Public health Dr Sanhita Chakrabati (06.12.22 - Term 2, 2022)



Welcome to our on-demand teaching session with Dr. Wrote, a renowned psychiatrist! If you have any questions or comments during the lecture, please use the chat function, and we'll be sure to moderate. The core theme for our discussion today is personality disorders. We'll talk about why people choose to take a deliberate overdose, and why one person may take three paracetamol while another takes twenty. We'll also look at why a personality disorder diagnosis can be taken as an attack, and how to approach a difficult diagnosis with a patient. Join us to learn how to work with patients who self-harm, and discover how to handle anxiety in an effective manner.
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Public health Dr Sanhita Chakrabati

Learning objectives

Learning Objectives: 1. Understand the potential causes of a person deliberately taking an overdose. 2. Identify behavioral patterns and indicators of personality disorders. 3. Describe the possible psychological impacts associated with the stigma of personality disorders. 4. Assess the risks associated with intervening and treating cases of personality disorder. 5. Develop strategies for addressing mental health needs of patients with personality disorders.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello, everyone and welcome. We're having a psychiatry lecturer with doctor wrote. And if you guys have any questions or want to engage, please do put it in the chat, and I will moderate. Thank you. Handing over to the doctor now. Hello, everybody. Thank you for coming. You've had a long morning already. Um, so, um, but my teaching style for adults is very informal. I encourage you to jump in with comments. I will ask questions, Um, and let's see if we can have a slightly different approach. I don't use slides, and I don't spend a lot of time on material that you can just look up your all adult learners. So, um, it's more about the experience of having a significant psychiatric illness. Apologize as well. For my voice, I've got a cold. If I have a coughing fit, please just be patient. It's not covid. It's just an ordinary cold, but it's still quite annoying. So welcome, everybody. And I'm sorry about the circumstances that mean that we meet like this. The core theme for our discussion today is personality disorders. And I'm sure as you already know, there are a number of different personality disorders defined by I. C d 10. I see d 11 changes things and doesn't separate them out into the different strands. We're not very good, in any case, at at separating out exactly what's going on when someone has personality disorder. So let's start with a very common scenario. Anybody who works in e. D does a night shift in particular will be familiar with this scenario. And that is a young woman brought in late teens early twenties, um, brought in by friend because she has told friend that she's taken a large overdose, although she's not clear on exactly what she's taken to the friend and doesn't want treatment is refusing tests. Is refusing any kind of examination, won't engage with history and so on. What are your first thoughts about how you the lucky junior doctor? Because you will be seeing these patient's? What do you think might be going on for her? What sorts of things do you think you might be able to do? What are you worried about? Any comments to get us started? Maybe if she's, uh, reluctant to any test, she might be hiding something like something of, uh, ingestion of some sort of drug or some sort of product that she doesn't want started to find out. Maybe anybody else? No. Okay, well, the first question to ask yourself is, Why is she here? She says she doesn't want anything. She's refusing treatment. She's refusing to engage, but she has attended the emergency department. Is she seeking safety? Yes. Among other things. What sorts of things might lead someone to take an overdose? A deliberate overdose of medications like she might be asking for. Like, uh, prescription, which she doesn't need or she just might get. She's addicted to something mhm cry for help. Sorry. Who's that? I said. It's a cry for help. A cry for help. Yeah. Could it be that they feel like she's like she's not being, um, treat like? Sometimes you have patient that you feel like they're not treated seriously until they have to take some kind of drastic action to be then treated seriously. So maybe she has, like, a malady or a problem, but a G P might have not been taking seriously. And then when she's overdose now, the GPS looked into things are on the line. Yeah. Okay. Yeah. Any other reason she might be depressed for had an argument depression argument. She might really want to be dead. Yeah, Sometimes people want to be dead. And so first thing to think about is not so much what people have done, but what they expected the outcome to be. So one night in E. D. As psychiatrist on call, I had a lady in her eighties come in with the deliberate overdose, and I had a lady aged 26 come in, both with deliberate overdose. My elderly lady had taken three paracetamol because it said on the packet that if you took more than two, you had to go and see a doctor immediately. She genuinely believed that that extra paracetamol would be fatal and she had come to hospital because she had no family, no Children. Her