic causes. So, is it that they developed, they've had a stroke or they've had a frontal lobe problem which has led to a change in their personality or, and also there's a specific syndrome called diogenes syndrome that presents in older adults uh that have become socially isolated and that lack social support and they can start becoming um start showing traits of personality disorder in terms of neglect and disinhibition. Um and, and hoarding. Um so that is something to look out for as well and, and a as well as thinking about substance use, which we've talked about also kind of other coping strategies and has that led to development of other disorders. So, is it that someone's developed an alcohol problem? And then developed depression. But there is this underlying personality difficulty, but it's now evolved over the course of their time into another mental disorder. So we're gonna talk about comorbidities and differentials, which I think we've talked about um a bit already. So we've talked about the teens being teens, um and whether that just needs to um settle after teenage. So the risk taking behavior, self-harm moodiness are common during adolescence and early adulthood and then settle down. So the thresholds for whether the behavior patterns are indicative of personality disorder kind of change based on the age and previously to the ICD 11, it wasn't considered in Children. We used to call it emerging personality disorder rather than giving them a diagnosis. Um But the other ones is, um again, I spoke about this before when there's a persistent lack of remission or a lack of um total remission. And it's good to explore whether there's APD. So someone in depression that they've had so many different antidepressants, they've tried therapy and there's always something that isn't quite resolving, then PD should be explored. It can also be at times of stress that things can get more difficult. And so someone with personality difficulty then presents with a AAA pattern of behavior that is more like personality disorder, but that will settle with time. And that's why we need to give it that length of time before making a diagnosis. We talk, we talked about OCD. Um and other neurodevelopmental um conditions ad HD, the PTSD with the hypervigilance and the rumination can again mimic PD um people with ASD and the lack of wanting social interaction and the social um interpersonal difficulties that come with ASD. Um and the Dysthymic and Cyclothymic disorder where there's a, a rapid change in the mood um that it, that can mimic the emotional lability of personality disorder. And then obviously, we've talked about substance misuse that can happen as a second um comorbidity. Um The fact that if you have a stroke in your frontal lobe, you can change your personality and the anxiety and depression. And it's important to bear in mind that people with bursitis were really struggle in life. And so it's not unexpected that they would then develop a level of social anxiety or depression because of their previous experiences. So it's all a constant learning. If you have a but level of poor attachment in childhood, you then develop personality disorder and your relationships really struggle with that. So then you continue to build this narrative and these cognitive um pictures of yourself and your mind and then that develops into anxiety and depression. And then that's where some of the therapeutic approaches that we see can be um can be quite helpful to tackle some of those narratives. So, moving on to assessment, um so in terms of assessment, we've touched on some of this before that you it's important to have collateral it's important to get the family view because they might have a completely different understanding of how that person um deals with stress. And that's a key question to ask, how do they cope when things don't go their way? How do they cope when it's, there's a high level of stress doing multiple meetings to see the different facets of that person's personality. So when their landlord is telling them that they have to move out, how are they coping with that when they go through a breakup, how are they coping with that? And throughout that all, it's really important to have that risk assessment because of the rapid fluctuation and the the the risk that people with personality disorder have to put themselves at risk through misadventure. So maybe not wanting to end their lives, but because of impulsive or risky behavior at that time of crisis, they can put themselves at risk for misadventure. And all of this can be done in specialists and nonspecialist settings. So you, you can easily see this relationship doing well in a GP setting because you can have that longitudinal relationship um as well as having uh then more formal ways of assessing it. So there's specific personality severity scales which you can use um and selfreported measures as well as ones that you can fill um with the patients themselves. But broadly, they cover the same um things we've covered. It's just a more structured way of people who like that more. Um So we have another poll here that asks about treatment before we move on to treatment. So the pool is how is Personality disorder treated? So do we just medicate them to sedate the patient? Is it through therapy? But there's limited options. Is it through inpatient stays a combination of medication and therapy or mostly through therapy and then medication for comorbidities. So people are responding that they think it's mostly therapy for medication and co and then medication for comorbid conditions, uh which is the correct response. So a lot of people think then we can medicate personality disorder. But a lot of the things are very ingrained and things that are ingrained tend to be more difficult to treat with medication and need therapeutic approaches. So, moving on to treatment options and then we have a few slides left to talk about treatment and then we'll summarize and then take some questions. So in terms of treatment options, we're gonna look at psychological. So that's the therapeutic options and family therapy, medication, um education and goal setting and managing transitions. So, starting off with the psychological therapies. So the main psychological therapy for present disorder, especially the uh the borderline um subtype um is D BT Galactic behavioral therapy. And it has key modules which focus on controlling your emotions, handling distress, practicing mindfulness and effectively relating with other people. So those you can see how it, those are kind of the key themes in the diagnostic criteria. And it's the key themes that D BT talks about. Um And it's done usually in groups. Um Also M BT mentalization based therapy also done in groups but can be done individually is a long term talking therapy aiming to improve your ability to kind of understand and recognize you and other people's emotions and mental states and help to examine your thoughts about yourself and others and kind of have a sense check of if it's valid. So it helps that narrative that we talked about that jumps to conclusions um and leads to people making incorrect assumptions that then cause them distress and inappropriate responses to that. Um There's also CBT uh which helps with some of the ruminations and the, the narratives that people build. So CBT is done one on one, there are some group CBT S as well, but usually it's done one on one. It's kind of focus on the here and now rather than the past and it focuses on how your thoughts lead to behaviors and then that leads to actions um and cognitive processes and kind of tackle some of that. And it's really helpful for people who have comorbid anxiety and depression um because it's one of the mainstays of treatment for that as well, some of the other things that can be done because personality disorder, a lot of the time is caused by early childhood experiences and attachment, long term psychotherapy. So a year plus can be really helpful to tackle some of those long term problems and really get to the root of them uh and reprocess them into a more functional way of relating with others. And kind of understanding why you may think that everyone is rejecting you and finding the root of that. And then that helps your future understanding and management of that emotion um as well as family therapy because again, some of the issues that arise with the families, um both because of the cause of the personality disturbance and also because of the impact that has the disorders had on the family. Um And the psychoeducation is really important around making a shared treatment plan. When do you need to go to hospital? How do you manage this risk? How are you gonna self regulate? So that happens a lot with um people who self harm, they can put kind of elastic bands around their wrists instead of self harming, they flick the elastic band as a less harmful way of coping with that stress. So moving on to kind of an inpatient and therapeutic um community programs. So, therapeutic communities are programs where you spend time in a group and you support each other to recover with your personality disturbance with the help of a facilitator. So most therapeutic communities are residential, usually in kind of a large house setting where you stay for all or part of the week. Um And in activities include some of the therapeutic options. So M BT and D BT um and, and they can be in group or individual as well as kind of household activity and chores, kind of helping that interpersonal functioning. And there's a very good no judgment um approach to these communities. And uh if you, if you're interested, there's a consortium of therapeutic communities that provides a directory of these in the UK. Um obviously, sometimes people need to come into hospital as well. Acute mental health hospital because the risk has gotten so high and the person is in a state of crisis where they're not able to regulate their emotions, so they cannot get to their baseline state and the risk is too high. So they need to come in for some inpatient kind of crisis, um cool down periods. And this is really good because some of the units we have in London, for example, have rather than going on to the inpatient ward, have some spaces where people can stay for 24 72 hours. And just kind of have that detachment from the outside world and taking a step back from the stressors that are causing the crisis to allow them to come back to their baseline emotional state. In terms of medication, it's usually used as we said to treat comorbid conditions. So people can develop depression. So we give them antidepressants and it can help with the angry, impulsive or irritable um feelings of hopelessness as well. Um They sometimes are treated with mood stabilizers that can help with mood swings and reduce how irritable or compulsive people get. Um So this is usually valproate, but there's new guidance now with use of valproate in people under um the age of 50. So we need to be cautious of that as well. But some people use other mood stabilizer as well like lamoTRIgine, um, antidepressants, usually we use um ones that are sedating as well. Some Mirtazapine, um and then antipsychotic medications. So medications um can help with symptoms of kind of detachment from reality and people with personality disorder can get kind of pseudo hallucinations and pseudopsychotic symptoms. Um And sometimes these are aided by again sedating. Uh some s sedative antipsychotic medications. Usually QUEtiapine is used because QUEtiapine not only is an antipsychotic and it's sedative, but it also helps with mood regulation. Um So as a little aside, if you have someone with psychosis that has mood dysregulation, QUEtiapine is a, is a very good antipsychotic for that. Um And obviously, we have some anti anxiety medications like SSRI S or there's some people with personality disorders that use beta blockers as well. So, uh propranolol, um the behavioral support, a lot of it is around, like I said, these kind of coping strategies and finding ways around it as well as avoiding drug and alcohol and giving them support if people have used that as a coping strategy. Linking them up with uh drug and alcohol services. So we've come to the summary page. So what have we covered? We have covered that there is a new classification of severity and trait domains. Um We need to be curious about the social impact and coping strategies to prevent further comorbidities and further risk. And we've understood and touched