Analysis

Personality disorder: why changing attitudes can benefit people with complex emotional difficulties

Perceived as having ‘complex needs’, people with a personality disorder often face exclusion from effective treatment

Perceived as having complex needs people with a personality disorder often face exclusion from effective treatment

  • Only one in four people diagnosed with a personality disorder has been referred to a specialist service
  • The average lifespan of service users with a personality disorder diagnosis is 19 years shorter than the general population
  • Mind advocates for a trauma-informed, formulation-driven and whole-system approach to care

It is well documented that people with a diagnosis of personality disorder face complex challenges.

They are vulnerable to anxiety and depression, as well as problems with alcohol and drugs. Health problems such as obesity and cardiovascular disease are common.

On

...

Perceived as having ‘complex needs’ people with a personality disorder often face exclusion from effective treatment

  • Only one in four people diagnosed with a personality disorder has been referred to a specialist service
  • The average lifespan of service users with a personality disorder diagnosis is 19 years shorter than the general population
  • Mind advocates for a trauma-informed, formulation-driven and whole-system approach to care
Illustration showing pieces of a puzzle in two heads. People with a personality disorder often face exclusion from effective treatment
Picture; iStock

It is well documented that people with a diagnosis of personality disorder face complex challenges.

They are vulnerable to anxiety and depression, as well as problems with alcohol and drugs. Health problems such as obesity and cardiovascular disease are common.

On average, their lives are 19 years shorter than the general population.

At the start of 2020, the Royal College of Psychiatrists issued its first position statement on personality disorders.

Failure to treat people with a diagnosis of personality disorder could be fatal

It warned that people with a diagnosis of personality disorder had not always been well served by services in the past, sometimes being turned away without the help they needed.

The college added that the idea people with a diagnosis of personality disorder could not be treated was ‘damaging and untrue’, and failure to treat could be fatal. One in ten people with a personality disorder die by suicide.

Only one in four of service users would ever have been referred to a specialist service.

‘Most traditional services are not well equipped for people with personality disorders’

Catherine Gamble, head of nursing education, practice and research, South West London and St George’s Mental Health NHS Trust

It is a conclusion that will come as little surprise to many working in this field.

1 in 10

people with a diagnosis of personality disorder in the UK die by suicide

Source: Royal College of Psychiatrists (2020)

‘Most traditional services are not well equipped for people with personality disorders,’ says Catherine Gamble, former RCN professional lead for mental health and now head of nursing education, practice and research, West London and St George’s Mental Health NHS Trust.

Catherine Gamble.
Picture: David Gee

In some cases, they can be perceived as ‘too complex’ for services, she adds.

Even the ‘personality disorder’ term itself is a controversial one, and there are those who would like to abandon its use entirely.

In 2018, a consensus statement from mental health charity Mind, supported by organisations including the RCN, suggested that the enduring problem of people with personality disorder facing exclusion from services stemmed, in part, from the diagnosis itself.

Six key points of Mind’s consensus statement

  1. The label of personality disorder is controversial and needs to change
  2. People given the label of personality disorder are likely to have experienced past trauma
  3. Early intervention is essential: asking the right questions early on helps to identify people’s difficulties so that appropriate interventions can commence and stop things getting worse
  4. A wide availability of different evidence-based interventions is important
  5. People diagnosed with a personality disorder experience complex social and system failures
  6. A trauma-informed, formulation-driven and whole-system approach to care is necessary

Source: Mind (2018)

Diagnosis of personality disorder should be seen as a ‘passport to effective help’

Mind’s consensus statement authors acknowledged that, as a diagnosis, personality disorder has its advocates: some see it as a ‘passport to effective help’.

‘The diagnostic label comes with a high degree of stigma and may often be used as a reason to reject people from specific health services, particularly because of the inclusion of the word “personality” in the diagnosis’

Stephen Buckley, head of information at Mind

But the term personality disorder is unhelpful and stigmatising, they argued, and one that is often used as a reason to reject people from the care they need.

