Download - Relationships and mental illness
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Mental illness and relationships
Dr. Nick Stafford, Consultant PsychiatristNHS & Private Practiceclinical-partners.co.uk
Seminar & discussion withRELATE Leicester July 2013
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DisclosuresPharmaceuticalsAstra Zeneca LtdOtsuka LtdBristol Myers Squibb LtdGlaxo Smith Kline LtdPfizer LtdEli Lilly LtdLundbeck LtdServier Laboratories LtdGW Pharma Ltd
Private PracticeClinical Partners LtdNuffield HealthBMI HealthcareClinics in:London, Leicester, Sutton Coldfield
Previously Vice Chair Bipolar UK
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Contents of talk
• Fundamentals
– Self, Attachment, Development, Social cognition
• Personality & disorder
• Bipolar disorder as a model
• Families
• Services and health care professionals
• Film examples
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Summary – systemic model
Individuals
Illness
Response to stress
Treatment
Education / Knowledge
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The brain is our lens of the world
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Perception determines relation
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Mental illness / Relationship System
Mental illness
Relationship
Protective factorsIndividual style
Attachment styleCommunication
Expressed emotion
NatureDegree
TreatmentsImpairmentsPersonality
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What makes the self?
Self
Others
World
Bio
Psycho
Past
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RelationshipsSpouse
Children
Friends
Colleagues
Neighborhood
BRIEF ENDURING
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Social sciences
Psychology Social Work
Sociology Anthropology
Doctor
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Insight
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Regulations
Law Custom
Agreement Groups
Society
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Attachment
Me
ATTACHMENT
Mummy
The World
Self
Dev
elo
pm
ent
Ad
ult
Lif
e
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Attachment style (childhood)
Attachment styles
Secure
Insecure
Anxious avoidant
Ambivalent
Disorganised
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Theory of mind
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Development
Acquaintance
Build Up
Continuation
Deterioration
Termination
BEGINNING
ENDING
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Adult attachment
SecureAnxious-
preoccupied
Dismissive-avoidant
Fearful-avoidant
Some forms of psychological maladjustment and clinical disorders are attributable in part to the effects of insecure working models and attachment styles.
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Security based strategyof affect regulation
SecureAnxious-
preoccupied
Dismissive-avoidant
Fearful-avoidant
Self-esteem thoughts about the selfSo
ciab
ility
th
ou
ghts
ab
ou
t o
ther
s
Positive Negative
Positive
Negative
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Security based strategy
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Attachment avoidance strategy
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Hyper-activation strategy
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BIPOLAR DISORDERAn example mental disorder
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Relationships in bipolar
• Key relationships– Divorce is twice as common– Loss of employment is twice as common
• Deficits in social cognition underpin these disabilities
• Treatments for these principal deficits– Psychoeducation– Functional remediation– DBT
• Things that don’t work– CBT– Counselling
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Bipolar disorder comorbidities
• Anxiety disorders
• Eating disorders
• Alcohol and substance misuse disorders
• Impulse control disorders
• Behavioural addictions
• Personality disorders (esp. Cluster B)
• Medical problems – CVS, CVA, Cancer, etc.
• Psychosocial problems
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COGNITION
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Social cognition - Bandura
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Social mirroring neurons
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The Root – Cognitive deficits
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PERSONALITY
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Personality (the study of)
• Changes
• Development
• Disorder
• Genetics
• Pathology
• Psychology
• Style
• Systematics
• Tests
• Type
• Traits
• Measuring
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Personality types & disorder
Personality type
• Hippocrates four temperaments– Yellow bile, Black bile
– Phlegm, Blood
• Eysenck– Extraversion / Neuroticism
• Myers-Briggs– Extraversion / Introversion
– Sensing / Intuition
– Thinking / Feeling
– Judging / Perception
Personality disorder (Type A,B,C)
• Paranoid
• Schizoid
• Schizotypal
• Antisocial
• Borderline
• Histrionic
• Narcissistic
• Avoidant
• Dependent
• Obsessive-Compulsive
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Paul Abbott
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COMMUNICATION
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Communication styles
Passive
Aggressive
Passive-aggressive
Assertive
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Communication
• How is this impacted on by the illness?
• Bipolar
– Mood state affects style of communication
• Depression predominates – Passive
• Mania disinhibited – Aggressive & Passive aggressive
– Thinking style can be different (social cognition)
– Relating styles affected by cognitive deficits (facial emotional recognition …)
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MOOD AND EMOTION
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Emotions
• What are they?
• Why have they evolved?
• How can they be helpful?
• How can they be unhelpful?
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Moods – Depression
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Why do people with bipolar have relationship problems?
• The impact of mania and depression
• Subsyndromal symptoms– Irritability– Depression
• Comorbid axis I disorders
• Personality traits and disorders
• Sleep disorders
• Treatments
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Moods – Mania
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Irritability
• Negatively affects ability to moderate emotions during social interaction
• Easily argumentative
• Evokes negative emotions in others
• Difficult for sufferer to distinguish their own irritableness
• Unpleasant to be around
• This is a predominant mood state in mania, depression and sub-syndromal states
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OTHER PROBLEMS
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Social anxiety disorder
• More than 80% of bipolars suffer with this
• Disabling anxiety in the context of mixing with others
• Avoidance of social contact leads to increased social anxiety
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Alcohol and substance misuse
• 60% of bipolars suffer alcohol dependence at some point in their lives
– Worsens illness prognosis
– Increases other comorbidities
– Reduces interpersonal functioning
– Reduces occupational functioning
– Cost
– Domestic violence
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Impulse control disorders
• Varied and can be pervasive
• Impulsive behaviour causes the person to lack judgment
• Consequential damage to self, others and relationships
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Behavioural addictions
• Sex
– Could be a problem even if kept within a faithful relationship
• Gambling
– Amounts of money wasted can be staggering
• Spending
– Typically when high but also when low
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Medication impact on a relationship?
• Overall improvements due to the treatment and improvement of the illness
• Side effects
– Impact on communication (sedation)
– Libido, impotence, delayed ejaculation
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FAMILY FACTORS
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Families - High expressed emotionFA
MIL
Y
PATI
ENT
HOSTILITY
EMOTIONAL OVER-INVOLVEMENT
CRITICAL COMMENTS
STRESS
ILLNESS
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Families - Low expressed emotionFA
MIL
Y
PATI
ENT
MORE EDUCATEDFAMILY DON’T HAVE TO PUT UP WITH THE
ILLNESS
FEEL PATIENT DOES NOT HAVE CONTROL
OVER ILLNESS
MORE RESERVED WITH CRITICISM
STRESS
ILLNESS
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TREATMENTS, SERVICES, RESOURCES
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DBT
• Dialectical behavioural therapy
• Training yourself to become more aware of your emotions and how they impact on you
• Form of psychotherapy
• Marsha M. Linehan
• Original use EUPD
• Mindfulness
• Distress tolerance
• Emotion regulation
• Interpersonal effectiveness
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Services for Relationships
• Generic psychiatric services
• GP counselling
• Rethink (carers)
• Relate (couples)
• All services to some degree assist
• Community institutions
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Impact of health professionals
• All health care professionals should play a key role in a patient’s relationships– Assessment and identification
– Education
– Treatment
– Therapy
• ‘Negative’ impact of HCPs on relationships– Changes lead to relationship revaluations
– Discovery of abuse
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Summary – systemic model
Individuals
Illness
Response to stress
Treatment
Education / Knowledge
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Overcoming
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Resources
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Resources
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THANK YOU