Borderline Personality Disorder Rapid Needs Assessment

Transcription

Borderline Personality Disorder: A rapid needs assessment
December 2013
East Sussex
Borderline Personality Disorder
Rapid Needs Assessment
December 2013
Miranda Scambler – Public Health Practitioner
Suzanne Daniel - FY2 Doctor in Public Health
Jason Mahoney – Programme Manager - Joint Commissioning
Jane Thomas - Consultant in Public Health
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December 2013
Contents
Page
Executive Summary
Key Facts and Figures
Issues and Gaps
Recommendations
1. Introduction
1.1 Context
1.2 Methodology
1.3 Defining Personality Disorder
1.4 National Policies and Guidance
2. National Evidence
2.1 Defining Borderline Personality Disorder
2.2 Causes of Borderline Personality Disorder
2.3 Prevalence of Borderline Personality Disorder
2.4 Hospital Admissions
2.5 Risks associated with Borderline Personality Disorder
2.6 Diagnosis of Borderline Personality Disorder
2.7 Treatment of Borderline Personality Disorder
2.8 Care Pathway for Borderline Personality Disorder
3. Local Evidence
3.1 Prevalence in East Sussex
3.2 Prevalence in Lewes Prison
3.3 Special Services for Borderline Personality Disorder
3.4 Borderline Personality Disorder in urgent and acute care services
3.5 Hospital Admissions
3.6 Services that include provision for personality disorder
3.7 Sussex Care Pathway for Personality Disorders
4. Future Need
5. Service Provision in Other Areas
6. Service user, Provider and Carer Voice
7. Evidence of Effectiveness and Best Practice
8. Conclusions
9. Recommendations
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Executive Summary
Key Facts and Figures
CURRENT POPULATION
•
There are an estimated 377,400 people aged 16-74 living in East Sussex, a 7.5% increase over
the last decade.
PERSONALITY DISORDER NATIONALLY
•
National prevalence estimates for borderline personality disorder (BPD) are 0.5-0.8% of the
population aged 16 and over.
•
Women aged 16-34 are estimated to be about 4.5 times more likely (1.4%) than men aged 16-34
(0.3%) to be diagnosed with BPD.
•
Three quarters of all hospital admissions for those with personality disorder diagnoses are for
BPD.
•
78% of all in-patient borderline personality disorder cases in the UK are diagnosed in women.
•
Life expectancy for those with personality disorder is significantly shorter than the general
population.
•
National evidence shows there is a lack of service provision for people with personality disorder.
PERSONALITY DISORDER LOCALLY
•
There are currently an estimated 1,900 adults aged 16+ with BPD in East Sussex.
•
•
We would expect to see approximately 1,350 females and 550 males with BPD locally.
•
The number of men with BPD who are on remand at Lewes prison is estimated to have
increased by 3.5% over the last 5 years.
•
Over one third of the prison population for whom there are records reside in East Sussex,
indicating that the prevalence of BPD within prison will impact on service demand upon release.
•
Since 2010/11 there have been 998 hospital admissions for 479 people with disorders of adult
personality and behaviour, representing a 53% increase over the last three years.
•
Since 2010/11 there have been a lower number of admissions for 20-34 year olds than
expected, and a greater number of admissions for 35-54 year olds.
•
Over the last year, hospital admissions for males who have personality disorder has increased
out of line with national rates.
•
Across all trusts admissions are three times more likely to be non-elective (emergency) than
elective.
•
BPD is the most prevalent of all personality disorders for those admitted to hospital (6.5 times
more prevalent than any other type).
•
In line with nationally, women admitted to hospital are 4 times more likely to have BPD than
men.
•
There is a clear association between hospital admissions of people with personality disorder and
deprivation.
•
By 2020 the age group with the highest prevalence for BPD in males (55-74 years) is expected to
increase by 13.6%, and for women an increase of 12.5% is expected.
In comparison to our ten nearest statistical neighbours East Sussex has the third greatest rise in
estimated BPD since 2003 (8.3%).
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The overall population of adults with BPD is expected to increase by 1% by 2020.
Issues and Gaps
GAPS IN SERVICE PROVISION
•
•
•
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A 2007 needs assessment on adult mental health across Sussex found specialist services for PD
to be underdeveloped and recommended these should be developed. West Sussex and Brighton
and Hove have developed these services but this has yet to be developed in East Sussex.
There is a lack of community provision for personality disorder in East Sussex in comparison to
similar areas.
Due to the numbers of people who are estimated to have PD in the county, both in the general
and criminal justice populations, there is likely to be a significant unmet need currently.
There is no specialist crisis service for people with BPD in East Sussex.
INFORMATION NOT CURRENTLY AVAILABLE
•
•
•
Similarly to mental illnesses there is no direct medical test to diagnose personality disorder and
difficulties diagnosing are compounded by the amount of information needed on personal
history in order to assess personality traits.
There are a very high number of “unknown” admissions types from Sussex Partnership NHS
Foundation Trust (SPFT) indicating that there is a need for improved recording methods.
Information on those who have been discharged from hospital and community provision for
most frequent users is currently being collated.
RECOMMENDATIONS
SERVICE RECOMMENDATIONS:
•
It is recommended that preventative interventions are needed, particularly to address the
relationship between high incidence of personality disorder and those within the criminal justice
system. Early interventions that address emotional intensity should be specifically targeted
towards young people entering the criminal justice system and first presenters to primary care.
•
It is recommended that a community personality disorders service should be developed as part
of a holistic, whole-system approach. The service should provide a range of therapeutic activities
which are available to members, aligned to assessed need. The STEPPS programme should form a
part of this alongside a community programme of activities and support. The service should
provide mentoring and/or volunteering opportunities for people with lived experience of
borderline personality disorder. This approach should be patient centred and where possible
involve the individual’s wider network of support.
•
It is recommended that crisis services could be improved by:
o Developing the mental health crisis service to be more inclusive of the specific needs of
people who have personality disorder, including signposting to IRIS and community
personality disorder services where appropriate.
o Investigating appropriate space for a small number of crisis or respite beds.
TECHNICAL RECOMMENDATIONS:
•
It is recommended that data collection of information regarding adults with personality
disorders, and borderline personality disorder in particular, is improved in the following ways:
o A joint approach between health, social care, police, criminal justice system, voluntary
sector and service users is further developed.
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o There is agreement across services on the specific traits indicating borderline personality
disorder and how this is systematically coded.
o There is regular collation of the feedback from service users regarding outcomes to
better inform policy and practice across mental health and community services.
•
It is recommended training is needed locally to enhance knowledge and skills of those supporting
people with borderline personality disorder.
RECOMMENDATIONS FOR FURTHER INVESTIGATION BY COMMISSIONERS:
•
It is recommended further research is needed on the impact borderline personality disorder has
on the health and wellbeing of people in East Sussex, particularly with regards to known risks
such as substance misuse and risk of self-harm.
•
It is recommended, in line with NICE guidance, there is further investigation into the amount of
drug treatment being prescribed for BPD currently by GPs or Mental Health Services as there was
not the scope within this work to investigate this nationally recognised issue.
•
It is recommended further information is needed into the reasons for high repeat hospital
admissions for people with personality disorders.
•
It is recommended Information on those who have been discharged from hospital and
community provision for most frequent users that is currently being collated should further
inform this needs assessment.
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1. Introduction
1.1. CONTEXT
The Quality, Innovation, Productivity and Prevention (QIPP) Programme aims to improve the
quality and delivery of NHS care while reducing costs. A service review was completed as
part of the East Sussex QIPP programme recommended there should be a review of the
impact of Borderline Personality Disorder on existing services, and consideration of how
services could be significantly improved within existing resources. This Borderline Personality
Disorders report will form part of that review. The focus of this work will primarily be
services commissioned by Clinical Commissioning Groups (that is, tiers 1-3 – detailed on
P20). Locally there are no services commissioned specifically to work at these tiers.
Personality Disorders were first defined by the American Diagnostic and Statistical Manual of
Mental Disorders as diagnosable diseases in 19801. Previous estimates of prevalence in the
United Kingdom are thought not to be widely applicable as research tended to involve
poorly standardised assessment tools and small study populations which were not
representative of the general population.2 More recent analysis by the Department of Health
in the United Kingdom suggests that between 5% and 13% of the population have
diagnosable personality disorder3, with approximately 4%, some two and a half million
people, who could benefit from professional help.4 This report will give an overview of the
main literature around Borderline Personality Disorder, arguably one of the most prevalent
types of Personality Disorder. It will look at how to define personality disorder; prevalence of
personality disorder; classifications of different types of personality disorder; causes of
personality disorder; diagnosing personality disorder, both national and local services and
interventions for personality disorder.
1.2. METHODOLOGY
The review uses best evidence, national and international literature, and local evidence to:
a)
Consider the initial literature search and any additional relevant guidance.
b)
Set out expected number of East Sussex cases.
c)
Set out current cases based on available data.
d)
Set out service provision and pathways.
e)
Evaluate the suitability of care pathways in relation to best practice and local evidence.
f)
Compare services in East Sussex with other areas in the South of England.
g)
Identify gaps in provision and where more efficient use of resources might apply.
1.3. DEFINING PERSONALITY DISORDER (PD)
In mental health, the word personality defines the set of characteristics or traits than make
each person an individual, including the ways we think, feel and behave.5 “Personality
Disorder” (PD) has proven a difficult term to define but there is general agreement that the
term refers to behaviours opposing commonly held expectations of what is “normal”, which
varies according to what is considered “normal” in different contexts.7 The traits of PD
behaviours are long standing characteristics noticeable from childhood or early teens.6
1
National Institute of Mental Health (2007) Science Update: National Survey Tracks Prevalence of Personality Disorders in U.S. Population
3
Coid, J., Yang, M., Roberts, A. et al. (2006) Violence and psychiatric morbidity in a national household population – a report from the
British Household Survey.
4
Easton, M. (26 November 2009) Struggling with Personality Disorder: The Way We Behave, BBC News Website (accessed December 2009)
http://www.bbc.co.uk/blogs/thereporters/markeaston/2009/11/struggling_with_personality_di.html
5
Bailey, S and Shooter, M - co-editors (2009) The Young Mind: an essential guide for parents, teachers and young adults. Bantam Press.
2
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December 2013
These behaviours can: make it hard to control feelings; can hinder coping strategies, make it
difficult to sustain relationships, cause difficulty in interpreting social clues and can cause
distress to the individual and/or to others. 6,7 Over recent years the World Health
Organisation (WHO)8 and the American Psychiatric Association9 have both tried to provide a
definitive definition of personality disorders, and these are the two most widely used
definitions by health professionals today:
• The WHO produced the “International Classification of Mental and Behavioural
Disorders” Definition (ICD-10) defining personality disorder as: ‘a severe disturbance in
the character, logical condition and behavioural tendencies of the individual, usually
involving several areas of the personality, and nearly always associated with considerable
personal and social disruption’.
• Alternatively, The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is based
on personality traits, or “enduring patterns of perceiving, relating to, and thinking about
the environment and oneself”, and defines a personality disorder as: 'an enduring
pattern of inner experience and behaviour that deviates markedly from the expectations
of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or
early adulthood, is stable over time, and leads to distress or impairment'.
To date researchers have not identified a qualitative distinction between normal personality
functioning and personality disorder10 and as such both classification systems for personality
disorder have little explanation of diagnosing presence versus absence of each personality
disorder, so people do not fit neatly into just one given category.11 However, the DSM-V
guide to personality diagnosis recognizes that certain patterns of personality “problems”
seem to be shared by fairly large numbers of people, and by identifying these patterns we
can develop ways of helping that can be used wider than on an individual basis.12 The three
clusters of PDs (Figure 1) include ten classifications of PD:
6
Mental Health Foundation Website (2003) Personality Disorders – an overview. http://www.mentalhealth.org.uk/information/mentalhealth-a-z/personality-disorders/
7
BBC Health (May 2009) Disorders/Conditions: Personality Disorder. (accessed 2013)
http://www.bbc.co.uk/health/conditions/mental_health/disorders_person.shtml
8
World Health Organisation (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic
Guidelines. Geneva: WHO.
9
American Psychiatric Association (1994) The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition ()
10
Livesley WJ. Diagnostic dilemmas in classifying personality disorder. In: Phillips KA, First MB, Pincus HA, editors. Advancing DSM.
Dilemmas in psychiatric diagnosis. Washington: American Psychiatric Association; 2003. pp. 153–189.
11
Tyrer, P. & Bateman, A.W. (2004). Drug treatment for personality disorders. Advances in Psychiatric Treatment, 10, 389–398
12
Bailey, S and Shooter, M - co-editors (2009) The Young Mind: an essential guide for parents, teachers and young adults. Bantam Press.
