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Personality disorder: A mental health priority area

July 2017
Australian and New Zealand Journal of Psychiatry 51(9):4867417717798

DOI:10.1177/0004867417717798

Authors:

Brin F S Grenyer

University of Wollongong

Fiona Ng

University of Nottingham

Michelle Townsend

University of Wollongong

Sathya Rao

Spectrum

Personality disorders have received limited recognition as a public health priority, despite the publication of treatment guidelines and reviews showing effective treatments are available. Inclusive approaches to understanding and servicing personality disorder are required that integrate different service providers. This viewpoint paper identifies pertinent issues surrounding early intervention, treatment needs, consumer and carer experiences, and the need for accurate and representative data collection in personality disorder as starting points in mental health care reform.

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https://doi.org/10.1177/0004867417717798

Australian & New Zealand Journal of Psychiatry

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DOI: 10.1177/0004867417717798

New Zealand College of Psychiatrists 2017

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Personality disorder is a complex and

severe mental illness, associated with

high usage of services and treatment

cost (Leichsenring etal., 2011), where

the economic benefits associated with

the provision of evidence-based inter-

ventions have recently been estab-

lished (Meuldijk etal., 2017). Globally,

personality disorders are estimated to

affect approximately 6% of the popula-

tion (Huang et al., 2009). Despite

this, the disorder has received limited

recognition as a public health issue.

Left untreated, individuals with the

disorder may experience disadvan-

tage, including failure to engage in edu-

cation or work (Ng et al., 2016), have

a high risk of suicide and experiencing

comorbid mental health disorders

(Leichsenring et al., 2011).

Internationally, best practice guide-

lines have been published in a number

of countries acknowledging challenges

associated with service provision,

aiming to improve services for indi-

viduals with personality disorder.

Guidelines were first developed in

1999 in New Zealand (Krawitz and

Watson, 1999), followed by the

United States, United Kingdom and

Australia (National Health and Medical

Research Council, 2012). These clini-

cal practice guidelines provide a road-

map for reform and consistently

recommend psychological interven-

tions as the first line of treatment. It is

recommended that clinical practice

guidelines for the management of per-

sonality disorder should be read in

conjunction with the Royal Australian

and New Zealand College of

Psychiatrists practice guidelines for

mood disorders (Malhi et al., 2015)

and deliberate self-harm (Carter etal.,

2016), given the high comorbidity.

There is an evidence base for the

effectiveness of various psychological

treatments for borderline personality

disorder (BPD) (e.g. cognitive behav-

ioural and psychodynamic therapies),

involving weekly sessions for 1 year,

all with similar outcomes (Cristea

et al., 2017). Most health workers

indicate a need for greater training in

these treatments for personality dis-

order (McCarthy et al., 2013). The

underlying general skills that are effec-

tive in all these models have been

described and tested (Bateman etal.,

2015; Beatson and Rao, 2014), mean-

ing any psychologist or psychiatrist

can implement effective care with

support.

There are, however, workforce

challenges to providing coverage of

psychological therapies. For example,

in Australia, access to psychiatrists is

limited, with 17 private psychiatrists

per 100,000 population practising in

major cities, 6.2 per 100,000 in inner

regional areas, 4.4 per 100,000 in

outer regional areas and only 3 per

100,000 in outer regional and remote

areas (Australian Institute of Health

Personality disorder: A mental

health priority area

Brin FS Grenyer1, Fiona YY Ng1, Michelle L Townsend1

and Sathya Rao2

Abstract

Personality disorders have received limited recognition as a public health priority, despite the publication of treatment

guidelines and reviews showing effective treatments are available. Inclusive approaches to understanding and servicing

personality disorder are required that integrate different service providers. This viewpoint paper identifies pertinent

issues surrounding early intervention, treatment needs, consumer and carer experiences, and the need for accurate and

representative data collection in personality disorder as starting points in mental health care reform.