Mind’s head of information Stephen Buckley says: ‘The diagnostic label comes with a high degree of stigma and may often be used as a reason to reject people from specific health services, particularly because of the inclusion of the word “personality” in the diagnosis, which could imply there is something inherently “wrong” with who the person is, rather than a set of symptoms they're experiencing.’

Personality disorders often linked to early attachment issues

Only 1 in 4

people who are diagnosed with a personality disorder are referred to a specialist service

Source: Royal College of Psychiatrists (2020)

Treatment for many personality disorders focuses on talking therapies, often delivered by nurses, and therapeutic communities, which offer intensive therapy and group support.

These tend to be five days a week rather than residential. Inpatient stays are often seen as a last resort.

Personality disorders are often linked to early attachment issues and this can affect how people engage with services and their ability to trust, says Kent and Medway NHS and Social Care Partnership Trust consultant psychotherapist Julie Dilallo.

Some will build up a long-term relationship with a nurse or other healthcare professional and develop trust.

‘The emphasis is on getting them back to functioning as soon as possible,’ she adds.

‘There is no recommended medication for these disorders, although many people with them will also have co-morbidities such as anxiety or depression where medication may be appropriate. But sometimes they will be on multiple medications without much benefit.’

How one trust has developed an active clinical pathway for people with a personality disorder diagnosis

Kent and Medway NHS and Social Care Partnership Trust runs talking therapy focus groups led by clinical nurse specialists for people with a diagnosis of personality disorder
Kent and Medway NHS and Social Care Partnership Trust runs talking therapy focus groups led by clinical nurse specialists for people with a diagnosis of personality disorder. Picture: iStock

One trust that has changed how a personality disorder diagnosis is viewed is the Kent and Medway NHS and Social Care Partnership Trust.

The trust has developed a more coherent and stepped service for those with personality disorders, and has given it a new name – complex emotional difficulties (CED).

Less about changing the label, more about changing attitudes

The term was decided following consultation with service users and families, some of whom found the ‘personality disorder’ title stigmatising.

James Osborne, clinical lead for the pathway for people with CED at Kent and Medway
James Osborne

But the change of name is just the start for the trust, which provides secondary mental health service in the community and in inpatient settings.

‘It was less about changing the name and the label and more about changing attitudes,’ says James Osborne, clinical lead for the pathway for people with CED at Kent and Medway.

Many staff would come into contact with people with a diagnosis of personality disorder, but did not have specialist training.

‘For many nursing staff it was about a lack of training and lack of skills,’ says Julie Dilallo, a consultant psychotherapist at the trust.

Complex emotional difficulties - tier three specialist service

The trust has now prioritised staff training, including placements in a therapeutic community, which offers intensive support.

The trust’s services offer people a clear pathway through secondary care services.

At its apex is a tier three specialist service. But there is support for people who don’t need this level of intervention and, crucially, also for those who find themselves in crisis and present at emergency departments (EDs).

Bespoke group interventions deal with those at risk of going into crisis or who are coming out of an inpatient setting.

People with a diagnosis of personality disorders might be referred through community mental health teams, may self-refer through the NHS psychological therapies service or may present through an ED.

‘We developed an inverted pyramid. Our aim was to be more coherent for our staff groups and to be clear about what our provision was,’ says Dr Osborne.

Talking therapy groups moved online during COVID-19

Clinical nurse specialist Tracie Fountain runs groups that focus on dialectical behavioural therapy (a talking therapy) for those who may have had a crisis or feel they are relapsing. Not all are diagnosis-specific as many who attend may not yet have a diagnosis.

During COVID-19, these groups have moved online.

‘We have seen a spike in referrals,’ says Ms Fountain. ‘It is a strange time which has affected everyone.’

People with personality disorders have been prioritised for contact by the trust during this time because they are known to be at high-risk.