husband had died fairly recently. All of her close friends were now dead, and she was afraid that no one would find her body. The 26 year old had taken 20 paracetamol and was a regular a tender, and knew perfectly well that at 20 paracetamol she wouldn't need any treatment, but she would get a few hours in the E. D. So it's not what people do. It's what they expect that act to do. And that's your first thing. Do not never, ever dismiss somebody who tells you that they're suicidal because they've chosen a method that you know will be completely ineffectual. Okay, so my little old lady, we had a very nice little respite place that just had six beds. And we popped her in there for a few days to help her come to terms with her new life and help her start to set up a new support network. And so on. 26 year old, well known to services frequent a tender, um, checked her levels, made sure she hadn't taken anything else, and we discharged her home again. Okay, so that's that's the first big lesson in dealing with people who self harm deliberately. Okay, so we talk about people being personality disordered and the scenario that I introduced you to at the beginning of the session, the young girl telling people that she had taken an overdose, but they're not disclosing what she had taken or when she'd taken it, confiding in a friend and then complying with the friend when the friend brought her into E. D, but still refusing to give full disclosure. What's going on there? Maybe the friends who brought her in, uh, not telling everything because they don't want, uh, they have this stigma of, uh, suicidal attempt. Where that they might think that she might be locked up. Yeah, they don't want they don't want for, like, an asylum or a mental asylum, which we don't want that for. Who Who's worried in this scenario, Where is the anxiety? Who is holding the anxiety? It's the friend. It's more like a responsibility being placed on someone else. Yeah, so she's passed responsibility to her friend, so she's passed on anxiety. But I know engaging with you the medic, even though she's sitting there in front of you. Where's that anxiety going? So there's not a trick question. There are no trick questions here to the medic. We got some fuzzy noise in there. Could you say that again? I think it's going to I think it's going to the medic because you're sitting there wondering, Okay, what's happening? What can I do? The more time that passes, the more you know, risk of mortality and things. Yeah, and that is exactly, consciously, subconsciously usually a little bit of a mix of the two. That is exactly what is going on for the patient. She is seeking to pass the anxiety. And if you can hand your anxiety to someone else, even for a few minutes, we all do that, don't we? We tell friends about what we're worried about. We tell our mom and dad we, we we talk about these things to share them, to get that little bit of relief from our anxiety. The problem is that someone with personality disorder, we'll do that pretty well, constantly. Okay, so it's normal to want a little bit of respite from your fears and anxieties. It is not normal to never want to engage with them, never want to deal with them and to deliberately pass them on to someone else. It's quite manipulative behavior, isn't it to say fine, you deal with it. I'm just going to sit here and let you all run around. And that's one of the reasons why people with personality disorders, even though it's a symptom of their disease, are so Sigma ties stigmatized, especially amongst people working in mental health because they are very, very difficult to help. Okay, the term itself. Personality disorder. What do you think of the term personality disorder? I think it's very. It's not very accurate. It's very like personality disorder. I mean, what can you pin that, too? It's not like depression. You can say this is depression, but it's very broad. It's hot on before defining a personality. So we have might have to define what is a personality, which is itself are very difficult to define us because it has change it. It modifies it, it is influenced or it is adaptive. And we we might not perfectly define the personality these other on the basis of how, as a group of people or as an individual and accustomed to more than one people or someone. Someone will behave as a normally what we expect as to be a normal behavior, but something disrupting, too. That might be say, okay, that's not normal. Or that's not how usually like, uh, how we say a unilateralism or altruism behavior, which we expect to happen is not performed. Uh, yeah, Manipulate, do it. Just as this scenario is just, just think for yourself. You. The distress is genuine, Okay? They're very manipulative. They're very difficult to work with. But their distress is genuine. Never, ever lose sight of that. Okay, no matter how frustrated you are, they are in distress. How would you feel if you're really distressed? You know there's something wrong with your life and how you're living it. And you're very unhappy in your life and someone says to you, Well, that's because your personality disordered. It's like a It's like an attack. Almost just It's like it's not. You're not separating me and the condition or the issue. It's like you're making me the condition like falling out. Yeah, it's It's, you know, it's like your whole personality