Keywords

Personality disorder, treatment needs, early intervention, consumer and carer, data reporting

1 School of Psychology, Illawarra Health and

Medical Research Institute, University of

Wollongong, Wollongong, NSW, Australia

Spectrum, The Personality Disorder Service

for Victoria, Eastern Health, East Ringwood,

VIC, Australia

Corresponding author:

Brin FS Grenyer, School of Psychology,

Illawarra Health and Medical Research

Institute, University of Wollongong,

Wollongong, NSW 2522, Australia.

Email: grenyer@uow.edu.au

717798ANP0010.1177/0004867417717798ANZJP PerspectivesGrenyer et al.

research-article2017

Viewpoint

2 ANZJP Perspectives

Australian & New Zealand Journal of Psychiatry, 00(0)

and Welfare, 2014). Mental health

nurses are a significant part of the

workforce but often are not trained in

psychological therapies; thus, improv-

ing access to funding psychologists is

the most viable option. There is

greater onus placed on psychologists

to provide treatment and support to

individuals with personality disorder,

yet the burden often falls to public ser-

vices which may struggle to provide

the community services required for

effective evidence-based care.

Consumers and carers have both

reported the difficulties in identifying

and accessing services (Lawn and

McMahon, 2015). Current mental

health schemes offered as part of uni-

versal health care in Australia, such as

the Better Access to Mental Health

Scheme and the Access to Allied

Psychological Services (ATAPS), sub-

sidise only 10–18 individual and 10–12

group sessions per calendar year,

which clinical guidelines and research

consider insufficient for meeting the

treatment needs of some individuals

with personality disorder (Beatson

and Rao, 2014; National Health and

Medical Research Council, 2012).

More concerning, at present, person-

ality disorders are not recognised on

the general practitioner’s mental

health care Medicare item list, sug-

gesting that current universal mental

health schemes are not suitably

designed to support the treatment of

personality disorder. Other treat-

ment access pathways such as

Australia’s National Disability

Insurance Scheme may not be a good

match for most people with personal-

ity disorder. The majority of people

with personality disorder respond

well if provided effective evidence-

based psychological treatment, and

therefore, recovery and living a con-

tributing life are achievable. Long-

term disability would mostly represent

a failure to access and receive evi-

dence-based community psychologi-

cal treatment. The implementation of

an alternative model for accessing

community-based treatment when

warranted by individuals is required.

At present, different state-based

initiatives in Australia – such as the

Project Air Strategy in New South

Wales and Spectrum Personality

Disorders Service in Victoria – are

available. South Australia, through its

state Mental Health Commission, has

commenced the process of reform.

We outline a number of areas of pri-

ority which require careful considera-

tion at this time of reform.

Improving treatment for

individuals with personality

disorder

Individuals with personality disorder

often access a variety of services, both

clinical and psychosocial, to assist with

their recovery. A national commit-

ment is needed to re-orient clinical

services to implement the National

Health and Medical Research Council

(NHMRC) clinical practice guidelines.

Stepped care models for personality

disorder have been developed using

brief interventions to intervene rap-

idly at the acute stage of illness, fol-

lowed by additional long-term

treatment as clinical need dictates

(Grenyer, 2014). The stepped care

approach also acknowledges individu-

als who have personality disorder

who do not require or wish to engage

in long-term care but can benefit from

immediate crisis care that provides

specific focused personality disorder

interventions (Grenyer, 2014). Long-

term evidence-based interventions

designed for the treatment of BPD

have demonstrated their effectiveness

in terms of outcomes and cost. A

recent systematic review identified

the benefits of providing evidence-

based interventions, with an average

cost saving of US$2987.82 per patient

per year (Meuldijk etal., 2017).