The changes in pathways have been achieved without additional funding, although extra government funding for mental health is likely to push more money into such services in the coming years.

What role can mental health nurses play in improving diagnosis and care?

A need to improve services for people with a diagnosis of personality disorder has come to the fore in recent years.

The implementation plan for the NHS Long Term Plan (a blueprint for health priorities for the NHS in England) over the next decade included ambitious targets to develop dedicated provision for mental health services by 2023-24, and greater integration between primary and community care services.

Improving diagnosis and care for this group is important – but what role do mental health nurses play in achieving this?

People with a diagnosis of personality disorder are likely to come into contact with nurses at several points in their care.

A person may self present or be brought in by the police for a medical assessment under section 136 of the Mental Health Act 1983.

Equipping nurses in these different settings to identify that personality disorder may be a potential diagnosis and to support them appropriately is challenging.

Greater emphasis needed on continued professional development in preregistration nursing courses

University of Central Lancashire school of nursing senior research fellow Gary Lamph says: ‘Nurses are really well-placed in terms of the skills they have, but given the high prevalence of personality disorder across the system, there needs to be much greater emphasis on this in preregistration nursing courses.’

University of Central Lancashire school of nursing senior research fellow Gary Lamph
Gary Lamph

But nurses already in practice may also need continued professional development, Ms Gamble says.

People with personality disorders may also present ethical dilemmas to nurses in terms of safeguarding and mental capacity, she suggests.

Decisions to discharge may be particularly difficult because of the possibility of self-harm or suicide attempts.

‘There needs to be a high level of support for staff who are dealing with these complex cases, the appropriate supervision and time out, and making sure caseloads are capped – otherwise it will have a significant impact on the well-being of staff.’

Building good relationships with healthcare professionals has been highlighted by people diagnosed with personality disorders as helping to build their confidence in the care they received.

Continuity of care and a willingness to understand the individuals’ circumstances were also important.

But those working in secondary care are aware they are probably seeing the tip of an iceberg with personality disorders – there are many more people who never come into contact with them.

According to Mr Lamph, personality disorders are prevalent, but often go undetected, with many people increasing in risk, complexity and distress before they can access evidence-based interventions and services.

‘What are we doing for those with mild to moderate disorder?

‘How are we equipping the workforce to work effectively with them? The fact that we are talking about this and there is a real emphasis on addressing personality disorders across the system is very positive.’

Early intervention is crucial to improve care of people diagnosed with personality disorder

Looking to the future, early intervention to improve care is crucial.

The Mind consensus statement stressed early intervention is essential: asking the right questions early on helps to identify people’s difficulties so that appropriate interventions can commence and stop things getting worse, it said.

Many personality disorders manifest themselves in the teenage years so child and adolescent mental health services can be involved and, as with so many services, the point of transition to adult services is important.

‘It is a joy to see people leave mental health services and go into university and employment’

Julie Dilallo, consultant psychotherapist at Kent and Medway NHS Social Care and Partnership Trust

But cases of personality disorder can come to light late in life – sometimes following a change in circumstances, such as a bereavement or upheaval in the family, which leaves the person in acute distress.

Ultimately, caring for people with a diagnosis of personality disorder is challenging, according to Ms Dilallo, but it can also be incredibly rewarding.

‘It is a joy to see people leave mental health services and go into university and employment.’

Types of personality disorder

The current system of diagnosis identifies ten types of personality disorder, grouped into the following three categories:

Suspicious

  • Paranoid personality disorder
  • Schizoid personality disorder
  • Schizotypal personality disorder
  • Antisocial personality disorder

Emotional and impulsive

  • Borderline personality disorder
  • Histrionic personality disorder
  • Narcissistic personality disorder

Anxious

  • Avoidant personality disorder
  • Dependent personality disorder
  • Obsessive compulsive personality disorder

Source: Mind

Find out more


Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to mentalhealthpractice.com
  • Bi-monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs