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Dedicated community-based services for adults with personality disorder: Delphi study

  • Mike J. Crawford (a1), Katy Price (a1), Deborah Rutter (a1), Paul Moran (a2), Peter Tyrer (a1), Anthony Bateman (a3), Peter Fonagy (a3), Sarah Gibson (a4) and Tim Weaver (a5)...

Summary

Dedicated community-based services have been recommended for people with personality disorder, but little is known about how such services should be configured. We conducted a Delphi survey to assess opinions about this. A panel of expert authors, service providers and service users agreed on only 21 (39%) of 54 statements on the organisation and delivery of care. Consensus was not reached on important issues such as working with people with a history of violent offending, the role of community outreach and the use of compulsory treatment. Further work needs to be undertaken before the optimal organisation of dedicated personality disorder services can be agreed.

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Copyright

Corresponding author

Dr M. J. Crawford, Department of Psychological Medicine, Faculty of Medicine, Imperial College London, Claybrook Centre, 37 Claybrook Road, London W6 8LN, UK. Email: m.crawford@imperial.ac.uk

References

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1 Coid, J, Yang, M, Tyrer, P, Roberts, A, Ullrich, S. Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry 2006; 188: 423–31.
2 Lewis, G, Appleby, L. Personality disorder: the patients psychiatrists dislike. Br J Psychiatry 1988; 153: 44–9.
3 Ramon, S, Castillo, H, Morant, N. Experiencing personality disorder: a participative research. Int J Soc Psychiatry 2001; 47: 115.
4 National Institute for Mental Health. Personality Disorder: No Longer a Diagnosis of Exclusion. Department of Health, 2003.
5 Binks, CA, Fenton, M, McCarthy, L, Lee, T, Adams, CE, Duggan, C. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2006; issue 1: CD005652.
6 Murphy, MK, Black, NA, Lamping, DL, McKee, CM, Sanderson, CFB, Askham, J, Marteau, T. Consensus development methods, and their use in clinical guideline development. Health Technol Assess 1998; 2: iiv, 18.
7 Crawford, M, Rutter, D, Price, K, Weaver, T, Josson, M, Tyrer, P, Gibson, S, Gillespie, S, Faulkner, A, Ryrie, I, Dhillon, K, Bateman, A, Fonagy, P, Taylor, B, Moran, P. Learning the Lessons: A Multi-method Evaluation of Dedicated Community-based Services for People with Personality Disorder. National Co-ordinating Centre for NHS Service Delivery and Organisation, 2007 (http://www.sdo.nihr.ac.uk/sdo832004.html).
8 Fiander, M, Burns, T. Essential components of schizophrenia care: a Delphi approach. Acta Psychiatr Scand 1988; 98: 400–5.
9 Heather, N, Dallolio, E, Hutchings, D, Kaner, E, White, M. Implementing routine screening and brief alcohol intervention in primary health care: a Delphi survey of expert opinion. J Subst Use 2004; 9: 6885.
10 Bateman, AW, Fonagy, P. Treatment of borderline personality disorder with psychoanalytically orientated partial hospitalisation: an 18-month follow up. Am J Psychiatry 2001; 177: 138–43.

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Dedicated community-based services for adults with personality disorder: Delphi study

  • Mike J. Crawford (a1), Katy Price (a1), Deborah Rutter (a1), Paul Moran (a2), Peter Tyrer (a1), Anthony Bateman (a3), Peter Fonagy (a3), Sarah Gibson (a4) and Tim Weaver (a5)...

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Dedicated community-based services for adults with personality disorder: Delphi study

  • Mike J. Crawford (a1), Katy Price (a1), Deborah Rutter (a1), Paul Moran (a2), Peter Tyrer (a1), Anthony Bateman (a3), Peter Fonagy (a3), Sarah Gibson (a4) and Tim Weaver (a5)...
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eLetters

Interesting times for personality disorder services

Timothy Agnew, specialist registrar in general psychiatry
31 October 2008

The recent Delphi study (Crawford, 2008) assessing opinion on community-based services for personality disorder (PD) was a welcome attempt to identify important components of PD service provision. Perhaps unsurprisingly, consensus within and between the three stakeholder groups was attained for only a minority of the questionnaire’s 49 items, probablyreflecting the rudimentary experience of service provision for personalitydisorder and the limited evidence base that exists to support development of such services.

While many of the consensus items reflect the heartening shift in attitudes towards personality disorder over the past few years, some responses were slightly surprising. For example, panellists reached consensus that most people with personality disorder require dedicated services to help them cope with their problems. When this is considered inlight of the estimate that 4% of the population have a personality disorder (Coid, 2006), and that “interventions aimed at helping people with PD develop better coping strategies need to be delivered over years not months”, the economic implications appear daunting. To contend that most people with personality disorder require dedicated services is to overlook factors such as severity and the issue of treatment-seeking versus treatment-resistance in PD (Tyrer, 2003). These factors are of prime importance in informing management on an individual level, but also in service planning. Many people with PD are treatment-resistant and, of those who are treatment-seeking, many will have a disorder of a severity which can be appropriately managed in primary care or in general mental health services. Furthermore, while lengthy interventions may be required for many people with PD, treatment should be guided by an individual case formulation which may indicate a less intensive intervention.

Another thought-provoking finding was that expert authors and serviceusers agreed that dedicated PD services should be open to self-referral; service providers disagreed. It would be unusual for an individual with PD to have problems severe enough to warrant specialist input and not first to come to the attention of general services. Professionals in general services and primary care frequently possess considerable skills in the management of PD, and it should be for them to make the decision of when to involve PD services. Allowing general services to be bypassed by self-referral could cause resentment towards PD services, especially if general services continue tohold overall clinical responsibility while receiving unsolicited and unwanted input from a specialist PD service. Needless to say, fragmentation of care in this patient group should be avoided at all costs.

This paper highlighted the need both for evidence gathering in this field and also for careful consideration of how to use all-too-finite resources most effectively. Realistically, most personality disordered individuals will continue to be managed in primary care or general mental health services. PD services have an important role to play in supporting,educating, and delivering specialist input where needed. However, care needs to be taken to integrate sensitively and effectively with existing services. How these fledgling services meet the challenges ahead will influence attitudes not only towards PD services, but to PD itself.

Coid J. et al. (2006) Prevalence and correlates of personality disorder in Great Britain. The British Journal Psychiatry. 188: 423 -31.

Crawford M.J. et al. (2008) Dedicated community-based services for adults with personality disorder: Delphi study. The British Journal of Psychiatry. 193: 342 - 343.

Tyrer, P. et al. (2003) Treatment-rejecting and treatment-seeking personality disorders: Type R and Type S. Journal of Personality Disorders. 17, 265–270.

Declaration of interest: None.

Dr Timothy Agnew MBchB MRCPsych PGDipCBPSpecialist Registar in General PsychiatryPsychotherapy DepartmentLarch house Stonneyfield Business ParkInvernessIV2 7PA

Telephone 01463 253667Fax 01463 718303
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Conflict of interest: None Declared

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