Training all mental health staff in

Australia to effectively work with indi-

viduals with personality disorder and

the implementation of brief and long-

term intervention services around

Australia are an urgent priority; as such,

these models can lead to significant

reductions in inpatient hospitalisation

and emergency department presenta-

tions (Grenyer, 2014). The need to

improve skills and knowledge of mental

health staff has been supported by the

need for a whole-of-system approach

such that staff working in specialist and

non-specialist organisations need to be

equipped with the skills and knowledge

in order to work with individuals with

personality disorder (Grenyer, 2013).

Assessing and intervening

early

Increasing evidence has suggested that

early intervention and diagnosis prior

to the age of 18 and intervening with

individuals who have emerging per-

sonality disorder are conducive to

improving outcomes (Chanen et al.,

2009). The NHMRC clinical practice

guidelines (National Health and

Medical Research Council, 2012)

make two pertinent recommenda-

tions: first, young people with emerg-

ing symptoms should be assessed for

possible BPD, and second, adoles-

cents should receive structured psy-

chological therapies. Yet despite this

clear guidance, there is ongoing reluc-

tance from health professionals in

diagnosing individuals with BPD prior

to the age of 18 years. This has poten-

tial to not only limit the types of ser-

vices individuals can access but also

delays access to effective treatment.

Primary care that is well connected to

schools and families provides good

opportunities to identify, intervene

and source additional support for

individuals with these emerging prob-

lems (Grenyer, 2013). Mental health

staff working with adolescents simi-

larly have the skills to assess and treat

young people with emerging symp-

toms if they are trained in contempo-

rary personality disorder treatment.

Sadly, most experienced staff identify

training and knowledge gaps in treat-

ing these disorders (McCarthy etal.,

2013).

One innovative example of early

intervention in Australia is the HYPE

(Helping Young People Early) clinic

based at the ORYGEN Youth Health

Grenyer et al. 3

Australian & New Zealand Journal of Psychiatry, 00(0)

(Chanen etal., 2009). This model pro-

vides integrative care for adolescents

between 15 and 25 years of age, offer-

ing psychotherapy, case management,

crisis care and support for families

and carers.

Improving the experience

of consumers, families,

carers and partners

There is a need to support all those

who embark on the treatment and

recovery journey from personality

disorders, which includes the family,

carers and partners of individuals with

personality disorder. Significant bur-

den, higher rates of psychological dis-

tress and reduced levels of wellbeing

have been associated with caring for

loved ones with personality disorder

(Bailey and Grenyer, 2014).

The consumer voice in personality

disorder has emerged in the past dec-

ade with the development of organi-

sations such as the Australian BPD

Foundation. These organisations play

an instrumental role in advocating for

consumers, carers and family mem-

bers, and increasing community

awareness of personality disorder.

Despite this work, considerable

stigma and discrimination continue to

be reported by both individuals with

lived experience and their carers,

within the community and the health

system (Lawn and McMahon, 2015).

This has been suggested to be per-

petuated by the attitudes and limited

knowledge on personality disorders

held by health practitioners. Alongside

an imperative to educate clinicians

already within the workforce, empha-

sis should also be placed on tertiary

and vocation education settings to

incorporate evidence-based knowl-

edge regarding personality disorder

for all pre-workforce clinicians. In the

community level, mental health liter-

acy in regard to personality disorder

is limited. The development of popu-

lation-based awareness campaigns,

not dissimilar to those designed to

improve awareness of depression and

schizophrenia, which involve individu-

als with personality disorder and their

carers, may address stigma and

increase awareness.

Research is also needed that

includes multiple perspectives to pro-

vide a greater insight into the experi-

ences of consumers (Ng etal., 2016).

This could be achieved through the

incorporation of differing methodolo-

gies in collective data, such as narra-

tive methods, ethnography, case

studies and participatory action

research. The development of a peer

workforce for personality disorder

may provide a unique opportunity for

the co-production of knowledge.

Accurate and

representative collection

and reporting of data

Improving the quality of health ser-

vices and understanding outcomes

for Australians living with personality

disorder are driven by the accurate

collection and reporting of data.

