Principles of managing patients with personality disorder

Personality Disorders, Risky Behaviors, and Adversity: The Moderating Role of Resilience

Individuals with personality disorders (PDs) comprise 30% to 40% of individuals receiving mental health treatment. Treatment of PDs is exceedingly difficult; therefore, research has focused on PD etiology and preventative factors. One known influence on PD etiology is adverse childhood experiences (ACEs). ACEs are associated with increased prevalence of several health risk behaviors (HRBs), including engagement in substance use, criminal, and risky sexual behavior. One protective factor, childhood resiliency, predicts lower prevalence of PDs and engagement in HRBs. We hypothesized that increased prevalence of ACEs would predict higher levels of PD symptoms and HRBs engagement. Furthermore, we predicted that childhood resiliency would moderate the relation between ACEs, PD symptoms, and HRBs. In the present study, students (N = 531) completed the Adverse Childhood Experiences survey, the Self-Administered - Standardized Assessment of Personality Abbreviated Scale, and the Childhood Youth and Resiliency Measure-28. They also responded to questions about substance use, criminal, and sexual behavior which were used to define a latent HRB variable. Structural equation modeling was conducted to examine study hypotheses. As hypothesized, we found positive relations between ACEs, PD symptoms, and our HRB latent variable. Childhood resiliency moderated both ACE and PD symptom paths. At lower levels of reported ACEs, individuals high in childhood resiliency reported fewer PD symptoms and HRBs than individuals low in childhood resiliency. At high levels of ACEs, childhood resiliency did not serve as a protective factor. Additionally, study findings suggest that childhood resiliency factors are integral for protecting against the development of these disorders.

DEA-based Performance Evaluation of Libraries: A Systematic Mapping study

Este estudio emplea un estudio de mapeo sistemático para analizar publicaciones sobre evaluación del desempeño de la biblioteca con análisis por envoltura de datos (DEA, por sus siglas en inglés). La revisión se basa en una búsqueda exhaustiva en la literatura académica que incluye bases de datos científicas de Scopus y Web of Science. Se seleccionaron 44 artículos publicados entre 1997 y 2018 como el núcleo del estudio. Los resultados muestran que los estudios publicados son realizados principalmente por especialistas en economía, administración, ingeniería y apenas por especialistas en bibliotecología y ciencias de la información. Curiosamente, una gran cantidad de los estudios se llevan a cabo en Taiwán y los Estados Unidos con un enfoque específico en la evaluación del desempeño de las bibliotecas universitarias. Los resultados de este estudio identifican lagunas en términos de técnicas, métodos y procesos utilizados para evaluar el rendimiento de las bibliotecas. Identificar estas brechas puede ayudar a los investigadores de las Ciencias de la Información y Bibliotecología a prestar más atención a la investigación sobre la evaluación del desempeño de las bibliotecas. Además, el estudio identifica las variables clave de entrada y salida en la evaluación del desempeño de las bibliotecas.

A Biblioterapia como ferramenta de restabelecimento emocional

Se reflexiona sobre el campo de acción del bibliotecario con énfasis en la efectividad de la biblioterapia para el restablecimiento de individuos que sufren trastornos emocionales. El objetivo general ha sido debatir temas relacionados con los trastornos emocionales, presentando sugerencias biblioterapéuticas como alternativas complementarias. El campo de acción, tanto para el bibliotecario como para cualquier otro profesional, implica darse cuenta de que cada profesión está vinculada a un determinado nivel de conocimientos. La biblioterapia como una práctica de lectura utiliza textos verbales y no verbales como complementos en el tratamiento de personas afectadas por enfermedades físicas o mentales. Se recomienda la biblioterapia para personas que enfrentan trastornos emocionales.

Prescribing in personality disorder: patients' perspectives on their encounters with GPs and psychiatrists

Objective

The purpose of this study was to explore the views of patients with personality disorder on their experiences of prescribing practices by general practitioners (GPs) and psychiatrists, and their expectations of primary and secondary mental health services.

Design

This was a qualitative study involving two focus groups. Discussion in the focus groups was recorded, transcribed verbatim and then analysed by a thematic analysis process to generate the key themes.

Setting

The study took place at a specialist outpatient personality disorder service in the UK.

Participants

A total of seven participants took part in the study. They were purposively sampled from an NHS specialist outpatient personality disorder service. All participants had a primary diagnosis of emotionally unstable personality disorder and their age ranged from 20 to 52 years.

