PERSONALITY DISORDER A WELSH PERSPECTIVE

JENIFER CLARKE-MOOREJENIFER CLARKE-MOORENursing Officer

Dept of Public Health and Health Professions

Aims of Session• Provide an Overview of Government

Strategies and discuss high level changes in Wales

• Consider the implications of NICE Guidelines on Borderline Personality Disorder 2008

CURRENT SITUATION

• 22 >8 Local Health Boards

• 14 >7+1 NHS Trusts

• Urban v rural

• Partial devolution

Health Strategies/Policies (examples)

• One Wales – joint manifesto• Wales a Better Country • Designed for Life: Creating world class Health and

Social Care for Wales in the 21st Century • Informing Healthcare• Healthcare Standards for Wales: Making the

Connections, Designed for Life • 'Building Strong Bridges' - Strengthening partnership

working between the Voluntary Sector and the NHS in Wales

Health Strategies/Policies..• National Service Frameworks

– Diabetes– Older People– Coronary Heart Disease– Children, Young People and Maternity Services– Renal– Adult Mental Health Services

• Strategy for Older People in Wales• Healthy Ageing Action Plan

“Raising The Standard” A Revised NSF and Action Plan for Adult Mental Health

Services in Wales A response to

NHS Reorganisation Designed for Life Review of Health & Social Care (Wanless) Review of the mental health NSF Health Commission Wales Review Strategic Review of Secure Services (Homicide Inquiries) Projected Implications of the draft Mental Health Bill Recognition of the Workforce agenda

Health Inspectorate Wales (HIW)MAY 2004 - HIW published two homicide

independent external review reports.

• Diagnosis of personality disorder

• Lack of service provision

Findings• There was a lack of integrated and co-

ordinated services in each case.

• Inadequacies in the provision of services for those individuals with a personality disorder and criteria set for access to mental health services that exclude such individuals from receiving appropriate support and treatment

FINDINGS• The lack of a proactive approach to the provision

of care, treatment and support where individuals are difficult to engage with.

• An immaturity in the application of the Care Programme Approach and Unified Assessment Process, including inadequate attention to the assessment, identification and management of risk.

• Poor communication and systems for the sharing of information across agencies and between organisations.

• The Welsh Assembly Government should ensure that commissioners and providers of mental health services in Wales examine the current provisions for the care and treatment of those suffering from a personality disorder and that commissioners put in place relevant services where there are currently none provided

Borderline personality disorder (BPD)

Borderline Personality Disorder: treatment and management National Clinical Practice Guideline

National Collaborating Centre for Mental Health

Commissioned by the

National Institute for Health and Excellence

Specific aims of this guideline• evaluate the role of specific psychosocial interventions in

the treatment of borderline personality disorder• evaluate the role of specific pharmacological interventions

in the treatment of borderline personality disorder• integrate the above to provide best-practice advice on the

care of individuals with a diagnosis of borderline personality disorder

• promote the implementation of best clinical practice through the development of recommendations tailored to the requirements of the NHS in England and Wales.

The guideline will also be relevant to the work, but will not cover the practice, of those in:

• occupational health services

• social services

• forensic services

• the independent sector.

Clinical Practice Recommendations Experience of care

Access to services

People with borderline personality disorder should not be excluded from services because of their diagnosis, gender or because they have self-harmed.

Developing an optimistic and trusting relationship

• Explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible attainable

• Build up a trusting relationship, work in an open, engaging and non-judgmental manner, and be consistent and attainable

• Be aware of sensitive issues, including rejection, possible abuse and trauma, and the stigma often associated with self-harm and BPD

INVOLVING CARERS

When assessing a person with personality disorder, healthcare professionals should

• Encourage carers to be involved where the individual has agreed to this

• Ensure that the involvement of carers does not lead to withdrawal of, or lack of access to, services

Undertaking assessmentsWhen assessing professionals should:

• Explain the process of assessment clearly to enable the individual to have some control in the process

