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At the heart of general practice since 1960

Why ?-blockers are vital cardiovascular tools

Dr Philip Sugarman and Dr Antony Walters advise how

to assess personality disorders and who to refer

Psychiatrists make an important distinction between personality disorder and mental illness. Disorders of personality are 'deeply ingrained and enduring behaviour patterns, manifesting themselves as inflexible responses to a broad range of personal and social situations'1. Such patients' thoughts and actions are often not acceptable in their own culture. With a limited repertoire of behaviour for diverse situations, they are often seen as inadequate, difficult or eccentric people. They cause long-term problems both for themselves, their families and carers, and others they come into contact with.

In contrast, mental illnesses, such as depression or psychosis, are episodic, with specific symptoms, from which patients can more clearly recover.

How many primary care patients have personality disorder?

Up to 10 per cent of the general population suffers from at least one type of personality disorder. Clinically significant cases represent a more severely affected group ­ around 2 per cent of the population2. Health-damaging lifestyles and abnormal illness behaviour are common and so it is often seen in frontline health care settings2, such as GP surgeries, NHS walk-in centres and contacts with NHS Direct.

Inner-city general practices have the highest rates, but suburban areas may have a different profile of types of personality disorder. Some studies have found specific associations: for example rural practices may have a higher prevalence of anankastic personality disorder (see table above).

Rates are of course high among psychiatric patients and in residential institutions. A majority of offenders have personality disorder.

When should a GP suspect?

GPs often see unreasonable patient behaviour and this is often a manifestation of the patient's anxiety. But where this is repeated ­ in either obvious or subtle ways ­ personality disorder should always be suspected. Other tell-tale signs include:

·chronic attendance and 'heartsink' patients

·non-adhererence to treatment and non-attendance

·violence and abuse

·shortlived or stormy relationships

·petty or serious offending

·poor parenting

·inability to hold down employment or manage finances

·poor diet, heavy use of tobacco, drugs and alcohol.

Abnormal illness behaviour has myriad varieties, and often complicates serious physical conditions. There are high rates of self-harm, violence and suicide, problems which present serious challenges to the public health agenda.

GPs are well advised to be tentative in making the diagnosis of personality disorder, leaving the question open as a suspected case. A brief collateral history from a relative may reveal problematic behaviour traceable from childhood into the present time.

The diagnosis can only be made in adulthood, when behaviour patterns have become stable and persistent. Because of the danger of inappropriate labelling, confirmation of diagnosis should be reserved for a psychiatrist. But diagnosis alone is not a reason for psychiatric referral.

What types might a GP see?

The WHO and US classifications1,4 offer a traditional list of categories originally promoted by German psychiatrist Kurt Schneider.

Clinically, patients present features of more than one category, and often have other diagnoses, such as mental illness, drug and alcohol problems ('co-morbidity'). More recently it has been found helpful to arrange this list into clusters (see page 61).

Cluster A

Cluster A personality disorders cover individuals typically perceived as odd or eccentric, who mostly cause few problems for others.

However, paranoid personalities can be argumentative, violently jealous or litigious. Schizotypy is closely related to schizophrenia.

Vignette: A young man dressed in black attends your surgery with strange pains in various parts of his body. His grandmother had schizophrenia. He makes poor eye contact and talks in a strange manner, but declines psychiatric referral. He complains excessively of medication side-effects. You never manage to help.

Cluster B

Cluster B disorders include dramatic, emotional and erratic presentations, and cover many people whose behaviour impacts on others, including health professionals.

Drug and alcohol problems are common. Women are more likely to be diagnosed as borderline or histrionic, men as antisocial. Severe cases can be described as 'psychopathic'.

Vignette: A woman describes elaborate symptoms, and has generated a thick record file. Every treatment seems to work for a short period only, and you are invariably left feeling ineffectual. Psychotropics have frequently been prescribed. She has attended since childhood and has irritable bowel syndrome and dyspareunia. Her problems settle with sexual abuse counselling.

Vignette: A known drug addict presses for diazepam and is intimidating. He has been removed from other surgeries' lists. Referral to the local drug and alcohol service with controlled prescription on their advice, leads, after two years, to complete abstinence and appropriate social behaviour.

Cluster C

Cluster C patients present as anxious or fearful, often with health worries about themselves or their relatives.

