An Overview of Cassel Hospital

Introduction

The Cassel Hospital is a psychiatric facility in a Grade II listed building at 1 Ham Common, Richmond, Ham in the London Borough of Richmond upon Thames. It is run by the West London NHS Trust.

Brief History

The Hospital

The hospital was founded and endowed by Ernest Cassel in England in 1919. It was initially for the treatment of “shell shock” victims (aka combat stress reaction). Originally at Swaylands in Penshurst, Kent, it moved to Stoke-on-Trent during the Second World War. In 1948 it relocated to its present site at No. 1 Ham Common, Ham.

The Building

The present hospital was originally a late 18th-century house known as Morgan House after its owner, philanthropist and writer, John Minter Morgan. Morgan died in 1854 and is buried in nearby St Andrew’s Church, Ham. In 1863 it became home to the newly married Duc de Chartres. In 1879 it became West Heath Girls’ School. The school moved to its present site in Sevenoaks, Kent in the 1930s, and the building became the Lawrence Hall Hotel until its purchase by the Cassel Foundation in 1947. The building was Grade II listed in 1950.

Facilities

The hospital developed approaches informed by psychoanalytic thinking alongside medicinal interventions, techniques of group and individual psychotherapy. It was here that Tom Main along with Doreen Wedell pioneered the concept of a therapeutic community in the late 1940s. Together they pioneered & developed the concept of psychosocial nursing. By promoting and being proud of the role of the nurse – rather than try to imitate therapists; working alongside the patient in everyday activities, Weddell & Main developed a whole new way of working that reduced dependence upon services and fostered patient’s working collaboratively. Nurses were supported and taught to understand their reparative need, to challenge their sense of omnipotence and to rely on the patient group as the most useful resource. In 1948 Eileen Skellern came for her training and joined the staff in 1949.

The hospital formally established a research department in 1995 and has collaborative relationships with University College London, Imperial College and the Centre for the Economics of Mental Health at the Institute of Psychiatry, London. It is now a psychotherapeutic community which provides day, residential, and outreach services for young people and adults with severe and enduring personality disorders.

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What is Milieu Therapy?

Introduction

Milieu therapy is a form of psychotherapy that involves the use of therapeutic communities.

Outline

Patients join a group of around 30, for between 9 and 18 months. During their stay, patients are encouraged to take responsibility for themselves and the others within the unit, based upon a hierarchy of collective consequences. Patients are expected to hold one another to following rules, with more senior patients expected to model appropriate behavior for newer patients. If one patient violates the rules, others who were aware of the violation but did not intervene may also be punished to varying extents based upon their involvement.

Milieu therapy is thought to be of value in treating personality disorders and behavioural problems, and can also be used with a goal of stimulating the patient’s remaining cognitive-communicative abilities.

Organisations known to use milieu therapy include:

  • Cassel Hospital, in London, UK.
  • Forest Heights Lodge in Evergreen, Colorado, US.
  • The United States Veteran’s Administration, US.
  • The Kansas Industrial School for Girls in Beloit, Kansas, US.

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What is a Therapeutic Community?

Introduction

Therapeutic community is a participative, group-based approach to long-term mental illness, personality disorders and drug addiction. The approach was usually residential, with the clients and therapists living together, but increasingly residential units have been superseded by day units. It is based on milieu therapy principles, and includes group psychotherapy as well as practical activities.

Therapeutic communities have gained some reputation for success in rehabilitation and patient satisfaction in the UK and abroad. In the UK, ‘democratic analytic’ therapeutic communities have tended to specialise in the treatment of moderate to severe personality disorders and complex emotional and interpersonal problems. The evolution of therapeutic communities in the US has followed a different path with hierarchically arranged communities (or concept houses) specialising in the treatment of drug and alcohol dependence.

Brief History

Antecedents

There are several antecedents to the therapeutic community movement. One of the earliest is the change in treatment of institutionalised patients in the late 18th century, continuing throughout the 19th century. A major contributor to this change is Philippe Pinel, a French physician who advocated for a more humane treatment of psychiatric patients. In the UK William Tuke founded the Retreat where patients were treated according to humanitarian principles, called moral treatment. Tuke based the treatment of mentally ill people partly on the Quaker ideology. The influence of Quaker principles continues through out the development of the therapeutic community.

Moral treatment focused on a more humane treatment of patients and a stimulating environment that engages them in healthy behaviour. An important distinction between the later therapeutic community is the strong hierarchy in moral treatment facilities. The superintendent had authority over and responsibility of the patients. The patients followed a strict schedule to promote obedience and self-control.

After the First World War, multiple varieties of living-and-learning communities for young adults were established. Examples are the Little Commonwealth school run by Homer Lane and the Q camps initiated by Marjorie Franklin. The Q camps were based on Planned Environmental Therapy, which focused on normally functioning parts of a patient’s personality and use them to deal with difficult social situations. These projects all emphasized shared responsibility and decision-making and participation in the community. What influenced the establishment of these projects were, among others, the developments in psychoanalytic theory in the UK.

United Kingdom

The work conducted by pioneering NZ plastic surgeon Archibald McIndoe at Queen Victoria Hospital and others at Northfield Military Hospital during World War II is considered by many psychiatrists to have been the first example of an intentional therapeutic community. But this story is prone to adopt a origin myth approach. The principles developed at Northfield were also developed and adapted at Civil Resettlement Units established at the end of the war to help returning prisoners of war to adapt back to civilian society and for civilians to adapt to having these men back amongst them.