is wrong. Your personality is so wrong. That is dis ordering you. It's quite a demeaning term. Or it could be the other way around as well that the person understood that you have some problem. Mhm. Yeah, and I've certainly had one patient. It can be quite difficult, quite a difficult diagnosis to give because people do find it very upsetting. And they would far rather and often try to persuade you that they have a d h. D or bipolar disorder or all sorts of other things and a very resistant. It's almost diagnostic in itself. When you say to somebody, Well, I I think there's some personality disorder going on here. It's almost diagnostic for them to turn around and say, No, it isn't because if you think about the traits of personality disorder, they're all stuff that we all do. They're all part of normal behaviors, so label mood Human beings have label mood. All you have to do is walk along the street on a sunny day and walk along the street on a gray, overcast, rainy day. You can see the mood of everybody around you is completely different. We all have a snapping point. We all have a button that somebody pushes and we just lose our temper and we're angry and were unreasonable. So if you think about a time in your life where you were unreasonable, we've all got these episodes. Think about a time when you really lost it through all your toys out of your prom. You're absolutely furious you were, but then, looking back on it, you recognize that you've been unreasonable and thought I've probably got some apologies to make. Just spend a moment or two just thinking about how not yet, not afterwards, when you were able to look back and reflect. But in that moment where you lost control of your emotions just for a few seconds, put yourself back in that place. Okay, so I'm not going to ask anybody to talk about it, because that's something that is intensely personal. But that sense of complete loss of control, the anger overwhelming you, the very strongly, highly expressed emotions. That's how somebody with personality disorder feels all the time. So even when they appear to be acting out and being annoying on purpose, try again. Try to remember that that's what's underlying it. That feeling is a very, very common feeling amongst people with the two most common personality disorders, the borderline and the emotionally unstable. So that's just something for you to mull over and reflect on. Imagine what your life would be like if you didn't feel that you had control of your emotions in any real or meaningful way most of the time. Okay, a little bit about the history of terms psychiatry, as you know, very modern discipline with perhaps the exception of imaging? Possibly not. Even with the exception of imaging, by far the most modern of the disciplines. Back in the 19 hundreds, people was trying to start to apply kind of scientific defining principles. Two people, how people worked and lots of experimental psychology trying to understand what was going on. And the those very early efforts to understand insanity were couched in language where the nearest equivalent they had to what we would now call a psychiatrist. It's called an alienist because people who were insane were believed to be alienated from their true Selves. And so those very early experiments and early psychiatry was very much about trying to understand that alienation. How did that separation from the true self happened? Why did it happen and how could you fix it? Because until comparatively recently and even now in many parts of the world, how you fix insanity is you isolate those people from the rest of society. So in their attempts to to understand what was going on between the normal and the alienated person. Naturally, a lot of people fall onto the borderline of that, and that's where we get our first personality disorder term from the borderline personality, and initially it meant somebody who was not didn't completely fall into the normal field. These days, we would call it traits of insanity, but they also were clearly not completely alienated from themselves. So they're on that border line between normal and not normal. So that's the beginnings of the term. Um, later, they added, in disorder, too clearly label it as a disease. And so that's how we got the the earliest defined personality disorder, the borderline personality disorder. Is there a difference? No trick questions, remember, Is there a difference between men and women? That means that women are more prone to the borderline and emotionally unstable personality disorders that would depend on many things a culture itself where the the person is have the upliftment, or in what way that the women or men are treated in a like very egalitarian, the equal principles or in a different, different manner. Mhm. Uh, it would also depend if that person might have, uh, I don't know how you how you define it, normal or abnormal upbringing, where some plan some other people or some other Children might have bringing up bringing have my different of them. Oh, might also be. I don't know whether this is perfect or not. Social economic status is Does that intense? Okay, good. You're you're kind of You're thinking in the right kinds of directions. Until very recently. Maybe as recently as 12. 