Pharmacotherapy of personality disorders

Prescribing in personality disorder: patients' perspectives on their encounters with GPs and psychiatrists

Objective

The purpose of this study was to explore the views of patients with personality disorder on their experiences of prescribing practices by general practitioners (GPs) and psychiatrists, and their expectations of primary and secondary mental health services.

Design

This was a qualitative study involving two focus groups. Discussion in the focus groups was recorded, transcribed verbatim and then analysed by a thematic analysis process to generate the key themes.

Setting

The study took place at a specialist outpatient personality disorder service in the UK.

Participants

A total of seven participants took part in the study. They were purposively sampled from an NHS specialist outpatient personality disorder service. All participants had a primary diagnosis of emotionally unstable personality disorder and their age ranged from 20 to 52 years.

Results

Five key themes emerged. Participants felt that medication has a powerful impact on their mind and body but expressed confusion and uncertainty on how it is affecting them. Participants had a need for a good relationship with their doctors (GPs or psychiatrists). They described a feeling of being dismissed and not believed, expressing a desire to confront the ‘powerful’ position of their doctors by showing anger. The nature of the doctor-patient relationship was seen to moderate positively or negatively the experience of doctors’ prescribing. Finally, there were key expectations of the primary-secondary care interface, including continuity of care, diagnostic clarity and a desire for different healthcare professionals to communicate with one another.

Conclusion

The doctor-patient relationship is an important medium for providing validation and seeking negotiation of therapeutic treatment strategies in patients with personality disorder. Given that personality disorder is associated with high rates of physical and mental health comorbidity, it is therefore vital for clinical guidelines and training packages to take more account of the relational aspects of prescribing in consultations for this patient group with a view to improve outcomes.

Assessing overweight and obesity across mental disorders: personality disorders at high risk

PURPOSE

The aim of the present investigation is to assess the prevalence of obesity in people diagnosed as having a mental illness and to investigate differences between disorders. This adds to the paucity of research in this particular population of people and assists with preventative knowledge to obtain optimum physical health.

METHODS

Data were collected for all 508 male and female inpatients (new and already existing) in a public mental health service centre in Western Australia between January and December 2008. Current weight for all patients and weight gain for some patients were calculated to obtain a body mass index (BMI) value, and diagnostic information was aligned to one of the six major categories of mental illness.

RESULTS

The percentage of obese inpatients (30.3%) was much higher than that of the general population (21.4%), with females showing a higher propensity toward obesity than males. Most diagnostic categories had a mean BMI in the overweight range, whereas Personality Disorders had a mean BMI in the obese range (30.07). A gradual increase in weight over a 9-month time period can be seen in most patients who were assessed on more than one occasion.

CONCLUSIONS

The proportion of obese people within the mental health system far exceeds that of the general population, with these people at a much greater risk of becoming obese. The highest level of obesity was found in people with a personality disorder rather than in people with psychosis. Further research is needed to ease out the mitigating factors behind weight gain occurring across disorders.

How personality became treatable: The mutual constitution of clinical knowledge and mental health law

In recent years, personality disorders – psychiatric constructs understood as enduring dysfunctions of personality – have come into ever-greater focus for British policymakers, mental health professionals and service-users. Disputes have focussed largely on highly controversial attempts by the UK Department of Health to introduce mental health law and policy (now enshrined within the 2007 Mental Health Act of England and Wales). At the same time, clinical framings of personality disorder have dramatically shifted: once regarded as untreatable conditions, severe personality disorders are today thought of by many clinicians to be responsive to psychiatric and psychological intervention. In this article, I chart this transformation by means of a diachronic analysis of debates and institutional shifts pertaining to both attempts to change the law, and understandings of personality disorder. In so doing, I show how mental health policy and practice have mutually constituted one another, such that the aims of clinicians and policymakers have come to be closely aligned. I argue that it is precisely through these reciprocally constitutive processes that the profound reconfiguration of personality disorder from being an obdurate to a plastic condition has occurred; this demonstrates the significance of interactions between law and the health professions in shaping not only the State’s management of pathology, but also perceptions of its very nature.