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December 2013
Figure 1: DSM-V Personality Disorders Grouped into Three Clusters
CLUSTER A
(odd/eccentric)
CLUSTER B
(dramatic/erratic)
CLUSTER C
(anxious/fearful)
Paranoid
Antisocial
Avoidant
Distrusting and suspicious
interpretation of the motives
of others
Disregard for the violation
of the rights of others
Socially inhibited feelings of
inadequacy, hypersensitivity to
negative evaluation
Schizoid
Borderline
Dependent
Social detachment and
restricted emotional
expression
Unstable relationships,
self-image, affects, and
impulsivity
Submissive behaviour, need to
be taken care of
Schizotypal
Histrionic
Obsessive-compulsive
Social discomfort, cognitive
distortions, behavioural
eccentricities
Excessive emotionality and
attention seeking
Preoccupation with
orderliness, perfectionism and
control
Narcissistic
Grandiosity, need for
admiration, lack of
empathy
(Source: British Psychological Society, Alwin et al, 2006)
A number of recent reviews13,14 have found widespread dissatisfaction with the classification
of personality disorders in the previous editions of the DSM which has led to a
recommendation for future research into a hybrid-trait-specific model which would retain
six of the 10 personality disorder (PD) types: Borderline PD; Obsessive-Compulsive PD;
Avoidant PD; Schizotypal PD; Antisocial PD and Narcissistic PD, each identified by a specific
pattern of impairments or traits.15
1.4. NATIONAL POLICIES AND GUIDANCE
Managing Dangerous People with Severe Personality Disorder, Proposals for Development
(1999)16 This Home Office paper discusses existing models, services and approaches, and
sets out the lack of treatment available for those people with severe PD who present a
danger to the public.
Personality Disorder: No Longer a Diagnosis of Exclusion. Policy Implementation Guidance
for the Development Of Services For People With Personality Disorder (2003) 17 The
National Institute for Mental Health in England (NIMHE) produced policy implementation
guidance for the development of services for people with personality disorder. This
document confirmed that PD services should be part of the core business of mental health
trusts and suggested that specialist multi-disciplinary PD teams should be established for
people with PD in significant distress, with difficulties or complex needs and the
development of specialist day patient services in areas with high morbidity from PD.
13
Bernstein DB, Iscan C, Maser J. The Boards of the Directors of the Association for Research in Personality Disorders and the International
Society for the Study of Personality Disorders. Opinions of personality disorder experts regarding the DSM-V personality disorders
classification system. J Pers Disord 2007; 21:536–551.
14
Pull C. The classification of personality disorders: crouching categories, hidden dimensions. European Psychiatry 2011; 26:64–68.
15
American Psychiatric Association (May 2013) About DSM-5 http://www.dsm5.org/ABOUT/Pages/DSMVOverview.aspx
16
Home Office (1999) Managing Dangerous People with Severe Personality Disorder, Proposals for
17
Department of Health (2003) Personality Disorder. No Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the
Development of Services for People with Personality Disorder. London: Department of Health.
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Breaking the Cycle of Rejection: Personality Disorder Capabilities Framework (2005).18 This
document, produced by NIMHE set out a framework to support the development of the
skills enabling more effective working between practitioners and people with personality
disorders and to support local and regional partners to deliver appropriate education and
training. In conjunction with the 2003 guidance this has led to an NHS commitment to
enhance and improve its service for PD.
The Bradley Report (2009)19 was a six-month independent review of the extent offenders
with mental health problems or learning disabilities could be diverted from prison and what
the barriers were to this. This review highlights need for the early identification of people
with mental health problems or learning difficulties entering the criminal justice system and
found that custody may exacerbate mental illness and may not be the right environment for
such people to be in and outlined potential for appropriate and timely intervention.
Borderline Personality Disorder: The NICE guidance on treatment and management (2009)
20
is based on best practice and systematic reviews of best available evidence.21 The main
guidelines are:
• Psychological treatment, especially for people with multiple co-morbidities or severe
impairment (or both) should include an explicit and integrated theoretical approach,
structured care in accordance with this guideline and supervision by a therapist. Twice
weekly sessions should be considered or this should be adapted to the persons need.
• Long term psychological interventions should be used for BPD (over three months in
duration).
• Drug treatment should not be used specifically for BPD.
• People with BPD should not be excluded from any other health or social care service.
• It is important to build a trusting relationship and work in an open, engaging and nonjudgemental manner: people would often have experienced rejection, abuse and
trauma.
• Care should be person-centred and people with BPD should have the opportunity to
make informed decisions along with their healthcare professional about their care and
treatment.
• Work in partnership and actively involve people with BPD in finding solutions,
encouraging consideration of different treatments/life choices and considering
consequences of their choices.
• Discuss any changes with the person (and their family and carers if appropriate)
beforehand and make sure changes are structured and phased as this may elicit strong
emotions.
• Ensure care plans support work with other care providers during endings, referrals and
transitions and that crisis service provision is available.
• Community Mental Health (CMH) services should be responsible for routine assessment,
treatment, and management.
18
Department of Health (2006) Personality Disorder Capacity Plans 2005. London: Department of Health.
Department of Health (2009) Lord Bradley's review of people with mental health problems or learning disabilities in the criminal justice
system
20
National Institute for Health and Clinical Evidence (2009b) Borderline personality disorder: treatment and management. NICE Clinical
Guidance 78, developed by the National Collaborating Centre for Mental Health
21
Kendall, T., Piling, S., Tyrer, P., Duggan, C., Burbeck R., Meader, N. and Taylor, C. (2009) Borderline and antisocial personality disorders:
summary of NICE guidance. In British Medical Journal, Vol 338: January 2009 – 293-295.
19
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CMH teams should develop comprehensive multidisciplinary care plans with service
users which should be shared with their GP. They should identify roles and
responsibilities for service providers and user, short term treatment aims, long term
goals and a crisis plan.
Mental Health Trusts should develop cross-discipline specialist PD services with expertise
in diagnosis and management of BPD to: provide consultation and advice to primary and
secondary care, provide assessment and treatment for people with complex needs, offer
expert diagnostic services to general psychiatric services, ensure clear communication
within and between services, work with Child and Adolescent Mental Health Services to
develop transitions to adult services, oversee implementation of NICE guidance, develop
training programmes for diagnosis, treatment and management, and monitor service
provision.
The Offender Personality Disorder Strategy22 (2011) Key Principles are that:
• The personality disordered offender population is a shared responsibility of (National
Offender Management Service (NOMS) and the NHS;
• Planning and delivery is a whole systems pathway approach across the criminal justice
system and the NHS from conviction, sentence, and community based supervision and
resettlement;
• Offenders with PD at high risk of serious harm to others are primarily managed through
the criminal justice system;
• Treatment and management is psychologically informed and led by psychologically
trained staff; that it focuses on relationships and the social context in which people live;
• Related Department of Education and Department of Health programmes for young
people and families will continue to be joined up with the offender PD pathway to
contribute to prevention;
• Experiences and perceptions of offenders and staff inform service design and delivery;
• The pathway will be evaluated focusing on risk of serious re-offending, health
improvement and economic benefit.
From these principles an offender personality disorder pathway is implementing new
arrangements for the assessment, management and treatment of offenders in prison and
the community. Services are primarily targeted at men who present a high risk of serious
harm to others and women who present a high risk of committing further violent, sexual or
serious criminal damage offences. Offenders are likely to have a severe personality
disorder/complex needs, and a clinically justifiable link between the personality disorder and
the offending. A key principle for the Pathway is that an offender’s pathway is
psychologically informed, and focuses on relationships and the social context in which
people live. NHS England and NOMS have currently put a tender out inviting proposals for a
credible, effective and robust longitudinal evaluation of the national OPD pathway to
demonstrate the impact of the pathway approach and assess whether the pathway is
effective and provides good value for money.
22
Ministry of Justice National Offender Management Service and Department of Health (2011) The Offender Personality Disorder Strategy.
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2. National Evidence
2.1. Defining Borderline Personality Disorder
The term ‘borderline personality’ was first proposed in 1938 the United States as a group of
patients who ‘fit frankly neither into the psychotic nor into the psychoneurotic group’.
Borderline Personality Disorder (BPD) is most common in adulthood and is present in just
under 1% of the population.18 BPD is characterized by mood instability, volatile relationships,
an unstable self image and impulsiveness, and is sometimes referred to as a disorder of
emotional regulation.23,24,25
The DSM V defines BPD as:
“A pervasive pattern of instability of interpersonal relationships, self-image, and affects
(mood), and marked impulsivity beginning by early adulthood and present in a variety of
contexts.”9
People with BPD sometimes experience patterns of rapid fluctuation between confidence
and despair, often accompanied by fear of abandonment and rejection and suicidal thinking.
These behaviours mean that people with BPD are at particular risk of self-harm, parasuicide
and completed suicide.14,17 According to NICE guidance, Borderline Personality Disorder is
often undiagnosed before the age of 18 although the features can be identified earlier.17
BPD is also associated with social, psychological and occupational functioning impairment
although the extent of these problems varies considerably and many people recover or learn
to manage their symptoms.17 Some people with BPD can maintain some relationships and
occupational activities while more severe forms experience very high levels of emotional
distress.17 People with more severe forms of BPD can experience repeated crisis, impulsive
aggression, and other impulsive behaviours such as excessive spending, substance misuse
and binge eating. 15 People with BPD also have high levels of comorbidity, including other
personality disorders as well as depression; anxiety disorder and substance misuse
problems, other personality disorders and are frequent users of psychiatric and acute
hospital emergency services.15,17 In turn, substance or alcohol misuse and stress can often
exacerbate the symptoms of BPD.15
2.2. Cause of borderline personality disorder
The cause of Borderline personality disorder is unclear but evidence indicates that there are
likely to be several contributory factors as opposed to a single cause of borderline
personality disorder. People can, however, be predisposed to BPD traits through both
environmental and genetic factors, and many report a history of abuse, neglect or
separation in childhood. 15 One study suggested that the number of people with BPD who
have experienced trauma such as physical, emotional or sexual abuse may be as high as
75%.26 Research also suggests that a series of events are likely to trigger the onset of the
disorder in early adulthood and that people with BPD are more likely to be victims of
violence, including rape, due both to being in a harmful environment as well as impulsivity
23
National Institute of Mental Health (2010) Borderline Personality Disorder: A brief overview that focuses on the symptoms, treatments,
and research findings.
24
Kendall, T., Piling, S., Tyrer, P., Duggan, C., Burbeck R., Meader, N. and Taylor, C. (2009) Borderline and antisocial personality disorders:
summary of NICE guidance. In British Medical Journal, Vol 338: January 2009 – 293-295.
25
National Institute for Health and Clinical Evidence (2009) Borderline personality disorder: treatment and management. NICE Clinical
Guidance 78, developed by the National Collaborating Centre for Mental Health.
26
Rethink National Schizophrenia Fellowship (2005) Personality Disorders Factsheet. RET0108
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and poor judgement in choosing partners and lifestyles. 15
According to the British Psychological Association,27 a combination of biological, social and
psychological factors are associated with the development of personality disorder but it is
difficult to show whether one of these is more predominant than the others. For example:
biological factors could include genetic, temperament or biochemical factors; psychological
factors could include childhood neglect, childhood abuse, post-traumatic stress disorder or
family relationships; and social factors could relate to culture, peer groups, socio-economic
disadvantage or gender related childhood maltreatment. These findings are supported by
The Mental Health Foundation28 and Personality Disorder Information Site.29 The British
Psychological Association concludes that:
“… It is apparent that no single factor within an individual’s environment,
even in combination with a biological vulnerability, would be likely to
produce a significant level of personality disorder. Therefore, multiple
adverse life experiences are likely to be necessary.”
Research suggests that the factors above which are of aetiological importance are highly
prevalent in British society, and as such it would be reasonable to suggest that prevalence of
personality disorder will increase in the UK over time, although no evidence exists to support
this claim.30
2.3. Prevalence of Borderline Personality Disorder
Information on borderline personality disorder has been limited until recent years.
International research conducted primarily in the USA and the UK between 1989 and 2009
place the prevalence of borderline personality disorder between 0.5% and 3.2%.31,32,33,34,35,
36,37
UK estimates place the prevalence at 0.5-0.8.38,32
Using DSM-V, the adult psychiatric morbidity in England survey 2007 estimated the
prevalence of BPD from age 16 and estimates that BPD is more prevalent in the younger
adult female population (1.4% of 16-34 year old women compared to 0.3% of men) (table 1).
27
Alwin, N., Blackburn, R., Davidson, K., Hilton, M., Logan, C., and Shine, J. (2006) Understanding Personality Disorder: A report by the
British Psychological Association.
