Question from practice: Have you heard of personality disorder?
A. Personality disorder is a mental health condition. The Royal College of Psychiatrists describes how those suffering from this disorder will experience difficulty in relationships with people at work and at home, may have difficulty in controlling their feelings and emotions, and will sometimes get into trouble because they find it hard to control their behaviour. These difficulties can lead to anxiety and depression or drug and alcohol problems. Eating disorders can occur at the same time. Emergence, a service-user led organisation, describes having personality disorder as painful, debilitating and stigmatising.
Research has shown that 4.4 per cent of the general population — about one and a half million people in the UK — has a personality disorder.1 The proportion is higher in regular users of primary care services (30–40 per cent), within the probation and prison services (45–50 per cent) and in homeless people (70–90 per cent).
Diagnosis and causes
Diagnosis should be by a trained mental health professional and involve an in-depth interview, looking at the person’s life history. Even so, people often receive mental health services for many years before they are diagnosed with personality disorder and recent research has shown a diagnosis of bipolar disorder can be wrongly given.2
The causes of personality disorder are uncertain and a combination of factors are thought to be involved, including genetics, a dysfunction of neural or neurobiological pathways at birth or during development, and either poor or too close an attachment to the primary care giver (eg, a parent) which leaves the sufferer with an unclear sense of self and difficulties in making other attachments.3,4 Although many sufferers come from stable and caring families, neglect and abuse is thought to play a part in about 70 per cent of personality disorder cases.
There are several categories of personality disorder and these can be split into three main categories: suspicious, emotional and impulsive, and anxious. The most researched disorder is borderline personality disorder (DSM-IV),3 also called emotionally unstable personality disorder (ICD-10). Sufferers will do things without thinking, find it hard to control their emotions and feel empty. They feel bad about themselves and often self-harm. They make relationships quickly, but easily lose them. They can also feel paranoid or depressed and, when stressed, may hear noises or voices. Early trauma, including loss and bereavement, can play a part in the development of borderline personality disorder and similarities with post traumatic stress disorder (PTSD) have led some to suggest that it should be regarded as a form of delayed PTSD.3
What are the risks?
Much has been made in the press of personality disorder. For example, in news stories, killers have been labelled as having a “severe and dangerous” personality disorder. However, this is not a clinical category of personality disorder and only a minority of sufferers are violent.
In most cases, people with personality disorder are vulnerable to abuse and violence themselves5 and, in fact, many people with a personality disorder will repeatedly harm themselves to provide relief from intolerable emotional distress (although not everyone who self-harms has personality disorder).6 The suicide rate in people with personality disorder is about 10 per cent although it is thought to be up to 49 per cent for those who have been inpatients in acute psychiatric wards.3
The aim of treatment is to facilitate change of deeply ingrained behaviours. All of us find changing learnt behaviour difficult and this is the case for many service users. For those who feel ready and are open to change, there are a number of psychological therapies, including cognitive behavioural therapy, dialectical behavioural therapy, mentalisation based therapy, cognitive analytical therapy, the STEPPS (systems training for emotional predictability and problem solving) programme and Schema therapy.
One of the most successful routes to change is through therapeutic communities. Such communities are provided through centres resembling a family house, where service users spend three to five days a week. This provides them with a framework containing other therapies as required but the experience of being in the community itself is the main agent of change. The purpose is to create a network of close relationships, much like a family, in which deeply ingrained behavioural patterns, negative cognitions and adverse emotions can be unlearnt in a safe environment. Some centres are residential. Therapeutic communities are also run in some prisons to support rehabilitation.
The outcome, at least in those who have received treatment or formal psychiatric assessment, is much better than was originally thought, with at least 50 per cent of people improving sufficiently to no longer meet the criteria for borderline personality disorder five to 10 years after first diagnosis.
Personality disorder usually appears in early adulthood or adolescence but can sometimes begin in childhood. Referrals to child and adolescent mental health services can come through schools, probation services, GPs, social services and other health professionals. The first-line treatment for emerging personality disorder is parenting skills and support (although many professionals are reluctant to diagnose before the age of 18 years because as some adolescent behaviour mimics the signs of personality disorder).
Pharmacological treatment by psychiatrists or GPs is often initiated during periods of crisis but the placebo response rate is high — the crisis is usually time limited and can be expected to resolve irrespective of treatment.5 There can be an expectation of drug treatment by patients and doctors, who often want to feel they are “doing something”.