• Offer post-assessment support

• Use non-technical language

• Explain the diagnosis and the use and meaning of the term BPD

Managing endings and transitions• Ending or withdrawal of treatments services is

structured and phased over time• The care plan maintains effective collaboration

with other care providers during endings and transitions, and includes the opportunity to access services in times of crisis

Treatments• Psychological therapies, therapeutic

communities, arts therapies, and

complementary therapies in the

management of borderline

personality disorder

Clinical practice recommendationsRole of psychological treatment

• Healthcare professionals should offer choice of modalities (for example individual or group) – must be well-structured, coherent theory of practice, therapist supervision

• Women with BPD, reducing self harm a priority may consider DBT

• Brief psychotherapy interventions (less than 3 months) should not be used for BPD

Research Recommendations• Randomised trial of complex interventions (DBT

and MBT) versus high-quality community care delivered by general mental health services should be undertaken

• Exploratory randomised controlled trials of outpatient psychosocial interventions ( ie schema focused, CAT, therapeutic communities) for quality of life, psychosocial functioning etc.

Development of an agreed set of outcome measures for BPD

• A consensus building exercise should be conducted to determine the main clinical outcomes that should be assessed in future studies

• Recommendations for specific measure of these outcomes should be selected that are valid, reliable and have already been used in this patient group.

The role of drug treatment.• Drug treatment should not be used specifically for

BPD or for the individual symptoms or behaviour associated with the disorder

• Antipsychotic drugs should not be used for the medium and long term treatment of BPD

• A randomised placebo-controlled trial should be conducted to investigate the effectiveness of mood stabilisers.

Management of crisis• Healthcare professionals should consult the

crisis plan and use the recommended psychological approach

• Short term drug treatment

• Management of insomnia

Configuration and organisation of services

• Mental Health Trusts to ensure that professionals working in secondary services, including CAMHS, CMHT`s are trained to assess risk and need, and provide treatment and management in accordance with this guidline.

Training should be provided by specialist PD teams based within mental health trusts.

Development of MD Specialist teams/services• Provide assessment and treatment services for

people with BPD who have particularly complex needs and/or high levels of risk

• Provide consultation/advice to primary and secondary care services

• Offer a diagnostic service when general mh services are in doubt about the diagnosis and/or management of BPD

• Develop systems of communication and protocols for information sharing among different parts of MH services including Forensic, LD and CAMHS

• Advise on an appropriate range of social and psychological interventions, including access to peer support, safe use of drug treatment in a crises for co morbidities and insomnia

• Support, lead and participate in the local and national developments of potential treatments, including multi-centre research

• Oversee the implementation of this guideline• Develop training programmes on the diagnosis

and management of BPD and that address problems around stigma and discrimination

• Specialist PD services should involve people with PD and carers in planning service developments.

Thank-you

Jeni.clarke-moore@wales.gsi.gov.uk

GWYLFA THERAPY SERVICE

Services for people who have a diagnosis of a “personality disorder”

GWENT HEALTH CARE TRUST

Dynamic psychotherapy, DBT, Therapeutic Community Tx, Schema Focused Tx.

CT and CAT show some promise. Pharmacotherapy - target specific problem

areas - Soloff’s Medication Algorithm:- Cognitive/perceptual Affective Impulse dyscontrol

No magic bullet Drugs alone insufficient to treat PD

PERSONALITY DISORDER SERVICEWHAT WORKS?

Main features of effective treatment:- Well structured. Apply effort to enhance compliance. Clear therapeutic focus. Theoretically highly coherent to P and T. Relatively long term. Encourage powerful attachment relationships

(which are worked within). Well integrated with other services.

PERSONALITY DISORDER SERVICEWHAT WORKS?

– Consultation/ advice/ support/ supervision service to CMHT’s.

– Specialist assessment & reporting to teams.– Clinical service for a small number of BPD

severely distressed patients who cannot be managed at CMHT level.

– Involvement in assessment to & ongoing liaison/ monitoring of patients who are referred to Out of Area PD Services.

