Rep36 Understanding Personality Disorder

3.2.1 Psychological therapies
Individuals with personality disorder are heavy
users of mental health services (Dolan, Warren,
Menzies 
et al
, 1996; Perry, Lavori & Hoke, 1987;
Skodol, Buckley & Charles, 1983), and often
come to services seeking help with other mental
health disorders or, in the case of borderline
personality disorder, because they have
deliberately harmed themselves. The range of
health services used by those with personality
disorders is extensive and the pattern of use of
services highly variable. For example, some
individuals may require lengthy inpatient
services, some may frequently use accident and
emergency services, and some may attend their
general practitioners regularly. This section will
only discuss treatments that have an evidence base.
There is no standard treatment for
individuals with personality disorders in the UK,
nor has any treatment been shown to be
superior to any other (Bateman & Fonagy, 1999).
Presently, those with personality disorders tend
to receive a rather bewildering array of
interventions: pharmacotherapy to help with
problems such as unstable mood and impulsivity,
inpatient treatment when there is a risk of
serious self-harm or a coexisting mental illness,
psychoanalytic therapy, cognitive therapy,
cognitive analytic therapy, dialectical behaviour
therapy, supportive therapy, and specialised
therapeutic community settings. This list is not
exhaustive and to date few treatments have been
systematically evaluated for their efficacy in
treating personality disorders; there are few
randomised controlled trials (RCT), many of the
studies reported to date are small (under 50
patients), and few have undergone replication by
independent researchers.
Existing treatment approaches for people
with acute mental health needs may not be
optimal for individuals with personality disorders
because their service use tends to be
characterised by problems such as high rates of
premature termination, poor patient outcomes
and high treatment cost (Waldinger &
Gunderson, 1984). Thus, there is a need to
develop more appropriate services. Some
clinicians have suggested that services for those
with personality disorder require highly
specialised skills and need to be developed as
separate – or tertiary – services; there are
problems in engaging those with personality
disorder in treatment and specialised dedicated
services may be better at this. Specialised services
would also be able to provide the more focused
and lengthier treatments required, more so than
general mental health services where there is a
necessity to treat a wider variety and greater
number of patients. Others argue that focusing
only on specialised services would be
inappropriate given the potentially large
numbers involved and the range of problems
likely to be encountered. In order to make the
best use of resources, it may be better to train
staff in more general mental health settings to be
able to offer appropriate interventions for
patients with personality disturbance or disorder
who often attend these services because of the
high prevalence of other co-existing psychiatric
disorders. Treatments that are both structured
and focused increase compliance and the
likelihood of patients and therapists forming a
collaborative working alliance, and they are likely
to be more effective as a consequence.