Results

Five key themes emerged. Participants felt that medication has a powerful impact on their mind and body but expressed confusion and uncertainty on how it is affecting them. Participants had a need for a good relationship with their doctors (GPs or psychiatrists). They described a feeling of being dismissed and not believed, expressing a desire to confront the ‘powerful’ position of their doctors by showing anger. The nature of the doctor-patient relationship was seen to moderate positively or negatively the experience of doctors’ prescribing. Finally, there were key expectations of the primary-secondary care interface, including continuity of care, diagnostic clarity and a desire for different healthcare professionals to communicate with one another.

Conclusion

The doctor-patient relationship is an important medium for providing validation and seeking negotiation of therapeutic treatment strategies in patients with personality disorder. Given that personality disorder is associated with high rates of physical and mental health comorbidity, it is therefore vital for clinical guidelines and training packages to take more account of the relational aspects of prescribing in consultations for this patient group with a view to improve outcomes.

Co-morbid personality disorder in early intervention psychosis clients is associated with greater key worker emotional involvement

AIM

Co-morbid personality disorder (PD) is associated with poorer outcomes in psychosis patients, but it is not known whether these patterns are present at illness onset. This study investigated the prevalence of co-morbid PD in clients of an Early Intervention in Psychosis Service (EIPS) and compared key worker engagement and service use between patients with and without co-morbid PD.

METHOD

Forty-nine participants were recruited from an inner London NHS EIPS. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) Axis II Disorders was administered to identify whether participants met criteria for a diagnosis of PD. Key workers completed measures investigating the therapeutic relationship and emotional involvement. Data on service use over a 2-year period from the date on which the patient was accepted by the EIPS were collected from electronic clinical records. Service use and key worker informed data were collected blind to PD diagnosis.

RESULTS

Twenty-two of the 49 (45%) patients met criteria for co-morbid PD. Keyworker worry and tension were significantly higher in relation to patients with co-morbid PD compared with those without. There were no significant differences between groups in appointments offered or attended, but patients with co-morbid PD were significantly less likely to be admitted to hospital than those without.

CONCLUSIONS

Co-morbid PD is common in EIPS patients. The EIPS model is both assertive and intensive; although this appears to be effective in preventing hospital admissions, this does not equip professionals to manage the higher emotional burden associated with a co-morbid PD diagnosis.

Attitudes to personality disorder of staff working in high-security and medium-security hospitals

The discourse surrounding personality disorder is largely negative, and the diagnosis is considered to be associated with a degree of stigma. This study aimed to investigate staff attitudes towards personality disorder in high-security and medium-security forensic-psychiatric hospitals in the UK. The Attitude to Personality Disorder Questionnaire was completed by 132 participants who were all current employees with clinical roles. Staff attitudes to personality disorder in the current study were significantly less positive than in comparable studies in similar settings. Having completed staff training surrounding personality disorder and being from a non-nursing professional background were the best predictors of positive attitudes to personality disorder. The findings of this study offer support to the pursuit of improving access to training in personality disorder for those working with this clinical presentation. Copyright © 2017 John Wiley & Sons, Ltd.

Management of personality disorders in acute in-patient settings. Part 1: Borderline personality disorders

General principles of management of patients with personality disorders admitted in crises to the in-patient unit are discussed. The role of the acute ward in the overall plan of care, the clinical thresholds to consider in deciding whether admission is appropriate and the main elements of the in-patient care plan are outlined. The management of patients with borderline personality disorder, who constitute the majority of such admissions, is discussed in detail.

The role of interpersonal personality traits and reassurance seeking in eating disorder symptoms and depressive symptoms among women with bulimia nervosa

INTRODUCTION

The role of interpersonal factors has been proposed in various models of eating disorder (ED) psychopathology and treatment. We examined the independent and interactive contributions of two interpersonal-focused personality traits (i.e., social avoidance and insecure attachment) and reassurance seeking in relation to global ED psychopathology and depressive symptoms among women with bulimia nervosa (BN).

METHOD

Participants were 204 adult women with full or subclinical BN who completed a battery of self-report questionnaires. Hierarchical multiple OLS regressions including main effects and interaction terms were used to analyze the data.

RESULTS

Main effects were found for social avoidance and insecure attachment in association with global ED psychopathology and depressive symptoms. In addition, two-way interactions between social avoidance and reassurance seeking were observed for both global ED psychopathology and depressive symptoms. In general, reassurance seeking strengthened the association between social avoidance and global ED psychopathology and depressive symptoms.

CONCLUSION

These results demonstrate the importance of reassurance seeking in psychopathology among women with BN who display personality features characterized by social avoidance.

