Clinical update

Personality disorders ISTOCK

Essential facts Individuals with a personality disorder can differ significantly from the average person in how they think, feel and behave. Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are two distinct conditions that have different care pathways. The Royal College of Psychiatrists says that around one in 20 people have some kind of personality disorder.

NICE quality standard on personality disorders (June 2015) uk/guidance/qs88 NICE quality standard on antisocial behaviour and conduct disorders in young people (April 2014) uk/guidance/qs59

What’s new The National Institute for Health and Care Excellence (NICE) has published a new quality standard on borderline and antisocial personality disorders. In particular, NICE says people with possible BPD or ASPD should have a structured assessment by a mental health specialist before they are given a diagnosis. Prescription of antipsychotic or sedative medication for these patients should be only for short periods if they have a crisis, or if they have another condition for which this medication is appropriate.

Causes/risk factors

Signs/symptoms Symptoms of BPD include emotions that are up and down; an unstable sense of identity, self-image and mood, with a fear of abandonment and rejection; and a strong tendency towards suicidal thinking and self-harm. People with BPD may have difficulties in establishing and maintaining relationships. Symptoms of ASPD include impulsivity, anger and associated behaviours, including recklessness and deceitfulness. As a result of their lack of regard for the consequences of their behaviour and for the feelings of others, people with ASPD may experience unstable personal relationships.

Expert comment Karen Wright, principal lecturer at the School of Health, University of Central Lancashire

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The causes of personality disorder are not fully known, but may include trauma in early childhood, such as abuse, violence and neglect. Neurological and genetic factors may also play a part. ASPD affects far more men than women, according to NHS Choices, but it tends to improve with age, reducing during the 30s or 40s. People with ASPD are at high risk of going to prison at some point in their lives. They are also three to five times more likely than the general population to misuse alcohol or drugs and are at high risk of self-harm or suicide.

Treatment NICE recommends that people with BPD be offered psychological therapies, and be involved in choosing the type, duration and intensity of therapy. Those with ASPD should be offered group-based cognitive and behavioural therapies, and have a say in the duration and intensity of these interventions.

‘These new standards combine two personality disorders that are complex, disabling and present some challenges to services – but they can also be very different. Those with BPD can be vulnerable, with few defences, and are likely to harm themselves, while those with ASPD may have no care for others. The concern is that health professionals

Emergence – service user-led organisation for people affected by personality disorder Department of Health handbook for people with personality disorders in the community Mind charity Mental Health Foundation Rethink Mental Illness charity Royal College of Psychiatrists

will see a greater similarity between them than exists. ‘Young people transitioning into adult services need a new assessment, rather than a label. While the reference by NICE to supervision for healthcare professionals is welcome, it must be done by someone who understands personality disorders.’

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