The term was coined by Thomas Main in his 1946 paper, “The hospital as a therapeutic institution”, and subsequently developed by others including Maxwell Jones, R.D. Laing at the Philadelphia Association, David Cooper at Villa 21, and Joshua Bierer.

Under the influence of Maxwell Jones, Main, Wilmer and others (Caudill 1958; Rapoport 1960), combined with the publications of critiques of the existing mental health system (Greenblatt et al. 1957, Stanton and Schwartz 1954) and the sociopolitical influences that permeated the psychiatric world towards the end of and following the Second World War, the concept of the therapeutic community and its attenuated form – the therapeutic milieu – caught on and dominated the field of inpatient psychiatry throughout the 1960s.

The first development of therapeutic community in a large institution took place at Claybury Hospital under the guidance of Denis Martin and John Pippard. Beginning in 1955 it involved over 2,000 patients and hundreds of staff. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other’s mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. One phrase commonly used to summarise this treatment philosophy is ‘the Community as Doctor’. ‘TC’s have sometimes eschewed or limited medication in favour of group-based therapies.

The Henderson Hospital first established in 1947 by Maxwell Jones and named after David Henderson evolved the specific concept of Democratic Therapeutic Community (DTC). Admission to and early discharge from the one year of residential treatment was by majority vote and residents of the DTC always held the majority in these votes. No psychotropic medication or one to one therapy sessions were available and so all the work of the DTC was pursued, on the one hand, in small or larger therapy groups or work groups and community meetings, which could be called (by the residents) day or night; and on the other hand, in the unstructured time in between these more formal spaces, in which belonging in and membership of a living community could become in itself a healing experience. The Henderson Hospital DTC became an international centre of excellence for the care of survivors of severe trauma who did not fall under conventional psychiatric classifications and towards the end of the twentieth century it was funded to replicate the treatment model in two other DTCs: Main House in Birmingham and Webb House in Crewe.

The availability of the treatment on the National Health Service in the UK came under threat because of changes in funding systems. Researchers at the University of Oxford and King’s College London studied one of these national Democratic Therapeutic Community services over four years and found external policy ‘steering’ by officials eroded the community’s democratic model of care, which in turn destabilised its well established approach to clinical risk management (this had been jointly developed by clients and staff). Fischer (2012), who studied this community’s development at first hand, described how an ‘intractable conflict’ between embedded and externally imposed management models led to escalating organisational ‘turbulence’, producing an interorganisational crisis which led to the unit’s forced closure. The three ‘Henderson’ DTCs had all closed their doors by 2008.

However, development of ‘mini’ therapeutic communities, meeting for three or fewer days each week and supported out of hours by various forms of ‘service user led informal networks of care’ (for example telephone, texting and physical support), now offers a more resource and cost effective alternative to traditional inpatient therapeutic communities. The most recent exponent, the North Cumbria model, uses a dedicated out of hours website moderated by service users according to therapeutic community principles. This extends the community beyond the face to face ‘therapeutic days’. The website guarantees a safe group-based response not always possible with other systems. The use of ‘starter’ groups as a preparation for entry into therapeutic communities has lowered attrition rates and they now represent a cost-effective model still aimed at producing durable personal and intergenerational effects; this is at odds with the current trend towards the defensive needs of service providers, rather than service users, for less intensive treatments and management of pathways to control risk.

United States

In the late 1960s within the US correctional system, the Asklepion Foundation initiated therapeutic communities in the Marion Federal Penitentiary and other institutions that included clinical intervention based upon Transactional Analysis, the Synanon Game, internal twelve-step programmes and other therapeutic modalities. Some of these programmes lasted into the mid-1980s, such as the House of Thought in the Virginia Correctional system, and were able to demonstrate a reduction of 17% in recidivism in a matched-pair study of drug-abusing felons and sex offenders who participated in the program for one year or more.

Modified therapeutic communities are currently used for substance abuse treatment in correctional facilities of several US states including Pennsylvania, Washington, Colorado, Texas, Delaware, and New York. In New York City, a programme for men is located in the Arthur Kill Correctional Facility on Staten Island and the women’s programme is part of the Bayview Correctional Facility in Manhattan.

Main Ideas

The therapeutic community approach aims to help patients deal with social situations and to change perceptions they have about themselves. Difficult situations are re-enacted and experienced and patients are encouraged to examine and try to learn from them with the help of group and individual therapy. The communities function as a living-and-learning situations, where every interaction can serve as a learning moment.

There is no encompassing definition of what a therapeutic community should be. Some have therefore also argued that it follows a family resemblance. A common conception of therapeutic community is a group of people living together in a non-hierarchical, democratic way that brings psychological awareness of individual as well as group processes. Furthermore, the community has clear boundaries of place, time and roles of the participants. They are democratic because the patients are involved in decision-making to encourage a sense of responsibility. This is fostered by the non-hierarchical structure that tries to minimise dependency on the staff.

A key principle is the creation of a culture of enquiry. Everyone within the community is encouraged to reflect and ask question about themselves and others. In this way the participants are supported by continuous feedback to create better self-awareness.

