Summary General principles of management of patients with personality disorders admitted in crisis are discussed. The role of the acute ward in the overall plan of care, the clinical thresholds to consider in deciding whether admission is appropriate and the main elements of the in-patient care plan are outlined. The management of patients with borderline personality disorder, who constitute the majority of such admissions, is discussed in detail, and that of patients with paranoid, antisocial and hysterical and histrionic personality disorders, who require admissions less frequently, is also assessed.
The management and treatment of personality disorders has caused considerable controversy among psychiatrists in the UK. In Chapter 11, Gwen Adshead outlines the main issues relating to the status of personality disorders as nosological entities and their treatability. Guidance from the National Institute for Mental Health in England helpfully raised many issues relating to this often-excluded group, which prevalence studies suggest constitutes 10–13% of the population (National Institute for Mental Health in England, 2003), and guidelines now exist for the treatment of cluster B disorders (Kendall et al, 2009; National Collaborating Centre for Mental Health, 2009). However, these reports and guidelines offer little advice about the role of the acute in-patient setting in the lifetime experiences of people with personality disorders.
The use of acute psychiatric wards in the treatment of personality disorders has been viewed as at the very least, unhelpful, and at worst, harmful. In a review of the literature on the usefulness of hospital admission for suicidal patients with borderline personality disorder, Paris (2004) concluded that there is no evidence to suggest that admission to this setting has any effect in reducing risks, has unproven benefits in terms of safety and is, in many cases, counterproductive in terms of self-harming and suicidal behaviour. Other reviews have endorsed this general conclusion.
For example Krawitz & Batcheler (2006) went so far was to say that ‘A strong consensus exists that overly defensive treatment measures can actually increase the long term risk in working with adults with borderline personality disorder’.