Currently, personality disorders are

often not specifically reported upon

within national reports, including

those from the Australian Institute

of Health and Welfare, but rather

classed within the ‘other’ category.

Internationally, personality disorders

have been excluded when reporting

on mental health morbidity (Tyrer

etal., 2010).

In the recent report on Healthy

Communities: Hospitalisations for

mental health conditions and inten-

tional self-harm in 2013–14, the other

category includes BPD, unspecified

delirium eating disorders and sleep

disorders (Australian Institute of

Health and Welfare, 2016). There is a

clear need to understand more about

this ‘other group’, particularly given

they represent close to a fifth of all

hospitalisations and 34% of all hospi-

talisations in individuals under 25 years

of age (Australian Institute of Health

and Welfare, 2016). Given population

data estimate the prevalence of per-

sonality disorders in 6.5% of the

Australian population (Jackson and

Burgess, 2000), it is likely a significant

proportion of other is represented by

individuals with personality disorder.

However, these data are more than

15 years old and require updating to

reflect current trends.

Rates of suicide for people with

personality disorder have been estab-

lished through examining longitudinal

studies of individuals who have sought

treatment and have been estimated to

be at approximately 10% (American

Psychiatric Association, 2001). The

national calls for suicide prevention in

Australia are silent on personality dis-

order, despite this diagnosis being

associated with a higher risk of self-

harm and suicidal behaviours (National

Health and Medical Research Council,

2012). Where they exist, studies have

predominately been based within

North America and no data are avail-

able for Australia. Also, the data

reflect individuals who have received

treatment, and it is unknown how this

translates to individuals who are not

engaging in treatment. The establish-

ment of a national suicide registry may

assist to understand mortality rates in

Australia – if mental health diagnoses

that include personality disorder are

linked.

Reforming the manner in which

personality disorder is serviced and

viewed in Australia will require a con-

sistent national approach involving

ongoing commitment from govern-

ment. We outline some of the perti-

nent issues surrounding personality

disorder; however, it is important to

recognise that ongoing changes as

part of national reform are required

in order to improve services and out-

comes for individuals with personality

disorder and their carers and their

families.

Declaration of Conflicting

Interests

B.F.S.G. is the Director of the Project Air

Strategy. S.R. is the Director of Spectrum

Personality Disorders Service. F.Y.Y.N.

and M.L.T. have no conflicts of interest to

declare.

4 ANZJP Perspectives

Australian & New Zealand Journal of Psychiatry, 00(0)

Funding

The author(s) received no financial sup-

port for the research, authorship and/or

publication of this article.

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Full-text available

Nov 2023

Borderline personality disorder (BPD) is a severe mental health condition marked by impairments in self and interpersonal functioning. Stigma from health staff may often result in a reluctance to diagnose, impacting recovery trajectories. Qualitative interviews were conducted with participants ( N = 15; M Age = 36.4 years, SD = 7.5; 93.3% female) with lived experience of BPD exploring topics of illness onset, insight, experience of diagnosis and treatment. Qualitative responses were analysed within a co‐design framework with a member of the research team who identifies as having a lived experience of BPD. On average, participant symptoms emerged at 12.1 years of age ( SD = 6.6 years, range 1.5–27), but diagnoses of BPD were delayed until 30.2 years ( SD = 7.8 years, range 18–44) resulting in a ‘diagnosis gap’ of 18.1 years ( SD = 9.6 years, range 3–30). Participant explanations for BPD emergence varied from biological, psychological and social factors. Benefits of diagnosis (e.g., fostering insight, aiding treatment planning and reducing isolation) were contrasted with challenges (e.g., stigma and treatment unavailability). Delay in diagnosis was common, and no participants reported receiving a diagnosis of BPD during their adolescence yet 85% felt they would have benefited from a diagnosis in adolescence. Only a quarter (27%) felt highly supported in the diagnostic process. An ideal four‐step diagnosis procedure was outlined based on recommendations from participants with a lived experience; this involved the following: (1) explain the process, (2) assess thoroughly, (3) explore how the features are active in everyday life and (4) link diagnosis to evidence‐based treatment planning.

