May meeting on Personality Disorder
07 . 09 . 22
May saw the return of in-person meetings for the Manchester Medical Society Section of Psychiatry with a symposium on Personality Disorder. The meeting began with a talk from Professor Peter Tyrer (Consultant in Transformation Psychiatry in Lincolnshire Partnership NHS Foundation Trust and Emeritus Professor of Community Psychiatry at Imperial College, London) outlining the new radical classification of personality disorders. Prof Tyrer began by reminding us that the idea that personality disorder is ingrained and untreatable is “rubbish!”. We heard that with the ICD-11 there is a move away from the current categories of personality disorder listed in ICD-10. There is now evidence from a number of countries that ICD-10 classifications are not being used in clinical practice despite high prevalence rates worldwide.
Professor Tyrer took us through the new tiered classification system, designed by a multi-national revision group, which encompasses personality difficulty, mild personality disorder, moderate personality disorder and severe personality disorder. Another major revision is that ICD-11 states that symptoms must have been present for two years or more, in contrast to ‘persistent since adolescence’ in ICD-10. This acknowledges that personality changes over time and also allows for early intervention in adolescence. Professor Tyrer ended with a call for de-prescribing, given the evidence that people with personality disorder are prescribed an average of three psychotropic drugs despite no evidence of their benefit, and development of new, shorter psychological interventions.
We then heard a very powerful talk from Jane Cannon MBE who took us through the experiences of her two children, Sam and Chris Gould, who both died by suicide in adolescence. Ms Cannon highlighted the negative impact on her children of not recognising their difficulties as borderline personality disorder. This is a view that was shared by Sam and Chris, who said “BPD is like a roadmap of me” and “I knew it wasn’t depression” when they both finally received the diagnosis. We were reminded that a key principle of the NHS is to “diagnose and treat”, yet there continues to be a reluctance to diagnose personality disorder, particularly in adolescents, together with an absence of evidence-based pathways in CAMHS.
Despite presenting with very similar difficulties, Sam and Chris received different interventions from CAMHS, some of which were very invalidating and ineffective for them. We heard that, whilst Sam and Chris had experienced trauma, they did not want this to become their identity or the focus of their treatment. When this was not acknowledged and respected, in either their diagnosis or their treatment plan, they felt unable to engage in treatment. Ms Cannon also shared the Coroner’s notification to prevent future deaths, issued in relation to her children, which highlighted that “There are risks associated with a reluctance to use a personality disorder diagnosis”. This was certainly something to reflect on for those of us working with children and young people and a powerful reminder of the importance of early intervention and diagnosis.
Dr David Kingsley (Consultant Child and Adolescent Psychiatrist & Clinical Director (CAMHS) Priory Healthcare and National Clinical Lead, CAMHS Low Secure Network, NHS England) then addressed some of the common arguments against diagnosis of personality disorder in adolescents and why these arguments should not prevent young people from accessing effective treatments. Commonly the argument of the “normal teenage brain” is used and whilst there is a reduced capacity to manage short term rewards for long term gain and increased risk taking in adolescence, Dr Kingsley reminded us that the extent and severity of symptoms is what makes them pathological at any age. We heard that the term “emerging personality disorder” is unhelpful in a young person who meets the criteria for a personality disorder diagnosis because it wrongly gives the impression that personality disorder will persist throughout their life.
Dr Kingsley highlighted the impact that failing to diagnose personality disorder has on epidemiological data and therefore commissioning of effective services for young people with personality disorder. Personality disorder did not feature at all in the Mental Health of Children and Young People Survey and, clinically, young people are often misdiagnosed with depression or in some cases subjected to harmful inpatient admissions. There is evidence that 30% of adult inpatients with Borderline Personality Disorder who self-harm, showed onset of their symptoms before the age of 12, yet with the current reluctance to diagnose personality disorder, effective treatments are not being commissioned and delivered.
The final talk was delivered by Dr Hannah Cappleman (Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust) who outlined the principles of trauma-informed care. We were reminded that trauma is widespread and the effects of childhood trauma often play out in therapeutic relationships. Dr Cappleman asked “can we provide good enough care?” in our day to day clinical work. Can we instil hope, give more time to listening to our patients and avoid being a source of re-traumatisation in both our consultations and our service structure?
We were then joined by all the speakers (and Professor Tyrer’s cat!) for a thought-provoking panel discussion on the challenges we face in NHS mental health services, particularly in respect to providing trauma-informed care in a system which does not always feel designed to support us to do so.
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