Analysis

Personality disorders: how the new consensus statement seeks to improve care and understanding

A consensus statement, published by MIND advocates change in the diagnosis and care of people living with a personality disorder, and calls for issues of neglect and exclusion to be addressed.  

A consensus statement, published by MIND advocates change in the diagnosis and care of people living with a personality disorder, and calls for issues of neglect and exclusion to be addressed.  

People diagnosed with a personality disorder often live a precarious and isolated existence, and endure a wide range of problems that exact a heavy toll. They are vulnerable to anxiety and depression, as well as issues with alcohol and drugs. One in ten will die by suicide, and physical problems such as obesity and cardiovascular disease are common. On average, their lives are shorter by 19 years than the general population.


Picture: iStock

That is the bleak assessment of a recently published consensus statement on personality disorders: Shining Lights in Dark Corners of People's Lives, supported by the Royal College of Nursing, the Royal College of General Practitioners, Mind and the British Psychological Society.

Stigmatising and excluding

1 in 16

Proportion of people worldwide who have at some point been given a diagnosis of personality disorder

In a foreword to the document, former health minister Norman Lamb says he is ‘horrified at the scandalous neglect and exclusion’ of people with a personality disorder diagnosis. His words echo the title of the policy implementation guidance published by the National Institute of Mental Health 15 years ago – Personality disorder: no longer a diagnosis of exclusion.

The consensus statement suggests that the apparently enduring problem of exclusion from services stems in part from the diagnosis itself. Personality disorder is unhelpful and stigmatising, it says, and is often used as a reason to prevent people getting access to the care they need.

But the statement’s authors also acknowledge that as a diagnosis, personality disorder has its advocates: some see it as a ‘passport to effective help’.


Gary Lamph

Gary Lamph is a lecturer in mental health nursing at the University of Salford and his doctoral thesis focused on personality disorder.

‘The term personality disorder is stigmatising,’ Dr Lamph says.

‘But there are mixed views from those I’ve worked with. Some found the diagnosis beneficial, in that it’s enabled them to access services and evidence-based treatments. However, even when it does that, I don’t know many who like the term because of the stigma associated with it.’

60-70%

Estimated percentage of the prison population who meet the diagnostic criteria of a personality disorder

Sue Mizen, chair of the medical psychotherapy faculty at the Royal College of Psychiatrists, agrees that, as a diagnosis, personality disorder is problematic.

‘Some people see even talking about diagnosis as medicalising a problem which isn’t really a medical problem,’ she says.

‘But it’s a tricky thing to get right because there are a few people for whom having a diagnosis is very helpful. They don’t understand why they are driven to behave as they do, and having the diagnosis, or diagnostic criteria, offers them an explanation.’

Key points in the consensus statement include:

  • The label of personality disorder is controversial and needs to change
  • People given the label of personality disorder are likely to have experienced past trauma
  • 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
  • A wide availability of different evidence-based interventions is important
  • People diagnosed with a personality disorder experience complex social and system failures
  • A trauma-informed, formulation-driven and whole-system approach to care is necessary

 

47

Percentage of adults in England who said they experienced at least one ‘adverse childhood experience’ such as abuse or exposure to domestic violence

Source: Shining Lights in Dark Corners of People’s Lives

Pockets of good practice aside, the interface between personality disorder and support services appears worryingly inconsistent and, as the consensus statement puts it, certainly ‘isn’t working as it needs to’.

Failure due to attachment issues

Dr Mizen says that central to that failure are the attachment issues experienced by many of those with a personality disorder diagnosis, which often go back to relationships with their parents.

‘Usually when a professional offers help, the person takes the help and gets better,’ she says. 'But for people with a personality disorder it sometimes works the opposite way. You offer help and people appear to get worse.

‘They get more disturbed by you being helpful and professionals find that difficult to cope with.’


Paul Farmer

Dr Lamph argues that the provision of effective support is limited by lack of investment and capacity to deliver what is required. But he also highlights the high prevalence of personality disorder, or personality disorder traits, which means people look for support in services beyond mental health.

‘There’s a real need for accessible treatment at different levels. People are accessing not just mental health services, but primary care, too. But they’re struggling to get treatment unless their problems escalate to the point where they’re able to get some high-end care.’

Mind chief executive Paul Farmer agrees that the help available is patchy at best, and often non-existent. He cites examples of people diagnosed with personality disorder being discharged after one-off appointments.

‘There’s a limited expectation of recovery as the focus is on management of symptoms and behaviour,’ Mr Farmer says.

‘As a result, people often feel like they are a problem – to services, their families and themselves.’

Despite the controversy surrounding the diagnosis and the issues around accessing support, clinical psychologist Alex Stirzaker believes improvement is possible. And furthermore, more money is not necessarily the solution.

Culture shift requirement

Core tenets of an effective intervention include:

  • Developing a consistent therapeutic environment and network of services
  • A consistent and respectful therapeutic relationship where a real sense of partnership can develop
  • Psychologically informed practice
  • Individual formulations
  • A trained workforce

Dr Stirzaker, a former NHS England national adviser on personality disorder, now with Avon and Wiltshire Mental Health Partnership NHS Trust, and part of the team that drew up the consensus statement, says what’s required is a culture shift.

‘It’s about moving away from trying to “fix” someone by giving them medication or somewhere safe or a house if they’re homeless. It’s not as simple as that. You’ve got to think about how you help people to manage their lives.’

As an example of that approach, she describes a training package run in her own trust where staff, primarily nurses, were encouraged to consider ways of practising more effectively.


Alex Stirzaker

‘It wasn’t an extended training programme,’ she says. ‘It was just a couple of days working fairly intensively and saying in what small ways can you change your practice.’

She adds: ‘It’s about changing the way we do things from what’s wrong to what’s happened to the person? How do we encourage them to think more effectively, and in thinking more effectively, can they make the changes they need to make? We don’t need to be so paternalistic.’

Changing culture can be difficult, but nonetheless she remains optimistic that it is possible. ‘There are people out there who can do this work,’ she says.

MIND: Shining lights in dark corners of people's lives


 

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