15 years ago, it was generally believed and accepted that only women developed the borderline and the emotionally unstable personality disorders. And that men did not in the same way that until very recently, autism was perceived as a disease of males and not of females. So how did those beliefs about gender and disease? How did what? What made people think in those kinds of ways to say women get this disease. Men get that disease, Maybe on behavior. Uh, yeah. Expect me about the field, like was the people was a field dominated by men. Your, uh, career feel dictated these kinds of things in the past. Mm. Yes. Yeah. Um, yes. Psychiatry and psychology is very much a discipline under history. Written by as one of my friends who is the exact opposite of an old white man says psychology. Psychiatry is history written by old white men. So yes, there, there is gender expectation. Would you say that women more likely to self inflict pain where men are more likely to like express? So then one? I think the antisocial bang or be quiet as of them, absolutely bang on. Who said that? Me, Claudia. Well done, Claudia. Yes, that's exactly the issue. It's because men and women express frustration and anger differently. Women direct their anger and frustration in words. These are broad generalizations, Okay? Women direct their anger inwardly and so harm themselves. Men direct their anger and frustration outwardly so they harm others. So if you in your future practice, come across a man in his kind of twenties thirties with a history of kind of petty violence, they a man will often have lots of short prison episodes because they've been in a fight kind of impulsive fight. These are not the guys who carefully plan a bank robberies and get themselves all organized with timings and things like that. These are the people that something annoys them and they lash outwards, and that will be a very common pattern for young men. Whereas young women direct that anger inwards and they cut, they burn they manipulate. They will do all sorts of things to try to relieve that anger and frustration, but they will do it to themselves. Okay? And so be aware that although more traditionally, insofar as we have any traditions at all in psychiatry being such a baby discipline, men tend to be associated with the schizotypal, the schizoid personality disorders, the antisocial personality disorders and so on, which make up a very small percentage of the personality disorders that actually they experience exactly the same range. And women, if you really deep down, also experience exactly the same range. So we thought a little bit about that. How labour mood is for people with the U. P D and BP D. Because that's something that we often see in a very direct way. And this drive to self harm means that quite often you'll find people that you see as a psychiatrist who have been treated unsuccessfully for years for depression by their GP, and they'll have tried every antidepressant their GP can think of, and often they'll be on quite complicated combinations of medications because the commonest presentation is this. I feel suicidal, so somebody goes to the G P says. I feel suicidal. I want to kill myself. It's there all the time. I hate myself. I hate my life. Um, g p. Not inappropriately. This is not a criticism of GPS, not inappropriately starts treating for depression. And an interesting thing about people with personality disorders is that even if they have a genuine depression running alongside their personality disorder, bearing in mind claims to want to self harm and suicide are are a symptom of the disease itself. A genuine parallel depression does not respond well to antidepressants. And so what you end up with is somebody who tries an antidepressant. They're very susceptible to placebo effect. And for about seven or eight weeks, looks like the G P has cracked the problem. 50 megs of sertraline Feeling better, Doctor Fantastic. Eight weeks down, the line is still working. Stop working, Doctor. I felt fine when you started it. That's fine. I've got plenty of room to put the dose up, so the dose starts to go up. You hit top dose, Still depressed. Still want to kill myself, doctor. And so you add in something else. And so it's not unusual in community psychiatry for somebody to be referred by the GP because they've got treatment resistant depression and nothing is working. And actually the reason nothing's working. No, don't do that, Garfield. Sorry, I have a cat called Garfield who is keen to join the lecture. Uh, since she's well meaning but doesn't know much about psychiatry, we won't let her. Um, so So you end up with somebody on complicated combinations of medications who still tells you that they want to kill themselves stuff works for a little while, then stops working doesn't work because they're actually not depressed. The wanting to harm themselves is about trying to make people understand how unhappy they are, how much they're struggling, how distressed they are. It is far more common for people with the personality disorders to die by misadventure than to die by suicide in spite of their frequent declarations. And one thing, if you go down the psychiatry route that you'll get used to and have to harden your heart to is the patient who tells you that if you do not admit them to a psychiatric ward, they are going to kill themselves, Okay, because they are desperately desperately searching for something that will make them feel