Autumn In-Brief 2018 V10 FINAL - Flipbook - Page 8
The pathway for personality disorder
Dr Richard Ford evaluates the structured support options
Fifteen years ago the NHS started to change its approach
to helping people with a personality disorder. Since then
there has been NICE guidance and therapists trained in
evidence based interventions; but have things really
changed? Only a minority of people currently access
treatment and still many people feel rejected:
“The fact of the matter is, I can be a difficult person. I
am having trouble regulating my moods, I have the
emotional intensity of a toddler, - but when I’m at my
worst, that’s when I need the most love and
acceptance to help me out of that place. Because
really, that’s all anyone with Borderline Personality
Disorder wants, to be loved and accepted for who we
are” - Claire (from Time to Change)
Establishing the baseline
Most patient information systems have either diagnostic
or more likely ‘clustering’ information. ‘Cluster 8’ is a
useful proxy to describe the needs of people with a
personality disorder. The figure below (a) shows a typical
mental health NHS trust we have worked with. We also
found that patients in cluster 8 were more likely than other
to be younger, female and white British.
(a) Population by patient type
12.4%
In this article, based on our experience of working with
services, we set out how providers of mental health
services can systematically and cost-effectively change
access and treatment pathways for people with
personality disorders.
What is a personality disorder?
There are many forms of personality disorder, the most
common form presenting to mental health services, and
the focus of this article is ‘borderline’ personality disorder
(BPD). This is most common in early adulthood and in
women; NICE estimates the prevalence of BPD at 1% of
the population and describes it as: characterised by
significant instability of interpersonal relationships, selfimage and mood, and impulsive behaviour. There is a
pattern of sometimes rapid fluctuation from periods of
confidence to despair, with fear of abandonment and
rejection, and a strong tendency towards suicidal thinking
and self-harm… People with borderline personality
disorder are particularly at risk of suicide.
NICE also has a guideline for anti-social personality
disorder (ASD). The prevalence of this disorder is higher
in men (3%) and lower in women (1%) and has a broad
spectrum of severity. Half of people in prison are said to
have this disorder and multi-agency working is key to
delivery of long term group programmes.
Service users, of course, have lived experience of how
services have helped or rejected them. Many will have
experienced the cycle of self harm and suicidal thoughts –
asking for help – being rejected – increasingly severe and
risky self harm – A&E – crisis admission. Once admitted
the cycle can continue leading to detention under the
MHA (Mental Health Act), transfer to psychiatric intensive
care and even long-term hospitalisation. Others, however,
will know about services that have helped them selfregulate their emotions and to become more independent.
8
87.6%
PD
Non-PD
At the same NHS trust we also found almost twice as
many people in cluster 8, compared to patients in other
clusters, who have made use of the crisis services in the
past year (see figure b below) they were also more likely
to go on to use inpatient services.
(b) Percentage of current in-service population that
have had a crisis referral in the last year (as of
31/10/17)
35.2%
17.1%
PD
Non-PD