A Cochrane report of 27 trials in which first- and second-generation antipsychotics, mood stabilisers, antidepressants and omega-3 fatty acids were tested showed that most beneficial effects were found for the mood stabilisers topiramate, lamotrigine and valproate semisodium, and the second-generation antipsychotics aripiprazole and olanzapine.7 However, the robustness of these findings is low, since they are based mostly on single, small studies. Selective serotonin reuptake inhibitors so far lack high-level evidence of effectiveness. The conclusion is that pharmacotherapy has limited value and should be reserved for co-morbid conditions, such as depression and obsessive compulsive disorder.8
If a diagnosis of personality disorder has been made, this suggests that the enquirer’s friend has entered the mental health system. She should have been given guidance as to what to do and may even have a community psychiatric nurse , but this is not always the case.
The general principle is to recommend that people seek help before they self-harm. Talking through the issues and finding healthy ways to cope is encouraged. Those who self-harm may also be referred to other services, which pharmacists can signpost (in your pharmacy’s signposting folder you should have numbers for the local mental health crisis team and Samaritans). Sufferers should be encouraged to make the call themselves. In addition, many people do not realise they can go to accident and emergency departments for mental health emergencies and not just physical emergencies. There is usually a psychiatric referral nurse on duty.
Pharmacy staff selling razor blades and who suspect self-harm are within their rights to refuse their sale or remove them from sale. It is important to remain compassionate but consistent in dealing with clients with personality disorder, taking a “kind but firm parent” approach, not raising your voice or becoming anxious.
There is debate in user groups about whether someone should be advised to “cut safely”, using sterile equipment and sterile dressings. Although it is best to refer the person to their GP, the pharmacist must put the patient’s best interests first and that may justify advising on tetanus, signs of infection and appropriate cleansing and dressing of wounds if he or she is resistant to seeking help.
Advice to family and friends
Family members and friends of people with personality disorder can be referred to Emergence, which has a carers group.3 Carers UK can also offer support, as can the mental health charities Rethink, Mind and Saneline. The acronym “SET” (support, empathy, truth” is useful to remember for interacting with the sufferer. Although there is a limit to what carers can do, they can reinforce positive behaviour, make sure they do not become anxious themselves and set boundaries that may help improve the person’s sense of self. Friends and family may find the book ‘Stop walking on eggshells: taking your life back when someone you care about has borderline personality disorder’ by Mason and Kreger (New Harbinger Puablications, 2010) helpful.
In addition, Mind suggests the following for those who want to support someone with personality disorder:
- Emphasise the positive aspects of the sufferer’s personality and make the most of their strengths and abilities — a diagnosis does not stop the person being likeable, intelligent, highly motivated or creative
- If the sufferer finds it helpful, be involved in discussions with mental health professionals where diagnoses and treatment approaches are explained
- Do not be judgemental or tell the sufferer that her or she is immature, inadequate, attention-seeking or making bad choices
- Try to help identify situations that bring out the best or worst in the sufferer. For example, even if they are uncomfortable with being close to people and ill at ease in company, they may be much more relaxed and lose their inhibitions when they are discussing a subject that really interests them. Encouraging them to join a particular club or further education class may be a way they can learn to enjoy company.
A lot of negative attitudes spring from ignorance about personality disorder and a national knowledge and understanding framework has been set up.9
More attention is now being paid to manifestations in adolescent groups and a , which lists some of the early signs of personality disorder development, such as refusing to go to school, shoplifting, drug and alcohol use and teenage pregnancy, has been published.10
1. Coid, Tyrer and Roberts. Prevalence and correlates of personality disorder in Great Britain. The British Journal of Psychiatry 2006;188:423–31.
2. Paris J. Borderline or Bipolar? Distinguishing borderline personality disorder from bipolar spectrum disorders. Harvard review of Psychiatry 2004;12:140–5
3. National Institute for Health and Clinical Excellence. Borderline personality disorder: treatment and management. Clinical guideline 78. 2009. Available at http://guidance.nice.org.uk/CG78 (accessed on 1 November 2011).
4 . Bowlby J, Ainsworth M. Breaking the cycle of rejection — the origins of attachment theory. Developmental Psychology 1992;28:759–75.
5. National Mental Health Development Unit. Breaking the cycle of rejection. The personality disorder capabilities framework 2003.
6. Royal College of Psychiatrists. Self harm, suicide and risk: helping people who self-harm. Report CR158; April 2010.
7. Lieb K, Völlm B, Rücker G et al. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. The British Journal of Psychiatry 2010;196:4–12.
8. Paris J. Recent advances in the treatment of borderline personality disorder. Canadian Journal of Psychiatry 2005;50(8):435–41.
9. Institute of Mental Health. . Available at: www.institutemh.org.uk (accessed on 1 November 2011 )
10. Haigh R. . Available at www.personalitydisorder.org.uk (accessed on 1 November 2011).
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