The therapeutic community approach is informed by systems theory, organisation theory and psychoanalytic practice.

Effectiveness

As an intervention model for drug-using offenders with co-occurring mental health disorders, therapeutic communities may help people reduce drug use and subsequent criminal activity. Research evidence for the effectiveness of therapeutic community treatment is substantial and a demonstration of the cost efficacy of a year of residential therapeutic community treatment was instrumental in funding being granted in the late 1990s for the replication of the Henderson Hospital DTC.

In Popular Culture

  • The Alfred Hitchcock film Spellbound takes place within a therapeutic community called Green Manors.
  • Leonard Cohen and his touring band The Army gave an impromptu concert at the Henderson Hospital DTC in August 1970, just before the Isle of Wight Festival, after being invited by one of the residents.

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What is BPDFamily.com?

Introduction

BPDFamily.com is an online support group for the family members of individuals with borderline personality disorder (BPD).

The group is one of the first “cyber” support groups to be recognised by the medical providers and receive professional referrals.

Outline

BPDFamily.com provides articles and message boards for family members to learn and share their experiences. The articles explain borderline personality disorder in understandable terms, and the discussion groups help to normalise the experiences of family members. The site appeals to family members who care about someone with BPD, but are frustrated with the relationship demands and conflict.

The site educates its members on concepts developed by Shari Manning PhD, Margalis Fjelstad PhD, Robert O. Friedel MD, and the NEA-BPD Family Connections Programme and reached out to academia for collaborations. The site has an interactive web program that teaches the basic principles of cognitive behavioural therapy (CBT).

The website and support group are certified as a reputable health information resource by the Health On the Net Foundation.

Funding has come from benefactors and member donations.

Use by Healthcare Professionals

BPDFamily.com is a listed reference site of the National Health Service (England), the National Alliance on Mental Illness, the National Education Alliance for Borderline Personality Disorder, and the Personality Disorders Awareness Network.

The group’s services and programmes are recommended in Primer on Borderline Personality Disorder, Abnormal and Clinical Psychology: An Introductory Textbook, Resources to Improve Emotional Health and Strengthen Relationships, I Hate You–Don’t Leave Me: Understanding the Borderline Personality, The Essential Family Guide to Borderline Personality Disorder, Stop Walking on Eggshells, and Discovering Your Inner Child: Transforming Toxic Patterns and Finding Your Joy. The site has been recommended by about.com expert Kristalyn Salters-Pedneault, PhD, Salon advice columnist Cary Tennis, PsychCentral columnist Kate Thieda, and by Randi Kreger at BPDCentral.

The organisation has been involved and referenced in clinical research studies conducted by: Columbia University, University of Wollongong (Australia), California State University, Sacramento, University of Toronto (Canada), University of Nevada, Bowling Green State University, Wright Institute (California), Colorado School of Professional Psychology, Long Island University, Alliant International University (California), Macquarie University (Australia), Middle Tennessee State University, Simon Fraser University (Canada) and Walden University. The organisation also supports industry research studies conducted by the Treatment and Research Advancements Association for Personality Disorder (TARA-APD).

In a January 2013 column, Kristalyn Salters-Pedneault at Boston University School of Medicine says that although she highly recommends this group for family members, readers with borderline personality disorder should keep in mind that some people have been hurt by their family member with BPD and are speaking from this perspective

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What is Olmstead v .L.C. (1999)?

Introduction

Olmstead v. L.C., 527 U.S. 581 (1999), is a United States Supreme Court case regarding discrimination against people with mental disabilities.

The Supreme Court held that under the Americans with Disabilities Act, individuals with mental disabilities have the right to live in the community rather than in institutions if, in the words of the opinion of the Court, “the State’s treatment professionals have determined that community placement is appropriate, the transfer from institutional care to a less restrictive setting is not opposed by the affected individual, and the placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.”

The case was brought by the Atlanta Legal Aid Society, Inc.

Background

Tommy Olmstead, Commissioner, Georgia Department of Human Resources, et al. v. L. C., by Zimring, guardian ad litem and next friend, et al. (Olmstead v. L.C.) was a case filed in 1995 and decided in 1999 before the United States Supreme Court. The plaintiffs, L.C. (Lois Curtis) and E.W. (Elaine Wilson, deceased 04 December 2005), two women were diagnosed with schizophrenia, intellectual disability and personality disorder. They had both been treated in institutional settings and in community based treatments in the state of Georgia.

  • Guardian ad litem: A legal guardian is a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person, called a ward.
  • Next Friend: In common law, a next friend is a person who represents another person who is underage, or, because of disability or otherwise, is unable to maintain a suit on his or her own behalf and who does not have a legal guardian. Also known as litigation friends.

Following clinical assessments by state employees, both plaintiffs were determined to be better suited for treatment in a community-based setting rather than in the institution. The plaintiffs remained confined in the institution, each for several years after the initial treatment was concluded. Both sued the state of Georgia to prevent them from being inappropriately treated and housed in the institutional setting.

Opinion of the Court

The case rose to the level of the United States Supreme Court, which decided the case in 1999, and plays a major role in determining that mental illness is a form of disability and therefore covered under the Americans with Disabilities Act (ADA). Title II of the ADA applies to ‘public entities’ and include ‘state and local governments’ and ‘any department, agency or special purpose district’ and protects any ‘qualified person with a disability’ from exclusion from participation in or denied the benefits of services, programs, or activities of a public entity.