better. Another thing that that people with with the E u P d and the bpd pattern in particular tell you about is a sense of emptiness. They feel unloved. They have a constant need for people to prove how much they are loved, and they never find it satisfying. And that is another very common symptom. But it's not the one that they tend to present with. You know, you go to your GP and say, You know, high G. P Yeah, I just feel really empty. I don't think anybody loves me and the G P size and rolls their eyes and things well, I can understand why she's not helpful for anybody, but is the reality of what happens? Because they are very difficult people to like and quite often have a history of struggling, not necessary to make friendships, but to maintain friendships because of these constant demands that they put on their friends. So how does this situation arise? How does human being reach a point where they are so miserably unhappy that they are desperate for somebody to look after them because they are no longer capable or feel capable of looking after themselves, either physically, mentally or emotionally. Anybody, anybody got any ideas where that comes from? Absentees burden our parents, uh, person who might have a childhood who might didn't have a perfect attention. Where from their parents. Yeah, my mother always used to say it was her job in life to be blamed for everything. But you're right. Almost invariably, you will find significant trauma in the childhood. And when I say significant, some of the stories that I hear still with all the experience behind me are very distressing to Garfield. You are really not helping go away. Um, so, for example, a young lady that I had in one of my jobs, um, she was 19 and she was in the acute psychiatric ward because we really didn't think she could keep herself safe. In the outside world, all the traits of e u p. D. Frequent, very violent, self harming very labor, mood splitting. I talk about splitting in a moment because that's quite an important thing to understand. So everything is either very good or very bad. In its smallest terms, it transpired that this young lady was mixed race white father, Afro Caribbean mother. Parents had had, uh, separation when she was about seven years old, and she spent alternate weekends with her father, who from the age of seven, when it was his weekend to have her prostituted her to his work colleagues. Mother was aware and continue to send child for father visitation. When she was 15, she finally became pregnant, and when her father found out, he beat her so severely that she miscarried a 24 week old baby on the bathroom floor, which he took away from her and when later prosecuted, said that he buried it at the edge of a field somewhere. But he couldn't remember where. If you think about that experience, it is almost more normal to be carrying that distress into adulthood. It would be very bizarre all to have an experience behind you like that and come out whatever normal means, always of extra term. And these are the stories that you will hear over and over again, and women and now boys again very much a gender assumption about sexual assault in childhood. And some of those assumptions are gradually being broken down, and so is it any wonder that a girl who was betrayed both by her father and by her mother had such levels of self loathing that her deliberate self harm, whilst not actually intended to kill her, was getting so severe that we thought it might just something for you to think about. And it may well be that you know someone who's been affected in this way. Maybe yourself can be very triggering. You've got my name. You can contact me very easily through Facebook if you need further support after this session, because it's difficult stuff. Yeah, the stories that you hear and one of the things that I do when I've had a hard day with stories like that is I'll often delay coming home and I'll go to some completely neutral place coffee shop, something like that, just until all of that emotional tension from the day has left so that I'm not bringing it into my home. So no matter how difficult there being, no matter how annoying they're being, please try to remember what has happened. And these stories of multiple episodes of abuse is why there's a move away from calling it a personality disorder and describing it instead, as complex PTSD see PTSD, you might see it written with a lower case C and then uppercase PTSD post traumatic stress disorder, because in some ways it kind of fits with the pattern of of PTSD. In most ways, it doesn't. I think there's still a lot of questions around whether or not that's an appropriate term because it muddies the water a little bit for, for example, servicemen with PTSD. But we're now pretty clear that, um, that this kind of trauma is what seems seems to create a vulnerability to mental health problems and particular this pattern of mental health problems that we've been describing today and what's very difficult. And I don't think anybody's really attempted it, is to try to investigate and understand. What about people who have terribly abusive childhoods but who don't develop these abnormal coping strategies? What protects them? What means that they are not vulnerable to this, and we just don't know. There's no genetic link that's been identified as you know, genetics, and proving