A Better Understanding: Psychiatry’s Social Contract

Mental Health Foundation, July 2015

In this report two key questions are considered: what is the nature of the “contract” between psychiatry and society, and what responsibilities and expectations are there on both sides to enable high quality NHS psychiatric care to be provided across the UK?

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Personality disorder across the life course

The Lancet, 21-27 February 2015

The pervasive effect of personality disorder is often overlooked in clinical practice, both as an important moderator of mental state and physical disorders, and as a disorder that should be recognised and managed in its own right. Contemporary research has shown that maladaptive personality (when personality traits are extreme and associated with clinical distress or psychosocial impairment) is common, can be recognised early in life, evolves continuously across the lifespan, and is more plastic than previously believed. These new insights offer opportunities to intervene to support more adaptive development than before, and research shows that such intervention can be effective. Further research is needed to improve classification, assessment, and diagnosis of personality disorder across the lifespan; to understand the complex interplay between changes in personality traits and clinical presentation over time; and to promote more effective intervention at the earliest possible stage of the disorder than is done at present. Recognition of how personality disorder relates to age and developmental stage can improve care of all patients.

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Classification, assessment, prevalence, and effect of personality disorder

The Lancet, 21-27 February 2015

Personality disorders are common and ubiquitous in all medical settings, so every medical practitioner will encounter them frequently. People with personality disorder have problems in interpersonal relationships but often attribute them wrongly to others. No clear threshold exists between types and degrees of personality dysfunction and its pathology is best classified by a single dimension, ranging from normal personality at one extreme through to severe personality disorder at the other. The description of personality disorders has been complicated over the years by undue adherence to overlapping and unvalidated categories that represent specific characteristics rather than the core components of personality disorder. Many people with personality disorder remain undetected in clinical practice and might be given treatments that are ineffective or harmful as a result. Comorbidity with other mental disorders is common, and the presence of personality disorder often has a negative effect on course and treatment outcome. Personality disorder is also associated with premature mortality and suicide, and needs to be identified more often in clinical practice than it is at present.

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Treatment of personality disorder

The Lancet, 21-27 February 2015

The evidence base for the effective treatment of personality disorders is insufficient. Most of the existing evidence on personality disorder is for the treatment of borderline personality disorder, but even this is limited by the small sample sizes and short follow-up in clinical trials, the wide range of core outcome measures used by studies, and poor control of coexisting psychopathology. Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions. The synergistic or antagonistic interaction of psychotherapies and drugs for treating personality disorder should be studied in conjunction with their mechanisms of change throughout the development of each.

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The British Journal of Psychiatry, September issue

The September issue (volume 205, issue 3) of The British Journal of Psychiatry has now been published.  Highlights of the issue include:

  • A paper by Wong et al found that the exponential curve was also evident in their assessment of paranoid thoughts in children, but the frequency of paranoid thoughts decreased with increasing age.
  • Kessing et al demonstrate that patients who started their lithium prophylaxis earlier in their illness demonstrated better outcomes, as indexed by decreased frequency of hospitalisation and increased use of lithium monotherapy.
  • Hung and colleagues show that risk of cancer is elevated in patients with affective disorder, with a greater increase in depressive illness compared with bipolar disorder.
  • Papoulias and colleagues performed a systematic review of the psychiatric ward as a therapeutic space and identified a lack of robust data linking design to outcomes; however, they report that the presence of private spaces and a homely environment within the unit may contribute to increased social interaction and patient well-being.

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