Personality Disorders Glos Care Pathway Overview

At present there is no local published pathway for personality disorders due to the complexity surrounding diagnosis. This guidance covers what services are available, the different levels of severity and what actions can be taken earlier on in the pathway to aid the patients' well-being and reduce unnecessary referrals when other routes may be more effective. This pathway will also act as an education and advice tool for managing patients with a personality disorder.

Please click the relevant flowchart box to be taken directly to textual information.

Red Flags
  • escalation of substance misuse
  • increased presentation to medical services e.g. increased A & E attendances
  • heavy utilisation of medical, health and social care services
  • increase in aggressive behaviour
  • indicators of domestic abuse
Urgent concern (if the patient):
  • is considered to be an immediate risk to themselves or others
  • is actively suicidal, has a current suicide plan, is at risk of self-harm
  • has psychotic symptoms, e.g. hallucinations, delusions
  • has severe agitation accompanying severe symptoms
  • presents with severe self-neglect
  • has deteriorating personal circumstances exacerbating their mental illness

If any urgent concern consider GP led pharmacological intervention, discussion and referral. Referrer Information for Mental Health Services- Gloucestershire including the Contact Centre, Mental Health Acute REsponse Service (MHARS) (formerly Crisis Resolution and Home Treatment Teams) can be found here.

2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here

Presentation

Personality disorders are severe disturbances in the personality and behaviours of an individual; not resulting from disease, damage or other insult to the brain, or from another psychiatric disorder. They are nearly always associated with considerable personal distress and social disruption. The symptoms of a personality disorder may range from mild to severe and usually emerge in adolescence, persisting into adulthood

UK figures estimate that 10% of the population have a personality disorder:

  • 5% emotionally unstable (e.g. borderline)
  • 3% dissocial/antisocial
  • 2% histrionic
  • 1% anankastic
  • 0.7% anxious/dependent
  • 0.6% prevalence for paranoid, schizoid and schizotypal

  • being overwhelmed by negative feelings such as distress, anxiety, worthlessness or anger
  • avoiding other people and feeling empty and emotionally disconnected
  • difficulty managing negative feelings without self-harming (for example, abusing drugs and alcohol, or taking overdoses) or, in rare cases, threatening other people
  • odd behaviour
  • difficulty maintaining stable and close relationships, especially with partners, children and professional carers
  • sometimes, periods of losing contact with reality

Symptoms typically get worse with stress

People with personality disorders often experience other mental health problems, especially depression and substance misuse.

Anankastic personality disorder is characterised by:

  • feelings of doubt and perfectionism
  • checking and preoccupation with details
  • stubbornness, caution and rigidity
  • insistent unwelcome thoughts of impulses that do not attain severity of obsessive-compulsive disorder

A person with antisocial personality disorder may:

  1. exploit, manipulate or violate the rights of others
  2. lack concern, regret or remorse about other people's distress
  3. behave irresponsibly and show disregard for normal social behaviour
  4. have difficulty sustaining long-term relationships
  5. be unable to control their anger
  6. lack guilt, or not learn from their mistakes
  7. blame others for problems in their lives
  8. repeatedly break the law

A person with antisocial personality disorder will have a history of conduct disorder during childhood, such as truancy (not going to school), delinquency-for example, committing crimes or substance misuse- and other disruptive and aggressive behaviours.

A person with an anxious/dependent personality disorder may:

  • have feelings of tension and apprehension
  • feel insecure and inferior
  • have a need to be liked and accepted, with a hypersensitivity to rejection and criticism
  • avoid certain activities by habitual exaggeration of the potential risks in everyday situations
  • have a great fear of abandonment
  • have a weak response to the demands of daily life
  • have a tendency to transfer responsibility to others

Borderline personality disorder (BPD) is a disorder of mood and how a person interacts with others. It's the most commonly recognised personality disorder.

In general someone with a personality disorder will differ significantly from an average person in terms of how he or she thinks, perceives, feels or relates to others.

The symptoms of BPD can be grouped into four main areas:

  • emotional instability- the psychological term for this is 'affective dysregulation'
  • disturbed patterns of thinking or perception- ('cognitive distortions' or 'perceptual distortions')
  • impulsive behaviour
  • intense but unstable relationships with others

Histrionic personality disorder  is characterised by:

  • shallow and labile affectivity
  • self-dramatisation
  • exaggerated expression of emotions
  • self-indulgence
  • lack of consideration for others
  • easily hurt feelings
  • continuous seeking for appreciation, excitement and attention

Paranoid personalty disorder is characterised by:

  • excessive sensitivity to setbacks
  • recurrent suspicions without justification
  • a difficulty in confiding in people, even friends
  • a difficulty to trust others as they believe they will take advantage
  • looking for signs of betrayal or hostility

A person with schizoid personality disorder may:

  • withdraw from affectional, social and other contacts due to preference for fantasy, solitary activities
  • be uninterested in forming close relationships including with family
  • prefer to be alone with own thoughts
  • get little pleasure from life
  • be emotionally cold towards others

Schizotypal personality disorder is characterised by:

  • difficulty in forming close relationships
  • thinking and expressing oneself in ways that others may find 'odd'
  • eccentric behaviour
  • a belief that they can read minds or have special powers
  • anxiety and paranoia in social situations
Differential Diagnosis