that things are genetics is is quite fashionable at the moment, with with the coming online of all sorts of different genetic analysis systems, so if you can manage it, working with people with what we currently call the personality disorders is enormously interesting. I have a question. I have a question. Uh, it's regarding you said, like some people even having a trauma traumatic child developed a personality and some doesn't, uh I mean, there can be a factor. Is that, uh, while having the childhood well, going to the trauma while they were infants or, uh, young? They might have some help or someone to say that who guided guided them at that moment. And if I just if we say if we say that if someone didn't have them yet, they didn't inflicted the pain on others while or themselves, it's something you have to do with the intelligence as, um, I don't know whether it's intelligence, eat you or emotionally. You, I don't know, but maybe something to do with intelligence. Yeah, No, that's, um, uh, there's no discrimination amongst victims in socio economic. In educational terms, they often don't do very well at school. But that's because Children are very quick at picking up when someone is a bit odd, where something's not quite normal, and the other challenge that you have is that because it's environmental, you will often find that there's a background of significant mental health issues in the parents and even in grandparents. And so the funk. The family tends to be dysfunctional in a multigenerational way because we learn to be adults and we learn to be parents by observing the adults and parents around us which almost invariably our our own family when we're young. So I suspect you're right. I suspect that the answer is that there is still somebody in that picture with a genuine and unconditional love for the child. We're now in the realms of opinion, and there's nothing wrong with opinion, because my first career I was actually a teacher in the girls' boarding school. And so I have the unusual ability amongst those who are not teachers of getting a strong sense. When I'm talking to someone of how old they are, I don't mean their biological age. They can be 36 I will have the feeling that I'm talking to, for example, an intelligent 15 year old, a 12 year old. I'm not very bright 17 year old. If you're not a teacher, you you don't really understand that feeling, but but there's a clear difference. As I'm sure you're all aware between your your physical age and your cognitive emotional age, and what I almost invariably find is that when I'm talking to someone that sense of the age of the person I'm talking to if I dig down even if they start saying, you know, you asked them obvious questions you know, you don't start by saying, you know was your father somebody who who repeatedly raped you You might start off with a kind of entry question, Right? So what was school like for you? And then when they tell you a bit about school and they'll often tell you that they were a bit bullied, that they didn't really have friends, that nobody, you know, they didn't have a great time at school? Um, you say was was home like that as well. And then it starts to come out what home life was like. And, um, I almost invariably find that the major trauma happened at the age of the person I feel like I'm talking to. So if I feel like I'm talking to a 12 year old That's where I will be looking as my first protocol to understand what's happened to you, because what seems to happen and we're in opinion territory here, don't forget is that some terrible trauma happens and the child continues to grow physically, continues to grow cognitively, but emotionally the trauma arrest them at that age. Now it's hard enough being 11 and coping with life with the emotions of an 11 year old. Imagine trying to cope with an adult life with the emotions of an 11 year old, and so they have to develop coping strategies. And those coping strategies appear very abnormal to the rest of us. You got somebody in front of you in E. D. Because they've cut themselves. There is no point, and indeed it would be wrong to tell them never to cut themselves again. Because this is a coping mechanism. You can't take it away without giving them something to replace it. Okay, so a much more useful question under those circumstances is, does it help? And usually they will say yes, very, very rarely. There'll be a bit surprised by that question because nobody ever asked them that, and then they'll say Well, no, actually, it didn't. And at that point you can start to talk about it becoming a bad habit and a difficult habit to break. But maybe they could try that. If they say yes, it does help. It's always interesting, although not essential to find out how it helps. And the most common answers are pretty heartbreaking. The pain makes me feel like I'm alive is a common response to that, and the other very common response is when I see the blood, I can see the badness coming out of me, and that again tells you something about what their experiences like. Nice guidance is that people with personality disorders should not be on any long term medications other than for conditions that are completely unrelated. And that's because of this business of their susceptible to placebo effect. You can get led down the garden path unwittingly and end up giving them all sorts of