The Supreme Court decided mental illness is a form of disability and that “unjustified isolation” of a person with a disability is a form of discrimination under Title II of the ADA. The Supreme Court held that community placement is only required and appropriate (i.e. institutionalisation is unjustified), when:

  • The State’s treatment professionals have determined that community placement is appropriate;
  • The transfer from institutional care to a less restrictive setting is not opposed by the affected individual; and
  • The placement can be reasonably accommodated, taking into account the resources available to the State and the needs of others with mental disabilities.

Unjustified isolation is discrimination based on disability. Olmstead v. L.C., 527 U.S. 581, 587 (1999).

The Supreme Court explained that this holding “reflects two evident judgments.”

  • First, “institutional placement of persons who can handle and benefit from community settings perpetuates unwarranted assumptions that persons so isolated are incapable or unworthy of participating in community life.”
  • Second, historically “confinement in an institution severely diminishes the everyday life activities of individuals, including family relations, social contacts, work options, economic independence, educational advancement, and cultural enrichment.” Id. at 600-601.

However, a majority of Justices in Olmstead also recognized an ongoing role for publicly and privately operated institutions:

“We emphasize that nothing in the ADA or its implementing regulations condones termination of institutional settings for persons unable to handle or benefit from community settings…Nor is there any federal requirement that community-based treatment be imposed on patients who do not desire it.” Id. at 601-602.

A plurality of Justices noted: “[N]o placement outside the institution may ever be appropriate . . . ‘Some individuals, whether mentally retarded or mentally ill, are not prepared at particular times – perhaps in the short run, perhaps in the long run – for the risks and exposure of the less protective environment of community settings ’ for these persons, ‘institutional settings are needed and must remain available’” (quoting Amicus Curiae Brief for the American Psychiatric Association, et al). “As already observed [by the majority], the ADA is not reasonably read to impel States to phase out institutions, placing patients in need of close care at risk… ‘Each disabled person is entitled to treatment in the most integrated setting possible for that person—recognizing on a case-by-case basis, that setting may be an institution’[quoting VOR’s Amici Curiae brief].” Id. at 605.

Justice Kennedy noted in his concurring opinion, “It would be unreasonable, it would be a tragic event, then, were the Americans with Disabilities Act of 1990 (ADA) to be interpreted so that states had some incentive, for fear of litigation to drive those in need of medical care and treatment out of appropriate care and into settings with too little assistance and supervision.” Id. at 610.

The Supreme Court did not reach the question of whether there is a constitutional right to community services in the most integrated setting.

About ten years after the Olmstead decision, the State of Georgia and the United States Department of Justice entered a settlement agreement to cease all admissions of individuals with developmental disabilities to state-operated, federally licensed institutions (“State Hospitals”) and, by 01 July 2015, “transition all individuals with developmental disabilities in the State Hospitals from the Hospitals to community settings,” according to a Department of Justice Fact Sheet about the settlement. The settlement also calls for serving 9,000 individuals with mental illness in community settings. Recently, the federal court’s Independent Reviewer for the settlement found significant health and safety risks, including many deaths, plaguing former State Hospital residents due to their transition from a licensed facility home to community-settings per the settlement. The Court has approved a moratorium on such transfers until the safety of those impacted can be assured.

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What is Organic Personality Disorder?

Introduction

Organic personality disorder (OPD), irrespective of the apparent nomenclature, is not included in the group of personality disorders.

For this reason, the symptoms and diagnostic criteria of the organic personality disorder are different from those of the other mental health disorders included in this various group. According to the Tenth Revision of the International Classification of Diseases (ICD-10) organic personality disorder is associated with a “significant alteration of the habitual patterns of premorbid behaviour”. There are crucial influences on emotions, impulses and personal needs because of this disorder.

Thus, all these definitions about the organic personality disorder support that this type of disorder is associated with changes in personality and behaviour.

Causes

Organic personality disorder is associated with “personality change due to general medical condition”. The organic personality disorder is included in a wide group of personality and behavioural disorders. This mental health disorder can be caused by disease, brain damages or dysfunctions in specific brain areas in frontal lobe. The most common reason for this profound change in personality is the traumatic brain injury (TBI). Children, whose brain areas have been injured or damaged, may present attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and organic personality disorder. Moreover, this disorder is characterised as “frontal lobe syndrome”. This characteristic name shows that the organic personality disorder can usually be caused by lesions in three brain areas of frontal lobe. Specifically, the symptoms of organic personality disorder can also be caused by traumatic brain injuries in orbitofrontal cortex, anterior cingulate cortex and dorsolateral prefrontal cortex. It is worth mention that organic personality disorder may also be caused by lesions in other circumscribed brain areas.

