Role of CMHT in the treatment of Personality Disorder

CMHTs should be able to provide an assessment, diagnosis and formulation function as outlined in the Assessment, Diagnosis and Formulation Section of this ICP. While most clinicians are well placed to describe and discuss personality traits and symptoms, a formal diagnosis of personality disorder should usually only be made by a senior psychiatrist. During the diagnosis process, is important that the patient receives balanced, honest feedback in a form which they can understand. Personal strengths should be emphasised while acknowledging difficulties and the importance of personal responsibility in the recovery process.

Explanation of treatment options and the relatively positive prognosis should be given. For example, patients are often heartened to hear that studies suggest that around three quarters of those meeting the diagnostic criteria for borderline personality disorder no longer do so after a period of six years.

While many patients describe a sense of relief on receiving a diagnosis or formulation that makes sense of their difficulties, many others find receiving a diagnosis of personality disorder an upsetting experience. This is at least in part due to myths and misinformation perpetuated by the media, and the associated stigma. Psychiatrists should consider giving verbal and written information on personality disorder when discussing the diagnosis with the patient and asking them to return with any questions once they have reflected on the information. It is also reasonable to advise patients about the large amount of misleading information regarding personality disorder on the internet, and recommend that they exercise caution in what they read. Some useful information leaflets are available in the Appendix.

Occasionally, patients can have difficulty with the term “personality disorder”. If this is the case, it may be helpful to explain that the term simply serves as short hand to describe sets of symptoms and traits which typically occur together, and has the principle purpose of ensuring delivery of the treatment that is best matched to the patient’s problems. Some patients with borderline personality disorder find the reframing of their difficulties as “emotional intensity disorder” (which is the terminology used in the STEPPS program) to be more acceptable. In any case, the terminology is much less important than the clinician and patient agreeing on the presenting features.

Assessment should aim to establish diagnosis and produce a formulation upon which an individual’s treatment plan should be based. Particularly important components of the assessment in guiding treatment planning include:

• phase of treatment
• symptoms
• personality traits
• needs assessment
• risk assessment
• environmental context

Most commonly, patients will be referred to a CMHT needing input at phase 1 or 2. See the General Principles Section for a more detailed description of phases of treatment.

Symptoms occur as a result of maladaptation of the personality to the environment. It can be helpful to think in terms of four broad headings:

• cognitive-perceptual (for example, excessive suspiciousness)
• affective (for example, emotional dysregulation and harmful anger)
  • interpersonal
  • relationship with self including sense of self
  • interpersonal relationships
  • relationship with society
• behavioural/impulse control (including self-harm and suicidal behaviour)

A personality trait or variable is a complex structure which represents a basic building block of personality. In any given individual, genetic factors and environmental factors transact with each other to form a complex biopsychological system which produces observable trait-based behaviour. This biopsychological system can be described in terms of both biological processes and psychological processes. Essentially, a personality trait represents a disposition to behave in a particular way.

The term “trait” is also sometimes used to refer to individual features of specific personality disorders, especially when the full diagnostic criteria are not met. For example, someone meeting four of the five criteria needed for a diagnosis of borderline personality disorder may be referred to as having “borderline traits”.

Some traits which are of particular importance in personality disorder are listed below with brief descriptions of associated behaviours. Traits can be usefully organised into four main higher order trait domains: dyregulated, detached, dissocial, and compulsive. There may be some overlap between some traits and it is worth noting that some of the names used for particular traits may have different meanings when used in other contexts. The traits below are drawn from the Personality Assessment Schedule (Tyrer, 2000), and other sources may label particular traits differently.

It is important to remember that no personality trait is inherently negative. Many traits can be described by more than one term, some with negative connotations and some with positive connotations. For example: impulsive versus spontaneous; stubborn versus determined; aloof versus self-contained and so on. Problems arise when a person’s personality traits are maladapted to their environment. With more extreme expressions of particular traits, maladaption is likely in a greater number of environments leading to greater severity of personality disturbance.

• Pessimism — holds a pessimistic outlook on life.
• Worthlessness — feelings of inferiority
• Lability — mood instability
• Anxiousness — anxiety-proneness
• Shyness — shyness and lack of self-confidence
• Sensitivity — personal sensitivity and tendency to self-reference
• Vulnerability — experiences excessive emotional distress when faced with adversity
• Childishness — excessive self-centeredness
• Resourcelessness — tendency to give up when faced with adversity
• Dependence — excessive reliance on others for advice and reassurance
• Submissiveness — limited ability to express own views or stand up for oneself
• Hypochondriasis — over-concern about illness and health

• Suspiciousness — excessive mistrust of others
• Introspection — prone to rumination and fantasy
• Aloofness — detachment and lack of interest in other people
• Eccentricity — oddness in behaviour and attitudes; unwilling or unable to conform

• Optimism — unrealistically optimistic, over-confident, excessively self-important
• Irritability — excessively irritable
• Impulsiveness — excessive impulsiveness
• Aggression — excessive levels of aggression
• Callousness — indifferent to the feelings of others
• Irresponsibility — indifferent to the consequences of one’s behaviour

• Conscientiousness — overly fussy, perfectionistic
• Rigidity — inflexibility and difficulty adjusting to new situations