drugs, all of which have nasty long term side effects but with no significant long term benefits. So a very difficult group of people to work with very interesting group of people to work with if you're the right kind of temperament, and they are certainly people who are going to whatever discipline urine. Remember, one in four people during their lifetime have a mental health problem. That means that they need expert help and support. And that means that whatever discipline you go into, you're going to have one in four of your patient's with a mental health problem that will also interact with their physical health problems. So, psychiatry, even if you want to be a knee surgeon, it's still very, very important for you to to just have a little window into at least what it's like to have a significant mental health problem. Okay, and somebody's got their hand up. But it's not telling me. Is that Assad who's got his hand up? Yes. Yes, ma'am. Hi. Come on in. What? What can we talk about? It was the self inflicting pain. Yeah, uh, like, as you said, uh, it says, uh, most people who are trying to drink make them feel a like But I never knew this, uh, this side of it. Most of the side. I thought I have met people who do this like slicing of risk with the blade. I always thought this was some kind of, uh, distraction, A distraction, which they feel from the inside like it's not a physical. It's like a broken heart or something distressing a support. And they feel that a pain physically will distract them like it will distract their behavior, distract their attention to something else. Yeah, The other thing, I also believe was they will, uh, like if someone else's say, Oh, the person is harmed. Maybe I should help. They might seek an attention to that. Like, I'm harm and please give like, uh, show me some empathy or respect in some man. Is this true as well or is just Yeah, I think again, You know, one of the reasons I love psychiatry is that human beings are infinitely variable. Um, and yes, sometimes, as you say, it's a distraction. And you will occasionally hear people say, because when it hurts physically, it doesn't hurt as much mentally or words to that effect. They tend to be quite secretive about their cutting or burning or whatever it is they do. Apart from the most extreme cases, it's actually often associated with shame. Um and so they might not. They tend not to in my experience, apart from very extreme cases, they do tend to be quite secretive and quite embarrassed. And we'll often dress, you know, if you see if you're if it's a nice day and you've got a young man or young woman kind of inappropriately heavily dressed. Um, I know in some cultures, obviously it's, you know, there there are other issues with with the concealment of the body and so on. But in a Western culture, if people are inappropriately heavily dressed, it may well be because they've been cutting. And it is a question that you sometimes have to ask outright as a psychiatrist, unless you know that that specifically why the person has presented to E. D. And that self harm can range from something that that looks like the really superficial scratch that a kitten might give you. When you're playing to one young lady that I worked with, who who was at the extreme end or V. U P D. Um, who managed to cut her abdominal wall so badly and then took the bus to E. D. Um, the E D consultant told me that had the bus gone too quickly over the humps. She might well have lost her gut onto the floor of the bus. So these are the extremes that you're dealing with. And again, we're kind of back to the think about the ends that we're trying to be achieved rather than the act itself. Yeah. Um, so So, yes. People have all sorts of reasons for self harming. Um, and we'll choose secretive places. I'm aware we're coming to the end. Um would choose secretive places and one of the things that if you work in acute services rather than in, um, the psychotherapy services, which are long term management, is to try to teach safe cutting because people tend to cut on their inner thigh because it's quite a private part of your body. Yeah, both males and females are usually covered up there. Um, but if you just think about the anatomy, that's very, very worrying indeed. Whereas cutting kind of on the top of the shoulders, the tops of the arms, the outer thigh, there are very few significant anatomical things there that people can can harm. And they're just as accessible and just as easily concealed. So cutting and self harm is a whole other lecture. We've just had a very quick breeze through just trying to give you a little bit of a feel for what it's like for somebody with one of the personality disorders. One of the two most common. You've had a very long morning. I'm going to stop now. Um but as I say, there aren't that many Phyllida Rose on on Facebook, so you can find me if you need to do go and have a good lunch break. Get some fresh air, get away from your desk, have something to to eat and drink and enjoy the rest of your day. Thank you very much for coming. Thank you. I have more questions, but I'd asked later, Yeah, you can ask And I mean, people can can start to go away, but you're welcome to to stay and ask. Another question or two is, uh, diverting The conversation is one of the concealment behavior as in, like overdressing, which people might ask, what