Diagnosis and Symptoms

The ICD-10 includes a diagnostic guideline for the wide group of personality and behavioural disorders. However, every disorder has its own diagnostic criteria. In case of the organic personality disorder, patient has to show at least three of the following diagnostic criteria over a six or more months period. Organic personality disorder is associated with a large variety of symptoms, such as deficits in cognitive function, dysfunctional behaviours, psychosis, neurosis, emotional changes, alterations in expression function and irritability. Patients with organic personality disorder can present emotional lability that means their emotional expressions are unstable and fluctuating. In addition, patients show reduction in ability of perseverance with their goals and they express disinhibited behaviours, which are characterised by inappropriate sexual and antisocial actions. For instance, patients can show dissocial behaviours, like stealing. Moreover, according to diagnostic guideline of ICD-10, patients can suffer from cognitive disturbances and they present signs of suspiciousness and paranoid ideas. Additionally, patients may present alteration in process of language production that means there are changes in language rate and flow. Furthermore, patients may show changes in their sexual preference and hyposexuality symptoms.

Another common feature of personality of patients with organic personality disorder is their dysfunctional and maladaptive behaviour that causes serious problems in these patients, because they face problems with pursuit and achievement of their goals. It is worth to be mentioned that patients with organic personality disorder express a feeling of unreasonable satisfaction and euphoria. Also, the patients show aggressive behaviours sometimes and these serious dysfunctions in their behaviour can have effects on their life and their relationships with other people. Specifically patients show intense signs of anger and aggression because of their inability to handle their impulses. The type of this aggression is called “impulsive aggression”. Furthermore, it is worth to be mentioned that the pattern of organic personality disorder presents some similarities with pattern of temporal lobe epilepsy (TLE). Specifically patients who suffer from this chronic disorder type of epilepsy, express aggressive behaviours, likewise it happens to patients with organic personality disorder. Another similar symptom between Temporal lobe epilepsy and organic personality disorder is the epileptic seizure. The symptom of epileptic seizure has influence on patients’ personality that means it causes behavioural alterations”. The Temporal lobe epilepsy (TLE) is associated with the hyperexcitability of the medial temporal lobe (MTL) of patients. Finally, patients with organic personality disorder may present similar symptoms with patients, who suffer from the Huntington’s disease as well. The symptoms of apathy and irritability are common between these two groups of patients.

Treatment

As it has already been mentioned, patients with organic personality disorder show a wide variety of sudden behavioural changes and dysfunctions. There are not a lot of information about the treatment of this mental health disorder. The pharmacological approach is the most common therapy among patients with organic personality disorder. However, the choice of drug therapy relies on the seriousness of patient’s situation and what symptoms are shown. The choice and administration of specific drugs contribute to the reduction of symptoms of organic personality disorder. For this reason, it is crucial for patients’ treatment to be assessed by clinical psychologists and psychiatrists before the administration of drugs.

Additionally, the dysfunctions in expression of behaviour of patients with organic personality disorder and the development of symptom of irritability, which are caused by aggressive and self-injurious behaviours, can be dealt with the administration of carbamazepine. Moreover, the symptoms of this disorder can be decreased by the administration of valproic acid. Also, emotional irritability and signs of depression can be dealt with the use of nortriptyline and low-dose thioridazine. Except from the symptom of irritability, patients express aggressive behaviours. At the onset of drug therapy for effective treatment of anger and aggression, the drug of carbamazepine, phenobarbital, benztropine (or benzatropine) and haloperidol can be administrated in order to reduce the symptoms of patients with organic personality disorder. In addition, the use of propranolol may decrease the frequent behaviours of rage attacks.

Finally, it is important for patients to take part in psychotherapy during drug therapy. In this way, many of the adverse effects of the medications, both physiological and behavioural, can be lessened or avoided entirely. Furthermore, the clinicians can provide useful and helpful support to patients during these psychotherapy sessions. Thus, the combination of drug therapy with psychotherapy can lead to the reduction of symptoms of this disorder and the improvement of patients’ situation.

What is Self-Defeating Personality Disorder?

Introduction

Self-defeating personality disorder (also known as masochistic personality disorder) was a proposed personality disorder.

It was discussed in an appendix of the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) in 1987, but was never formally admitted into the manual. As an alternative, the diagnosis personality disorder not otherwise specified remains in use in the DSM-5. A classification proposed for future versions is the personality disorder-trait specified (PD-TS). Some researchers and theorists continue to use the DSM-III-R criteria. The official diagnostic code number was 301.90 (personality disorder NOS).

Refer to Self-Handicapping.

Diagnosis

Definition Proposed in DSM III-R for Further Review

Self-defeating personality disorder is:

  • A) A pervasive pattern of self-defeating behaviour, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which they will suffer, and prevent others from helping them, as indicated by at least five of the following:
    1. Chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available.
    2. Rejects or makes ineffective the attempts of others to help them.
    3. Following positive personal events (e.g. new achievement), responds with depression, guilt, or a behaviour that produces pain (e.g. an accident).
    4. Incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g. makes fun of spouse in public, provoking an angry retort, then feels devastated).
    5. Rejects opportunities for pleasure, or is reluctant to acknowledge enjoying themselves (despite having adequate social skills and the capacity for pleasure).
    6. Fails to accomplish tasks crucial to their personal objectives despite having demonstrated ability to do so (e.g., helps fellow students write papers, but is unable to write their own).
    7. Is uninterested in or rejects people who consistently treat them well.
    8. Engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice.
    9. The person may often avoid or undermine pleasurable experiences […]
  • B) The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.
  • C) The behaviors in A do not occur only when the person is depressed.

