What is a personality disorder? 5 questions for the experts plus user view

Anabel Unity Sale and Simeon Brody ask two mental health leaders five of the hard questions that still need answers, while a service user makes the case for treatment

Personality disorder affects an estimated 10 per cent of the population but it remains a controversial diagnosis.

Attributed to people who have difficulty coping with life and act in a way that causes distress to themselves or others, there is a continuing debate as to whether it exists as a medical condition and whether it can be treated.

A recent government report found support for people with the diagnosis was “very sparse”, with many mental health services operating “exclusionary practice” against them . Below we hear from those in the mental health sector about their views on this contentious issue.

1 Do personality disorders exist? Or are they a way of describing people whose behaviour is difficult to categorise?
Richard Kramer, director of policy, Turning Point
“They are not a mental illness in the sense that schizophrenia and bipolar disorder are – they are an underlying fault in the core personality.

However, it is almost impossible to disentangle mental state from personality components. Labels can lead to stigma for an individual and having an academic debate about whether personality disorders exist compounds the individual’s isolation. It  risks condemning them to the periphery of health care and core mental health services.”

Marcus Roberts, head of policy and parliamentary unit, Mind
“Mental health experts remain unconvinced personality disorders are mental disorders.

Much depends on which personality disorder we’re talking about. My particular interest is in antisocial personality disorder, the symptoms of which include failing to conform to social norms, law breaking and impulsiveness.

It is taking complex social issues and sweeping them up into the individual – as if the source was a malfunctioning of the  person, and this should be the primary site for our interventions.

Imagine we had a drug that ‘cured’ antisocial behaviour – would we be happy to use it? It sounds more like a chemical cosh  than a treatment.”

2 How do you suggest social care professionals treat someone in this position?
Richard Kramer
“A range of interventions, including psychological and drug treatments.

Psychological treatment is most effective when the client’s social circumstances are settled. Social care professionals need  to consider wider issues such as difficulties with housing, finance, employment or social interaction.

Not all practitioners can support or treat people with personality disorders and the inter-personal skills, experience and attitudes of mental health professionals are crucial. A therapeutic bond is critical if the person is to engage and remain in treatment.

Social care professionals are well placed to offer consistent and containing responses to inter-personal conflict and  ingrained behaviour.”

Marcus Roberts
“I am struck by the extent to which the term personality disorder is applied to people with complex needs.

We need to join up services more effectively, with different professionals working together. 

With antisocial personality disorder it is really the same old debate about dual diagnosis and multiple needs. This problem has been around for ever. We need a more co-ordinated care plan approach with clear ownership and responsibility.

Would it help if we viewed complex need as the norm, with single diagnosis as the exception, and built our service models
from there?”

3 How should the mental health sector respond to this group?
Richard Kramer
“The sector needs to see personality disorder as part of the legitimate business of mental health services.

It should work together to persuade government to invest in more services as current provision is inadequate and excludes too
many people. It can help to research and develop service models for this challenging group, and to develop the evidence base on what works.

Turning Point is actively supporting the Department of Health’s national personality disorder programme to develop new ways to manage and treat people with personality disorders.”

Marcus Roberts
“The extent to which mental health services are the right place for people with personality disorders is the big question.

Mind is concerned the government’s proposed Mental Health Act reforms could see hospitals being used to detain difficult or
challenging people, even when they can offer them no therapeutic benefit. This isn’t what a health service should do, and it isn’t the job of hospitals.

At the same time, there are people who have symptoms identified with personality disorders who should be in mental health
services for therapeutic reasons.

Many people experiencing other mental health problems also behave in ways associated with personality disorders. There is evidence these people may be excluded from services because their behaviour is too challenging.”

4 How can the mental health lobby work together to encourage clinicians and practitioners to work with people with personality disorder?
Marcus Roberts
“Keep the pressure on the government for better services. The emphasis on multi-disciplinary work reminds us we need to work with organisations dealing with housing, criminal justice and drug and alcohol misuse. For me, the personality disorder question is more about complex needs than mental health in isolation.”

5 If personality disorder is the diagnosis, what’s the prognosis? Is it treatable and do people recover?
Richard Kramer
“It is treatable. There are real grounds for optimism and improvements in the management of symptoms, even if a condition isn’t curable.

A common mistake is to think a personality disorder diagnosis means you can’t work with people and they will never improve,  so why bother trying. Because personality disorder is usually a negative diagnosis, the presumption is there will be a negative prognosis.

“We can’t deny people are challenging to work with, but there can be measurable improvements in related areas, such as reducing self-harm. Personality disorder often coexists with other mental health problems that are treatable. The underlying ethos is recovery – helping the individual to become the person they were never allowed to be.”

The User View
Before 2003 Marion Janner, then 44, had never had a serious mental illness. As her 20-year relationship with her partner Sylvia broke down in 2004 Janner became increasingly depressed. She started to self-harm, felt suicidal, was prescribed antipsychotic drugs and anti-depressants by her doctor and saw a therapist.

In 2005 she was sectioned for one month and, after being discharged, was referred to a hospital’s specialist borderline personality disorder service. There she found she has five of the nine qualifying symptoms of borderline personality disorder (BPD), even though she has never been given this diagnosis officially.

She says: “People have recognised a cluster of symptoms as BPD but feel it is unhelpful to use this label, even though I use the service. They want me to have the treatment but not the label.”

Janner is open about her mental illness and self-harming but is reluctant to tell people about her BPD “in case they think I’m a maniac”. Fortunately, she has received support from family and friends as well as social care professionals.

Related articles
A professor of community psychiatry discusses the new classification of personality disorders and the difficulties in diagnosis

Contact the authors
simeon.brody@rbi.co.uk

anabel.unity.sale@rbi.co.uk

This article appeared in the magazine on the 26th October , under the headline, Do personality disorders exist