MENTAL HEALTH

Health Evidence Bulletins - Wales
Team Leader: Dr. Lyn Harris

Date of Completion: 2.3.98

PERSONALITY DISORDERS

This document is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation

The Statements The Evidence
1.1 Prevention and Promotion
1.1a. Promotion of adequate parenting is likely to be beneficiali although no evidence has been found on the effectiveness of interventions to reduce childhood abuse in reducing personality disordersii. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
ii.
Project Team and Internal Review Group (see inside front cover)
1.2 Diagnosis and Assessment
1.2a. Promotion of greater awareness in primary care is recommended and full multidisciplinary assessment is likely to be beneficiali. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
1.2b. The classification and diagnosis of personality disorder remain difficult i.
It is suggested that an approach based on different types of symptomatology rather than diagnostic categories may be better when deciding treatment or in designing research projects ii.
i. Mallet P, Glascoe S. Chapter 2.7. Personality disorders in Mental Health. A Technical Document produced by the Health Gain Panel of Review. Cardiff: Welsh Health Planning Forum, 1995
(Type V evidence - expert opinion)
ii. Roth AD, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: Guilford Press, 1996
1.3 Treatment and Care.
1.3a. Dialectical behaviour therapy may be of value i. i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
1.3b. Judicious use of drug therapy (monoamine oxidase inhibitors (MAOIs), carbamazepine and neuroleptics) is likely to be beneficial. No clear drug preference is annotatedi,ii. i. Cornelius JR, Soloff PH, Perel JM, Ulrich RF. Continuation pharmacotherapy of borderline personality disorder with haloperidol and phenelzine. American Journal of Psychiatry 1993; 150: 1843-1848
(Type II evidence - randomised controlled trial)
ii. Soloff PH, Cornelius J, George A, Nathan S, Perel JM, Ulrich RF. Efficacy of phenelzine and haloperidol in borderline personality disorder. Archives of General Psychiatry 1993; 50: 377-385
(Type II evidence - randomised controlled trial)

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1.3c. Personality disorder is frequently a co-morbid condition and it is well established that the presence of Cluster A and B personality disorders reduces the likelihood of good outcome from symptom orientated treatment of Axis I disorders, in particular, depression and anxiety i. i. Roth AD, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: Guilford Press, 1996
(Type IV evidence - observational studies)
1.3d. Observational studies suggest that therapeutic community treatment produces a significant improvement in up to 40% of clients but treatment effects are difficult to summarise given the heterogeneity of the client group and methodological problems. A randomised controlled trial is recommended as the report’s conclusion is ‘not proven’ i. i. Cornah D, Stein K, Stevens A. The therapeutic community method of treatment for borderline personality disorder. Development and Evaluation Committee (DEC) Report No. 67. Southampton: Wessex Institute of Public Health Medicine, March 1997
(Type IV evidence - Summary of 6 observational studies)
1.4 Rehabilitation and Continuing Care.
1.4a. The benefits of long term support with strict limit setting may be beneficiali.
Research is urgently required given the long term chronic nature of the conditions, the relative ineffectiveness of current treatments and the costs to society and the service ii.
i. Original Protocol. Welsh Health Planning Forum. Protocol for investment in health gain. Mental health. Cardiff: Welsh Office, April 1993
(Type V evidence - expert opinion)
ii. Roth AD, Fonagy P. What works for whom? A critical review of psychotherapy research. New York: Guilford Press, 1996
(Type I evidence - systematic review)
1.4b Community Mental Health Team (CMHT) Management is not inferior to non-team standard care in those with a dual diagnosis (mental illness and disordered personality) in any important respects and is superior in promoting greater acceptance of treatment. It may also be superior in reducing hospital admission and avoiding death by suicide i. i. Tyrer P, Coid J, Simmonds S, Joseph P, Marriot S. Community mental health team management for those with a severe mental illness and disordered personality.
Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 1
(Type I evidence - systematic review)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk