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Enys Delmage Consultant in Adolescent Forensic Psychiatry.

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Emerging Personality Disorder Enys Delmage Consultant in Adolescent Forensic Psychiatry
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Page 1: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Emerging Personality Disorder

Enys DelmageConsultant in Adolescent Forensic Psychiatry

Page 3: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Family Born in Exeter – mother aged 17 Biological father unknown – could be any one

of three men (ages 25-45) – two have left the area and one is in prison (serious assault on another woman)

Lives with mother who is sofa-surfing throughout pregnancy but gets local authority housing

Mother gave up drugs when she found out she was pregnant (5 months) but has started using again since he was born

Page 5: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Social Interactions School are worried about attendance and

have queried autism Often inappropriately dressed for the weather Paul struggles to maintain friendships and

shows “no emotions – just looks distant all the time”

Lashes out when people try to cuddle him Social services struggle to engage mother

who is frequently not in, abusive when she is there and appears to be intermittently using drugs

Page 7: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

School and Home Rejects authority – hates police and teachers No engagement with CAMHS or local authority Was designated as a “child in need” and has had 2

placements in local authority care (emergency foster placements) but returned to mother (who now has four other children)

CPP in place Violent to mother at times (Olweus 1979) – “out of

control” – “ADHD” (Farringdon 1990) though no diagnosis; “all started suddenly a few months ago – maybe he’s got schizophrenia – his uncles have that”

Cruel to family dog – withholds treats, teases it, squeezes its neck and holds it down on the floor until it barks

Page 9: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Risk Behaviour Not attending school Long PNC record from 10 (cf. McAra, 2007) – violence,

abusive to authority figures Prolific self-injurious behaviour Sexually vulnerable – uses large amounts of cannabis,

alcohol and amphetamines, and frequently gets these via sexual liaisons with older men

Hard to track him Known to YOT but has rejected CAMHS and LA input Not permanently living with mother - can be of no fixed

abode at times No long-term partner/friends – uses people

instrumentally

Page 11: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

What next?

1. Nothing – disappears or continues low-level offending and rejection of support until some degree of burnout in late 20s

2. Serious offence and STC/YOI/”secure college”3. LASCH4. Self-harm and hospital5. Dead6. Engaged with YOT worker and begins to develop

good links with a small number of individuals whom he trusts, gets into education, develops prosocial coping mechanisms, starts a family and breaks the cycle

Page 14: Enys Delmage Consultant in Adolescent Forensic Psychiatry.
Page 19: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Frontal Lobes

• Not really developing meaningfully until age 17 (Gur 2004)

• NIMH study:• Organisation increasing with age

(Schmithorst 2002): dtMRI

• Frontal lobe development up to 25 (Sowell 2001; Blakemore 2006; Vizard 2008)

• Process of proliferation and attrition of grey matter (Gogaty 2004)

• Cognitive processing and information processing slower with more grey than white matter (Yurgelen-Todd 2003)

Page 20: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Proliferation and Attrition• Brain development continues into the early twenties (Blakemore, 2006;

Sowell, 2001)

• Teenage years: proliferation of grey matter (processing) (M>F) followed by

“pruning” (F>M) with replacement by white matter (transmission of info)

(Giedd, 1999; Blakemore, 2006) – frontal lobe is last to develop (Sowell,

1999; Gogaty 2004)

• Executive development increases over the course of adolescence (Anderson,

2001) and into adulthood (Sowell, 2003)

• Ability to engage in consequential thinking increases throughout adolescence

in tandem with these changes (Steinberg, 2009)

• Judgement also: gradual course into 20s (Cauffman, 2000)

• Social cognitions (self awareness, theory of mind) and perspective-taking

also evolves into 20s (Blakemore, 2006)

Page 21: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Judgement and Empathy• Slow judgement abilities, but...