Inpatient management of borderline personality disorder at Helen Joseph Hospital, Johannesburg

Objective

The aim of this report was to establish a profile of patients with borderline personality disorder (BPD) admitted to the acute inpatient psychiatric assessment unit at the Helen Joseph Hospital, in Johannesburg, over the course of 1 year.

Methods

A retrospective record review was conducted to investigate the prevalence, demographics, reasons for admission, treatment, length of stay and follow-up of a group of inpatients during 2010 with a diagnosis of BPD, based on DSM-IV-TR diagnostic criteria, allocated on discharge.

Results

Considering evidence retrospectively, the quality of the BPD diagnosis allocated appeared adequate. Statistical analysis revealed findings mainly in keeping with other reports, for example, that patients with BPD are above-average users of resources who make significantly more use of emergency services and that they generally do not adhere well to their scheduled outpatient follow-up arrangements. The longer average length of inpatient stay of this group with BPD, however, exceeded the typically brief period generally recommended for acute inpatient containment and emergency intervention.

Conclusion

Implementation of targeted prevention and early intervention strategies, based on systematised programmes such as dialectical behavioural therapy and mentalisation based therapy, may be useful in addressing these problems experienced with integrating the in- and outpatient management of BPD.

Lifetime trauma victimization and PTSD in relation to psychopathy and antisocial personality disorder in a sample of incarcerated women and men

Purpose

– Antisocial personality disorder (ASPD) and psychopathy are similar, but distinct, psychiatric conditions that are common in male and female inmates; a segment of the population with high rates of trauma exposure. It is unclear whether specific types of lifetime trauma are associated with ASPD and psychopathy in incarcerated women and men. Furthermore, the unique roles of post-traumatic stress disorder (PTSD) symptom severity and trauma victimization in antisocial personality disturbance are not well-understood. The paper aims to discuss these issues.

Design/methodology/approach

– This study investigated associations between trauma variables (different kinds of traumatic experiences and PTSD) and antisocial personality variables (ASPD and psychopathy) in a sample of incarcerated women and men who participated in a randomized clinical trial for major depressive disorder. In total, 88 incarcerated men and women were assessed for ASPD diagnosis, psychopathy severity, PTSD symptom severity, and history of physical, sexual, and crime-related trauma. Regression analyses predicted ASPD or psychopathy from trauma variables, controlling for gender.

Findings

– Physical trauma was the only form of trauma that was significantly related to psychopathy. Physical trauma and crime-related trauma were associated with ASPD. PTSD symptom severity was not associated with psychopathy or ASPD.

Originality/value

– There are associations between some kinds of lifetime trauma exposure and current ASPD/psychopathy in the target sample, but these associations do not appear to be mediated through current PTSD symptoms.

Personality disorders in geriatric inpatients in a tertiary hospital

OBJECTIVE

To assess the prevalence of personality disorders in general medical geriatric admissions.

METHODS

Forty of 508 general medical geriatric admissions screened at a large tertiary hospital, who were eligible as defined by a Mini-Mental State Examination score of over 23 and capable of informed consent, were assessed by direct interview and discussion with the patient's family or close contact to determine personality traits.

RESULTS

Eight (20%) of these patients were found to satisfy DSM-IV criteria for a personality disorder. They were found to have significantly lower global assessments of functioning, impaired overall functioning and lower quality of life compared with non-personality disordered patients. None of their personality disorders had been recognised by their treating teams.

CONCLUSIONS

This study supports the need for systematic research into the area and the need for increased clinical awareness of the issues.

The impact of a diagnosis of personality disorder on service usage in an adult Community Mental Health Team

PURPOSE

Patients with a diagnosis of personality disorder (PD) have multiple and diverse needs. It has been noted that individuals with personality disorder are high users of health care resources, especially psychiatric services, ambulance services and emergency departments. In addition PD has been shown to be a significant predictor of disability and mental health consultations independent of Axis I disorders and physical conditions. This study aimed to compare the patterns of service usage, clinical ratings of symptoms and functioning, as well as demographic and clinically relevant historical variables between a group of patients with PD and a random sample of all other patients registered with a South London Community Mental Health Team.

METHODS

A case–control design was used to examine service usage patterns over a one-year period for 73 cases and 96 controls. Diagnoses were established by clinician discussion. Clinical outcomes were measured with Health of the Nation Outcome Scales and Global Assessment of Functioning, while service use was recorded using ten variables obtained from case note review.

RESULTS

People with a diagnosis of PD were more often white and had a history of abuse, particularly childhood emotional abuse. They were higher users of some aspects of the service as compared to controls, and had significantly higher severity of symptoms and poorer functioning on clinician-rated measures.