Exclusion from DSM-IV

Historically, masochism has been associated with feminine submissiveness. This disorder became politically controversial when associated with domestic violence which was considered to be mostly caused by males. However a number of studies suggest that the disorder is common. In spite of its exclusion from DSM-IV in 1994, it continues to enjoy widespread currency amongst clinicians as a construct that explains a great many facets of human behaviour.

Sexual masochism that “causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” is still in DSM-IV.

What is True Self and False Self?

Introduction

True self (also known as real self, authentic self, original self and vulnerable self) and false self (also known as fake self, idealised self, superficial self and pseudo self) are psychological concepts, originally introduced into psychoanalysis in 1960 by Donald Winnicott.

Winnicott used true self to describe a sense of self based on spontaneous authentic experience and a feeling of being alive, having a real self. The false self, by contrast, Winnicott saw as a defensive façade, which in extreme cases could leave its holders lacking spontaneity and feeling dead and empty, behind a mere appearance of being real.

The concepts are often used in connection with narcissism.

Characteristics

Winnicott saw the true self as rooted from early infancy in the experience of being alive, including blood pumping and lungs breathing – what Winnicott called simply being. Out of this, the baby creates the experience of a sense of reality, a sense that life is worth living. The baby’s spontaneous, nonverbal gestures derive from that instinctual sense, and if responded to by the parents, become the basis for the continuing development of the true self.

However, when what Winnicott was careful to describe as good enough parenting – i.e., not necessarily perfect – was not in place, the infant’s spontaneity was in danger of being encroached on by the need for compliance with the parents’ wishes/expectations. The result for Winnicott could be the creation of what he called the false self, where “Other people’s expectations can become of overriding importance, overlaying or contradicting the original sense of self, the one connected to the very roots of one’s being”. The danger he saw was that “through this false self, the infant builds up a false set of relationships, and by means of introjections even attains a show of being real”, while, in fact, merely concealing a barren emptiness behind an independent-seeming façade.

The danger was particularly acute where the baby had to provide attunement for the mother/parents, rather than vice versa, building up a sort of dissociated recognition of the object on an impersonal, not personal and spontaneous basis. But while such a pathological false self stifled the spontaneous gestures of the true self in favour of a lifeless imitation, Winnicott nevertheless considered it of vital importance in preventing something worse: the annihilating experience of the exploitation of the hidden true self itself.

Precursors

There was much in psychoanalytic theory on which Winnicott could draw for his concept of the false self. Helene Deutsch had described the “as if” personalities, with their pseudo relationships substituting for real ones. Winnicott’s analyst, Joan Riviere, had explored the concept of the narcissist’s masquerade – superficial assent concealing a subtle hidden struggle for control. Freud’s own late theory of the ego as the product of identifications came close to viewing it only as a false self; while Winnicott’s true/false distinction has also been compared to Michael Balint’s “basic fault” and to Ronald Fairbairn’s notion of the “compromised ego”.

Erich Fromm, in his book The Fear of Freedom distinguished between original self and pseudo self – the inauthenticality of the latter being a way to escape the loneliness of freedom; while much earlier the existentialist like Kierkegaard had claimed that “to will to be that self which one truly is, is indeed the opposite of despair” – the despair of choosing “to be another than himself”.

Karen Horney, in her 1950 book, Neurosis and Human Growth, based her idea of “true self” and “false self” through the view of self-improvement, interpreting it as real self and ideal self, with the real self being what one currently is and the ideal self being what one could become.

Later Developments

The second half of the twentieth century has seen Winnicott’s ideas extended and applied in a variety of contexts, both in psychoanalysis and beyond.

Kohut

Heinz Kohut extended Winnicott’s work in his investigation of narcissism, seeing narcissists as evolving a defensive armour around their damaged inner selves. He considered it less pathological to identify with the damaged remnants of the self, than to achieve coherence through identification with an external personality at the cost of one’s own autonomous creativity.

Lowen

Alexander Lowen identified narcissists as having a true and a false, or superficial, self. The false self rests on the surface, as the self presented to the world. It stands in contrast to the true self, which resides behind the façade or image. This true self is the feeling self, but for the narcissist the feeling self must be hidden and denied. Since the superficial self represents submission and conformity, the inner or true self is rebellious and angry. This underlying rebellion and anger can never be fully suppressed since it is an expression of the life force in that person. But because of the denial, it cannot be expressed directly. Instead it shows up in the narcissist’s acting out. And it can become a perverse force.

Masterson

James F. Masterson argued that all the personality disorders crucially involve the conflict between a person’s two selves: the false self, which the very young child constructs to please the mother, and the true self. The psychotherapy of personality disorders is an attempt to put people back in touch with their real selves.

Symington

Neville Symington developed Winnicott’s contrast between true and false self to cover the sources of personal action, contrasting an autonomous and a discordant source of action – the latter drawn from the internalisation of external influences and pressures. Thus for example parental dreams of self-glorification by way of their child’s achievements can be internalised as an alien discordant source of action. Symington stressed however the intentional element in the individual’s abandoning the autonomous self in favour of a false self or narcissistic mask – something he considered Winnicott to have overlooked.