28
Mental Health Foundation Website (2003) Personality Disorders – an overview. http://www.mentalhealth.org.uk/information/mentalhealth-a-z/personality-disorders/ (accessed July 2013)
29 Personality Disorder Website (2009) PD Congress Presentations 2009: Ten things to know about Personality Disorder.
http://www.personalitydisorder.org.uk/news/2009/11/ten-things-to-know-about-personality-disorder/
30
Moran. P. (2010) The influence of social, demographic, physical and any other risk factors on the prevalence and consequences of
personality disorders. Mental Health and wellbeing 2010 (539-544)
31
Zimmerman, M. and Coryell, W. (1989) DSM-III personality disorder diagnoses in a non patient sample. Demographic correlates and
comorbidity. Archives of General Psychiatry, 46, 682-689.
32
Maier, W. et al (1992) Prevalences of personality disorders (DSM-III-R) in the community. Journal of Personality Disorders, 6, 187-196
33
Black, D., et al (1993) Personality disorder in obsessive-compulsive volunteers, well comparison subjects and their first degree relatives.
American Journal of Psychiatry 150, 1226-1232
34
Moldin, S.O. et al (1994) Latent structure of DSM-III-R Axis II psychopathology in a normal sample. Journal of Abnormal Psychology 2
35
Samuels, J., Eaton, W. et al (2002) Prevalence and correlates of personality disorders in a community sample. British Journal of Psychiatry
180, 536-542
36
Coid, J. et al (2006) Prevalence and correlates of personality disorder in Great Britain, British Journal of Psychiatry 188, 423-431
37
Yueqin Huang, et al (2009) DSM–IV personality disorders in the WHO World Mental Health Surveys. The British Journal of Psychiatry 195,
38
Macmanus, S. et al (2007) Adult psychiatric morbidity in England, 2007 Results of a household survey. NHS the information centre for
health and social care
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Table 1: Age-specific prevalence (% of sample population) of borderline (BPD) personality
disorders in people aged 16-74 and living in England, 2000 and 2007.
Age Group
16-34 (%)
35-54 (%)
55-74 (%)
All aged 16-74
(%)
Men
0.3
0.2
0.4
0.3
Women
1.4
0.5
-
0.7
All Adults
0.8
0.4
0.2
0.5
Adapted from table 6.2 Adult psychiatric morbidity in England, 2007
More recent research in the US suggests that prevalence of lifetime BPD could be greater
than previously realised, at nearly 6%, occurring equally in men and women.39 Within
primary care, the prevalence of BPD ranges from 4 to 6% of primary attenders,40,41 with this
cohort likely to more frequently visit their GP and to report psychosocial impairment.
However, BPD is still thought to be under-recognised by GPs. 35
In mental healthcare settings, many studies report a prevalence of all types of personality
disorder in more than 50% of the sampled population, with BPD the most prevalent subtype
in non-forensic mental healthcare settings. Within community settings there is little
percentage difference between men and women, while within services there is a greater
prevalence in women as they are more likely to seek treatment.42 The majority of those
diagnosed are women aged between 25 and 44 years.43,44,45 with most people showing
symptoms in late adolescence or early adult life, although some may not come to the
attention of psychiatric services until much later.37 Diagnosing borderline personality
disorder at earlier ages has proved controversial due to developmental changes, although it
is thought to affect between 0.9 and 3% of the population of under 18 year olds.46,47
39
Grant, B.F. et al (2008) Prevalence, Correlates, Disability, and Comorbidity of DSM-V Borderline Personality Disorder: Results from the
Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 2008 April ; 69(4): 533–545.
40
Moran, P., Jenkins, R., Tylee, A., et al. (2000) The prevalence of personality disorder among UK primary care attenders. Acta Psychiatrica
Scandinavica, 102, 52–57.
41 Gross, R., Olfson, M., Gameroff, M., et al. (2002) Borderline personality disorder in primary care. Archives of Internal Medicine, 53–60.
42
43 Bailey, S and Shooter, M - co-editors (2009)The Young Mind: an essential guide for parents, teachers and young adults. Bantam Press
44 Alwin, N., Blackburn, R., Davidson, K., Hilton, M., Logan, C., and Shine, J. (2006) Understanding Personality Disorder: A report by the
British Psychological Association.
45 Rethink National Schizophrenia Fellowship (2005) Personality Disorders Factsheet. RET0108
46
Lewinsohn, P. M., Rohde, P., Seeley, J. R., et al. (1997) Axis II psychopathology as a function of Axis I disorders in childhood and
adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1752–1759.
47
Bernstein, D. P., Cohen, P., Velez, C. N., et al. (1993) Prevalence and stability of the DSM III-R personality disorders in a community-based
survey of adolescents. American Journal of Psychiatry, 150, 1237–1243.
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Figure 2: Range and scale of Personality Disorder in England:
(Source: Benefield, N and Joseph, N, 2009)
Figure 2 illustrates the range and scale of Personality Disorder in England. This definition
includes 5 million people in the UK that have some form of diagnosable personality
disorder,48 with approximately 4% of people with diagnosable personality disorder (two and
a half million people) who would benefit from help in the U.K.
2.4. Hospital Admissions
According to national Hospital Episode Statistics, a majority (75%) of all hospital admitted
personality disorder diagnoses in the UK are for Emotionally Unstable Personality Disorder
(EUPD) – which is known internationally as Borderline Personality Disorder (BPD) (Figure 3).
Figure 3: UK NHS 2009-2010 Breakdown of PD Diagnoses per hospital admission
* Diagnoses are based on the World Health Organization (WHO) International Classification of Diseases (ICD-10).
Source: UK Department of Health, Hospital Episode Statistics
48
Benefield, N and Joseph, N (2009) Personality Disorder: Bradley and beyond, presented at the National Personality Disorder Programme,
2009.
14
December 2013
2009/10 data shows that approximately 70% (6,300 out of 8,900) of hospital admissions for
personality disorder in the UK are diagnosed in females and 30% in males. Borderline (78%)
and Histrionic Personality Disorders (81%) are more commonly diagnosed among females
while Antisocial (86%) and Obsessive Compulsive Personality Disorder (69%) are more
commonly diagnosed among males (figure 4).
Figure 4: UK 2009-2010 Personality Disorder Hospital Admissions by Gender
* Diagnoses are based on the World Health Organization (WHO) International Classification of Diseases (ICD-10).
Source: UK Department of Health, Hospital Episode Statistics
2.5. Risks associated with personality disorder (PD) /borderline personality disorder (BPD)
Analysis of psychiatric case registers and mortality data suggests that for men and women
with PD, life expectancy is significantly shorter than for the general population (18.7 years
shorter and 17.7 years shorter respectively), with the highest mortality rates amongst
younger age groups. 49 Of particular prevalence in the literature is the association between
PD and “Axis I” disorders from the DSM-V classification, including mental health problems
such as depression, post-traumatic stress disorder, anxiety disorders, bipolar disorders, and
impulse control disorders such as deficit hyperactivity disorder.50,51 BPD is also particularly
associated with drug or alcohol dependence (within this cohort there tends to be more men
than women with BPD with an estimated 35% to 55% of those with substance misuse issues
having symptoms of a personality disorder.52),53 those with an eating disorder, those within
the criminal justice system54 and those presenting with chronic self-harm.55,56 As a result of
higher frequency of self-harm amongst people with borderline personality disorder, there is
also a recognised increased risk of suicide, with 60 to 70% attempting suicide at some point
in their life, and estimated suicide completion in approximately 10%.57 The link between BPD
49
Fok M.L.Y., Hayes R.D., Chang C.-K., Stewart R., Callard F.J., Moran P. (2012) Life expectancy at birth and all-cause mortality among
people with personality disorder. Journal of Psychosomatic Research, August 2012, vol./is. 73/2(104-107), 0022-3999;1879-1360
50
Bailey, S and Shooter, M - co-editors (2009) The Young Mind: an essential guide for parents, teachers and young adults. Bantam Press
51
52
53
Zanarini, M. C., Frankenburg, F. R., Dubo, E. D., et al. (1998) Axis I comorbidity of borderline personality disorder. American Journal of
Psychiatry, 155, 1733–1739.
54
55
Linehan, M. M., Armstrong, H. E., Suarez, A., et al. (1991) Cognitive-behavioral treatment of chronically parasuicidal borderline patients.
Archives of General Psychiatry, 48, 1060–1064.
56
Alwin, N., Blackburn, R., Davidson, K., Hilton, M., Logan, C., and Shine, J. (2006) Understanding Personality Disorder: A report by the
British Psychological Association
57
Oldham, J. M. (2006) Borderline personality disorder and suicidality. American Journal of Psychiatry, 163, 20–26.
15
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and depression has been shown to increase both the number and the seriousness of suicide
attempts.58
Within the Criminal Justice system over half of those in the UK prison system were found to
have a personality disorder,59 the most common being antisocial and borderline personality
disorders.52 The APMS prisoners’ survey60 (1998) used a screening tool (SCID-II) and a sample
of clinical interviews using DSM-V to estimate prevalence of Personality Disorders among
prisoners in England and Wales and found males on remand most likely to present with a
borderline personality disorder (table 2)
Table 2: Prevalence (%) of Personality Disorders in Prisoners in England and Wales.
Prison Group
Male remand
Male sentenced
Female prisoner
Any personality Disorder
78%
64%
50%
Borderline Personality Disorder
23%
14%
20%
Source: APMS Prisoners’ survey 1998
Research has indicated that preventative interventions are needed to address this
relationship, specifically targeted towards children in care during childhood and those who
enter the criminal justice system when young. 61 Studies have also shown that people with
BPD experience significantly greater impairment in their work, social relationships and
leisure compared with those with depression.62
2.6. Diagnosis of Borderline Personality Disorder
BPD is one of the most contentious of all the personality disorder subtypes to diagnose as it
is usually diagnostically co-morbid with depression and anxiety, eating disorders such as
bulimia, post-traumatic stress disorder (PTSD), substance misuse disorders, bipolar disorder
(with which it is also sometimes clinically confused) and psychotic disorders.63 Research
suggests that because of this high level of comorbidity it is uncommon to see an individual
with a “pure” borderline personality disorder64 which occurs in only 3-10% of cases.65 Until
2002 doctors and nurses were taught not to diagnose personality disorder because once
people were diagnosed, they were often excluded from services. Perceptions of personality
disorder have since evolved and there have been psychological, social and biological causal
links evidenced in more recent research. 56 Diagnostic criteria for the two main classification
systems differ substantially, yet both have relatively broad criteria for diagnosis:
58
Soloff, P. H., Lynch, K. G., Kelly, T. M., et al. (2000) Characteristics of suicide attempts of patients with major depressive episode and
borderline personality disorder: a comparative study. American Journal of Psychiatry, 157, 601–608.
59
Singleton, N., Meltzer, H., Gatward, R., Coid, J. & Deasy, D. (1998). Psychiatric morbidity prisoners in England and Wales. London: HMSO.
60
Singleton N, Meltzer H, Gatward R, Coid J, Deasy D (1998) Psychiatric Morbidity among Prisoners GSS
61
62
Skodol, A. E., Gunderson, J. G., McGlashan, T. H., et al. (2002) Functional impairment in patients with schizotypal, borderline, avoidant, or
obsessive-compulsive personality disorder. American Journal of Psychiatry, 159, 276–283.
63
64
Fyer, M. R., Frances, A. J., Sullivan, T., et al. (1988a) Comorbidity of borderline personality disorder. Archives of General Psychiatry, 45,
348–352.
65
Pfohl, B., Coryell, W., Zimmerman, M., et al. (1986) DSM-III personality disorders: diagnostic overlap and internal consistency of
individual DSM-III criteria. Comprehensive Psychiatry, 27, 21–34.
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Diagnostic criteria: DSM classification system
Diagnostic criteria for personality disorder refer to behaviours or traits that are characteristic of the
person's recent and long term functioning since early childhood. Personality disorder describes a
constellation of behaviours or traits that cause either significant impairment in social or occupational
functioning or subjective distress. To be diagnosed with borderline personality disorder, a person must
show an enduring pattern of behaviour that includes at least five of the following symptoms:
Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment,
•
whether real or perceived
A pattern of intense and stormy relationships with family, friends, and loved ones, often veering
•
from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings,
•
opinions, values, or plans and goals for the future (such as school or career choices)
Impulsive and often dangerous behaviours, such as spending sprees, unsafe sex, substance abuse,
•
reckless driving, and binge eating
Recurring suicidal behaviours or threats or self harming behavior, such as cutting
•
Intense and highly changeable moods, with each episode lasting from a few hours to a few days
•
Chronic feelings of emptiness and/or boredom
•
Inappropriate, intense anger or problems controlling anger
•
Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off
•
from oneself, observing oneself from outside the body, or losing touch with reality
Diagnostic criteria: ICD classification system
Diagnostic criteria include variety of conditions which indicate a person's characteristic and enduring
patterns of inner experience (cognition and affect) and behaviour(s) that differ markedly from a culturally
expected and accepted range.
