PERSONALITY%20DISORDERS

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PERSONALITY DISORDERS

• Tela Wilson, Psy.D., Psych II

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Objectives

• Refer to POST Performance Objectives

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• As a youth, he fought with other boys, stabbed
  animals with red hot irons, became a thief, spent
  time in a juvenile detention center. Became an
  assassin at 23, exiled to Syria and Egypt, before
  his rise to power. Reported that he shot and
  killed a member of his cabinet during a meeting.
  Caused the deaths of thousands. Who is he?

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(No Transcript)
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Cluster B Personality Disorders

• People with Cluster B disorders tend to be
  dramatic, emotional, and attention-seeking.
• They have intense interpersonal conflicts.
• Personality disorders are characterized by
  inflexible long-standing and maladaptive
  personality traits that cause significant
  functional impairment or subjective distress.
• Temperamental deficiencies
• Rigidity in dealing with life problems
• Defective perceptions of self and other

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Antisocial personality disorder (301.7)

• Cluster B personality disorder
• Pervasive pattern of disregard for, and violation
  of, the rights of others that begins in childhood
  or early adolescents and continues into
  adulthood.
• Also referred to a psychopathy, sociopathy or
  dyssocial personality disorder
• At least 18 years old
• History of three or more symptoms of Conduct
  Disorder before age 15.
• At least 4 antisocial symptoms as an adult
• Fail to conform to social norms with respect to
  lawful behavior.

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• Irritable and aggressive
• Get into fights or commit acts of physical
  assault.
• Lack of empathy
• Callous, cynical and contemptous of the feeling,
  rights and sufferings of others
• Excessively opinionated, self-assured and cocky
• Glib, superficial charm
• Blame victim for being foolish

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Psychopaths

• Subcategory of APD
• more severe
• More intense
• Cold, callous
• Unemotional
• White collar psychopaths
• Able to control their criminality, but still act
  out in other ways.

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Hare Psychopathy checklist - revised

• 3 factors
• Arrogant deceitful interpersonal style
• Deficient affective experience
• Impulsive irresponsible interpersonal style
• Doesnt believe DSM-IV-TR captures personality
  aspect of the disorder
• Overemphasizes behavioral manifestations and
  criminality

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Narcissistic personality disorder (301.81)

• Pervasive pattern of grandiosity, need for
  admiration, lack of empathy that begins by early
  adulthood and is present in a variety of
  contexts.
• Grandiose sense of self-importance
• Often preoccupied with fantasies of unlimited
  success, power, brilliance, beauty or ideal love
• Believe they are superior, special, or unique
  and expect others to recognize them as such
• Require excessive admiration
• Sense of entitlement, unreasonable expectation of
  especially favorable treatment
• Unconscious or unwitting exploitation of others
• Lack of empathy

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HISTORY

• Phillipe Pinel- 1729
• Observed people with explosive irrational
  violence. These patients seemed to understand
  their actions surroundings, did not display
  delusions
• Manie sans delire mania without delirium

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History continued -

• 1891 Koch introduced term psychopathic
  inferiority
• attempted to define a physical basis rather than
  moral condemnation

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Statistics

• 2 US population
• More frequent in urban environments
• Lower socioeconomic groups
• Rates comparable across ethnicities
• 5x more common among 1st degree biological
  relatives of males
• 10x more common among 1st degree relatives of
  females

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Etiology

• APD- brains mature abnormally slow rate
• Similarities between the EEGs of adult
  psychopaths and normal adolescents
• Egocentricity
• Impulsivity
• Selfishness
• Unwillingness to delay gratification

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• Early brain damage in frontal cortex
• Similarities
• Poor long term planning
• Low frustration tolerance
• Shallow affect
• Irritability aggressiveness
• Socially inappropriate behavior
• impulsivity

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Etiology continued -

• Prolonged separations from primary caregivers,
  desertion and divorce (not death)
• Fathers antisocial or deviant behavior
• Mothers unaffectionate, neglectful care

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Epidemiologic Catchment Area study

• Study of psychiatric illnesses
• 15,000 people in 5 US cities
• Did not include individuals in prison
• Found
• 2 -4 men .5-1 women antisocial
• In the US this would mean approximately 7 million
  Americans antisocial

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Treatment Options

• Unfortunately, most APD/NPD dont think anything
  is wrong with them, referred because of others.
• Typically untreatable
• If going to treat, should be highly structured
  and secure inpatient setting.
• Use of psychotherapy
• Is there capacity of patient to form attachments?
• Can patient form genuine emotional relationship
  with therapist?

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European Description of Dissocial Personality
Disorder

• ICD-10 Classification of Mental and Behavioral
  Disorders
• Personality disorder, usually coming to attention
  because of a gross between behavior and the
  prevailing social norms, characterized by at
  least 3 of the following
• Callous unconcern for the feelings of others
• Gross and persistent attitude of irresponsibility
  and disregard for social norms, rules and
  obligations
• Incapacity to maintain enduring relationships,
  though having no difficulty in establishing them
• Very low tolerance to frustration and low
  threshold for discharge of aggression, including
  violence
• Incapacity to experience guilty and to profit
  from experience, especially punishment
• Marked proneness to blame others, offer plausible
  rationalizations
• Persistent irritability
• Conduct disorder during childhood not always
  present

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• C cannot follow the law
• O - obligations ignored
• R - remorselessness
• R - recklessness
• U - underhandedness
• P - planning deficit
• T - Temper

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Were they?
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Special Populations
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Who is a special needs inmate?

• These inmates have a physical or mental
  disability, or have lifestyles that limit his or
  her capacity to function in the normal inmate
  population
• Do NOT forget that an inmate that has special
  needs is still incarcerated FOR A REASON!

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Mental Health and Prisons The Challenge

• Mental disorders occur at high rates in all
  countries
• 450 million people worldwide suffer from mental
  health or behavioral disorders
• Many disorders are present before incarceration,
  but others are exacerbated by the stress of prison

• Prisons are bad for mental health
• Overcrowding
• Various forms of violence
• Lack of privacy
• Lack of meaningful activity
• Isolation from social networks
• Inadequate health services
• Stigma and discrimination by staff and other
  prisoners

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Mental Health and Prisons The Benefits of
Responding to Issues

• For Prisoners
• Improve quality of life
• Reduce stigma
• Likelihood of decreasing recidivism

• For Employees
• Prisoners with unattended to mental health needs
  further complicate and negatively effect the
  environment and places greater demands on staff
  this is reduced by addressing and treating mental
  health needs

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Mental Health Disabilities

• Subdivided into three categories
• Developmental Disabilities
• Often referred to as mentally retarded
• Based on IQ testing and has different levels of
  severity
• In general, offenders on GP yards that are
  classified MR are mildly mentally retarded
• Learning Disabilities
• Mental Illness

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Mental Retardation Signs

• At first, MR inmates may seem normal, or just a
  little slow. However, signs include
• Lack of personal hygiene
• i.e. forgetting to shower or brush their teeth
• Difficulty communicating
• Offenders may not be understood because their
  thinking is not logical

• Unusual or inappropriate social behavior
• They may think things are funny when no one else
  does or make inappropriate remarks
• Lacking basic life skills
• i.e. not knowing how to make a collect call
• Remember, these are SIGNS, not conclusive proof
  of retardation

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Managing MR Inmates

• Retarded people have difficulty functioning in
  numerous situations, especially new ones.
• They may seem confused and come across as
  defiant, though they are genuinely having
  difficulty learning.

• It is your job to BE ALERT! Take care to not
  misread this behavior.
• Remember that for the retarded inmate, this is
  not behavior he can control, it is a result of
  mental and learning deficits.

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COMMUNICATE!