CONCLUSION

This study confirms previous findings that people with PD have more severe symptomatology and greater degrees of functional impairment when compared to those without. Community clinicians should routinely screen attenders to predict likely difficulties that might arise and to make provision for these difficulties in the treatment and management of clients.

A treatment goal checklist for people with personality disorder

BACKGROUND

Agreement between client and therapist on treatment goals has been consistently linked with improved treatment outcomes. Having clear and collaborative goals may be particularly important when working with clients diagnosed with personality disorders who are often difficult to engage and test the boundaries of therapy. This paper outlines the development of a personality disorder treatment goal checklist aimed at helping clients and therapists to identify and prioritize their goals for therapy.

METHOD

The checklist was developed using self-reported problems of the first 90 participants randomized into the psychoeducation and problem solving (PEPS) trial. Problems were coded and categorized into problem areas. The checklist was viewed by two service users who gave suggestions for improvements.

RESULTS

The final checklist consists of 161 items in 16 problem areas.

CONCLUSIONS

The checklist may provide a clinically useful tool for working with this client group.

Comorbidity of psychiatric and personality disorders in first suicide attempters: a case-control study

OBJECTIVES

Comorbid psychiatric and personality disorders in suicide attempters pose greater estimated risk of suicide than psychiatric disorders alone. The current study aimed to evaluate prevalence and pattern of psychiatric and/or personality morbidity and comorbidity in first-time suicide attempters in comparison to the age and sex matched community sample.

METHODS

Socio-demographic variables, family background, psychiatric morbidity and comorbidity in survivors of first suicide attempt were compared to age and sex matched community controls. Structured (Mini International Neuropsychiatric Interview plus) and semi-structured (International Personality Disorder Examination) clinical interviews were utilized to evaluate for axis-I and axis-II (personality) diagnosis. Risk-rescue rating was administered to assess medical seriousness of suicide attempt.

RESULTS

Individuals who made a first suicide attempt showed significantly lower educational achievement (P<0.0001; OR 1.56; 95% CI 0.89-2.74), but no significant difference in other socio-demographic variables compared to the controls. Cases had high family history of psychiatric illnesses (31% vs. 7%; P<0.0001; OR 5.97; 95% CI 2.48-14.35); high prevalence of psychiatric disorders (89% vs. 25%; P<0.0001; OR 24.27 95% CI 11.21-52.57), personality disorders (52% vs. 24%; P<0.0001; OR 3.43; 95% CI 1.88-6.28), comorbidity of psychiatric and personality disorders (51.6% vs. 19.5%; P=0.022; OR 3.01; 95% CI 1.14-7.92), and high overall prevalence of any axis-I and/or axis-II (personality) morbidity (93% vs. 41%; P<0.0001; OR 19.12; 95% CI 8.05-45.43), compared to controls.

CONCLUSION

Survivors of first suicide attempt are at nineteen times increased odds of having psychiatric morbidity and/or comorbidity, especially with personality disorders. Personality evaluation and management in such individuals may result in better comprehensive approach to health care.

How personality became treatable: The mutual constitution of clinical knowledge and mental health law

In recent years, personality disorders – psychiatric constructs understood as enduring dysfunctions of personality – have come into ever-greater focus for British policymakers, mental health professionals and service-users. Disputes have focussed largely on highly controversial attempts by the UK Department of Health to introduce mental health law and policy (now enshrined within the 2007 Mental Health Act of England and Wales). At the same time, clinical framings of personality disorder have dramatically shifted: once regarded as untreatable conditions, severe personality disorders are today thought of by many clinicians to be responsive to psychiatric and psychological intervention. In this article, I chart this transformation by means of a diachronic analysis of debates and institutional shifts pertaining to both attempts to change the law, and understandings of personality disorder. In so doing, I show how mental health policy and practice have mutually constituted one another, such that the aims of clinicians and policymakers have come to be closely aligned. I argue that it is precisely through these reciprocally constitutive processes that the profound reconfiguration of personality disorder from being an obdurate to a plastic condition has occurred; this demonstrates the significance of interactions between law and the health professions in shaping not only the State’s management of pathology, but also perceptions of its very nature.

An evaluation of a managed clinical network for personality disorder: breaking new ground or top dressing?

RATIONALE, AIMS AND OBJECTIVES

This article describes an evaluation of an innovative managed clinical network in the UK. The purpose of the network was to establish a better-coordinated service for those with personality disorder. The network was evaluated with regard to the extent it met its stated and implied outcomes; the process whereby it was established and operated; and the views of the various stakeholders involved. Managed clinical networks are briefly reviewed.