Similarly to mental illnesses, there are no direct medical tests to diagnose a personality
disorder. There are a considerable number of psychometric instruments and clinical tools
that are currently being used, by both psychiatrists and psychologists. Examples are SCID-II,
ZAN-BPD, MCMI-III, IPDE, PAI. Doctors identify specific characteristics and personality traits
using ICD-10 or DSM-V and different combinations of traits indicate which type of
personality disorder is present. Psychiatrists will also look at the longevity of the symptoms;
that they are not a result of alcohol or drugs; that they are not connected to another
psychiatric disorder; and that they cause negative consequences or significant distress to a
person’s life. For diagnosis purposes, traits must be seen in a combination of at least two of
the following: thoughts, emotions, interpersonal control or impulse control.66
Correctly diagnosing PD is problematic because of the amount of information needed about
personal history, family, work and social life to address the parameters of different
personality traits, and also due to the nature of PD itself meaning there is a potential
concealment of this information. In addition, traits may be associated with alternative
causes or may meet the criteria for more than one PD.67,68 Women with borderline
personality disorder are more likely to have co-occurring disorders such as major depression,
anxiety disorders, or eating disorders. In men, BPD is more likely to co-occur with disorders
such as substance abuse or antisocial personality disorder. According to the U.S. National
Comorbidity Survey Replication about 85% of people with borderline personality disorder
also meet the diagnostic criteria for another mental illness.69 This can also affect treatment
decisions as treatment for one type of PD may not be the most suitable for another.
66
Bornstein RF. Reconceptualizing personality disorder diagnosis in the : the discriminant validity challenge. Clin Psychol Sci Pract.
1998;5:333–343
68
Widiger TA. Trull TJ, et al. Performance characteristics of the DSM-IIIR personality disorder criteria sets. In: Widiger TA, Frances AJ, Pincus
HA, et al., editors. DSM-V sourcebook. Vol. 4. Washington: American Psychiatric Association; 1998. pp. 357–373
69
National
Institute
of
Mental
Health
(accessed
2013)
What
is
Borderline
Personality
Disorder
http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml
67
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December 2013
2.7 Treatment of Borderline Personality Disorder
General adult mental health services in England and Wales offer varying levels of service
provision for people with PD since the decision was made in 2003 to expand services to
include the treatment of personality disorders. Although these services are for PD generally,
most users seeking services are likely to have a diagnosis of BPD and this is anticipated in the
service provision.70
a) Pharmacological treatment
Nationally, the treatment for BPD is challenging and guidance suggests that drug treatment
should not be used specifically for BPD, although the use of medication has increased.
Several drugs are being prescribed as they have an impact on certain behaviours
(antidepressants in particular) however, their benefit has been moderate. 71,72,73 The use of
antidepressants, mood stabilisers and antipsychotics is common in clinical practice.
Pharmacological treatments are often prescribed based on target symptoms shown by the
individual, with chemicals often prescribed to help regulate emotions.74 A longitudinal study
found that 75% of participants with BPD were prescribed combinations of drugs at some
point75, and research into care of people with BPD indicates that many people are taking
several classes of psychotropic drug simultaneously.76 Psychotropic drugs have clinically
significant side effects ranging from weight gain, diabetes and cardiovascular disease to
problems with self-esteem,77 with the balance of risk and benefit more unfavourable in
young people due to treatment-emergent suicidal ideation.78
b) Psychological Intervention
Psychotherapies are at least partially effective for many patients and over the last 15 years
Dialectical Behaviour Therapy has been developed specifically to treat BPD79 with indications
of positive effects, particularly for self-harming.80 Other psychotherapies have been
developed with empirical support behind them, including: mentalisation therapy; Cognitive
Behaviour Therapy (CBT); Schema-focused therapy and Transference-focused therapy.63 In
1995 Blum et al introduced Systems Training for Emotional Predictability and Problem
Solving (STEPPS) which is a 20 week group treatment combining cognitive behaviour
elements and skills training with a systems component for people with whom the individual
with BPD regularly interacts. STEPPS is currently used in the US and the Netherlands and is
designed to complement ongoing treatment (e.g. medication, individual therapy, case
70
71
Blum, N., St John, D., Pfohl, B., et al. (2008) Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients
with borderline personality disorder: a randomized controlled trial and 1-year follow-up. American Journal of Psychiatry, 165, 468–478.
72
Zanarini, M. C., Frankenburg, F. R., Hennen, J., et al. (2004a) Mental health service utilization by borderline personality disorder patients
and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65, 28–36
73
Binks, C. A., Fenton, M., McCarthy, L., et al. (2006a) Pharmacological interventions for people with borderline personality disorder.
Cochrane Database Systematic Review, CD005653.
74
75
Zanarini, M. C., Frankenburg, F. R., Hennen, J., et al. (2003) The longitudinal course of borderline psychopathology: 6-year prospective
follow-up of the phenomenology of borderline personality disorder. American Journal of Psychiatry, 160, 274–283.
76
Zanarini, M. C., Frankenburg, F. R., Hennen, J., et al. (2004a) Mental health service utilization by borderline personality disorder patients
and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65, 28–36.
77
Mackin, P., Watkinson, H. M. & Young, A. H. (2005) Prevalence of obesity, glucose homeostasis disorders and metabolic syndrome in
psychiatric patients taking typical or atypical antipsychotic drugs: a cross-sectional study. Diabetologia, 48, 215–221.
78
Hammad, T. A., Laughren, T. & Racoosin, J. (2006) Suicidality in pediatric patients treated with antidepressant drugs. Archives of General
Psychiatry, 63, 332–339.
79
80
Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs
therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006;63:757–66.
18
December 2013
management). In this context STEPPS has been found to improve impulsivity, negative
affectivity, mood and social functioning in people with BPD. STAIRWAYS is a one-year groupbased programme developed for clients with Emotional Intensity who have completed the
STEPPS Programme with several skills from the STEPPS programme repeated in more. The
STAIRWAYS Programme encompasses three main aims:
1. Identifying how the additional skills might help overcome some of the problems
participants are still having
2. Reinforcing the skills to manage emotional intensity
3. Applying the new skills to specific goals and challenges in their lives; for example,
getting a job, taking a class or expanding their social life.81
Psychological and psychosocial interventions are delivered in a variety of ways and settings
within the NHS by clinical psychologists, psychiatrists, nurses, social workers and other
mental health therapists. 62
c) Art therapies
Arts therapies use art media to communicate and include art therapy, dance movement
therapy, drama-therapy and music therapy. Art therapies were developed in the US and
Europe and are currently offered in the UK for those with personality disorders, including
those with BPD. This is specifically designed to help those who find it hard to express their
feelings and thoughts verbally.
d) Therapeutic Communities
A therapeutic community is a consciously designed social environment within a residential or
day unit with a programme using techniques in which the community itself is the primary
therapeutic instrument. Therapeutic communities for personality disorder range from fulltime residential hospitals to units operating for a few hours a week. While none treat
borderline personality disorder exclusively, it has recently been demonstrated that the
admission characteristics of members show high levels of personality morbidity, with most
exhibiting diagnosable features of at least three personality disorders. For personality
disorders, non-residential communities are mostly within NHS mainstream mental health
services, and residential units are in both NHS and tier 3 organisations.82
2.8. Care Pathway
Recognising Complexity: Commissioning guidance for personality disorders (2009), the
Department of Health commissioning guidelines83, recognise the importance of a “whole
system” approach to comprehensive and co-ordinated service provision. Provision is
provided in Tiers: Tiers 1–3 are community services; Tiers 4-6 are residential and very
intensive services, taking regional referrals (national referrals for tier 6) and including secure
and forensic services.
81
Partnership NHS Foundation Trust Website (accessed December 2013) Stairways
83
Department of Health, (2009) Recognising complexity: Commissioning guidance for personality disorder services.
82
19
December 2013
Source: Department of Health, 2009
20
December 2013
3. Local Evidence
3.1. Prevalence of personality disorder in East Sussex
According to the 2007 adult psychiatric morbidity survey the overall prevalence for
borderline personality disorder was at 0.5% of adults aged 16 or over.84 When extrapolated
to East Sussex (Table 3), this indicates that in 2012 there was an expected 1,885 people aged
16-74 in the county with Borderline Personality Disorder, an increase of 145 over the last
decade.
Table 3: Estimated prevalence of BPD in adults (aged 16 – 74) in East Sussex 2003-2012
2003 population
348,343
Disorder
Borderline
Personality
Disorder
UK Prevalence
2006
Population
359,694
2009
Population
368,701
2012
Population
377,357
Prevalence estimates (total)
5 per 1,000
1,740
1,800
1,845
1,885
Source: adapted from ONS population estimates 2012
Table 4 uses prevalence estimates of borderline personality disorder (BPD) from the 2007
adult psychiatric morbidity survey, to show the expected number of cases of BPD for East
Sussex, England and the South East by age and gender. Estimates show that women aged 1634 years are approximately 4.5 times more likely than men of a similar age to have
borderline personality disorder.
Table 4: Expected number of BPD cases based on 2012 mid year population estimates
Men with BPD
16-34
35-54
Women with BPD
55-74
16-34
35-54
55-74
England and
Wales
21560
15388
22640
99133
39133
-
South East
3089
2426
3565
14199
6184
-
East Sussex
155
136
256
714
360
-
Eastbourne
34
25
43
157
65
-
Hastings
31
25
39
151
62
-
Lewes
28
26
48
126
69
-
Rother
22
21
50
100
57
-
Wealden
39
40
77
181
108
-
Source; 2012 mid-year population estimates
According to national estimates we would expect to see approximately 1,355 females with
borderline personality disorder in East Sussex, nearly 2.5 times the expected 550 males with
borderline personality disorder.
In comparison to our 10 nearest statistical neighbours, East Sussex has the third greatest rise
in estimated BPD population since 2003 (+8.3%) behind Shropshire (+8.4%) and Kent
84
Macmanus, S. et al (2007) Adult psychiatric morbidity in England, 2007 Results of a household survey. NHS the information centre for
health and social care
21
December 2013
(+10.7%), nearly twice the estimated rise in Worcestershire (+4.5%) and Dorset (+4.9%)
which are the two areas with the closest estimated number of 16-74 year olds with BPD
(figure 5).
Figure 5: Estimated prevalence of borderline personality disorder in adults (aged 16 – 74)
compared to our statistical neighbours 2003-2012
Source: adapted from ONS population estimates 2003 to 2012
3.2. Prevalence of personality disorder in Lewes Prison
Lewes prison is a category B male prison established in 1853 which holds adults and local
young people on remand. The prison currently has an operational capacity of 729, including
174 spaced in a new house block opened in 2008. All health care, both in-patient and outpatient, is provided by the Sussex Partnership NHS Foundation Trust (the Trust), including
nurse led primary health care, inpatient care to people accommodated in the prison's
healthcare centre and a specialist in-reach mental health team for people with mental health
problems. Clinical staff are complemented by 3 uniformed officers that work full-time in the
Health Care Centre (HCC). A health promotion programme is being developed including
improving access to psychological therapy and group/individual talking sessions. The prison
has 2 part-time psychiatrists and a recently appointed occupational therapist.85 A Care
Quality Commission Report following an inspection in November 2012 commented very
favourably in their findings and spoke to patients who said that they generally found a
positive attitude in the staff and services provided.86
HMP Lewes currently holds 671 prisoners (as at 20th November 2013). Whilst this is below
maximum capacity, not all prisoners can share cells for either risk or medical reasons
meaning that spaces may be lost. The average length of stay is 10 weeks. Ethnic monitoring
data shows that currently 79% of prisoners identified themselves as white, 8.4% as Black,
4.3% as Mixed Ethnicity, 2.6% as Asian and 6% as other or not stated, indicating a
85
86
The Independent Monitoring Board (HMP Lewes Annual Report 1st February 2012 - 31st January 2013
Care Quality Commisison Inspection Report (Dec 2012) HMP Lewes – Prison Healthcare Department
22
December 2013
significantly higher number of people of Black ethnicity that currently ONS population
estimates suggest for the South East (1.6%) and for East Sussex (0.6%)87.
