Personality Disorder as delivered by John O Neil, Homelessness Training Unit, SLAM; Dr. Emma Williamson, SLAM to the LNNM Homeless nursing conference April 4th 2014

1. Homelessness and
Personality Disorder
John ONeil
Training Lead, Nurse
Homeless Training Unit
Dr Emma Williamson
Highly Specialist Clinical Psychologist
Psychology in Hostels Project (Lambeth)

2. Why is this important to our work?
• 60-70% UK homeless population meet criteria for
a Personality Disorder
• 5-15% of the general population
• 30% severe MH problems (Incl. Depression,
Anxiety, Schizophrenia)
• Overrepresented histories of neglect, abuse and
traumatic life events
• Trauma shown in childhood & continuing
throughout life for this group
(Maguire et al, 2009; Cockersell, 2011; Fazel et al, 2008; Rees, 2009).

3. PD and Physical Health
• High users of health services
• Associated with less healthy lifestyle choices (substance
abuse, smoking, physical neglect, sexual promiscuity)
• Risk (suicide, self-harm, aggression/violence)
• Research suggests people with BPD more likely to have –
Obesity High Blood Pressure
Fibromyalgia Chronic Fatigue Syndrome
Arthritis Urinary Incontinence
Back Pain Venereal disease
Diabetes Arteriosclerosis or hypertension
Hepatic disease Cardiovascular disease
Gastrointestinal disease
(El-Gabalawy et al, 2010; Salters-Pedneault, 2008)

4. Why is Health a Problem?
• Symptoms lead people to make poorer lifestyle
choices
• And/Or - the same things that cause BPD (e.g.
genetics, exposure to stressful events) also cause
some health problems
• Link between BPD and physical health is complex
• More research needed to fully understand
connection
(Salters-Pedneault, 2008)

5. How does it develop?

6. Nature vs. Nurture
Temperament (nature) +/- 50%
[genetic; chromosomal; cerebral pathology; neurotransmission]
Character (nurture) +/- 50%
[psychodynamic; attachment; social learning; trauma]

7. Neurobiological developmental changes in
victims of childhood maltreatment

9. What can disrupt attachment?
• Trauma
• Unpredictable, Uncontaining, Frightened or Frightening
parents.
• Develop insecure attachment and complex trauma.
• Abuse (Violence, sexual abuse, neglect, witnessing attack
on care giver)
• From Infancy the person learns to either -
– Fear abandonment
– Fear closeness
– Fear both

10. Consequently……
• Struggle to process or control emotions
• Find it hard to recognise their own internal states and those of
others
– So confusing world, scary,
– People incomprehensible & unpredictable
– All in action to control feelings rather than thinking about
them.
• Use substances to damp down feelings
• Impulsive behaviour - not thinking.
• Risk taking
• DSH, Suicide. Need to see emotional pain in concrete way
> cutting
• Can effectively pull others into action as well and out of
boundaries

11. For individuals with personality disorder
People are Terrifying!
And lots of their behaviour stems from Anxiety
Leading to - poor trust, avoidance of engagement,
challenging, argumentative behaviour,

12. As a diagnosis
Three P’s must be present:
Pervasive
Persistent
Pathological

19. Risk Management Planning
Identifying
Triggers
Reviews
General Risk
Management Plan
Risk Assessment

20. Risk Management interventions
Preventative risk taking - attention to working
relationships, education and early warning signs of
relapse
Management of escalating situations - including de-
escalation techniques, rapid responses and crisis
intervention and
Post incident supportive management - positive
support for victims and a culture of learning not
blaming
Morgan and Hemmings (1999)

21. Assessing suicide risk
Helplessness
Hopelessness
Intent
Method
Protective Factors

22. Mary’s Story

23. Additional Tips for working with PD
Find it hard to trust and easily feel abandoned,
therefore -
• Be Consistent and Reliable (same time, place)
• Dependable (assertively outreach even when they
keep being rejecting; however balance with not
being overly intrusive as this can also feel
violating for this client group due to Hx of abuse)
• Familiar member of staff to develop relationship
• Pay attention to breaks (e.g. give plenty of
warning about holidays, changes in staffing )
• Find creative, flexible ways to engage – what
motivates/interests the client?

24. Take home message -
For individuals with personality disorder
People are Terrifying!
Therefore lots of their behaviour stems from
Anxiety