• Amygdala (reward, emotion processing) is quick to develop

• Thought to account for increased risk taking and arousal in adolescence

(Royal Society, 2011)

• Increased impulsivity, sensation-seeking and risk-taking behaviour (van

Leijenhorst, 2010; Baird, 2005; Steinberg, 2007)

• Empathy continues to develop gradually (Strayer, 1993)

• Heightened vulnerability to peer influence (Steinberg, 2007)

• Those aged 11-13 have markedly poorer reasoning skills than those aged 16

and 17 (Scott, 2004) and poorer consequential thinking in comparison to

adults (Baird, 2004)

Page 22: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Emotion vs. consequences

• “If you’ve been insulted, your emotional brain says ‘kill’, but your frontal lobe says ‘you’re in the middle of a cocktail party so let’s respond with a cutting remark instead’”

• Impulse control experiments demonstrate that adolescents use different parts of their brain to control impulses (cerebellum) and are less good at it (Luna, 2001)

• Emotional recognition not as good in teens (Baird, 1999)

• “Affect regulation” – ability to delay impulsive and emotional reactions sufficiently to allow for rational selection of appropriate response (Giancola, 2000)

• Decision-making often weaker than in adults (Scott, 2008)

• Less future-orientated in decisions (Greene, 1986; Nurmi, 1991)

Page 23: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Intellect and Risk Perception

• Role of experience – acquiring new information and “practicing” cognitive abilities (Flavell, 1993)

• Developmental differences in both biochemistry and anatomy that limit:

1. Perception of risk both to the individual and to others;2. Control of impulses;3. Understanding of consequences;4. Control of emotions (Lexson, 1998; Rutherford, 2002)• Tend to weight gains more heavily than losses compared to adults

(Furby, 1992; Benthin, 1993; Gardner, 1993)

• Peer influence: more susceptible (peaks at 14) (Steinberg, 1986; Scott, 1995)

• More likely to falsely confess (Redlich, 2003)

Page 24: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Childhood Trauma SequelaeAJP 2014: Gray Matter Abnormalities in Childhood Maltreatment: A Voxel-Wise Meta-Analysis (Lim L, Radua J, Rubia K)Reduced grey matter in amygdala and insulaCanJPsych 2013: Childhood Maltreatment and Aggressive Behaviour in Violent Offenders with Psychopathy (Kolla N, Malcolm C, Attard S, Arenovich T, Blackwood N, Hodgins S) Association between childhood physical abuse and lifetime reactive aggression Mistreatment also associated with psychological problems and changes in the HPA axis (overactivity=increased impulsive aggression, underactivity=lack of empathy, non-responsiveness to punishment and increased instrumental aggression (Kiehl, 2001)) Young people who have experienced abuse: 11 times more likely to be arrested for a violent crime (English 2002; see also Boswell 1995)Conduct Disorder in YOIs/STCs: 80-90%

Page 25: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Trauma Impact (Perry, 2002)

Page 26: Enys Delmage Consultant in Adolescent Forensic Psychiatry.
Page 27: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Conduct Disorder: Everyone’s Business Children with Conduct Disorder/Mixed

Disorder of Conduct and Emotions (Health) Juvenile Delinquent/YO (CJS) “Chav” (Daily Mail) NEET (Education) LAC/”Child in Need” (Local Authority) “My son” How many? NICE – 1.2 million (E+W+S+I) Secure beds? 200ish

Page 28: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Conduct Disorder• Diagnosis? Dissatisfactory• Based not on internal traits, but on behaviour...• ....which can have multiple origins• Less than 50% conversion rate to adult PD• Stealing, truanting, fire-setting, lying, offences involving confrontation with a victim, use of a weapon, running away from home, destruction of property of others, aggression to people or animals

• How does it differ from normal teenage behaviour? Just degree?

Page 29: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Conduct Disorder vs. Typical Development• Different brain scans (Fallon 2005; Fairchild 2011) – prefrontal cortex and grey matter differences•Impaired moral socialisation (Wootton 2005, Blair 2005, Kochanska 2007)•Maltreatment also linked to violent offending (English, 2002)• Adults: poorer quality decisions despite longer deliberation period (De Brito 2013) and reduced frontal lobe volume in adults mistreated as children (De Brito 2009)

Page 30: Enys Delmage Consultant in Adolescent Forensic Psychiatry.

Challenges?• Paul – 17 years and 364 days…• Transitions managed badly• Hard to get this group recognised• Hard to discuss medication• Research is difficult to do• Distance and numbers can make it even harder• Lack of evidence base and perception of poor outcomes makes it less attractive

• Can be risky – physical, mental, financial• BUT – usually the most in need, damaged, complex, disenfranchised group you could hope to find in CAMHS


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