Throughout 2012 the population at the prison decreased slightly which reflected a 1% fall in
the male remand population in England and Wales. However the population at Lewes is
expected to increase after the announced closure of 7 public sector prisons with a loss of
2600 places.88 In November 2013, 32% of prisoners were on remand awaiting trial which is
consistent with historical trends for Lewes prison:
If we apply national estimates to these figures (as described previously) this would indicate
that there are currently 49 prisoners (23% of total population) under remand with borderline
personality disorder, and 64 sentenced prisoners (14% of total population). This compares to
approximately 38 prisoners under remand with BPD in 2008,89 and 66 sentenced prisoners
with BPD, showing an increase of 11 over the last 5 years of prisoners under remand who
are likely to have borderline personality disorder. Of the 671 prisoners there are 515 for
whom there are recorded reception addresses. Prisoners entering HMP Lewes are received
predominantly from East Sussex and Brighton and Hove (32%) (Table 5). Nearly one quarter
of those in HMP Lewes (23%) have no recorded reception addressed and are assumed to be
foreign nationals or of no fixed abode. With one third of the prison population residing in
East Sussex, the prevalence of BPD within the prison is likely to be impacting on the demand
for local BPD services on release.
Table 5: Area of Residence of the HMP Lewes Population November 2013
% of total prison population
Area
East Sussex
15%
Brighton and Hove
17%
West Sussex
17%
Kent
8%
London
6%
Surrey
3%
Middlesex
1%
Further Afield
10%
Unrecorded
23%
Source: HMP Lewes
Of the 32% from East Sussex, and Brighton & Hove: 73% were from the three major centres
in the area: Brighton & Hove (52%); Eastbourne (13%); and Hastings (8%) (Figure 6),
indicating that the biggest impact on PD services for males released from HMP Lewes will
most likely be in Brighton and Hove.
87
88
89
ONS (2011statistics) Ethnic Group and Religion
The Independent Monitoring Board (HMP Lewes Annual Report 1st February 2012 - 31st January 2013
HM Prison Service and East Sussex Downs and Weald NHS PCT (2008) HM Prions Lewes Healthcare Needs Assessment 2008
23
December 2013
Figure 6: Town of Residence for Prisoners Residing in East Sussex November 2013
Source: HMP Lewes
A 2012 audit of healthcare in Lewes prison found mental health issues and hypertension to
be the most prevalent health issues of a sample of 43 prisoners aged over 50 years. The
audit noted a need for more regular mental health clinics to improve monitoring.90
3.3. Specialist Services for Borderline Personality Disorder
Services at Tiers 1 to 3 encompass community team-based treatments and intensive day
services. Residential and very intensive services are designated as being Tier 4 services.
Key elements of need for people with personality disorder include a sense of belonging to a
community, having a place of safety to go to, establishing connections and attachments,
trusting relationships and creating a life outside of the “personality disorder” label. Clinical
staff within local Trust-provided community services are trained in the STEPPS programme
so there is specialist skill, knowledge and interest that can be utilised, although there is no
systematic structure currently in place to pool these skills.
Commissioning of ‘Prescribed Services’ became the responsibility of NHS England in April
2013, comprising of 8 units for approximately 450 people designated across the country to
provide Tier 4 BPD services. NHS England also now have responsibility for all local Trustprovided secure facilities, community secure and forensic teams, including those relating to
a new women-only facility with low secure beds which opened in Chichester in 2012.
There are currently no services in East Sussex which are designed to specifically meet the
needs of people with borderline personality disorder. The geography of East Sussex makes it
problematic to create an accessible “hub” as a drop in space for those with personality
disorder. However, an online website “IRIS” has just been launched as a virtual community
and there are ongoing discussions to further meet these needs.
Lavender Lodge was a residential facility set up in 2003 to address high external placements
of women in secure services, which evolved in to a specific BPD service for women not only
‘stepping-down’ from medium secure units but increasingly ‘stepping up’ from acute in90
Eva Chakraborti and Olivier de Brett (2012) Chronic disease management at HM Prison Lewes: an audit
24
December 2013
patient admissions. Between 2008/09 and 2012/13 there were 27 admissions to Lavender
Lodge, 70% of which were of women ‘stepping-up’ from acute in-patient services. Between
December 2012 and Summer 2013 the average length of stay was 241 days, with a shortest
of 7 days and a longest of 983 days (2.75 years). There were also 10 short stay ‘crisis’
admissions during the last 18 months, accounting for 63 additional bed days.91
The cost of Lavender Lodge is £980,000 per annum or £163,000 per bed. This compares with:
• Acute in-patient bed costs (in East Sussex) of £112,000 on average.
• Locked Rehabilitation beds (in East Sussex) of £84,000
• Low Secure Unit beds (in Sussex) of £138,000
• Medium Secure Unit beds (in Sussex) of £158,00092
Subject to the local CCG Governing Body’s decision Lavender Lodge has recently been
decommissioned, with those women supported in this residential facility being resettled
within East Sussex and supported by alternative existing resources. No equivalent or similar
service to Lavender Lodge is available in either West Sussex or Brighton and Hove.
A 2007 needs assessment looking at adult mental health across East Sussex, West Sussex and
Brighton and Hove found specialist services for PD to be under-developed and
recommended all three areas should explore the possibility of developing specialist services
for personality disorder locally.93 This has been developed in West Sussex and Brighton &
Hove, as outlined later in the report, but has yet to be developed in East Sussex.
3.4. Personality Disorder in urgent and acute care services
It is recognised that people with a borderline personality diagnosis can fall into a “repetitive
and distressing pattern of hospital admissions”.94 NICE guidelines suggest that people with
personality disorders are referred to local alternatives to admission before admission is
considered, for example a crisis resolution team.95 These findings have led to a local shift to
avoid hospital admissions for people with personality disorder, yet there appears to remain
a significant number of admissions locally. Local guidelines on working with people with
personality disorder who are accessing acute and urgent care were established in 2013 to
address these issues; provide clarity of the roles; provide consistency of approach and to
facilitate a service users “attachments” in the community rather than with acute inpatient
services.96 Guidelines suggest:
• Joint care and crisis plans should be undertaken with detail of purpose of attendance
at Inpatient units, Crisis Resolution & Home Treatment Teams (CRHTs) and Accident
& Emergency Mental Health Liaison Teams (MHLTs), and should include key partners
and a comprehensive risk formulation to inform decisions at times of crisis or
increased risk.
• Complex case reviews should be considered for those with an admission of more
than 21 days and no apparent progress.
91
East Sussex Joint Commissioning Unit – Mental Health
East Sussex Joint Commissioning Unit – Mental Health
93
Hastings and Bexhill PCT, East Sussex Downs and Weald PCT, West Sussex PCT (2007) Mental Health Needs Assessment for Adults aged
16-64 in East and west Sussex.
94
Grace, M. & Gerry, L. Client controlled brief acute admissions for BPD clients with a history of troublesome hospitalisations. Article
prepared for Brighton Assertive Outreach Team, Sussex Partnership NHS Foundation Trust.
95
Borderline personality disorder: treatment and management, NICE Guideline 2009
96
Sussex Partnership NHS Trust (June 2013) Guidelines for working with people with personality disorder who access urgent and acute care
services.
92
25
•
•
•
•
•
December 2013
Community, acute and specialist services need to work collaboratively, and with
services users and families/carers where possible, and a positive risk management
approach taken
Reason for A&E attendance should be recorded and there should be liaison between
all relevant services including acute, community and specialist where relevant.
Referral to CRHT should be for agreed intervention based on liaison with community
teams
In the absence of commissioned Tier 4 and ‘crisis’ housing services , hospital
admissions may at times be inevitable. Hospital admissions should: be clear about
the diagnosis, any other diagnoses of mental illness, and the “stage” the patient is at:
o Stage 1: first presentation for admission and/or early stage; diagnosis of BPD
and/or other mental illness to be verified, short term mental health service
involvement.
o Stage 2: occasional presentation for admission (once or twice in a year),
usually an acute crisis; known diagnosis, known to mental health services for
considerable time.
o Stage 3: repeated presentation for admission (more than twice a year),
usually associated with increase in psychosocial stressors. Known diagnosis;
long term involvement with mental health services; been through various
specific treatments.
When on a ward, patients should continue to access community treatment in which
they are engaged, or should access brief relevant psychological and occupational
therapy services (as specified in the guidelines) if unable to leave the ward.
3.5. East Sussex Hospital Admissions
Inpatient hospital activity data described below is sourced from Secondary Uses data (SUS
data) made available by the Commissioning Support Unit (CSU) covering inpatient hospital
episodes in the three years 2010/11, 2011/12 and 2012/13. One episode of care is the time a
patient spends in the continuous care of a consultant. Episodes of care were selected by
looking for ICD10 codes F60 to F69 (disorders of adult personality and behaviour) in the
primary diagnosis position or any other secondary diagnosis position. An admission can be
made up of several episodes when responsibility is transferred to another consultant. The
quality of coding may vary between hospital provider and over time. The information
outlined below looks at hospital admissions excluding attendances at A&E.
Between 2010/11 and 2012/13 there were 997 admissions for East Sussex residents with
disorder of adult personality and behaviour as a primary or other diagnosis position. Specific
personality disorder was coded in nearly 9 in 10 (87%) admissions (Figure 7).
26
December 2013
Figure 7: % of hospital admissions by type of personality or behaviour disorder in East
Sussex 2010/11 to 2012/13
Source: SUS data, 2013
Over the last three years hospital admissions for those with either a primary other secondary
diagnosis position of a disorder of adult personality and behaviour have risen by 53%, from
268 in 2010/11 to 411 in 2012/13, with a total of 998 admissions over the three years. This
includes a total of 1,084 episodes of care for 479 individual patients in East Sussex. It should
be noted that improved coding may be a contributing factor to this rise. Notably the greatest
rise in admissions over the last three years has been for Wealden, although Eastbourne
(+37%) and Rother (+85%) have seen greater increases over the last year. Unlike the rest of
East Sussex, admissions for residents of Lewes have been steadily decreasing over since
2010/11 (Figure 8).
Figure 8: Hospital admissions for those with a disorder of adult personality and behaviour
in East Sussex by district/borough, 2010/11 to 2012/13
There is a clear association between the number of admissions of people with disorders of
adult personality and behaviour with areas of deprivation in East Sussex (Figure 9: where 1 is
most deprived and 5 is least deprived).
27
December 2013
Figure 9: Hospital admissions and Index of Multiple Deprivation Quintiles in East Sussex
Quintile
RATE
PER
1,000
1
4.1
2
2.5
3
1.2
4
0.8
5
0.7
Of the ten wards with the highest rates of admission for people with disorders of adult
personality and behaviour (Figure 10), seven are ranked within the most deprived quintile of
East Sussex (IMD rank where 1 is most deprived and 101 is least deprived).
Figure 10: Hospital admissions and Index of Multiple Deprivation Score in East Sussex
RANK
Source: Public Health Intelligence Team, 2013
WARD NAME
RATE
PER
1,000
IMD
RANK
1
Upperton
8.7
24
2
Central St
Leonards
8.1
1
3
Gensing
5.9
2
4
Hampden Park
5.9
12
5
Hellingly
5.4
60
6
Devonshire
4.9
9
7
Newhaven
Valley
4.7
20
8
Seaford South
4.7
66
9
Lewes Bridge
4.4
47
10
Sidley
4.4
8
Figure 11 shows that, as would be expected the greatest number of admissions are recorded
from Sussex Partnership NHS Foundation Trust (SPFT), followed by East Sussex Healthcare
NHS Trust (ESHT) and Brighton and Sussex University Hospitals NHS Trust (BSUHT). Across all
Trusts, 75% of admissions non elective (emergency) and 25% elective (a planned admission).
This rises to 78% of SPFT admissions being non-elective, 83% of ESHT admissions and 85% of
admissions from BSUHT. Figure 11 also shows that SPFT is the only Trust with “unknown”
admission types (58% of admissions for people with a disorder of adult personality and
behaviour), indicating that there is a need for improved recording methods.
28
December 2013
Figure 11: Elective and Non Elective Hospital Admissions for disorders of adult personality
and behaviour in East Sussex by provider, 2010/11 to 2012/13
Of the 590 SPFT admissions of people from East Sussex with disorders of personality and
behaviour, the majority (56%) were referred to Eastbourne District General Hospital (EDGH)
(Table 6). However, over half the referrals to EDGH (184) did not have type of admission
recorded. Similarly 55% (127) of ESHT admissions were to EDGH. BSUHT are most likely to
report admissions to the Royal Sussex County Hospital.
Table 6: Referrals for hospital admissions in East Sussex 2010/11 to 2012/13
TOP
PROVIDER
S
MAIN HOSPITAL SITE REFERRED TO
NUMBER OF
REFERRALS
% OF TOTAL
REFERRALS
SPFT
Department of Psychiatry (Eastbourne District General)
Woodlands (St Leonards on Sea)
Mill View Hospital (Brighton and Hove)
Meadowfield (West Sussex)
331
160
22
18
56%
27%
4%
3%
ESHT
Eastbourne District General Hospital
Conquest Hospital (St Leonards on Sea)
127
96
55%
42%
Royal Sussex County Hospital (Brighton and Hove)
Princess Royal Hospital (West Sussex)
42
22
59%
31%
BSUHT
Over the last year there have been lower numbers of hospital admissions of people with
disorders of adult personality and behaviour for those aged between 20 and 34 than we
would expect in comparison to aggregated percentages over the last three years (Figure 13).
There has also been an increase in admissions for those aged 35 to 54 over the last year,
particularly amongst the 40-44 age group.
29
December 2013
Figure 13: Hospital admissions for those with a disorder of adult personality and behaviour
in East Sussex by age, 2012/13 and 2010/11 to 2012/13
In 2012/13, 38% of hospital admissions for adults of disorders of personality or behaviour
were for males and 62% for females. This compares to an average of 28% males admissions
and 72% female admissions between 2010/11 and 2012/13, in line with national averages
(30% and 70% respectively).97
Emotionally Unstable Personality Disorder (Borderline Personality Disorder) is the most
prevalent of all personality disorders for those admitted to hospital (Figure 14), 6.5 times
more prevalent than any other, but slightly below national evidence (75% of admissions).
Figure 14: Hospital admissions for specific personality disorders in East Sussex 2010/11 to
2012/13
* Numbers under 5 have been suppressed
Borderline personality disorder (66.5%), Paranoid personality disorder (64.2%), Dissocial
personality disorder (63.2% and Histrionic personality disorder (66.7%) are more likely to
have personality disorder as primary diagnosis for admission than secondary or other
diagnosis (Figure 15). However, numbers that this assertion is based on are small for
dissocial personality disorder and histrionic personality disorder.
97
Commissioning Support Unit (2013) Secondary Uses data
30
December 2013
Figure 15: Primary and Secondary admissions for specific personality disorders in East
Sussex 2010/11 to 2012/13
Between 2010/11 and 2012/13, four times as many females with borderline personality
disorder as a primary or secondary diagnosis have been admitted to hospital than males
(440 and 104 respectively). This is in line with national trends which indicate that 78% of
admissions of people with borderline personality disorder are female. Figure 16 shows that
this trend is continued across all age groups, with the exception of 55-59 year olds where
83% of admissions between 2010/11 and 2012/13 were male. However, numbers for some
ages are very small and should be treated with some caution. Admissions for females aged
15-34 is 5.8 times that of males. This is greater than the 4.5 times difference suggested by
prevalence estimates for those aged 16-34.
Figure 16: Hospital admissions for Emotionally Unstable Personality Disorder (Borderline
Personality Disorder) in East Sussex 2010/11 to 2012/13 by gender
For both females and males, for two thirds of admissions of people with emotionally
unstable personality disorder (borderline personality disorder), the disorder is the primary
diagnosis for admission.
31
December 2013
3.6. Services that include provision for personality disorder
Given the high rates of presentation to acute services, Consultants have developed an
approach to enable planned admissions of short duration for those presenting with BPD and
risk-taking behaviours.
Services providing support for people with personality disorder across East Sussex, including
borderline personality disorder include:
•
•
•
•
•
•
•
Amberstone hospital provides active rehabilitation for service users with enduring
mental health conditions as part of their recovery journey.
Assessment and Treatment Services (ATS) provide assessment and treatment for adults
within secondary mental health services. People with more complex needs and requiring
care coordination will receive input via the recovery and wellbeing team that sits within
this service. The multi-disciplinary team provides services to people with a range of both
functional and organic conditions. There are three teams:
o Eastbourne, Hailsham and Seaford ATS and assertive outreach team - West (St
Mary’s House, Eastbourne)
o Hastings and Rother ATS and assertive outreach team - East (Cavendish House,
Hastings)
o High Weald, Lewes and Havens ATS (Hill Rise, Newhaven and satellites across the
patch in Uckfield, Crowborough and Lewes)
Bramble lodge provides active rehabilitation for male service users with enduring mental
health conditions as part of their recovery journey.
Department of Psychology (Eastbourne) provides in-patient acute beds for a variety of
mental health conditions. The Crisis Resolution Home Treatment Team is based on site
and gate-keeps all admissions as well as providing urgent triage for referrals into the
service and home treatment to a caseload of acutely unwell service users in their own
home.
Early Intervention in Psychosis provides a specialist early intervention assessment and
treatment service to people aged 14 to 35 suspected of developing a first psychotic
illness. Because of the complex presentation, care is coordinated using a Care
Programme Approach (CPA) and a named Care Co-ordinator. Referrals are taken from
primary and secondary care. People are referred to the ATS when appropriate. Services
are available across multiple sites in East Sussex.
Liaison psychiatry is provided at both general hospital sites in East Sussex (Conquest
Hospital, Hastings and Eastbourne District General Hospital) providing urgent assessment
in the emergency department and input to all areas regarding mental health assessment
and advice.
Woodlands Centre for Acute Care (Hastings) provides in-patient acute beds for a variety
of mental health conditions. The Crisis Resolution Home Treatment Team is based on
site and gate-keeps all admissions as well as providing urgent triage for referrals into the
service and home treatment to a caseload of acutely unwell service users in their own
home.
Sussex Partnership provides a range of service to support people with personality disorder
including STEPPS, a skills training programme developed for people who have features of
Borderline Personality Disorder or Emotional Intensity Disorder which uses the techniques of
cognitive behavioural therapy. Through STEPPS people with a diagnosis of personality
disorder can learn how to manage their own mental wellbeing. Currently there are two
32
December 2013
facilities, the Lighthouse in Brighton and Hove, and Bluebell House in West Sussex set up
using the STEPPS approach. There is no equivalent service in East Sussex.
3.7. Sussex Care Pathway - Personality Disorders:
The Sussex Partnership NHS Foundation Trust (SPT) personality disorders care pathway
provides the detail of clinical services and recommended resources and information for
Primary Care PD Tier 1, Secondary Care PD Tier 2, Specialist Care Tier 3, and Specialist inpatient Services PD Tier 4. The pathway is designed to meet the health and social needs of
people with a suspected or diagnosed personality disorder and is for adults of all ages. The
decision to localise was taken in order to reflect best evidence, including expert opinion, and
local commissioning arrangements. The following care map has been locally developed for
use in Sussex (Figure 17)
Figure 17: Personality Disorders – Care Pathway for Personality Disorder in Sussex
Source: Map of Medicine, accessed August 2013
33
December 2013
4. Future need
Local population projections (Figure 18) suggest that by 2027 the population of East Sussex
will increase by approximately 4% from 531,200 to 553,300, equating to a 5.6% increase in
males and 2.8% increase in females in the county. However, the 0 to 24 year old population
is projected to decrease by 5.7% from 143,200 to 135,000. The 40 to 54 cohort is also
expected to decrease by 4.5% by 2027. Conversely, the population aged 30 to 39 will
increase across the county with the exception of Eastbourne (-1.2%) and Hastings (-0.8%).
The 55+ population is projected to increase by 6.8%, the greatest increases expected in
Eastbourne (7.4%).66
Figure 18: East Sussex population pyramid – 2012 mid-year estimate and 2027 projections
90+
85-89
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
10%
5%
0%
5%
East Sussex 2012 Males
East Sussex 2012 Females
East Sussex 2027 Males
East Sussex 2027 Females
10%
Source: ONS, 2013
In order to predict the future demand for services it is important to understand the
population projections for East Sussex. As shown in the three graphs below, while there is an
expected decrease in males (-1.6%) and females (-6.6%) aged 15-34, and in males (-14.1%)
and females (-14.0%) aged 35-54, there is an expected increase in population size over the
next 15 years in the age-group with the highest prevalence of borderline personality
disorder (55-74 years) in men (+13.6%). While there is no national data on prevalence of BPD
for women in this age group, the female population in general is also expected to increase
by 12.5% by 2027 which will impact on service provision.
34
December 2013
Figure 19: East Sussex population projections Male and Females age 15-34, 2012-2027
Source: ONS, 2013
Source: ONS, 2013
Source: ONS, 2013
Projecting adult needs and service information system (PANSI)
The Department of Health Projecting Adult Needs and Service Information System (PANSI)
looks at how demography and certain conditions can impact on populations aged 18 to 64
years. Figure 22 shows the predicted change in population of adults with BPD between 2012
and 2020.
35
December 2013
Figure 22: Estimated prevalence of BPD in East Sussex by district/borough – 2012 to 2020
NB: This table is based on the report Adult psychiatric morbidity in England, 2007. The prevalence rates have been applied
to ONS population projections for the 18-64 population to give estimated numbers predicted to have a mental health
problem, projected to 2020.
Source: PANSI, accessed November 2013
Between 2012 and 2020 there is expected to be a minor increase in the population of adults
with borderline personality disorder in East Sussex (just under 1%) with the greatest increase
expected in Lewes, while Wealden is the only area where the population is expected to
decline (Figure 22). In comparison to our statistical neighbours the predicted increase in
people with borderline personality disorder in East Sussex is much smaller than in areas such
as North Somerset, Kent and West Sussex, whereas Shropshire, Worcestershire and Dorset
are expected to see a drop in people with BPD by 2020 (Table 7).
Table 7: Estimated prevalence of borderline personality disorder in adults (aged 16 – 64)
compared to our statistical neighbours 2012-2020
2012
East Sussex
Shropshire
2020
1,361
1,374
810
791
West Sussex
2,157
2,243
Worcestershire
1,529
1,499
Kent
3,976
4,166
Gloucestershire
1,637
1,650
Devon
1,967
1,958
Essex
3,808
3,954
North Somerset
538
575
Dorset
1,031
1,006
Suffolk
1,933
1,944
NB: This table is based on the report Adult psychiatric morbidity in England, 2007. The prevalence rates have been applied
to ONS population projections for the 18-64 population to give estimated numbers (rounded to the nearest 10) predicted to
have a mental health problem, projected to 2020.
Source: PANSI, accessed November 2013
36
December 2013
5. Service provision in other areas
WEST SUSSEX
In West Sussex Bluebell House provides a specialist day service to those diagnosed with PD
(BPD in particular) and who can benefit from intensive support over a period of about 12
months. Bluebell House is a Tier 3-4 service and therefore referrals come from community
based mental health teams/in-patient wards. The service cannot be directly accessed other
than through the secondary care route. People using the service will typically have suffered a
history of abuse, rejection and neglect and the therapeutic programme consists of a range of
interventions, varying from intensive psychological therapies, arts therapies and
occupational therapy, to general support and activity groups, both at the centre and in the
community. The centre is staffed by NHS Professionals and volunteers who have previously
used the service. A crisis support service is not currently operated in West Sussex. To ensure
the service developed to effectively meet need it was important to ensure services were
geographically accessible and making sure clear communication channels existed across the
multiple teams and three inpatient units involved.
In community based teams (Assessment and Treatment Service) there are a number of
practitioners who have a particular expertise in working with those with PD although this
isn’t in every team. There is also some limited psychology input that can be accessed.
Services in West Sussex include:
• Adur, Arun and Worthing: Day hospital - full rollout of STEPPS / STAIRWAYS and a
mentalization stream. Limited capacity for one to one therapy.
• Chichester: Regular STEPPS/STAIRWAYS stream, and schema focused / mentalization
interventions. Limited capacity for one to one therapy
• Crawley: Regular STEPPS/STAIRWAYS. Limited capacity for one to one therapy
• Horsham and Mid Sussex: Regular STEPPS/STAIRWAYS. Limited capacity for one to
one therapy
Anybody needing specialist in-patient support goes through the specialist funding panel
route and once approved will go to a placement funded by NHS England.
BRIGHTON AND HOVE
The Lighthouse Recovery Support Project opened in April 2013 and is a Personality Disorder
service covering PD Tiers 1-3. Lighthouse offers an intensive programme of therapies at
specialist level, including STEPPS, STAIRWAYS, other psychological therapies, occupational
therapy (OT) and art groups. It incorporates a fully integrated programme between Sussex
Partnership Trust and third sector partners Sussex Oakleaf and Mind and so is supported
intensively by a community programme, including activities, skills development, social
inclusion and vocational recovery work and is open seven days a week, with extended hours
on some days. The service launched with an initial cohort of 20 patients ('members')
referred from Brighton Recovery teams and Mill View Hospital and from October 2013
includes a community support programme to individuals in the assessment and treatment
services. The Lighthouse Project aims to provide a meaningful alternative to hospital
admission, A&E attendance and reliance on GP and other services, and members will play a
large part in running the service.