on the treatment and of course progression of personality disorder. So with 10 minutes to spare, we can take some questions, Molly, an incredible presentation. Thank you so much for giving us such a comprehensive summary of um personality disorder. But also uh some of the big changes that have been made. We've got some brilliant questions from the audience and if you're in the audience at the moment and you have a question, uh please pop it into the chat and we'll try to get through as many of them as we can, but I'm going to just start at the top and we have a great question from Abby Lark, which is, is jealousy and negative emotion too depends, I'm Italian. So a lot of people are jealous in Italy and it's considered culturally normal. Um So yeah, it depends on the cultural context and I guess it depends on the level of dysfunction. So a lot of the time there is a psychiatric condition called Othello's, which is uh morbid jealousy, which is one of the riskiest um psychiatric conditions in terms of the chances of um murdering your spouse, uh, which is a, you know, fun topic to, to consider. But Othello's, um, is kind of the end spectrum of jealousy. So it depends on, basically, I think for any psychiatric condition or personality disorder, is it affecting functioning? Is the first question? Because if it's not affecting functioning, then, you know, the severity is low. And I guess the ethical question and the kind of more philosophical question is if it's not affecting functioning, is it a disorder or is it just something that that person has? Um So if it's, if it doesn't carry risk and it's not affecting the person, they're functioning or other people, then it's, it can be a variation on normal. Um There's a plenty of very quietly delusional people in the community that never come to the attention of psychiatric services. Um And that's a really important, that's a, that's a really important bit of the criteria, isn't it? Um I got a great question from Maria, which is this uh is it possible to have a personality disorder fight childhood adverse events? Yeah, you, you, you can, so it's, it's unlikely um but it can happen. So some people, um for example, don't have any adverse events in childhood uh but then can have a really traumatic experience in their early adulthood and then that leads to personality disorder. Um So things like disability, uh like sudden loss of a limb. Um and some people that have had to undergo kind of torture or adversity in war also can then develop personality disorder. Um So there is a uh I would say the majority of people have had adverse childhood experiences. Um and especially people at the severe end of the spectrum, usually have had abuse and kind of every modality, especially people that end up in uh forensic services. Um but there can be people that develop certain aspects of personality disorder or that personality difficulty that I spoke about um later with without adverse um an interesting question from Alias, which is what would help you differentiate between AD HD with significant emotional dysregulation and maladaptive responses to past experience versus personality disorder. Yeah, I think um so I did a talk here on ADHD and uh I think it's in your library. So for the person who has that question, I think if, if you're interested in it, go and watch that talk as well because I go into it a lot. Um But yeah, so it's a common underdiagnosed condition. Um both ways. So there's a lot of people that have been diagnosed with personality disorder that have undiagnosed adhd because you have impulsivity and you have the kind of social difficulties as well. Um I guess with AD HD, it's very specific criteria. So it has to have started before a certain age in childhood. Um It needs to be again, same as PD in certain contexts, but it doesn't have usually some of the trait domains. So the trait domains that we spoke about with personality disorder and the kind of fast emotional fluctuations is not as pronounced in AD HDA. Lot of people with um adult AD HD, for example, are very functional in society. Um And I, and also I think it's the response to stress that is very different in personality disorder than it is to AD HD. They don't have that intensity of um response to stress, but then the decrease in coping and the coming out of the personality domains um as much as AD HD patients do. Perfect. And I've just popped the link into the app where you can get uh access to the previous er, sessions which doctor Capanna has, er delivered, just download the app type in me primary care that'll all come up. So they're, they're right there. Um So hopefully that helps, er, ali, er, question from uh Katie Kra has the diagnosis of narcissistic personality disorder been removed from the CD 11. Yeah. So f from um from what I've looked and on the IC 11 is now this is, this is how you diagnose PD. All the subcategories are gone. It's just personality disorder, mild, moderate severe and then you can add the trait domains. Um The only exception is that borderline subtype, but it's not a diagnosis, it's a specifier to kind of describe the pattern. Um And a question from Masa Shahe which is um is PMDD A personality disorder. I think it's a separate, I think it comes under dysphoric disorders but it's not listed under, II don't know which bit of the CDI. I wish I was a walking library of the CD 11. But I'm, I'm, uh, I'm, I'm not, sadly, but II think it's under dysphoric disorders or mood disorders. Um, but it's, it's not included under personality disorder. Um, so a question from Grace, which is what, what are the major problems about personality disorder, which would consider making a care plan and an admission to a psychiatric ward. So, I guess, um so I'll use an example, I guess for, for someone that is, I keep trying to use borderline, but it's gone now for someone who's presenting in, in distress. So for example, someone who's just broken up with their girlfriend and they're saying, you know, I, I'm suicidal, they've called the police, they said they drank a bunch of alcohol. They've taken an overdose, their girlfriend has broken up with them, they don't see any way forward. Um And it's really triggering their sense of abandonment, which they really struggle with and their