• When communicating with MR inmates
• Give specific and concrete directions
• Use simple and direct language
• Use small, ordered directions
• Check to see steps are followed
• Do not give abstract directions
• "Fill this bucket with water and use the mop to
  wash the floor" versus "Clean this place up"

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Protecting MR Inmates

• Mentally retarded offenders can be easily
  manipulated or abused by other inmates because
  they are impressionable and sometimes eager to
  please.
• It is your job to not only protect them from
  physical, sexual, and emotional abuse, but also
  make sure that other inmates don't talk them into
  engaging in illegal behaviors.

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Learning Disabilities

• Intelligence is average or above average, but the
  inmate has difficulty using and understanding
  language.
• This includes problems with
• Listening
• Speaking
• Reading
• Writing
• Mathematics
• Logical thinking

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Helping Inmates with Learning Disabilities

• Make sure they get the information they need
• Give directions slowly and clearly
• Demonstrate behaviors and activities (if needed)
• Offer assistance do not complete tasks for them
• Protect them from others who might take advantage
  of them
• Be understanding
• Encourage independence

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Mental Illness Emotional Disturbances

• Signs may occur often or sporadically, but
  include
• Mood Changes
• Behavior Changes
• Changes in eating or sleeping patterns
• These signs need to be observed for significant
  and prolonged changes that are unrelated to
  current events

• Most common
• Schizophrenia
• Anxiety Disorders
• Paranoia
• Hypochondria
• Depression

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Remember

• Mentally ill inmates
• Are not "bad" people, they are sick
• Have real symptomsunderstand their feelings are
  genuine
• Take reinforcement from you! Stay positive and
  professionalit can diffuse potentially bad
  situations.

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Mental Illness Personality Disorders

• Inmates with personality disorders want their OWN
  rules, NOT to play by others'
• They are impulsive and often act without
  consideration of consequence
• Often compulsive liars without guilt
• They do not learn from experience, and are
  irresponsible, insisting, and entitled

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Working with Personality Disorders

• Be straightforward and factual
• Be consistent with enforcing rules
• Be mindful of attempts to manipulate and
  compromise
• When in doubt, contact mental health staff

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Mental Health and Prisons What Can Be Done?

• Refer prisoners who display mental health issues
  to mental health staff
• Provide prisoners with access to treatment and
  care
• Ensure availability of psychosocial support and
  medication (if necessary)

• Provide staff training
• Provide literature to prisoners on their issues

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Physical Disabilities

• Deaf inmates
• Carry a pen and paper to communicate
• To get their attention, tap them on the shoulder
• Blind inmates
• Familiarize this inmate with his living area
• When offering assistance, allow the inmate to
  take your arm for guidance

• Diabetes
• Diabetic coma is caused by not enough insulin in
  the blood stream
• Insulin shock is the result of too much insulin
  in the blood stream
• Both have symptoms that look similar to
  intoxicationknow your inmates and get medical
  attention immediately

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Physical Disabilities Continued

• Paraplegia
• Accommodations are made for inmates that are
  wheelchair bound, but remember that they are
  INMATES
• Be respectful, but cautious

• Epilepsy
• Seizures generally last 2 to 3 minutes
• When encountering an inmate having a seizure
• Remove all objects nearby
• Loosen tight clothing
• Turn the person on their side
• Call for medical assistance

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Medical Issues and Prison
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Medical Issues and Prison

• Though not in the top 5 health care issues,
  cancer, diabetes, and HIV/AIDS are also issues
  present in the prison population.
• Cancer accounts for 3.1 of health issues
• Diabetes and HIV/AIDS account for less than 1 of
  health issues

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Medical Issues and Prison Issues

• Inmates access to the medical department may be
  restricted to scheduled opening times, except for
  emergencies.
• Many facilities will not allow inmates to keep
  their own medications, making them dependent on
  the healthcare staff for dosing.
• Many tools necessary for managing disease are not
  permitted outside of the medical unit, making
  self-care impossible. For example, inmates with
  diabetes may not be able to keep glucose
  monitoring devices, lancets, insulin, or syringes
  in their possession for security reasons.
• Inmates have very few options with diet choices,
  adding to the challenge of medically managing
  inmates with certain chronic conditions (e.g.,
  diabetes and hypertension).
• The correctional environment can be unhealthy in
  itself, with lack of cleanliness, overcrowding,
  poor ventilation and lack of adequate lighting
  producing environmental concerns. Also, smoking
  is a common trait among the incarcerated, with
  estimates as high as 67 of inmates meeting
  clinical criteria for alcohol or drug use
  disorders.