The value of psychological treatment for borderline personality disorder: Systematic review and cost offset analysis of economic evaluations

Article

Full-text available

Mar 2017
PLOS ONE

Aim Borderline Personality Disorder (BPD) is a common mental health condition with high patterns of service utilisation of inpatient and community treatment. Over the past five years there has been significant growth in research with economic data, making this systematic review a timely update. Methods Empirical studies written in English or German, published up to December 2015, and cited in major electronic databases were examined using the PRISMA systematic review method. Papers were included that had one of the following: data related to cost of BPD to society, the individual, the carer or families; cost benefits of interventions. Reported cost data were inflated to the year 2015 and converted into US- dollars (USD

) using purchasing power parities. Results We identified 30 economic evaluations providing cost data related to interventions for BPD across 134,136 patients. The methodological quality was good, almost all studies fulfilled ≥ 50% of the quality criteria. The mean cost saving for treating BPD with evidence-based psychotherapy across studies was USD

2,987.82 per patient per year. A further mean weighted reduction of USD

1,551 per patient per year (range

83 - $29,392) was found compared to treatment as usual. Evidence-based psychological treatment was both less expensive as well as more effective, despite considerable differences in health cost arrangements between individual studies and countries. Where it was able to be calculated, a significant difference in cost-savings between different types of evidence-based psychotherapies was found. Discussion Individuals with BPD consistently demonstrate high patterns of service utilization and therefore high costs. The findings of this review present a strong argument in favour of prioritizing BPD treatments in reimbursement decisions, both for the affected individual and the family. The provision of evidence based treatment, irrespective of the type of psychological treatment, may lead to widespread reductions in healthcare costs.

Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis

Article

Full-text available

Mar 2017

Importance: Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective. Objective: To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations. Data sources: Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses. Study selection: Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone). Data extraction and synthesis: Data extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted. Main outcomes and measures: Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios. Results: Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at posttest, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g = 0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16; 95% CI, -0.29 to -0.03; P = .02). Publication bias was persistent, particularly for follow-up. Conclusions and relevance: Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.

Recovery from Borderline Personality Disorder: A Systematic Review of the Perspectives of Consumers, Clinicians, Family and Carers

Article

Full-text available

Aug 2016
PLOS ONE

Purpose Longitudinal studies support that symptomatic remission from Borderline Personality Disorder (BPD) is common, but recovery from the disorder probably involves a broader set of changes in psychosocial function over and above symptom relief. A systematic review of literature on both symptomatic and personal recovery from BPD was conducted including the views of consumers, clinicians, family and carers. Materials and Methods A PRISMA guided systematic search identified research examining the process of recovery from BPD. Longitudinal studies with a follow-up period of five or more years were included to avoid treatment effects. Results There were 19 studies, representing 11 unique cohorts (1,122 consumers) meeting the review criteria. There was a limited focus on personal recovery and the views of family and carers were absent from the literature. Rates of remission and recovery differ depending upon individual and methodological differences between studies. Data on symptomatic remission, recurrence and diagnosis retainment suggests that BPD is a stable condition, where symptomatic remission is possible and the likelihood of recurrence following a period of remission is low. Conclusion Symptomatic remission from BPD is common. However, recovery including capacities such as engaging in meaningful work was seldom described. Future research needs broader measures of recovery as a sub-syndromal experience, monitoring consumer engagement in meaningful vocation and relationships, with or without the limitations of BPD.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders

Article

Full-text available

Dec 2015

Objectives: To provide guidance for the management of mood disorders, based on scientific evidence supplemented by expert clinical consensus and formulate recommendations to maximise clinical salience and utility. Methods: Articles and information sourced from search engines including PubMed and EMBASE, MEDLINE, PsycINFO and Google Scholar were supplemented by literature known to the mood disorders committee (MDC) (e.g., books, book chapters and government reports) and from published depression and bipolar disorder guidelines. Information was reviewed and discussed by members of the MDC and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to rigorous successive consultation and external review involving: expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest in mood disorders. Results: The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders (Mood Disorders CPG) provide up-to-date guidance and advice regarding the management of mood disorders that is informed by evidence and clinical experience. The Mood Disorders CPG is intended for clinical use by psychiatrists, psychologists, physicians and others with an interest in mental health care. Conclusions: The Mood Disorder CPG is the first Clinical Practice Guideline to address both depressive and bipolar disorders. It provides up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. Mood disorders committee: Professor Gin Malhi (Chair), Professor Darryl Bassett, Professor Philip Boyce, Professor Richard Bryant, Professor Paul Fitzgerald, Dr Kristina Fritz, Professor Malcolm Hopwood, Dr Bill Lyndon, Professor Roger Mulder, Professor Greg Murray, Professor Richard Porter and Associate Professor Ajeet Singh. International expert advisors: Professor Carlo Altamura, Dr Francesco Colom, Professor Mark George, Professor Guy Goodwin, Professor Roger McIntyre, Dr Roger Ng, Professor John O'Brien, Professor Harold Sackeim, Professor Jan Scott, Dr Nobuhiro Sugiyama, Professor Eduard Vieta, Professor Lakshmi Yatham. Australian and new zealand expert advisors: Professor Marie-Paule Austin, Professor Michael Berk, Dr Yulisha Byrow, Professor Helen Christensen, Dr Nick De Felice, A/Professor Seetal Dodd, A/Professor Megan Galbally, Dr Josh Geffen, Professor Philip Hazell, A/Professor David Horgan, A/Professor Felice Jacka, Professor Gordon Johnson, Professor Anthony Jorm, Dr Jon-Paul Khoo, Professor Jayashri Kulkarni, Dr Cameron Lacey, Dr Noeline Latt, Professor Florence Levy, A/Professor Andrew Lewis, Professor Colleen Loo, Dr Thomas Mayze, Dr Linton Meagher, Professor Philip Mitchell, Professor Daniel O'Connor, Dr Nick O'Connor, Dr Tim Outhred, Dr Mark Rowe, Dr Narelle Shadbolt, Dr Martien Snellen, Professor John Tiller, Dr Bill Watkins, Dr Raymond Wu.

Psychotherapy for borderline personality disorder

Article

Full-text available

Oct 2014

Objective: This paper aims to provide a succinct overview of the factors common to empirically validated psychotherapies for borderline personality disorder (BPD), including the treatment structure required. Conclusion: Individual psychotherapy remains the cornerstone of treatment for BPD. Factors common to empirically validated modalities of therapeutic treatment have been identified. These need to be provided within an individualised and structured treatment framework. Improved outcome of treatment for BPD can then be achieved.

An integrative relational step-down model of care: The Project Air Strategy for Personality Disorders

Article

Full-text available

Jan 2014

Brin F S Grenyer

Personality disorders, particularly borderline disorders (BPD), represent a significant treatment challenge for mental health services in part because of the severity of the disorder, but also because of the high prevalence. Aproximately one quarter of emergency mental health presentations and inpatient admissions are from people with personality disorders. Evidence-based treatment for BPD is psychological therapy based on clinical guidelines, yet the prevalence of the disorder presents a challenge to specialist intervention programs that typically are unable to meet the high clinical demand. Similarly, the particular nature of the disorder can challenge the capacity of teams to maintain compassion towards clients, given the particular features of the disorder that can induce negative countertransference responses. An integrative step-down whole of service approach that is based on a relational model is described that focuses on both the intrapsychic difficulties of the individual, as well as broader interpersonal conflicts that can challenge treatment teams, families and carers, and the broader community. The model includes the whole system supporting the client in the strategy. The Project Air Strategy for Personality Disorders outlines approaches to clinical leadership and service re-design, targetted training, the provision of brief and longer term treatments, rapid access to psychological assistance, support for families and carers, and better access to information and clinical resources to provide a more hopeful and integrated treatment.