The pathway model for the Lighthouse service is designed so:
o Tier 1 – can access community programmes and support
37
December 2013
o Tier 2 – are supported by the community teams but can access STEPPS within
these teams and can use Lighthouse as a drop in service
o Tier 3 – can access the whole programme of therapies both within the
Lighthouse and in the community.
Initial findings suggest that a degree of flexibility might be beneficial within the model as the
behaviours of people at Tier 3 can be too chaotic to effectively access the therapy
programme and additional stabilising within the community could be beneficial, some
people at Tier 2 are eager to have therapy but can’t access it, and additional input for those
at Tier 1 could prevent their behaviours from escalating further.
STEPPS groups are now also being piloted within Wellbeing services in Brighton (an early
intervention package), as well as groups for adolescents and their parents.
KENT AND MEDWAY
The Kent and Medway Personality Disorder Service follows NICE recommendations of
evidence based psychological interventions centred on an individual’s interpersonal
experience, as part of a coherent and well managed longer-term care package. In keeping
with this approach a psycho-social therapeutic community programme has been developed
placing emphasis on exploring the developing relationships between service users and staff
over an extended year long therapy programme. Treatment for people diagnosed as having
borderline or severe personality disorder with complex emotional needs is provided through
the Brenchley Unit Therapeutic Community in Maidstone (West Kent) and Ash Eton
Therapeutic Community based in Folkstone (East Kent):
Ash Eton Therapeutic Community
These facilities offer a psycho-social therapeutic community over an extended year long
therapy programme for up to 24 people at one time, with an emphasis is on supporting
service users to better recognise and manage the feelings generated within themselves by
others. Services include a four week introductory group to help orientation, daily community
meetings, a talking therapy group for up to 8 people at a time, art therapy, a writing group,
studio time where all members including staff spend time together doing activities, and a
leavers group which can be attended for up to a year following completion of the
programme.
Brenchley Unit Therapeutic Community
This unit offers a three-day-a-week therapeutic community over 12 months for people
diagnosed with a Severe or Borderline Personality Disorder comprising of up to 24 members
and five therapists. The Brenchley programme also offers intensive group psychotherapeutic
treatment which takes place in set groups, including the full community group, small therapy
groups, art therapy and activity groups. There are several elements to the Brenchley
community including: a weekly outreach programme offering up to 2 years of
psychotherapy; a Preparatory group over 4 weeks for those assessed as suitable for the
therapeutic community; a community therapy treatment programme; a therapeutic
community for those with longstanding psychological and emotional problems and a history
of multiple service use who are able to sustain a relationship, and contribute to the running
and development of the programme.
There is no individual therapy or key working within the community and integral to all
treatment is linking with other professionals. Service user’s testimonials and evidence based
38
December 2013
monitoring and evaluation research projects indicate a reduction in Accident and Emergency
services, inpatient admissions and use of prescribed drugs as a result of involvement with
the therapy programme.
ESSEX
A noted model of Tier 3 best practice is ‘the Haven’ in Colchester, Essex which is a large
house run by a 3rd sector organisation, from which low level information, advice and
support is provided along with a telephone helpline for those known to services in distress,
and respite care. This facility also accommodates local Trust provision of structured day
programmes by specialist staff including nurses, psychological and occupational therapists,
using evidence based approaches such as STEPPS and STAIRWAYS. Over a one year period
this service is reported to have worked with 110 registered clients with BPD and significantly
reduced in-patient admissions as well as demands for a wide range of associated services
including police, A&E, and non-specialist community mental health services.
39
December 2013
6. Service user, carer and provider voice
The Quality, Innovation, Productivity and Prevention (QIPP) Programme aims to improve the
quality and delivery of NHS care while reducing costs. A service review that was completed
as part of the East Sussex QIPP programme has recommended that there should be a review
of the impact of Borderline Personality Disorder (BPD) on existing services, with
consideration of how services could be significantly improved within existing resources.
There is a lack of information on personality disorder in general from a service user or
provider perspective. This section of the needs assessment draws upon existing
international, national and local research to build a picture of the views of service users,
carers and service providers on specialised personality disorder (PD) services. Highlighting
the opinions of these people who have experience of these services is a valuable tool in the
prioritisation and shaping of the development of future specialist services. This in itself may
help encourage the successful engagement of a population of service users that have been
traditionally difficult to engage in treatment services. Below is a summary of the main
themes and outcomes:
The importance of specialist PD services
Many patients with a diagnosis of BPD will have been known to mental health services for
some time, and so are well-placed to offer opinions as to the effectiveness of different types
of services and interventions for the management of their problems. One area of interest in
particular for East Sussex is the provision of specialist PD services (as opposed to general
community mental health teams and psychiatric services), as at present there are no
specialist services in the local area. Qualitative research indicates that people who have
accessed non-specialist personality disorders report a perceived stigma concerning patients
with PD diagnoses and a lack of informed staff concerning personality disorders.98 This
finding has been supported by research looking at experiences of staff working with people
with borderline personality disorder (BPD) in non-specialist services, which identified a
tendency for staff to have generalised negative opinions of people with BPD, specifically
relating it to manipulation and bad behaviour.99
Patients have been found to feel more accepted and to be more positively engaged when in
contact with specialist personality disorder services.100 However, accessing specialist services
when needed can be problematic, particularly if a person is experiencing a crisis outside of
normal working hours, which can result in people presenting to mental health services via
the police and emergency services.101 One research study suggests that the ability to selfrefer might help prevent such crisis episodes.102 Services users have suggested an ideal
personality disorder service would advocate a humane and caring response to service users,
an out-of-hours service and safe house, an advocate service and a telephone helpline.103,104
98
“I think we’re all guinea pigs really”: a qualitative study of medication and borderline personality disorder. Rogers, B. & Acton, T. Journal
of Psychiatric and Mental Health Nursing, 19: 341-347 (2012).
99
A Qualitative Investigation of the Clinician Experience of Working with Borderline Personality Disorder. Treloar, A.J. New Zealand Journal
of Psychology, 38(2), 30-34, (2009).
100
“I think we’re all guinea pigs really”: a qualitative study of medication and borderline personality disorder. Rogers, B. & Acton, T. Journal
of Psychiatric and Mental Health Nursing, 19: 341-347 (2012).
101
Borderline Personality Disorder: Treatment and Management. The British Psychological Society and Royal College of Psychiatrists. (2009)
102
Services for people with personality disorder: The thoughts of service users. Haigh, R. (2002).
103
Experiencing personality disorder: a participative research. Ramon, S., Castillo, H. & Morant, N. International Journal of Social Psychiatry,
47, 1-15 (2001).
40
December 2013
Research has identified psychotherapy as a particularly valued aspect of specialist
personality disorder services. While complex and challenging, psychotherapy is perceived to
enable the most significant changes and outcomes. In particular Dialectic Behaviour Therapy
(DBT) is useful for improving coping skills105 and helping service users view personality
disorder as a controllable part of themselves rather than something that controls them.106
Group therapy is also valued by providing shared identity, social networking, and provision
of clear, written information about new services as they develop.107
Service user views on goals of treatment
Research into the views of service users with a diagnosis of Borderline personality disorder
in East London identified that when engaging with a specialist service, people had a number
of aims to fulfil, including: learning to accept themselves and build self-confidence; taking
control of their moods, emotions and negative thinking; improving relationships by building
trust and allowing vulnerability in close relationships; reducing self-harming behaviours and
suicidal thinking; working on practical achievements and finding employment.108 However,
studies suggest that sometimes the aims that service users would like to achieve when
engaging with services did not meet the aims of the service. In this sense some services were
seen as being too rigid and narrow in focus, for example by concentrating on just one issue
instead of looking also at others that were of equal importance to the service user. 93 Both
service users and carers of service users identified that services generally need to take a
more holistic view of the patient, their family and their home environment. 109,110
Varied views on achieving recovery
Service users differed in their views as to whether they had made progress following
engagement with a specialist service, with a range of responses from having made no
progress at all, to classifying themselves as ‘recovered’. The use of the term “recovered”
proves problematic for some service users as personality disorder is not perceived to be
something that can be cured and so the use of the term “recovered” doesn’t adequately
reflect the ongoing process of learning to cope with problems and developing a meaningful
life within the limitations of the disorder. Overall, a fluctuating progress was commonly
described, with people having made some progress towards their goals, but still living with
their BPD and the daily difficulties it can bring.111
Local qualitative research studies
STEPPS – West Sussex
Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group
104
Learning the Lessons: a Multi-Method Evaluation of Dedicated Community-Based Services For People with Personality Disorder.
Crawford, M., Rutter, D., Price, K. et al. (2007). London: National Co-ordinating Centre for NHS Service Delivery and Organisation
105
Crawford, M., Rutter, D., Price, K. et al. (2007). London: National Co-ordinating Centre for NHS Service Delivery and Organisation.
106
It’s about me solving my problem: clients’ assessments of dialectical behaviour therapy. Cunningham, K., Wolbert, R. & Lillie, B.
Cognitive and Behavioural Practice, 11, 248-258 (2004).
107
108
Borderline Personality Disorder: A Qualitative Study of Service Users’ Perspectives. Katsakou, C., Marougka, S., Barnicot, K., Savill, M.,
White, H., Lockwood, K. & Priebe, S. PLoS ONE 7(5): e36517 (May 2012). Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3355153/
109
A Life Tiptoeing: Being a Significant Other to Persons with Borderline Personality Disorder. Ekdahl, S., Idvall, E., Samuelsson, M. &
Perseius, K. Archives of Psychiatric Nursing, 25(6), 69-76 (2011).
110
111
Borderline Personality Disorder: A Qualitative Study of Service Users’ Perspectives. Katsakou, C., Marougka, S., Barnicot, K., Savill, M.,
White, H., Lockwood, K. & Priebe, S. PLoS ONE 7(5): e36517 (May 2012). Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3355153/
41
December 2013
treatment program piloted by Sussex Partnership NHS Trust by adding it into existing care
pathways. STEPPS combines cognitive-behavioural elements and skills training, with good
evidence of efficacy internationally, and overwhelmingly positive feedback from those
completing the programme to date regarding improved self-awareness, confidence and
coping strategies.112
Conclusion
Whilst qualitative information regarding borderline personality disorder is limited, the
studies outlined above show that:
• Specialist services and knowledge are perceived to foster greater engagement and as
such achieve more positive outcomes
• A more holistic approach to personality disorder services would be beneficial.
• Effective support is more likely when the goals of services and service users are
aligned
• Written information on a services is highly valued
112
Harvey R, Black DW, Blum N (2010). Systems Training for Emotional Predictability and Problem Solving (STEPPS) in the United Kingdom:
A preliminary report. Journal of Contemporary Psychotherapy, 40:225-232.
42
December 2013
7. Evidence of Effectiveness and Best Practice
Access to services
People with borderline personality disorder should never be excluded from services because
of their diagnosis or history of self-harm. Those with BPD from minority ethnic groups should
have equal access to culturally appropriate services and if language is a barrier the access or
engagement then information and intervention should be accessible in their preferred
language, involving an interpreter if necessary. 113
Evidence of Personal Experience of Care
The 2009 NICE guidance on treatment and management of people with BPD outlined
national evidence of personal experiences of BPD which highlighted that:
• Borderline Personality Disorder can be extremely debilitating due to difficulties
controlling mood, feelings, emotions, relationships and communication, which can in
turn lead to coping mechanisms such as self-harm. Assessment of BPD must
recognise that mechanisms such as self-harm are usually indicative of internal
emotions.
• People with Borderline Personality Disorder report feelings of rejection on
assessment for services due to the traumatic focus on past experiences this entails
which makes engagement more difficult. Clear explanations about the process and
information about the service is highly valued.
• Diagnosis can prove positive in the sense of providing control and a degree of
legitimacy about the experience, but can also prove negative as it can be associated
with feelings of loss of hope and reports of denial of services due to diagnosis.
Healthcare professionals need to be aware of stigma surrounding BPD and be
sensitive to the potential impact of diagnosis
• Specialist services were felt to be most effective, particularly in behaviour change, as
was early intervention. People felt that when in crisis an out of hour’s crisis service
was needed. The literature shows that there are not enough services for people
with personality disorder and healthcare professionals need to establish a
collaborative partnership with the service user that is non-judgemental, supportive,
caring and positive. Working with service users to explore potential crises triggers
and management strategies is useful as part of a care plan including crisis advice.
• People reported a “post-therapeutic dip” when leaving residential support services as
they adjusted to independent living.
• While complex and challenging, psychotherapy was seen as helpful and positive, with
some preferring the opportunity to share experiences in groups, and some preferring
individual therapy. Treatments can differ for individuals and client choice is crucial.
• Leaving treatment can be difficult for people with borderline personality disorder and
can evoke strong emotions of rejection. A more structured approach to “endings” is
needed along with information about support groups and self-management
techniques.