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7 Ways Inmate Can Receive Quality Medical Care in
Corrections

• Treat inmates with respect
• Listen attentivelylisten for cues that
  distinguish a normal medical call out from an
  emergency
• Be honest
• Maintain appropriate boundariesthey may be
  patients, but they are inmates first
• For Doctors/Nurses Avoid the defensive medicine
  temptationdo not order more tests or medications
  for an inmate than you would for any other
  patient
• Focus on what you can do for them, not what you
  cannot do for them
• DOCUMENT, DOCUMENT, DOCUMENT!!!!!!!!!!!!!!!!!!!!!!
  !!!!!!!!

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LGBTI Population in Prison

• Prisoners that are lesbian, gay, bisexual,
  transsexual, or intrasexual are among the most
  vulnerable population of prisoners
• Prisoners that are openly gay or that are
  effeminate (in male prisons) or masculine (in
  female prisons) are at high risk for sexual
  assault and abuse
• Though many of these inmates are housed in
  Protective Custody, they are still at risk
• It is especially important for staff to recognize
  signs of abuse and follow PREA regulations when
  necessary

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Anatomical Issues with Transgendered Inmates

• Though transgendered inmates may be in the
  process of transitioning before being
  incarcerated, they are gender classified by their
  sexual organs. If they have not undergone
  complete transitioning, they are still their
  gender of birth.
• It is an important boundary issue that they be
  referred to as a man if not fully transitioned to
  a woman, and vice versa.
• Referring to the inmate as the gender that they
  have not yet transitioned to unconsciously sets
  them apart from everyone and can also cause
  unwanted attention to them.

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Suicide Prevention

• In the Corrections Environment

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Statistics

• Suicide is the leading cause of death in American
  Jails
• It is the third leading cause of death in
  American Prisons
• The majority of suicides are accomplished through
  hanging, which causes brain death in 4 minutes,
  and result in death in 5 or 6 minutes

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Statistics Per State

• The leading 5 states in prison suicide are
  California, Texas, New York, Illinois, and
  Maryland.
• Nevada is tied for 27th in prison suicides per
  state for 3 in 2010

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Mental Health Prevalence

• Major Depression
• 29.7 of population in Jails
• 23.5 of population in Prisons
• 16 of population in Federal Prisons
• Previous Mental Health Institutionalization
• 10 in combined population of all three have had
  at least one psychiatric hospitalization prior to
  incarceration
• APA review in 2000 found that 20 of prison and
  jail inmates are in need of psychiatric care and
  5 are actively psychotic

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Risk Factors

• Depression
• Any serious mental illness, such as schizophrenia
  and bipolar disorder
• Substance Abuse
• The combination of mental illness and substance
  abuse
• Borderline and Antisocial Personality Disorders
• Impulsivity and aggression
• History of suicide attempt or family history of
  suicide
• Serious physical illness or chronic pain
• Long Sentence
• Severe guilt or shame
• Rape or threat of rape
• Any recent drug/alcohol ingestion (Depression
  sets in when the euphoric effects wear off)

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High Risk Time Frames

• The first 24 hours of confinement!
• Intoxication or withdrawal
• Waiting for trial
• During sentencing
• After count time
• Around holidays
• After visitation
• Impending release
• After receiving bad news (i.e. death of a loved
  one, divorce, etc.)

