Personality disorder service provision: a review of the recent literature
| Date | 12 June 2017 |
| Published date | 12 June 2017 |
| DOI | https://doi.org/10.1108/MHRJ-03-2016-0006 |
| Pages | 65-82 |
| Author | Sacha Evans,Faisil Sethi,Oliver Dale,Clive Stanton,Rosemary Sedgwick,Monica Doran,Lucinda Shoolbred,Steve Goldsack,Rex Haigh |
| Subject Matter | Health & social care,Mental health |
Personality disorder service provision: a
review of the recent literature
Sacha Evans, Faisil Sethi, Oliver Dale, Clive Stanton, Rosemary Sedgwick, Monica Doran,
Lucinda Shoolbred, Steve Goldsack and Rex Haigh
Abstract
Purpose –The purpose of this paper is to describe the evolution of the field of personality disorder since the
publication of “Personality disorder: no longer a diagnosis of exclusion”in 2003.
Design/methodology/approach –A review of both the academic literature contained within
relevant databases alongside manual searches of policy literature and guidance from the key stakeholders
was undertaken.
Findings –The academic and policy literature concentrates on treating borderline and antisocial personality
disorders. It seems unlikely that evidence will resolutely support any one treatment modality over another.Criti cism
has arisen that comparison between modalities misses inter and intra patient heterogeneity and the measurement
of intervention has become conflated with overall service design and the need for robust care pathways.Apparent
inconsistency in service availability remains, despite a wealth of evidence demonstrating the availability of
cost-effective interventions and the significant inequality of social and health outcomes for this population.
Research limitations/implications –The inclusion of heterogeneous sources required pragmatic
compromises in methodological rigour.
Originality/value –This paper charts the recent developments in the field with a wealth of wide-ranging
evidence and robust guidance from institutions such as NICE. The policy literature has supported the findings
of this evidence but current clinical practice and what patients and carers can expect from services remains at
odds. This paper lays bare the disparity between what we know and what is being delivered. The authors
argue for the need for greater research into current practice to inform the setting of minimum standards for
the treatment of personality disorder.
Keywords Personality disorder, Personality disorder literature, Personality disorder policy,
Personality disorder service, Personality disorder service provision
Paper type Literature review
Introduction
In 2003, the National Institute for Mental Health England published “Personality disorder:
no longer a diagnosis of exclusion”. This Government policy guide became a truly seminal paper
(National Institute for Mental Health in England, 2003a, b). It challenged the healthcare
community to address marked shortcomings in the treatment of personality disorder.
Specifically, it brought to our attention the variable practice and institutionalised stigmatisation
which, to varying degrees, explicitly barred patients with personality disorder from mainstream
services. This state of affairs had arisen largely due to a perception of the untreatability of
personality disorder despite many examples of good practice.
“Personality disorder: no longer a diagnosis of exclusion”highlighted the difficulties that people
diagnosed with personality disorders had in accessing appropriate services. It quoted a survey
by the National Institute of Mental Health England which found that only 17 per cent of NHS
trusts had a dedicated personality disorder service; 40 per cent provided “some level of service”;
and 28 per cent had no service. The key service delivery issues identified were: a lack of
dedicated personality disorder services; inappropriate care pathways; and mental health
professionals without adequate skills, expertise or training.
Received 6 March 2016
Revised 23 September 2016
13 February 2017
Accepted 7 April 2017
The National Personality Disorder
Service Review Group was partly
funded by the General Adult
Faculty of the Royal College of
Psychiatrists through a small
project grant, and West London
Mental Health NHS trusts’
Research and Development
Department.
Sacha Evans is based at West
London Mental Health NHS
Trust, London, UK.
Faisil Sethi is based in South
London; and is at Maudsley NHS
Foundation Trust, London, UK.
Oliver Dale is a Clinical Lead for
the Personality Disorder Pathway
at West London Mental Health
NHS Trust, London, UK.