is this? Then they might divert or insult in some manner. The person who might is asking what happened to you that that was a different way of saying Yeah, yeah, yes, very much so and, um and that can be part of them. Passing the anxiety to you. Yeah, I'm going to conceal what I've done, and it's up to you to try to tease out of me whether or not what I've done is dangerous. There's another thing I have found regarding people who have survived suicide like they have attempted it. Somehow they survived it. You know, I don't know about recurring attempts of suicide, but people who have attempted and survived is, uh, some. I don't know whether they have just heard of it, that people who attempted suddenly when the pain inflicts, they think of this was a very bad idea. I wish I could have not. Is this, uh, common like suddenly, after when the pain effects while hanging or drowning? To think of this was a very bad idea. I shouldn't have done this. Does this happen? Like a second mood swing that this was, um, yeah. So a very important question to ask people who have made a suicide attempt and who have survived, um, is how do you feel about having survived? And some will say, Well, they'll give you all sorts of answers a lot of people will be genuinely regretful that they've survived and maybe quite angry with you that you've interfered with their plans. Other people will recognize that it wasn't the right thing to do. Um, that they overreacted to a situation that there is an alternative. And so they're actually glad they survived. And a lot of people have very mixed feelings about it that that's very much a piece of string question. And, of course, for people who succeed, we will never know that answer. We will never know if they had that last moment of regret. And what's quite interesting about it is that even though it's not illegal in the UK to commit suicide, it used to be. But it's no longer illegal to commit suicide or to attempt suicide. Um, nonetheless, it is still one of the reasons that we can detain people under Section two or three of the Mental Health Act against their will specifically to prevent them from committing suicide. And that's quite an interesting conflict of ideas to me that we can prevent someone with capacity. They understand that doing this will mean that they are dead, and if they don't do it. They will be alive, so they understand the consequences. It's not illegal. They have capacity. But under the Mental Health Act, it is my responsibility to do all I can in my power to prevent them. And that includes involuntary admission to an acute psychiatric ward. Psychiatry is full of conflict between opinions, ideas, personal beliefs in lots of ways more than in other disciplines, in my opinion. And that is one of the reasons why psychiatrists have regular supervision to help them to explore and examine those ideas and how they're affecting, how they work, how they interact with patient's and so on. Doctor, you touched on splitting before, so I did yes, and I didn't and enlarge on it. But I was just wondering, How would you manage that on the ward per se? So, like, they're obviously disturbing other patient, their own progression as well as the team's community. How would you manage that? Because you can't really seclude them. No, what? What you have to do is you have to work as a very strong team and essentially refused to be split, so splitting works on lots of levels. The patient themselves will perceive everybody in their world as black and white. You are either the most fantastic doctor in the world, the only person whoever listens to them, the only person who's ever helped them. Or you are absolutely dreadful, human being who hates them, who's trying to make their life worse, etcetera, etcetera, etcetera. So it works. Splitting works on that level, but it also works on team level. They they will wittingly or unwittingly attempt to split the team into those who feel sorry for them. And we'll be nice to them and look after them and do what they want. And those who say no, this is personality disorder. We have two boundary it and no, we're not going to do that. Yes, you can tell me that you're going to kill yourself. Still not going to do it, And so they will split the team into those who think you're being too harsh and those who support you and and again, it makes them very challenging. And, um, they're often dealt with in specialist units where the team have particular training in how to deal with splitting. But yes, you're quite right. It can become very difficult. Um, I mostly do crisis work. And because you only engage with the patient for a short period of time in crisis work a matter a small number of weeks rather than months and years. Um, it's very easy in crisis for a patient to split the team in that way, and and that can become very acrimonious and very difficult. Thank you, Doctor. My pleasure. I'm sorry to end the morning on such a somber note, but I hope you found bits and pieces of this interesting and, um, enjoy what's left of your day. Thank you very much. Bye. Thank you. Thank you. Thank you, everyone for attending and engaging as well. We do fill out the feedback form and the certificate has been posted. The next lecture has started as well. And I've put with the link in the chat. Take care, everyone. Thank you, Doctor. Thank you, everyone high. Come on,