• There is little support for families and carers, with the impact of borderline
personality disorder leading to high scoring on scales measuring burden and
depression. Many families and carers feel excluded from the service user’s
113
43
December 2013
treatment. Collaborating with families/carers (when the service user is in
agreement) and supporting them could provide a valuable resource for the person
with borderline personality disorder.
Five key clinical practice recommendations emerge from these findings:
• No-one with BPD should be excluded from services due to diagnosis or history of selfharm.
• An optimistic and trusting relationship needs to be developed with the service user
• Family and carers should be involved with the consent of the person with BPD
• Assessments should involve clear explanation of the process of assessment and of
the diagnosis in non-technical language, and should offer post-assessment support.
• Difficulties with endings and transitions should be effectively managed114
Role of Pharmacological Treatment
Research and available evidence on the effectiveness of individual drugs is limited but there
is some evidence that pharmacological treatments can help reduce specific symptoms
experienced by some people with borderline personality disorder including anger, anxiety,
depressive symptoms, hostility and impulsivity. However, there is no evidence that the
fundamental nature of borderline personality disorder is altered in the short or the long
term. Therefore drug treatment should not be used specifically for borderline personality
disorder or behaviour associated with the disorder, nor should antipsychotic drugs be used
for these reasons. Drug treatment may be considered in the overall treatment of co-morbid
conditions. Further research is needed into the effectiveness of pharmacological treatments
for borderline personality disorder. 79
Recent evidence from the Prescribing Observatory for Mental Health UK Quality
Improvement Programmes (POMH-UK QIP) looking at prescribing for personality disorder
highlighted the huge discrepancy between national guidance recommendations and clinical
practice. A national baseline audit of over 2,500 patients in 2012 found that, in opposition to
NICE guidance:
• 4 out of 5 patients were prescribed at least one medication from four drug groups:
antipsychotics, antidepressants, mood stabilisers and sedatives.
• Just over half of patients with PD and no co-morbid mental illness were prescribed at
least one antipsychotic, and the majority of prescriptions were of at least 6-month
duration.
• Benzodiazepines were prescribed in a third of patients without co-morbid psychotic
illness.
• Two-thirds of patients had a written crisis plan which was accessible in the clinical
records. Only two-fifths of these crisis plans mentioned medication, and in just over a
quarter there was no evidence that the patient had been involved in its
development.115
Role of Psychological Treatment
The 2009 NICE guidance on treatment and management of people with BPD recommends
that psychological treatment for people with BPD should use an explicit and integrated
approach with the treatment team, therapist and service user, structured care, provision for
therapist supervision, and a frequency of service adapted to the person’s needs. Dialectal
114
115
Prescribing Observatory for Mental Health UK (Nov 2012) Prescribing for people with borderline personality disorder (PD)
44
December 2013
behaviour therapy should be considered in cases of self-harm. It is also important to develop
an agreed set of outcome measures to assess interventions, including analysis of quality of
life, function and symptoms. 79
Management of crises
A characteristic of many people with BPD is that they can often present in crisis, and as a
result they can be regular users of psychiatric and acute hospital emergency services.
Medication is commonly started when a patient presents in crisis although there is no
evidence for the effectiveness of this. For this reason, medication use should be limited and
always considered in the context of a longer-term treatment plan involving psychological
and/or social intervention. The patient’s capacity to consent in a time of crisis should always
be considered. Currently, people with BPD may present to a range of services and carers
may or may not be involved in this. Crisis teams within mental health services may be
involved if immediate support and assessment of risk is needed. A crisis plan should always
be consulted and clinical practitioners should: remain calm and unthreatening whilst trying
to understand the crisis from the persons viewpoint; use empathetic open questioning to
explore the reason for distress and identify the onset and course of current problems;
stimulate reflection about solutions without minimising the stated reasons for the crisis and
without offering solutions before full clarification of the problems; explore other options
before considering admission to a crisis unit/inpatient admission; and offer appropriate
follow up with an agreed timetable with the person. If short term drug treatment is
considered necessary risks must be evaluated and consensus reached amongst all involved.
The drug should never be used in place of more appropriate intervention and should be used
for no longer than one week on the minimum. Once the crisis has been resolved or subsided
the crisis plan and overall care plan should be updated as soon as possible to reflect current
concerns and treatment strategies. 79
Service configuration and organisation
In 2003 the Department of Health outlined the problems faced by many people with
personality disorder who try to access appropriate primary or secondary care services. As a
result of this standards have been set for service delivery and mental health trusts in
England now have responsibility to meet the needs of those with personality disorder using
local expertise, suitable skills and multi-agency working. Research on service configuration
and organisation suggests that the complexity of personality disorder requires more than
one type of intervention to be offered by most services. Patient choice and active
participation should be encouraged; there should be a coherent model for understanding
personality disorder, clear communication which values the person within the service, and
services for those in crisis. 116
The role of inpatient services
People with Borderline Personality Disorder have been shown to be high users of inpatient
services,117 yet the effectiveness of this as an intervention is uncertain as there is a paucity
of evidence on the impact of inpatient care on borderline personality disorder. To date,
literature on inpatient treatment for personality disorder is based largely on expert opinion,
with a general consensus that long admissions in standard psychiatric inpatient units are
116
Crawford, T. N., Price, K., Rutter, D., et al. (2008) Dedicated community-based services for adults with personality disorder: Delphi study.
The British Journal of Psychiatry, 193, 342–343.
117
Bender, D. S., Dolan, R. T., Skodol, A. E., et al. (2001) Treatment utilization by patients with personality disorders. American Journal of
Psychiatry, 158, 295–302.
45
December 2013
unlikely to be helpful,118 and as such, if such treatments are needed they should be short
term and focussed on crisis management.119 The scant evidence suggests that the most
effective treatment of borderline personality disorder occurs at outpatient settings. The
Nice guidance uncovered no evidence answering clinical questions about the role of
specialist services. 80
The Care Pathway
NICE guidance outlines principles that should be applied in the development of a care
pathway for those with borderline personality disorder as the development of a care
pathway would ensure resources are used effectively and services are suited to need. Key
recommendations include:
1. Mental health trusts should develop multidisciplinary specialist teams/services for PD
that:
a) Are responsible for the routine assessment, treatment and management of people
with BPD, including diagnosis when general psychiatric services are in doubt
b) Provide consultation and advice to primary and secondary care services and training
programmes on the diagnosis and management of BPD
c) Provide and/or advise on social and psychological interventions
d) Work with CAMHS teams to govern transition into adult services
e) Develop clear communication with primary and secondary care including the
establishment of information sharing protocols among different services (including
in the forensic setting)
f) Are involved in development of new treatments for people with BPD nationally and
locally
2. Service user needs and preferences should be considered when developing the
multidisciplinary treatment and care programme. Promoting choice, developing a
trusting relationship between patients and those working with them, and planned
endings and transition are key to care plans.
3. Psychological treatment services should have an explicit and integrated theoretical
approach with provision of therapist supervision. Brief interventions (less than 3
months) should not be used specifically for BPD
118
Bateman, A. W. & Tyrer, P. (2004) Services for personality disorder: organisation for inclusion. Advances in Psychiatric Treatment, 10,
425–433.
119
Fagin, L. (2004) Management of personality disorders in acute in-patient settings. Part 1: borderline personality disorders. Advances in
Psychiatric Treatment, 10, 93–99.
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December 2013
8. Conclusions
PERSONALITY DISORDER NATIONALLY
• National prevalence estimates for borderline personality disorder (BPD) are 0.5-0.8% of
the population aged 16 and over.
• Women aged 16-34 are around 4.5 times more likely (1.4%) than men aged 16-24
(0.3%)to have BPD
• Three quarters of all hospital admitted personality disorder diagnoses are for BPD.
• 78% of all in-patient personality disorder cases in the UK are diagnosed in women.
• Life expectancy for those with personality disorder is significantly shorter than the
general population
• National evidence shows there is a paucity of service provision for people with
personality disorder
PERSONALITY DISORDER LOCALLY
• There are currently an estimated 1,900 adults aged 16+ with BPD in East Sussex
• We would expect to see approximately 1,350 females and 550 males with BPD locally.
• In comparison to our ten nearest statistical neighbours East Sussex has the third greatest
rise in estimated BPD since 2003 (8.3%)
• The number of men with BPD who are on remand at Lewes prison is estimated to have
increased by 3.5% over the last 5 years
• Over one third of the prison population for whom there are records reside in East Sussex,
indicating that the prevalence of BPD within prison will impact on service demand upon
release.
• Since 2010/11 there have been 998 hospital admissions for 479 people with disorders of
adult personality and behaviour, representing a 53% increase over the last three years.
• Since 2010/11 there have been a lower number of admissions for 20-34 year olds than
expected, and a greater number of admissions for 35-54 year olds
• Over the last year, hospital admissions for males who have personality disorder has
increased out of line with national rates
• Across all trusts admissions are three times more likely to be non-elective (emergency)
than elective.
• BPD is the most prevalent of all personality disorders for those admitted to hospital (6.5
times more prevalent than any other type).
• In line with nationally, women admitted to hospital are 4x more likely than men to have
BPD
• There is clear association between hospital admissions of people with PD and
deprivation
• By 2020 the age group with the highest prevalence for BPD in males (55-74 years) is
expected to increase by 13.6%, and for women an increase of 12.5% is expected.
• The overall population of adults with BPD is expected to increase by 1% by 2020.
47
December 2013
GAPS IN SERVICE PROVISION
• A 2007 needs assessment on adult health across Sussex found specialist services for PD
to be underdeveloped and recommended these should be developed. West Sussex and
Brighton and Hove have developed these services but this has yet to be developed in
East Sussex.
• There is a paucity of community provision in East Sussex for personality disorder in East
Sussex in comparison to similar areas.
• Due to the numbers of people who are estimated to have PD in the county, both in the
general and criminal justice populations, there is likely to be a significant unmet need
currently.
• There is no specialist crisis service for people with BPD in East Sussex.
INFORMATION NOT CURRENTLY AVAILABLE
• Similarly to mental illnesses there is no direct medical test to diagnose personality
disorder and difficulties diagnosing are compounded by the amount of information
needed on personal history in order to assess personality traits.
• There are a very high number of “unknown” admissions types from Sussex Partnership
NHS Foundation Trust (SPFT) indicating that there is a need for improved recording
methods.
• Information on those who have been discharged from hospital and community provision
for most frequent users is currently being collated.
48
•
December 2013
9. Recommendations
RECOMMENDATIONS
SERVICE RECOMMENDATIONS:
•
It is recommended that preventative interventions are needed, particularly to address the
relationship between high incidence of personality disorder and those within the criminal
justice system. Early interventions that address emotional intensity should be specifically
targeted towards young people entering the criminal justice system and first presenters to
primary care.
•
It is recommended that a community personality disorders service should be developed as
part of a holistic, whole-system approach. The service should provide a range of therapeutic
activities which are available to members, aligned to assessed need. The STEPPS
programme should form a part of this alongside a community programme of activities and
support. The service should provide mentoring and/or volunteering opportunities for
people with lived experience of borderline personality disorder. This approach should be
patient centred and where possible involve the individual’s wider network of support.
•
It is recommended that crisis services could be improved by:
o Developing the mental health crisis service to be more inclusive of the specific
needs of people who have personality disorder, including signposting to IRIS and
community personality disorder services where appropriate.
o Investigating appropriate space for a small number of crisis or respite beds.
TECHNICAL RECOMMENDATIONS:
•
It is recommended that data collection of information regarding adults with personality
disorders, and borderline personality disorder in particular, is improved in the following
ways:
o A joint approach between health, social care, police, criminal justice system,
voluntary sector and service users is further developed.
o There is agreement across services on the specific traits indicating borderline
personality disorder and how this is systematically coded.
o There is regular collation of the feedback from service users regarding outcomes to
better inform policy and practice across mental health and community services.
•
It is recommended training is needed locally to enhance knowledge and skills of those
supporting people with borderline personality disorder.
RECOMMENDATIONS FOR FURTHER INVESTIGATION BY COMMISSIONERS:
•
It is recommended further research is needed on the impact borderline personality disorder
has on the health and wellbeing of people in East Sussex, particularly with regards to known
risks such as substance misuse and risk of self-harm.
•
It is recommended, in line with NICE guidance, there is further investigation into the
amount of drug treatment being prescribed for BPD by GPs or Mental Health Services
•
It is recommended further information is needed into the reasons for high repeat hospital
admissions for people with personality disorders.
•
It is recommended Information on those who have been discharged from hospital and
community provision for most frequent users that is currently being collated should further
inform this needs assessment.
49

Borderline Personality Disorder Rapid Needs Assessment

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