Vaknin

As part of what has been described as a personal mission to raise the profile of the condition, psychology professor (and self-confessed narcissist) Sam Vaknin has highlighted the role of the false self in narcissism. The false self replaces the narcissist’s true self and is intended to shield him from hurt and narcissistic injury by self-imputing omnipotence. The narcissist pretends that his false self is real and demands that others affirm this confabulation, meanwhile keeping his real imperfect true self under wraps.

For Vaknin, the false self is by far more important to the narcissist than his dilapidated, dysfunctional true self; and he does not subscribe to the view that the true self can be resuscitated through therapy.

Miller

Alice Miller cautiously warns that a child/patient may not have any formed true self, waiting behind the false self façade; and that as a result freeing the true self is not as simple as the Winnicottian image of the butterfly emerging from its cocoon. If a true self can be developed, however, she considered that the empty grandiosity of the false self could give way to a new sense of autonomous vitality.

Orbach (False Bodies)

Susie Orbach saw the false self as an overdevelopment (under parental pressure) of certain aspects of the self at the expense of other aspects – of the full potential of the self – producing thereby an abiding distrust of what emerges spontaneously from the individual himself or herself. Orbach went on to extend Winnicott’s account of how environmental failure can lead to an inner splitting of mind and body, so as to cover the idea of the false body – falsified sense of one’s own body. Orbach saw the female false body in particular as built upon identifications with others, at the cost of an inner sense of authenticity and reliability. Breaking up a monolithic but false body-sense in the process of therapy could allow for the emergence of a range of authentic (even if often painful) body feelings in the patient.

Jungian Persona

Jungians have explored the overlap between Carl Jung’s concept of the persona and Winnicott’s false self; but, while noting similarities, consider that only the most rigidly defensive persona approximates to the pathological status of the false self.

Stern’s Tripartite Self

Daniel Stern considered Winnicott’s sense of “going on being” as constitutive of the core, pre-verbal self. He also explored how language could be used to reinforce a false sense of self, leaving the true self linguistically opaque and disavowed. He ended, however, by proposing a three-fold division of social, private, and of disavowed self.

Criticisms

Neville Symington criticised Winnicott for failing to integrate his false self insight with the theory of ego and id. Similarly, continental analysts like Jean-Bertrand Pontalis have made use of true/false self as a clinical distinction, while having reservations about its theoretical status.

The philosopher Michel Foucault took issue more broadly with the concept of a true self on the anti-essentialist grounds that the self was a construct – something one had to evolve through a process of subjectification, an aesthetics of self-formation, not something simply waiting to be uncovered: “we have to create ourselves as a work of art”.

Literary Examples

  • Wuthering Heights has been interpreted in terms of the true self’s struggle to break through the conventional overlay.
  • In the novel, I Never Promised You a Rose Garden, the heroine saw her outward personality as a mere ghost of a Semblance, behind which her true self hid ever more completely.
  • Sylvia Plath’s poetry has been interpreted in terms of the conflict of the true and false selves.

What is Sadistic Personality Disorder?

Introduction

Sadistic personality disorder (SPD) is a personality disorder involving sadomasochism which appeared in an appendix of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). The later versions of the DSM (DSM-IV, DSM-IV-TR and DSM-5) do not include it.

The words sadism and sadist are derived from Marquis de Sade.

Definition

Sadism involves deriving pleasure through others undergoing discomfort or pain. The opponent-process theory is one way to help explain how an individual may come to not only display, but also enjoy committing sadistic acts. Individuals possessing sadistic personalities tend to display recurrent aggression and cruel behaviour. Sadism can also include the use of emotional cruelty, purposefully manipulating others through the use of fear, and a preoccupation with violence.

Theodore Millon claimed there were four subtypes of sadism, which he termed enforcing sadism, explosive sadism, spineless sadism, and tyrannical sadism.

SubtypeDescriptionPersonality Traits
Spineless SadismIncluding avoidant featuresInsecure, bogus, and cowardly; venomous dominance and cruelty is counterphobic; weakness counteracted by group support; public swaggering; selects powerless scapegoats.
Tyrannical SadismIncluding negativistic featuresRelishes menacing and brutalising others, forcing them to cower and submit; verbally cutting and scathing, accusatory and destructive; intentionally surly, abusive, inhumane, unmerciful.
Enforcing SadismIncluding compulsive featuresHostility sublimated in the “public interest,” cops, “bossy” supervisors, deans, judges; possesses the “right” to be pitiless, merciless, coarse, and barbarous; task is to control and punish, to search out rule breakers.
Explosive SadismIncluding borderline featuresUnpredictably precipitous outbursts and fury; uncontrollable rage and fearsome attacks; feelings of humiliation are pent-up and discharged; subsequently contrite.

Comorbidity with other Personality Disorders

Sadistic personality disorder has been found to occur frequently in unison with other personality disorders. Studies have also found that sadistic personality disorder is the personality disorder with the highest level of comorbidity to other types of psychopathological disorders. In contrast, sadism has also been found in patients who do not display any or other forms of psychopathic disorders. One personality disorder that is often found to occur alongside sadistic personality disorder is conduct disorder, not an adult disorder but one of childhood and adolescence. Studies have found other types of illnesses, such as alcoholism, to have a high rate of comorbidity with sadistic personality disorder.

Researchers have had some level of difficulty distinguishing sadistic personality disorder from other forms of personality disorders due to its high level of comorbidity with other disorders.

Removal from the DSM

Numerous theorists and clinicians introduced sadistic personality disorder to the DSM in 1987 and it was placed in the DSM-III-R as a way to facilitate further systematic clinical study and research. It was proposed to be included because of adults who possessed sadistic personality traits but were not being labelled, even though their victims were being labelled with a self-defeating personality disorder. Theorists like Theodore Millon wanted to generate further study on SPD, and so proposed it to the DSM-IV Personality Disorder Work Group, who rejected it. Millon writes that “Physically abusive, sadistic personalities are most often male, and it was felt that any such diagnosis might have the paradoxical effect of legally excusing cruel behavior.”

Sub-Clinical Sadism in Personality Psychology

There is renewed interest in studying sadism as a personality trait. Sadism joins with subclinical psychopathy, narcissism, and Machiavellianism to form the so-called “dark tetrad” of personality.

What is Personality Development Disorder?

Introduction

A personality development disorder is an inflexible and pervasive pattern of inner experience and behavior in children and adolescents, that markedly deviates from the expectations of the individual’s culture.

Personality development disorder is not recognised as a mental disorder in any of the medical manuals, such as the ICD-10 or the DSM-IV, nor the more recent DSM-5. DSM-IV allows the diagnosis of personality disorders in children and adolescents only as an exception. This diagnosis is currently proposed by a few authors in Germany. The term personality development disorder is used to emphasize the changes in personality development which might still take place and the open outcome during development. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.

Adults usually show personality patterns over a long duration of time. Children and adolescents however still show marked changes in personality development. Some of these children and adolescents have a hard time developing their personalities in an ordinary way. DSM-IV states, for example, that children and adolescents are at higher risk to develop an antisocial personality disorder if they showed signs of conduct disorder and attention deficit disorder before the age of 10. This led Adam & Breithaupt-Peters (2010) to the idea that these children and adolescents need to be looked at more carefully. The therapy which these children and adolescents need might be more intense and maybe even different from looking at the disorders traditionally. The concept of personality development disorders also focuses on the severity of the disorder and the poor prognosis. An early diagnosis might help to get the right treatment at an early stage and thus might help to prevent a personality disorder outcome in adulthood.

Description

Similar to the adult diagnosis personality disorder these children display enduring patterns of inner experience and behaviour deviating markedly from the expectations of the individual’s culture. These patterns are inflexible and pervasive across a broad range of personal and social situations, lead to clinically significant distress or impairment in social, occupational or other important areas of functioning and they are stable and of long duration (more than a year).

The term personality development disorder (Persönlichkeitsentwicklungsstörung) was first used in German by Spiel & Spiel (1987). Adam & Breithaupt-Peters (2010) adapted the term to a more modern concept and suggested the below definition.

Cause

Similar to adult personality disorders there are multiple causes and causal interactions for personality development disorders. In clinical practice it is important to view the disorder from multiple perspectives and from an individual perspective. Biological and neurological causes need to be observed just as much as psychosocial factors. Looking at the disorder from only one perspective (e.g. (s)he had a bad childhood) often results in ignorance of important other factors or causal interactions. This might be one of the main reasons why traditional treatment methods often fail with these disorders. Only a multi-perspective view can provide for a multi-dimensional treatment approach which seems to be the key for these disorders.

Diagnosis

The diagnosis personality development disorder should only be given carefully and after a longer period of evaluation. Also a thorough diagnostic evaluation is necessary. Parents should be questioned separately and together with the child or adolescent to evaluate the severity and duration of the problems. In addition standardised personality tests might be helpful. It is also useful to ask the family what treatment approaches they have already tried so far without success.

Definition

According to Adam und Breithaupt-Peters personality development disorders are defined as complex disorders:

  • Which show similarity to a certain type of personality disorder in adulthood.
  • Which persist over a long period of time (more than a year) and show a tendency towards being chronic.
  • Which have a severe negative impact on more than one important area of functioning or social life.
  • Which show resistance to traditional educational and therapeutic treatment methods.
  • Which result in a reduced insight into or ignorance of the own problem behaviour. The family usually suffers more than the child or adolescent and has a hard time dealing with the diminished introspection.
  • Which make positive interactions between the children/adolescents and other people merely impossible. Instead social collisions are part of everyday life.
  • Which threaten the social integration of the young person into a social life and might result in an emotional disability.

Treatment

Personality development disorders usually need a complex and multi-dimensional treatment approach (Adam & Breithaupt-Peters, 2010). Since the problems are complex, treatment needs to affect the conditions in all impaired functional and social areas. Both educational and therapeutic methods are helpful and problem and strength based approaches work hand in hand. Parents need to be included as well as the school environment. Treatment methods need to be flexible and adjustable to the individual situation. Even elements of social work can be helpful when supporting the families and in some cases medication might be necessary. When suicidal behaviours or self-injuries are prominent treatment might best be done in a hospital.

For some personality development disorders (e.g. borderline personality disorder) treatment methods from adults can be adapted (e.g. dialectical behaviour therapy, Miller et al., 2006).

References

Adam, A. & Breithaupt-Peters, M. (2010). Persönlichkeitentwicklungsstörungen bei Kindern und Jugendlichen. Stuttgart: Kohlhammer Verlag.