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Warning Signs

• Talking about suicide or wanting to die
• Discussing ways in which it can be completed
• Talking about feeling hopeless
• Talking about feeling trapped
• Acting agitated or aggressive
• Behaving recklessly
• Sleeping too little or too much
• Not talking to others not coming out of cell for
  yard or tier time
• Showing rage
• Displaying extreme mood swings

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Warning Signs Continued

• Expressing excessive guilt or shame over offense
• Having a history of suicide attempts
• Expressing hopelessness/helplessness
• Excessive anxiety
• Extreme calm after a period of agitation
• Preoccupation with the past
• Packs up/gives away belongings
• Participates in self harming (parasuicidal)
  behaviors for attention
• Paranoia

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Depression

• Though any of the previous factors may contribute
  to suicidal intent, 70 to 80 of all suicides
  are committed by people who are severely
  depressed
• The most common symptoms of depression include
• Feelings of inability to continue
• Extreme sadness and/or crying
• Social isolation
• Fluctuations in appetite, weight, and sleep
• Mood/behavior changes
• Tension and anxiety
• Loss of motivation

• Cont
• Loss of self esteem
• Loss of interest
• Poor hygiene
• Difficulty concentrating
• Easily angered or increased agitation

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Suicide Prevention in Corrections

• Upon intake, assess suicide risk and imminent
  suicide risk. Risk status can change over time
  staff need to recognize and respond to changes in
  an inmates mental condition
• Information to follow an inmate in case of
  movement
• Previous/current threats
• Behaviors of depression
• History of psychiatric care
• PC or seg status
• Appropriate observation in isolation
  cellsremember, any segregation increases the
  risk for suicide!

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Identifying Suicidal Inmates

• PAY ATTENTION!!!!!

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The MOST critical time to pay attention to
warning signs is during the intake process!!

• OBSERVATION
• Pay attention to the inmates speech, attitude,
  and state of mind.
• Look for scars from previous attempts.
• Look for signs of recent trauma.
• Look for signs of current intoxication or
  withdrawal.

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Intake

• QUESTIONNAIRE
• This screens inmates personal histories as well
  as past/current mental and physical health.
• Try to do it in private and use language the
  inmate can understand.
• If the inmate is intoxicated, put under direct
  observation until he can participate.

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Intake

• DISPOSITION
• Following the observation and interview steps, a
  housing determination is made.
• Automatic isolation is not the key for suicidal
  inmates!
• This reinforces the risk for suicide.
• If isolation is needed, they need to be under
  direct staff supervision.

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Two Levels of Suicidality

• Low Risk Suicidal Inmates
• Not actively suicidal, but have a history of
  attempts or have current thoughts
• Should be housed with other inmates and checked
  by staff at regular, frequent intervals
• High Risk Suicidal Inmates
• Actively suicidal by expressing threats or
  engaging in suicidal behaviors
• Should be placed on suicide watch status and
  placed in suicide dress with no personal
  belongings

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But what about fakers?

• TAKE ALL THREATS SERIOUSLY! Do not make a
  judgment call regarding the sincerity of the
  threatcontact medical or mental health staff to
  assess and make a decision about the necessary
  intervention.

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When communicating with suicidal inmates, do not

• offer solutions or give advice
• become angry, judgmental, or threatening
• act sarcastically or make jokes
• placate and make promises
• challenge the inmate to follow through on the
  suicidal threat
• And above all, DO NOT IGNORE THE THREAT!

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Manipulation

• Inmate may threaten suicidal behavior to get
  something they want, or avoid something they
  dont want.
• Remember, its not your responsibility to make
  this call!
• Refer the inmate to mental health and
• DOCUMENT, DOCUMENT, DOCUMENT!

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Suicide Attempt/Completion

• 94 of inmate suicides are by hanging.
• NEVER assume the inmate is dead!
• 1. Call for back up
• 2. Survey the area for safety and security
• 3. Get help and cut inmate down
• Protect the head and neck as much as possible
• 4. Initiate CPR while back up calls for medical
• Even if there are no vital signs, do not stop CPR
  until medical staff tells you to do so

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Suicide Myths (Dont believe them!!!)

