Personality Disorder Integrated Care Pathway (PD ICP) 11: Personality Disorder Service July 2015
Acknowledgements This document was produced by a partnership of NHS Highland staff, volunteers, service users and staff from other public and third sector organisations. The NHS Highland Personality Disorder Service will coordinate future reviews and updates of this document. NHS Highland would like to thank everyone involved in the creation of this document. July 2015
Contents 11 Personality Disorder Service 11.1 Services offered by the PDS... 11.1.1 Specialist Assessment and Treatment Recommendations 11.1.2 Dialectical Behaviour Therapy (DBT)... 11.1.3 Coping and Succeeding (CAS) Day Service... 11.1.4 Consultation... 11.1.5 Education and awareness... 11.2 Services not currently offered by the PDS... 11.3 How to access these services... References...
11. Personality Disorder Service The NHS Highland Personality Disorder Service (PDS) is a specialist outpatient service for NHS Highland. The PDS offers consultation, assessment and specific psychosocial interventions. It does not currently offer a case management service. 11.1 Services offered by the PDS The main services offered by the PDS are: 11.1.1 Specialist Assessment and Treatment Recommendations In order to ensure that patients receive the most appropriate treatment recommendations, the PDS uses a standardised assessment to produce a formulation and a phase-based treatment plan. The assessment includes current symptoms, personality traits, detailed background history (including trauma history) and mental state examination. The information is gathered from various sources including patient history, case-records, informant histories from professionals and social network members and formal structured assessment tools. The main purpose of the standardised assessment is to allow the collaborative development of a formulation of the relevant biological, psychological and social factors into a description of the patient s life and personality which helps contextualise current problems and symptoms and identify which problems, themes and goals will be the focus of treatment. Usually, 5 to 6 hours are spent face-to-face with the patient. In addition, time is spent reviewing notes, speaking with informants, and constructing the formulation and treatment plan. The assessment, formulation and treatment recommendations are then discussed with the patient. This process usually takes around 8 weeks, at the end of which time a detailed assessment letter, formulation and treatment recommendations are sent to the referrer, with copies to all members of the care team and the patient. It is recommended that this documentation is kept at the front of the psychiatric casenotes in the Important Information section. It is hoped that the formulation and treatment plan generated by the assessment will usefully inform future clinical contacts and care planning. Best available evidence suggests that standard psychiatric care organised by a psychologically-informed formulation can deliver benefit roughly equivalent to specific psychosocial interventions such as DBT. 11.1.2 Dialectical Behaviour Therapy (DBT) This is a primarily Phase 1 (stabilisation) intervention for patients with severe borderline personality disorder. DBT is an intensive psychosocial intervention largely based on cognitivebehavioural principles. It comprises a weekly skills training group, concurrent weekly individual psychotherapy and weekly peer supervision for all therapists. The treatment usually lasts six months to one year. For patients with co-occurring post traumatic stress disorder (PTSD), the DBT Prolonged Exposure protocol (DBT-PE) may be of benefit. This Phase 2 trauma reprocessing intervention is delivered within the individual component of DBT treatment and bears many similarities to the standard prolonged exposure approach (PE) for PTSD uncomplicated with borderline personality disorder. DBT-PE can only be delivered to patients as part of an overall DBT treatment and not
as a stand-alone intervention. DBT is an intensive intervention for patients with severe and complex borderline personality disorder. Therefore referrers should only consider DBT if STEPPS or other secondary care approaches are inappropriate for reasons of complexity or severity. To ensure that a holisitic approach is taken to each patient s care and treatment needs, to allow for effective structuring of the environment, and to optimise communication and collaboration between the patient and the services involved, patients in DBT are required to be on the Care Program Approach. DBT can be offered only when clinically indicated by reason of severity and cannot be offered solely because of local lack of availability of other better matched, less intensive options. 11.1.3 Coping and Succeeding (CAS) Day Service The CAS (Coping and Succeeding) Day Service for people with personality disorder is a community-based service which takes place each Friday from 0930 to 1530 at Rowans, New Craigs Hospital. The usual length of treatment is 36 weeks. CAS has been developed in partnership with service users along Recovery principles and represents a co-produced service. The service is primarily directed at helping a person enhance interpersonal and social connections in order to help them build a life away from mental health services. This process usually has benefits for self-image. CAS has a primary focus on Phase 3 (integration) and, to a lesser extent, Phase 2 (exploration and change). It is not an intervention with an emphasis on Phase 1 (stabilisation). Other interventions such as DBT or STEPPS are more appropriate for stabilisation of harmful behaviours. Furthermore, patients with post-traumatic features are likely to benefit from specific trauma work (Phase 2) before making best use of CAS. The CAS Day Service includes elements of structured group work, self-directed time and social time. Broad themes covered in the core groups include promotion of physical health and wellbeing; living skills; self-management; and vocational rehabilitation. These themes are addressed by providing direct information and education; enabling direct introduction to new activities/behaviours; and making and highlighting links between people and services. In the spirit of co-production, participants play the major role in planning and organising the content of the group activities and the day to day running of the service. Participants develop and work towards their own goals in the interpersonal, occupational, recreational and educational domains. The overall aims include promotion of self-management and planning for a worthwhile life without mental health services. The service is not only for individuals with borderline personality disorder, but is for any patient who meets the general criteria for personality disorder or whose personality disorder is in early remission. Potential CAS members must be ready to make changes. CAS would not be suitable for people who do not meet the general diagnostic criteria for personality disorder; people with current risk issues which preclude safe placement in a community setting (for example, people who present a significant risk of violence to others or a significant risk of harming themselves); or people who are unwilling or unable to usefully work cognitively and behaviourally, for example people with active substance dependence, brain injury, or low weight anorexia nervosa. New participants can join the group at frequent intervals. 11.1.4 Consultation The PDS is currently developing its consultation function. The aims include to provide a range of consultation modes including recommendations on the general management and treatment
of personality disorder, discussion of specific aspects of a clinical case, specific supervision for professionals engaged in delivering general or specific psycho-social treatments to patients with personality disorder, full case consultation and formal further opinions. Requests for consultation are welcomed. See below for contact details. 11.1.5 Education and awareness Until now, much of the education and awareness delivered by the Personality Disorder Service has been on an ad-hoc basis. Educational sessions have been provided to various audiences in many settings. Sessions have usually followed specific requests and been tailored according to particular needs. In some settings, educational sessions have been co-delivered with service users. Service user involvement in education and awareness-raising adds the patient s unique experience of living with personality disorder to the clinician s perspective. The Personality Disorder Service educational programme is currently undergoing a process of development, including evaluation of the possibility of electronically available educational modules. Currently, the main regular educational sessions occur four times per year. Each session covers a different personality disorder-related subject and lasts for approximately 2 hours. Dates and topics are distributed by email. Anyone with an interest in personality disorder can contact the PDS to be placed on the distribution list. As well as these regular sessions, the PDS service will consider any request for education on subjects related to personality disorder. See below for contact details. The PDS has hosted development of this PD-ICP document, which is hoped to serve as a valuable educational resource. Each section summarises an important topic in personality disorder and useful resources and links can be found throughout. The publication of this document will be supported by an educational and awareness-raising program. The educational support aims to be broad in scope, including New Craigs Hospital, Community Mental Health Teams, Addictions Services, Primary Care, Accident and Emergency and Secondary Care Community Services. This list is not intended to be exclusive, and the PDS will endeavour to respond to all requests for awareness-raising of the PD-ICP document. 11.2 Services not currently offered by the PDS Although requests for the following services are sometimes received, the PDS is currently unable to provide: Case management A general diagnostic service. Secondary care teams are well placed to make the diagnosis of personality disorder and the diagnosis should be made before referral to the PDS, which should ordinarily be for one of the reasons below. Stand alone trauma work. In other words, although trauma work is available for patients in DBT, it cannot be provided outwith the DBT setting. 11.3 How to access these services Although the options available to treat personality disorder in NHS Highland have increased considerably over recent years, it remains the case that no single intervention represents a complete treatment for personality disorder.
Care and treatment of personality disorder in NHS Highland follows a matched care model and most patients with personality disorder will not require referral to the PDS. Reasons to consider referral to the PDS include: Complexity, including lack of response to treatments provided within other settings Severity, as indicated by, for example, potentially lethal parasuicidal behaviour or emergency psychiatric hospital admission Lack of treatment progress after adequate trial of appropriate treatment, including identified need for a structured intensive Phase 3 (integration or making connections) intervention Currently, the PDS only accepts referrals from secondary care mental health services. Discussion of potential referrals with the PDS is encouraged, see below for contact details. The standardised assessment supersedes the previous system used by the PDS where patients were referred for specific interventions such as DBT or CAS Day Service and a single PDS referral form (details of which can be found below) replaces the separate DBT and CAS forms. The referral form has a clinician-completed component and a patient-completed supporting statement. Referrals cannot be processed until both parts are received. It is recommended that patients are informed that they are being referred for assessment rather than for a specific treatment such as DBT, even if it seems likely that this will be offered. Contact details Personality Disorder Service Psychotherapy Department Greenfields House New Craigs Hospital Leachkin Road Inverness IV3 8NP Telephone: 01463 253681 Personality Disorder Service Referral Form
References Bateman, A., & Fonagy, P. (2009). Randomised controlled trial of out-patient mentalisation based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166, 1355 1364. McMain, S., et al. (2009). A randomised controlled trial of dialectical behaviour therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166, 1365 1374.