emotions are very high. Um If you know that person and usually that person kind of settles um after a few hours and then actually you're seeing them and it's been a few hours and they're still really suicidal or you've discharged them wanting to see them the next day and they're taking another overdose and they keep presenting with self-harm and they're just not able to regulate, then you would admit. So that's kind of, uh, the side of the self-harm for someone who has more dissocial, um, traits, it would be an escalation in risk to others. So, you know, they've lost their accommodation. Um, they've gone and moved in with their father or their mother and they've assaulted them, they've had an argument with their best friend and assaulted them. They've been arrested a few times and when you've seen them, they've tried to also assault you because nobody gets them, nobody wants to do things the way that they want to do things nobody understands. Then the level of risk is too high for discharge safely and they need that moment to, um, to, to kind of come back to their emotional, their baseline, emotional state bearing in mind. Most of the people in forensic units have, um, the social personality disorder, which is now just called, I would say severe personality disorder with the social traits. Um, that, that tells you a lot about that. They, they do require quite a lot of, um, inpatient management, whether that's in the criminal justice system or, or not. Uh, we've got time for maybe a couple more. We're almost, we're almost at time but, uh, got some great questions. Um, er, still coming. Which, um, one is from Clare Colligan. Er, what can be done for a patient who, whenever discharged from hospital makes significant suicide attempts, what what can be done for those patients? So, so usually it depends, I mean, it depends on the patient as always. But um it basically, I would say it usually depends on the patient's pattern of behavior. So if it's someone that really struggles with abandonment and that's their trigger, sometimes when we discharge those patients from hospital, they, it kind of triggers that sense of abandonment and rejection. And so their risk increases so you can discharge them with like a crisis team that goes to see them every day so that they have, they still feel that the hospital isn't just throwing them aside and neglecting them that they're actually being supported and these teams can go in and see them up to twice a day in the community. Um If they have a supportive family, you can make a crisis plan with the family. A lot of the time we ask the family not to give them all their medication to reduce the risk of overdose. Um There, you know, if the patient is willing to kind of make a crisis plan with you. So like if it gets unbearable, you call this number or you take yourself to hospital, a lot of the person has disorder patients know their limits. Like a lot of don't actually want to kill themselves. It's that they cannot cope with the level of distress when they're in crisis. And so coming up with ways to avoid that like, you know, putting the um elastic band around the wrist instead of self harming or calling a crisis line or having a specific escalation plan. And if you have patients that repeatedly just want admission, usually that's worked out in therapy because sometimes the longer the admission and the amount of times they're admitted, actually, it's more harmful because it's feeding that narrative that they're safe when they're looked after and then they get abandoned. Um, and a lot of them have had that in their childhood, um, adverse experiences. Uh, so making a really good care plan with them when they're in their baseline state, um, is, is a good way to make that crisis plan. Um, excellent question from, er, Doctor Bushra Kamal, which is, can we diagnose personality disorder in primary care or does the diagnosis have to come from secondary care? II think it can come from primary care? Great. Um, and maybe one last question, um, which is a great question actually. Um, um, from AO, which is, is there a answer to that? I just read it. You don't know the answer? I don't know the answer if there's any cultural preference. Awesome. Um, so we'll, we'll, we'll maybe pop that into our thread at the end of the event. Um, and, um, and we'll, let's see if we can try and find you an answer for that because it's a really good question. Um, just to say if I went on with that is that it depends on the, the bit about the culture of it is part of the diagnostic criteria. So I guess it's like it's also dependent on the stigma. So in Italy, for example, where I'm from, there's less people with personality disorder diagnosis because people just say, oh, they're just a bit odd and there's a big stigma to do with mental health. Same in, same in some in the African continent or in the, or, or in Asia, there's, there's some people who just get looked after by their families and just labeled as a bit odd, so they never actually get that diagnosis. Um So it's, it's partly the cultural acceptance and the, the, the stigma associated, I think kind of dictates the prevalence as well. I think that's a pretty good answer actually. Um I think you've pretty much tackled the question there um, er, in a, in a, in a really good way. Um Just a massive thank you from us. Um, er, Doctor Capanna once again for an amazing presentation, uh really thorough and I hope that um, that everyone else en enjoyed it as well. Um We have got a whole range of primary care events coming up for those who uh find these helpful. Um, you can um access the catch up on the app from previous ones and you can get, er, invites to the next ones on the app as well and it will also allow you to get your certificate. Um, I have popped a link to the feedback form into the chat. Once you complete that feedback form, er, you'll get a notification with your, er, certificate and, um, you'll also get, uh, notified when we add any catch up content. So I hope you find that really useful. Thank you so much to everyone in the audience for joining us this evening. Um, thank you to doctor for once again an amazing uh teaching session and I hope everyone has a really wonderful rest of your day. Thank you so much. Bye. Thank you.