• Myth 1 People who threaten suicide dont commit
  suicide.
• FACT Most people who commit suicide have made
  direct or indirect statements of their
  intentions.
• Myth 2 People who have attempted suicide in the
  past will not do it again.
• FACT A history of attempts increases the
  likelihood of repeated attempts.

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Suicide Myths Continued

• Myth 3 Suicidal people are intent on dying.
• FACT Most suicidal people dont WANT to die, but
  they believe that is the only way out of their
  current situationthey think they are out of
  options.
• Myth 4 Talking to people about their suicidal
  thoughts will cause them to follow through.
• FACT You CANNOT make someone suicidal by
  discussing suicide.

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Suicide Myths Continued

• Myth 5 All suicidal people are mentally ill.
• FACT Suicidal people are extremely depressed and
  unhappy, they are not necessarily mentally ill.
• Myth 6 If someone really wants to kill
  themselves, theres nothing you can do about it.
• FACT Almost ALL prison and jail suicides CAN BE
  PREVENTED!

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You have the ability to prevent suicides.

• It takes attention to, observation of, and
  knowledge of the information weve discussed, and
  the courage to take action.

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Discussion Case Example
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Mr. Thomas

• Mr. Thomas is in his sixties. He has been
  incarcerated for 10 years for the murder of his
  wife. He is being treated for a serious medical
  condition which may be cancer.
• He has never had communication with family or
  friends. He works as a porter and is trusted by
  the officers. He was told yesterday that the
  parole board continued him for 10 more years.
• His parole appearance occurred during a week when
  the normal unit SC/O was on leave. Mr. Thomas
  often spoke with him about life in general.
• Today, two days after the parole hearing, Mr.
  Thomas was found hanging in the supply closet.

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What were Mr. Thomas's Risk Factors?

• Serious physical illness
• Possible undiagnosed depression
• Parole news creating hopelessness
• Lack of usual social stimulation while SC/O was
  away isolation
• Access to supply closet and lethal means

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How could Mr. Thomas's suicide have been
prevented?
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Hey youyeah, YOU!

• Correctional staff, NOT just inmates, can also be
  at risk for suicide. This includes officers,
  nurses, case workers, psychologists, etc.
• Not only do you have "normal" problemsnot enough
  money, not enough time, stress, bills, etc.you
  work everyday with some of the darkest of human
  kind that view you as "the enemy."

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Sound familiar?

• After balancing the checkbook until 1am and
  finding that the mounting bills provided you
  nothing more than a fitful sleep, you wake up and
  realize that it's 445am, and your shift starts
  at 5am. No time to prepare yourself for the day,
  you battle terrible drivers, arrive at work, and
  are greeted by your supervisor that is none too
  happy about your tardiness. During your shift,
  you feel underappreciated by "the brass" and are
  subjected to constant verbal harassment by
  inmates. After enduring this for 8 hours, you
  encounter the same bad drivers on the way home,
  where financial, relational, and other stressors
  await.
• On top of other potential risk factors, is it
  really that surprising that officers,
  specifically, commit suicide at a rate that is
  double that of the regular population?

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You are NOT alone!

• Don't hold everything in. Talk to family and
  friends. See a therapist. Set aside time for
  things you enjoy. But don't ignore your stress
  and hope it goes away.
• Stress, depression, anger, etc. will ONLY go away
  if you face it with healthy coping skills.

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Put beautifully by a former C.O.

• We have all been in some very dark places in our
  lives.  I know that I have, and sometimes suicide
  seems like a solution. What has helped me to hold
  on in seemingly hopeless times is something my
  father shared with me in my darker days. No
  matter what position you are in, there is always
  hope and potential while you still have life.
  Once your life is gone there is no hope, there is
  no recovery. It is over, and there is no getting
  it back. If this reaches anyone out there who is
  contemplating this as an option, please talk to
  someone.Call the Ventline. I hate hearing the
  news of corrections workers killing themselves.
  Everyone makes mistakes, poor choices, and is
  afraid of consequences. But no consequence is so
  severe that one should do this to themselves. God
  bless you all. Take care of yourselves and one
  another.