Vignette: A middle-aged woman with agoraphobia is brought in by her daughter. Both are excessively concerned about minor symptoms and receive help gratefully. In fact, they live together and take each other's medication, and are well-known to the local pharmacy. With a medicine cupboard cleared of all but fluoxetine, the mother's independence improves with behaviour therapy, and the daughter leaves home.

What causes personality disorder?

Is it genetic?

Personality differences in general are heavily genetically determined. There is also evidence for a genetic component for some behaviours, such as violence and the early onset of alcoholism in men.

Brain research has begun to clarify the role of neurotransmitters: for example, deficient serotonin activity in the brain mediates abnormal impulsiveness and aggression.

Some personality disorders can be thought of as mild forms of mental illness, the

strongest link being between those found in cluster A and disorders such as schizophrenia, which are familial.

Psychological theorists, from Sigmund Freud onwards, have focused on failure to progress through early development, partly as a result of adverse upbringing.

This leads to problems in relationships in later life. The importance of childhood separation, neglect and abuse is increasingly recognised.

How does a GP help these patients?

A patient and forgiving approach is essential. Any doctor should focus on real illnesses, underlying problems, and prevention. It is proper to start with the presenting

problem, but rapidly move to the underlying problems.

The box on the right offers some advice on what to say to patients.

Many patients will agree that they have had problems of the same kind for many years or throughout their lives

Who should be referred?

Referrals should be selective. GPs should try first to address any physical health care problems and more amenable mental health problems, such as depression. Where it transpires that little progress can be made

with a demanding patient, a brief collateral history should be taken from carers, by telephone if necessary.

The main issue for referral is not diagnosis, but whether specialist referral is likely to help the patient. This depends partly on the local provision of specialist services. Informal inquiry to the services can be helpful. The patient's full agreement is essential ­ positively motivated patients are the most likely to benefit.

Psychology, psychotherapy and counselling services have expanded in recent years, both in the NHS and independent sectors, but remain overwhelmed with demand. It is important to use only professional services with qualified and trained staff. Specialist services for abuse victims of all kinds are also increasingly available.

Busy general psychiatrists, outside of teaching centres, may mainly wish only to exclude more treatable mental illness. However, mental health and social service day centres provide the level of support many personality-disordered people require.

Tertiary services, such as residential units for personality disorder and forensic psychiatry units, concentrate on a small number of selected cases.

No patient should, however, be labelled as 'untreatable' without an assessment from a tertiary service.

What about 'dangerous severe personality disorder'?

Dangerous severe personality disorder ­ DSPD ­ is an unhelpful label. This ongoing Government initiative has had a major stigmatising effect on psychiatric patients3.

It is intended to apply to a very small group of 'psychopaths', especially serious offenders about to leave prison.

Controversially, psychiatrists may be required to give evidence of dangerousness in order to justify indefinite detention, even in some individuals who have not been convicted of any offence.

This goes well beyond current mental health law.

Doubts about diagnosis and risk assessment, together with human rights concerns, have fuelled opposition, not least from the Royal College of Psychiatrists.

At present new laws and new services are being considered, but the proposals have not been finalised.

In our view this debate should not be allowed to detract from efforts to help the much wider group of patients.

Philip Sugarman is a general and forensic psychiatrist and is medical director and

general manager, St Andrew's Hospital Group, Northampton

Antony Walters is a GP in Northallerton,

North Yorkshire, and joint medical director

of Hambleton and Richmondshire Primary Care Trust

Main personality disorders

What to say

to patients

·Patients can be reassured that they are not mentally ill or going mad

·It is useful to acknowledge the 'stress', 'worry' or 'upset' that the patient has been suffering; this may help move beyond an initial symptom presentation or demand

·Many patients will

agree they have had problems of the

same kind for many years or throughout

their lives

·There are many helpful euphemisms that, if carefully chosen, are better than a formal diagnosis in most cases: quick-tempered, strong-willed, a worrier, sensitive, bad nerves, neat and tidy, likes a drink, a loner, doesn't

go out much....

References

1 World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Description and Diagnostic Guidelines. Geneva: WHO, 1992

2 Tyrer P, Stein G (eds). Personality Disorder. London: Gaskell, 1993

3 Wright NM et al. Managing violence in primary care: an evidence-based approach. Br J Gen Pract. 2003,53,557-62

4 American Psychiatric Association. DSM-IV. Diagnostic and Statistical Manual of Mental Disorders. 4th ed.

Washington DC: APA, 1994.

5 Home Office and Department of Health. Managing Individuals with Dangerous Severe Personality Disorder. London: 1999 www.homeoffice.gov.uk

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