Personality Disorders Can Represent A Challenge

Published Date: 02 Nov 2017

Personality disorder according to the DSM-IV-TR (American Psychiatric Association (APA), 1994:p275) is, "an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time and leads to distress or impairment". Borderline Personality Disorder (BPD) is further defined as a historical pattern of instability in interpersonal relationships, self-image, affect and marked impulsivity (APA 1994:p280). These definitions of personality disorder would suggest that the long standing nature of the disorder, together with its impact on relationships may have a negative impact on effective interventions (Woods and Richards 2003).

Nosological systems such as the DSM-IV-TR (APA, 1994) and the ICD-10 (World Health Organisation, 1992) have criteria by which the disorder is diagnosed, although these diagnostic criteria are very similar there are some differences (Cahrland, 2006). Charland (2006) criticises the legitimicy of the label and the classification systems, he contests that the group of personality disorders containing borderline personality disorder are actually defined implicitly on morals of the assessor by which behaviours are permissible by the individual’s culture and societal norms and anything outside this societal norm is seen as lacking. For example the intense anger and instability in interpersonal relationships common in the diagnostic criteria for BPD would suggest some moral deficits in concern for others well being in the person being assessed.

BPD is present in under 1% of the population and is most commonly diagnosed in early adulthood with women being more likely to be diagnosed than men (NICE 2009), conversely men who often-times meet the diagnostic criteria for BPD are diagnosed with Antisocial Behaviour Order (Tredget 2001) . Within mental healthcare settings BPD is the most prevalent type of personality disorder found, between 60-70% of people with a diagnosis of BPD who self harm will attempt suicide at some time in their life (Oldham 2006). Paris (2007) states that BPD is characterised by emotional instability: the individual experiences intense emotional arousal which prolongs itself before returning to a calm state; impulsivity where there is a disregard of negative consequences of behaviours for example, anger and self harm; and cognitive symptoms such as auditory hallucinations, delusions and paranoid feelings. BPD is characterised by extreme reactions from the service user with intense experiences of anger, sadness, emotional attachment and detachment, self harm which can include cutting, alcohol abuse and drug misuse as well as psychotic-type experiences.

Service users experience of mental health services are characterised by negative and sometimes damaging staff attitudes; coercion; and being passed from one service to another (Fallon 2003). An example of these negative attitudes is where staff are encouraged, either directly by superiors or by the culture within their teams, to direct their efforts away from those with a diagnosis of personality disorder in favour of helping those service users with a diagnosis of schizophrenia (Tredget 2001).

Attempts to overcome this evident deficit in health care provision are highlighted within the policy implementation guidance for people with a personality disorder (National Institute for Mental Health in England (NIMHE) 2003), which has indicated that most mental health services fail to provide a service for those with a diagnosis of personality disorder. The policy context providing the underpinning principles to support the process of therapeutic engagement can be found within the NSF for Mental Health (DoH, 1999) which identifies the following themes in delivering care: accessibility; choice; involvement of service users; and carers in planning care; empowerment and support from staff.

Whilst engagement with service users is ostensibly at the heart of the therapeutic alliance, something that is repeatedly drummed into under-graduate student nurses (Wrycraft 2009), engagement is also supposedly of paramount importance to modernisation agendas, there are concerns that this is more rhetoric than reality (Taylor 2001) with growing examples of government policy becoming sound bites to capture the public’s attention to gain popularity, rather than tackling the complex problems of the NHS.Greener (2004) using discourse analysis of health policy since 1997 suggests that health policy has undergone three major periods. Firstly policy was related to continuity and the role of mental health staff as experts who knew the system best. This was followed by a rationalist performance management approach characterised by targets and standards and finally by consumer based around the concept of patient choice.

To counter these criticisms, the National Institute for Clinical Excellence (NICE) was developed to undertake technology assessments of available treatments and to determine which of those treatments are clinically effective and to be made available to the public. However criticisms of this approach state that rather than end the postcode lottery and improve access for patients the approach has been to restrict access to certain treatments (Summerhayes and Catchpole 2006).

Despite these overtly public criticisms it appears that driving force of government mental health policy has focussed upon further system reform in terms of improving overall quality and standards of service provision (Department of Health 2002). In support of these reforms Appleby (2007) points to the success of new services in keeping people with BPD out of hospital as in the case of Crisis Resolution and Home Treatment Team; preventing relapse in the case of Assertive Outreach Teams and the overall reduction in the suicide rate since the implementation of the National Suicide Prevention Strategy (Department of Health, 2002).

The collaborative therapeutic relationship is pivotal for the collaborative involvement of patients and carers to improve patient acceptability and treatment concordance. The Department of Health Policy Guidance on Personality Disorder (NIMHE 2003) suggests that this does not occur due to the stigmatising beliefs of professionals. It recommends the effective training and guidance to support professionals working with this service user group to prevent burnout and fatigue. Whilst it has been reported that supervision has been helpful to prevent professional fatigue when working with service users with challenging needs (White & Winstanley 2010), there is limited evidence of evaluation of supervision to professionals working with this service user group.

The collaborative therapeutic relationship is pivotal for the collaborative involvement of patients and carers to improve patient acceptability and treatment concordance. The Department of Health Policy Guidance on Personality Disorder (NIMHE 2003) suggests that this does not occur due to the stigmatising beliefs of professionals involved with the service users care. It recommends the effective training and guidance to support professionals working with this service user group to prevent burnout and fatigue. Whilst it has been reported that supervision has been helpful to prevent professional fatigue when working with service users with challenging needs (White & Winstanley 2010), there is limited evidence of evaluation of supervision to professionals working with this service user group.

With the movement towards more community based care, with admission to mental health units as a somewhat of a last resort for those who require a place of safety led to the development of criteria for service users to access the service and these were generally determined with reference to the label of Serious Mental Illness (King 2001). This categorisation was directly linked to the care in the community agenda of caring for people with mental illness discharged from institutional care and was found to be legitimate criteria for access to services. Exclusion criteria for the services such as CMHT was related to the 'treatability' of service users. Such service users find it difficult to access services due to the effects of professional stigma and labelling of service users with a diagnosis of personality disorder (Raven 2009). It would therefore appear that there is a significant paradox present in the delivery of services for service users with a diagnosis of personality disorder. Despite the policy rhetoric of accessibility to mental health services with the removal of the treatability clause in the Mental Health Act (2007), service users’ experiences reflect that professional attitudes can lead to disempowerment, dehumanising and controlling interventions that result in increasing distance between professional and service users (Markham and Trower 2011).

The conceptual framework for professionals working with those with a diagnosis of BPD, initially related to Weiner’s (1980) model of helping behaviour, states that intentions to help are facilitated by sympathetic emotional responses and helping is withheld in response to angry emotional reactions (Murdin, 2010). These emotional reactions are a product of the individual helper’s, attributions, beliefs and expectations toward the individual who requests help. Attributional dimensions of controllability, whereby the individual is able to exert control over the behaviour for example self harm, and stability of presentation, for example when there is a long standing and pervasive pattern of response as in emotional outbursts in BPD which follows a predictable pattern to elicitation, have been found to cause anger whereas the dimensions of uncontrollability and instability have been found to cause empathic reactions (McGuiness and Dagnan 2001). Using similar methodology Markham and Trower (2011) has demonstrated that similar angry reactions occur more often and more intensely with regard to the psychiatric diagnosis of BPD compared to empathic reactions towards service users with diagnosis such as schizophrenia. Therefore 'the less likely a presentation to change and considered to be within the control of the individual the more likely the mental health professional is to become angry and frustrated.' (White & Winstanley 2010)

These cognitive models and approaches emphasise the relationship between mental processes and subsequent actions, and that these processes are based on perceptions of the participant and serve to ground cognitive processes in reality. In understanding the cognitive model it is first useful to consider it within the context of a cognitive taxonomy (Ingram & Hollon 1986). Sakamoto (2000) in explaining the taxonomy identifies four distinctive cognitive categories: cognitive structure; cognitive proposition; cognitive operation and cognitive products. Structure relates to the manner in which information is stored in memory in terms of long and short-term memory. Propositions are the content of the information stored within memory and play a central role in the production of knowledge, in that knowledge is generated within the individual in the form of schematic representation and that this is stored in a hierarchical nature where for example, everyday items of cats or dogs are stored within the category of pets and can be further categorised in terms of breeds or types and can be contained within a general category of domestic animals. These knowledge structures are innate and used to make sense of everyday experience.