Clive Stanton is the Director of
Mental Health Intensive Care at
Prince of Wales Hospital, Eastern
Suburbs Mental Health Service,
Sydney, Australia; and is at the
University of New South Wales,
Sydney, Australia.
Rosemary Sedgwick is a CT3
Psychiatry Trainee at South
London; and is at Maudsley
NHS Foundation Trust,
London, UK.
Monica Doran and Lucinda
Shoolbred are both based at
West London Mental Health
NHS Trust, London, UK.
Steve Goldsack is a Specialist
Peer Support Worker in
Personality Disorder at
Medway Engagement Group
and Network, Chatham, UK.
Rex Haigh is based at the
Department of Sociology and
Social Policy, Nottingham
University, Nottingham, UK.
DOI 10.1108/MHRJ-03-2016-0006 VOL. 22 NO. 2 2017, pp. 65-82, © Emerald Publishing Limited, ISSN 1361-9322
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The report envisioned services in which specialist treatment and management for these conditions
was available to all, particularly focussed at the level of local and forensic services. Recommendations
included: the use of specialist multidisciplinary teams; the Care Programme Approach; using a
“hub and spoke”model; offering specialist interventions and training; and supporting the
development of self-help networks. In addition, it recognised the need to manage risk positively, and
in consultation with forensic services, especially in the presence of offending behaviour.
This was a clarion call to address the needs of those with personality disorders. They described the
best practice of the time and called for the further development of services. It recognised the need for
education of colleagues and further research into the understanding and management of personality
disorder in order to ensure an evidence-based approach. Crucially, it championed the centrality of
service user involvement in the delivery of services at all stages and this co-production was key to the
success of the paper and the National Personality Disorder Programme which followed.
This review aims to see what policy, guideline and academic outputs have arisen since the
paper’s publication. Conventional methods for academic literature reviews do not lend
themselves to the consideration of such a diverse range of literature covering the clinical and
service concept of personality disorder. As far as we are aware, this is the first attempt at bringing
together both non-academic outputs such as policy and guidelines with more traditional
academic literature. The hope being to describe to the reader how the landscape of personality
disorder has developed in recent history.
Method
Manual searches were undertaken for policy documents and guidelines. The manual searches
were heavily weighted towards resources associated with key stakeholders (Department of
Health, NHS England, and the Royal College of Psychiatrists), organisations specific to
personality disorder, and mental health charities.
Medline, PUBMED, CINAHL, PsycINFO, Web of Science and the Cochrane Database of
Systematic Reviews were searched for the literature relating to personality disorder services.
The search terms included (in combination): “personality disorder”with “service”,“management”,
“intervention”, and “user”. Additional searches were undertaken to supplement information, as
required. Searches were conducted in July 2016. Inclusion criteria were peer-reviewed literature,
written in the English language, published from 1 January 2002 to 9 July 2016, conducted in
human samples and pertaining to personality disorder and available services. The primary interest
was personality disorder services’provision in the UK, but literature from other countries was
included where appropriate. This review focusses on adult mental health services in the
community or inpatient settings, including specialist forensic services. Literature related primarily
to non-adult and non-health forensic settings, or the criminal justice system were not included.
The first author screened all titles. The abstracts of potentially relevant literature were then screened
by three of authors and the fulltexts of any potentially relevantpapers were obtained. Thesearches
were supplemented with forward/backward citation and manual reference exploration.
Results
The attrition diagram in Figure 1 summarises the search results for all types of literature.
The results of the searches are detail in Table I.
Summary of findings
Classification. The current classification of personality disorders is controversial. For some time, there
has been discontent; with a sense that the diagnostic categories do not adequately capture
information about severity or functionality (Yang et al., 2010; Tyrer, Crawford and Mulder, 2011).
This arose from the lack of utility of many categories compared with the high frequency use of mixed
personality diagnoses (Tyrer, 2011a). DSM-5 attempted to address this by incorporating two models
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