Supporting a Person With Personality Disorder: A Study of Carer Burden and Well-Being

Article

Full-text available

Apr 2014

Personality disorders are characterized by impaired interpersonal functioning. There are few studies and little data available using validated questionnaires on the impact of caring for a person with personality disorder. The 287 carers included in this study were administered the McLean Screening Instrument for Borderline Personality Disorder-Carer Version, Burden Assessment Scale, Grief Scale, Difficulties in Emotion Regulation Scale, Mental Health Inventory-5, and a qualitative question. Scores were compared to those of published comparison groups. Burden and grief were significantly higher than that reported by carers of persons with other serious mental illnesses. Carers endorsed symptoms consistent with mood, anxiety, and posttraumatic stress disorders. A qualitative concept map highlighted the impact of caregiving on the interpersonal environment. Carers of persons with personality disorder report grieving their change in life and impairment in well-being. Carers are burdened, and appear more so than carers of persons with other serious mental illnesses. The results highlight the need for interventions to support carers.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

Article

Oct 2016

Objective: To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations. Method: Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm. Results: The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care. Conclusion: The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Experiences of care by Australians with a diagnosis of borderline personality disorder. (Open access http://onlinelibrary.wiley.com/doi/10.1111/jpm.12226/abstract)

Article

Jun 2015
J PSYCHIATR MENT HLT

Accessible summary Borderline personality disorder (BPD) is a complex and challenging mental health condition for the person and service providers who support them. This paper reports on the results of a survey of 153 people with a diagnosis of BPD about their experiences of attempting to receive support in managing this mental health condition. It provides their perceptions of a range of experiences not reported in the existing literature, including general practitioner roles, urban and rural differences, public and private hospital differences, and comparison of usefulness of support across multiple support types. People with a diagnosis of BPD continue to experience significant discrimination when attempting to get their needs met within both public and private health services. Further education for nurses and other health professionals is indicated to address pervasive negative attitudes towards people with a diagnosis of BPD. Abstract There is limited understanding of the experience of seeking and receiving treatment and care by people with a diagnosis of borderline personality disorder ( BPD ), their perceptions of barriers to care and the quality of services they receive. This study aimed to explore these experiences from the perspective of Australians with this diagnosis. An invitation to participate in an online survey was distributed across multiple consumer and carer organizations and mental health services, by the P rivate M ental H ealth C onsumer C arer N etwork ( A ustralia) in 2011. Responses from 153 people with a diagnosis of BPD showed that they experience significant challenges and discrimination when attempting to get their needs met within both public and private health services, including general practice. Seeking help from hospital emergency departments during crises was particularly challenging. Metropolitan and rural differences, and gender differences, were also apparent. Community supports were perceived as inadequate to meet their needs. This study provides data on a range of experiences not reported in existing literature, including general practitioner roles, urban and rural differences, public and private hospital differences, and comparison of usefulness of support across multiple support types. Its findings can help inform better training for health professionals and better care for this population.

Treatment of personality disorder

Article

Feb 2015

The evidence base for the effective treatment of personality disorders is insufficient. Most of the existing evidence on personality disorder is for the treatment of borderline personality disorder, but even this is limited by the small sample sizes and short follow-up in clinical trials, the wide range of core outcome measures used by studies, and poor control of coexisting psychopathology. Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions. The synergistic or antagonistic interaction of psychotherapies and drugs for treating personality disorder should be studied in conjunction with their mechanisms of change throughout the development of each. Copyright © 2015 Elsevier Ltd. All rights reserved.