METHODS

Methods to gather evaluation data included documentary analysis, the use of specially devised tools to assess partnership, staff development needs and record keeping, and interviews.

RESULTS

While the network had achieved its objectives to establish new operational structures and communication networks and staff showed a high level of commitment, it was unclear whether the network had maintained or improved the clinical service. Record keeping for assessment and clinical intervention was at an early stage and there was a need for more systematic use of assessment instruments and data management systems. The creation of a new category of staff - the Network coordinator - raised problems of delivery and staff development.

CONCLUSIONS

On the basis of this evaluation and at this stage of one network's development it is concluded that the benefits of a managed clinical network remain theoretical rather than proven.

Personality disorders in patients seeking appearance-altering procedures

The practice of psychological risk assessment (PRA) is an indispensable component of the screening process for patients seeking elective appearance-altering procedures (AAPs). Despite the need for more literature in PRA, some risk factors for psychological adverse outcomes have been established. Among these risk factors are personality disorders. This article provides some background regarding psychological risk factors associated with personality disorders for patients seeking AAPs and a brief introduction to personality disorders for the surgeons to be better prepared to identify these conditions while conducting a PRA.

Scotland's national approach to improving mental health services: integrated care pathways as tools for redesign and continuous quality improvement

National Health Service (NHS) Scotland is taking a national approach to improving the quality and safety of mental health services. This programme relies on implementing integrated care pathways (ICPs) for people with mental health conditions across the whole journey of care.

This long-term improvement programme has started with the publication of national standards by NHS Quality Improvement Scotland (NHS QIS), setting out the framework of what needs to be developed in each local area.

The emphasis of development and implementation of the ICPs lies with local NHS Boards to ensure they are developed with local ownership and to meet the needs of the local population. However, to ensure accreditation by NHS QIS, the local ICPs must incorporate the national standards and evidence improvement to the quality of care provided.

A concerted effort has been made to ensure good involvement of service users, social work colleagues and NHS staff in order to get buy-in from all stakeholders.

NHS QIS is also supporting local boards and their partner agencies in their implementation of ICPs through a team of National ICP Coordinators and has developed a web-based toolkit to act as an electronic resource: www.icptoolkit.org . This supportive and facilitative approach helped to ensure that person-centred care was driving service redesign.

This is the beginning of a long-term improvement programme that has been carefully staged and is being facilitated in order to give it the best chance for success. In Scotland, ICPs for mental health are being used as a tool for service redesign and continuous quality improvement and a way to focus on meeting service user needs.

Perspectives on the prevalence and treatment of personality disorder

Personality disorder (PD) is the most prevalent psychiatric disorder. A methodical literature search identified that PD is under researched compared with other mental health problems such as depression or schizophrenia. Social and psychotherapeutic approaches emerge as dominant treatment approaches with PD where there is good evidence of efficacy. Collaborative group-based therapeutic approaches appear to offer a therapeutic counterpoise to the anti-social traits often prevalent in PD. A retrospective analysis of formal group therapy on acute inpatient units (treating PD patients among other mental health disorders) reveals only one violent incident in over 40,000 treatment hours of formal group therapy. It is argued that group-based and social therapy should be the recommended treatment approach because these approaches have been shown to create a safe and contained milieu, establishing a good base for therapeutic gain with PD patients. The case for widening the scope of collaborative group and community-based therapies is considered and the merits and shortcomings of a key worker system with PD patients are critiqued.

Transtornos de personalidade, psicopatia e serial killers

OBJETIVO: Apresentar as características básicas dos diversos transtornos específicos de personalidade, mas centrando-se no transtorno de personalidade anti-social, fazendo sua diferenciação com psicopatia. O estudo ainda se propõe a abordar a figura do serial killer, apontando a presença de aspectos psicopáticos no homicídio seriado. MÉTODO: Uma revisão bibliográfica foi feita no sentido de se abordar convergências e divergências entre diversos autores sobre um assunto tão polêmico, sobretudo quanto à viabilidade de tratamento dessa clientela forense. RESULTADOS: Enquanto o transtorno de personalidade anti-social é um diagnóstico médico, pode-se entender o termo "psicopatia", pertencente à esfera psiquiátrico-forense, como um "diagnóstico legal". Não se pode falar ainda de tratamento eficaz para os chamados "serial killers". CONCLUSÃO: Os transtornos de personalidade, especialmente o tipo anti-social, representam ainda hoje um verdadeiro desafio para a psiquiatria forense. O local mais adequado e justo para seus portadores, bem como recomendação homogênea e padronizada de tratamento são questões ainda não respondidas.