– Training and staff development

GWYLFA THERAPY SERVICE KEY FUNCTIONS

GWYLFA THERAPY SERVICE SERVICE MODEL

Community Mental Health Team/ In-patient services

Consultation Service

Clinical Service

Out of Area Services

GWYLFA THERAPY SERVICES

• Liaison with local services.

•Consultation service.

• Systemic interventions.

•Assessment.

• Formulation.

• Intensive therapeutic programme.

• Training.

• User group.

GWYLFA THERAPY SERVICES•Information resource.

•Out of Area Referrals:- • Assessment.• Recommendations re: which of area treatment. • Liaison/ monitoring.• Agree therapeutic focus, goals, length,

return asap.• Knowledge base about OAP’s

Diagnosis of PD or a suspected Personality Disorder, including dual diagnosis with other psychiatric illness e.g. PD + Bipolar Disorder.

Challenging or Tx interfering behaviour over protracted period.

Resistant to change over protracted period. CMHT have run out of ideas - are “stuck”.

GTS - REFERRAL CRITERIA TO CONSULTATION SERVICE

GTS - REFERRAL CRITERIA TO CLINICAL SERVICE

Diagnosis of Borderline Personality Disorder or significant features of Borderline Personality Disorder.

Repeated and risky Deliberate Self Harm. Suicide risk high. CMHT have exhausted local options. Gwylfa service have been involved in ongoing

consultation/ team support. Referral to Gwylfa Clinical Service agreed with PDS

Staff during Care Planning Meeting/ Case Discussion. Patients on enhanced CPA.

FEATURES INDICATING THAT A PATIENT IS BETTER MANAGED BY

ANOTHER CLINICAL SERVICE Actual ongoing risk to others that would be more

effectively managed by Forensic Services.

Learning Disability.

Aspergers Syndrome.

Acquired Brain Damage.

High levels of drugs and/or alcohol abuse that

prevents engagement in psychological treatment.

Acute stages of co-morbid psychiatric illness.

–Consultant Clinical Psychologist (1WTE)

–Consultant Nurse (1WTE)

–Consultant Psychotherapist/Psychiatrist (0.4 WTE)

–Principal Clinical Psychologist (1WTE)

–PhD Research Student (1 WTE)

–Administrator (0.5 WTE)

GWYLFA THERAPY SERVICE STAFF IN CORE TEAM

–Central to user population – Newport probably the best.

–Consulting rooms.

–Group rooms.

–Admin office.

GWYLFA THERAPY SERVICE PHYSICAL RESOURCES

GWYLFA THERAPY SERVICE THERAPEUTIC TARGETS

• Severe behavioural problems (DSH) behavioural control (no DSH).

• Cut off “Quiet desperation” reviving emotional experience. Working through trauma & addressing dissociation.

GWYLFA THERAPY SERVICES SKILLS BASE

• Dialectical Behaviour Therapy.

• Psychoanalytic Psychotherapy.

• CBT.

• CAT.

• Individual and group work.

• Staff supervision and consultation.

PROBLEMS/ ISSUES NEEDING SERVICE DEVELOPMENT

•Treatment intensity – limits the clinical service. Day patient therapeutic community would increase impact.

•Lack of supported housing prevents GTS providing local service. Joint schemes needed.

•No clinical service to men – where are they?

•Mental Health Act – likely to increase demand.

Referrals

2005 2006 2007/ 8 Number of Referrals 55 42 38

Consultation Only 12 14 13 Assessed 36 35 25 Ref’d on/

inappropriate 5 3 13

• Active cases as at:- Dec 05 Dec 06 Mar 08 • New/ Being assessd 13 13 14 • Consultation 11 11 11 Clinical service 7 15 21

• Out of area cases Out of area cases Dec 05:- Number = 4 2 likely to return within next 6 months.

Out of area cases Dec 06:- Number = 5 1 likely to return within next 2 months.

Out of area cases Mar 07 = 4 One in medium secure MJ who it has been confirmed has a psychosis (not PD) as we asserted 18 mths previously.

• Out of Area cases returned.