Other conditions which may have similar symptoms to personality disorders or enhance personality disorder symptoms include:

Comorbidity is high amongst personality disorder patients. Regardless of the comorbidities that may exist, the personality disorder should be addressed and treated separately

Initial Assessment

respectful probing and reflective listening
  • help the patient feel understood and valued
  • promote optimism and motivation while assessment, diagnosis, and strategies are negotiated and actioned
  • this in itself is therapeutic

Take a full psychiatric history including:

  • history of self-harm
  • history of suicide attempt/s
  • history of early childhood attachments
  • history of abuse/trauma
  • response to any treatment for depression in the past

Enquire into past medical history

If the patient is violent or has been a victim of violence consider assessment of:

  • current or previous violence, including severity, circumstances, precipitants and victims
  • the presence of comorbid mental disorders and/or substance misuse
  • current life stressors, relationships and life events
  • additional information from written records or families and carers (subject to the person's consent and right to confidentiality).

Violent or aggressive behaviour is defined as:

"any incident where a GP or his or her staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health."

The potentially violent patients service (PVPS) can provide specialist advice to support practices to plan the needs of the patients: providing telephone advice and specialist advice in developing a management plan. Where patients are removed from the practice list following a violent or aggressive incident, and assessment of ongoing risk has been made, the PVPS will provide primary care support  for the individual, with the aim of returning the patient back to mainstream primary care as soon as practicable.

Referral to the PVPS required that the incident/s have been reported to the Police and have been given an incident number.

Referrals can be made by contacting the Primary Care Development and Engagement Manager based at Gloucestershire Clinical Commissioning Group on 0300 4211685/ 07880 055656 or by emailing cherri.webb@nhs.net

GP Led Self-Management

Provide advice/refer/signpost patients to any of the following self-management services:

Consider referral to or signpost patient to Gloucestershire's Community Drug & Alcohol Recovery Service

  • Substance misuse is in itself not an exclusion to other work, but it will likely impair it, so this may be the first step.

Practice Point

The 2gether Contact Centre may be contacted for advice at any stage:
Tel: 0800 151 499
Email: 2gnft.FPCC-Admin@nhs.net
Address: Tri Service Centre, Waterwells Police HQ, Waterwells Drive, Gloucester, GL2 2BP.

The Gloucestershire Council Social Care Helpdesk may also be contacted for support:
Tel: 01452 426868
Email: socialcare.enq@gloucestershire.gov.uk

When to Refer

Consider contact with and/or referral to Mental Health Services following presentation with Red Flags or if the patient is at risk of harming themselves or others around them.

Where antisocial personality disorder is suspected and the person is seeking help, consider offering a referral to an appropriate mental health service depending on the nature of the presenting complaint.

If a person presents in primary care who has repeatedly self-harmed or shown persistent risk-taking behaviour or marked emotional instability, consider referring them to community mental health services for assessment for borderline personality disorder.

Consider referring a person with diagnosed or suspected borderline personality who is in crisis to a community mental health service when:

  • their levels of distress and/or the risk of harm to self or others are increasing
  • their levels of distress and/or the risk of harm to self or others have not subsided despite attempts to reduce anxiety and improve coping skills
  • they request further help from specialist services.

Consider referral to Mental Health Intermediate Care Team (MH ICT) for further advice/assessment/support and local services.

Contact details and referral advice for 2gether's Contact Centre, Mental Health Acute Response Service (MHARS) (formerly Crisis Resolution and Home Treatment Teams) and other mental health services that accept direct referral are available here.

Ongoing Primary Care Management

Please see National & NICE Guidance section for Ongoing Primary Care Management

Violent or aggressive behaviour is defined as:

"any incident where a GP or his or her staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health."

The potentially violent patients service (PVPS) can provide specialist advice to support practices to plan the needs of the patients: providing telephone advice and specialist advice in developing a management plnan. Where patients are removed from the practice list following a violent or aggressive incident, and assessment of ongoing risk has been made, the PVPS will provide primary care support for the individual; with the aim of returning the patient back to mainsteam primary care as soon as practicable.

Referral to the PVPS requires that the incident/s have been reported to the Police and have been given an Incident Number.

Referrals can be made by contacting the Primary Care Development and Engagement Manager based at Gloucestershire Clinical Commissioning Group on 0300 4211685/07880 055956 or by emailing cherri.web@nhs.net

Notification of Serious Untoward Incidents (SUIs)

Recent reviews of serious incidents have identified potential system and process changes which could improve the quality and responsiveness of care for people who require secondary care mental health services.

It would be helpful if GPs could please share any information in relation to substance misuse with 2gt, particularly when a patient is injecting, as this aids clinical risk assessment and management. It is also really helpful if referrals into mental health services contain an appropriate risk assessment.

In all instances when a patient dies unexpectedly, especially if the cause of death is suspected suicide, GPs should inform 2gt as soon as possible. This will allow 2gt to quickly put in place support for those bereaved and minimise the risk of appointment letters etc. being sent to the deceased.

Contact: gordonbenson@nhs.net (Assistant Director of Governance & Compliance, 2gt)

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