FO 22/8/06 SH 12/12/06 LE 7/3/07

CH 5/12/07 MW 22/2/08 MJ transferred to Medium Secure (

• Closed Cases Total:- 25 32 28 • Treatment • Consultation 18 23 13 • Ref’d to Forensic 2 0 1 • To Prison 1 • Dropped out 4 1 • Inappropriate 5 5 13

Patients in clinical service Mar 08 Therapy Started From Financial Yr

Prevented? Returned from OCT

Patient Name 05-06 06-07 07-08

VA 1 S, E, OCT

MB 1 S, E, OCT

LH 1 S, E, OCT

VAB 1 S, E, OCT AG 1 S, E, OCT

SH

1

Dec 06 4/12 adm’n prevented long

adm’n

KJ

1

Earlier Discharge from Pillmawr & maintained in Community

AMcG 1 S, E, OCT

SM

1 S, E. OCT Topped up previous

DBT OCT.

FO

1 Facilitated dis from

OCT SS 1 S, E, OCT

MW

1 Provided Tx, whilst

in supported living. LE 1 S, E, OCT

JD 1 S, E, OCT

CH

1

S, E, OCT Continuing Tx started Out of County.

ZJ 1 S, E, OCT

JL 1 S, E, OCT

DM 1 S, E, OCT DM2 1 S, E

RM 1 S, E, OCT

CR 1 S, E, OCT

Totals Grand Total = 20 S= Suicide, E= Serious escalation of emotional dysregulation & high risk self harm, OCT = Out of County (Residential) Treatment.

Types of intervention received by patients in clinical service - 31st March 2008

Count of Patient Name

Current Therapy Type

Current Type CAT CBT DBT DBT GRP Mentzn Other

Totals

Clinical 2 2 4 8 3 2

Grand Total 2 2 4 9 3 2 22

Patients who have been discharged from the Gwylfa Therapy Clinical

Service.

Fin Yr Refs

Closed Reasons 07-08 Grand Total

Ass/Advice/Cons Complete 13 13

Inappropriate 13 13

Sent to Prison 1 1

Grand Total 27 27

COST SAVINGS

Name Start Date Fin Year

Days saved in Fin Yr

Months Saved

Cost Saving 1st Fin Yr

Cost Saving 2nd Fin Yr

KH 01/06/2006 06-07 303 9.93 132455.70 27540.30

FO 01/08/2006 06-07 242 7.93 105789.70 54206.30

CR 01/09/2006 06-07 211 6.92 92238.13 67757.87

SH 01/12/2006 06-07 120 3.93 52457.70 107538.30

VB 01/07/2006 06-07 273 8.95 119341.28 40654.72

AG * 01/10/2006 06-07 181 5.93 79123.70 80872.30

MW 01/04/2006 06-07 364 11.93 159121.70 874.30

SM 01/12/2006 06-07 120 3.93 52457.70 107538.30

AS 01/03/2007 06-07 30 0.98 13114.43 146881.57 Cost Saving 06-07

(Plus costs saved from patients in the service carried over from 05-06)

AD 01/02/2007 06-07 58 1.90 25354.56 134641.44 831454.62

JD 01/05/2007 07-08 335 10.98 146444.43 13551.57 Minus Gwylfa Service costs = 250,000

CD P 01/07/2007 07-08 274 8.98 119778.43 40217.57

ACTUAL EST. SAVING 06-07 = 581454.62

ZJ 01/09/2007 07-08 212 6.95 92675.28 67320.72

LE 01/06/2007 07-08 304 9.97 132892.85 27103.15 Cost Saving 07-08

CH 04/12/2007 07-08 118 3.87 51583.41 108412.59 1324994.20

JL 01/03/2008 07-08 30 0.98 13114.43 146881.57 Minus Gwylfa Service cost 250,000

ACTUAL EST. SAVING 07-08 = 1074994.20

GWYLFA THERAPY SERVICE.

Services for people who have personality disorder.

Copies of slides from GTS Administrator:-

Helen.Speirs@Gwent.wales.nhs.uk

GWENT HEALTH CARE TRUST