Department of Psychological Medicine, Imperial College, London, UK
Correspondence: Professor Peter Tyrer, Paterson Centre, 20 South Wharf Road, London W2 1PD, UK
Declaration of interest P.T. is the head of a group (IMPALOX) that receives funding from the Home Office to evaluate the new assessments for dangerous and severe personality disorder.
* Paper presented at the second conference of the British and Irish Group for
the Study of Personality Disorders (BIGSPD), University of Leicester, UK, 31
January to 3 February 2001.
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ABSTRACT |
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Aims To compare the outcomes of different treatment models.
Method The outcome of patients with this combined diagnosis was compared in a systematic review of three randomised controlled trials in which different forms of community outreach treatment or intensive case management were compared with standard care.
Results The results from the three studies showed that the outcome of comorbid diagnoses was worse than that of single diagnoses. Although assertive approaches reduced in-patient care, they sometimes did so at the expense of increasing social dysfunction and behavioural disturbance.
Conclusions For those with comorbid severe mental illness and personality disorder, the policy of assertive outreach and care in community settings may be inappropriate for both public and patients unless modified to take account of the special needs of this group.
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INTRODUCTION |
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There is now a general belief that most patients with severe mental illness can be treated largely in the community, with only brief periods of admission. However, for those with gross personality disorder who are treated at special hospitals a very much longer period of treatment is common. We felt that it might be valuable to examine the outcome of those with comorbid severe mental illness and personality disorder, to determine whether there were important differences between the effects of different service intervention policies.
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METHOD |
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In this current set of investigations, however, all effects were examined between those with and without personality disorder; and the influence of personality status on response to each service intervention (i.e. the interaction between personality and service type) was recorded. This was part of a Cochrane systematic review first established in 1997 (Tyrer et al, 1999). The only specific hypothesis tested was that those with comorbid personality disorder and severe mental illness would have a better response to focused community treatment, as they are generally considered to be ill-placed in hospital.
Patients, assessments and procedures
All patients in two of the studies had a psychotic illness with frequent
hospital admissions, and in the third
(Merson et al, 1992)
the patients were emergency presentations to the psychiatric services; 70% of
these had schizophrenia or affective disorders. Assessments of clinical
symptoms in all studies was with the Comprehensive Psychopathological Rating
Scale (CPRS) (Åsberg et al,
1978). Social function was recorded with the Social Functioning
Questionnaire (SFQ) (Tyrer,
1990) in two of the three studies reported here.
The procedures for randomisation and assessment intervals differed. In one study, randomisation took place at the point of presentation as an emergency (Merson et al, 1992), with assessments at baseline and after 2, 4 and 12 weeks. In the second study, randomisation took place at the time when in-patients were assessed as fit for discharge (Tyrer et al, 1998). In the UK700 study, randomisation took place at the point of discharge and a follow-up (Creed et al, 1999).
In all three studies personality was assessed using the Personality Assessment Schedule (PAS) (Tyrer & Alexander, 1979) although in the UK700 study a shorter version, the Rapid Personality Assessment Schedule (PASR) (Van Horn et al, 2000) was used. In all analyses a simple distinction was made between personality disorder and no personality disorder. The threshold for the diagnosis of personality disorder using the PAS is a little higher than that for ICD-10 personality disorders (Tyrer et al, 1994), which equates to the level of personality difficulty in a dimensional scale (Tyrer & Johnson, 1996).
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RESULTS |
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In the second study there was a major shortage of beds in the Brent area, and for much of the period of the study a significant proportion of admissions were extra-contractual referrals to different hospitals (Tyrer et al, 1998). This probably accounted for the greater length of admission of Brent patients; those with personality disorder, in particular, had very long periods of in-patient treatment in the year after recruitment to the study. The interaction between personality status and site of service was significant.
In a separate part of the study, the number of contacts with police were
recorded in the year of the study. Of 26 incidents involving 16 patients with
the police, most were found in those with personality disorder within the
flamboyant (cluster B) grouping. These were significantly more common in
patients allocated to community-oriented management
(Gandhi et al, 2001).
All but two of these incidents were in the Paddington component of the
project, significantly more than one would expect by chance
(2=4.7 (after Yates' correction), d.f. 1, P=0.03) and
this is unlikely to be explained by demographic differences alone. It seems
likely that the long period of in-patient treatment of those with the comorbid
diagnosis in the Brent area reduced problems in the community and could be
perceived as giving some protection to the public.
In the third study, there was an imbalance between the allocation of patients with personality disorder to intensive or standard case management, so that approximately only 1 in 4 of those with personality disorder were allocated to intensive case management. The small numbers made the interpretation of data difficult and there were no clear differences in any of the main outcome variables, with the exception of duration of in-patient care, the main outcome measure of the study. Those with comorbid personality disorder and psychosis had a shorter duration of in-patient treatment in the 2 years of the study (Fig. 1).
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DISCUSSION |
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The findings go some way in supporting the notion that personality disturbance is more important than mental illness state in determining disturbed and antisocial behaviour, and perhaps should be assessed more commonly in ordinary practice. Whereas violence in severe mental illness is the same for those treated by intensive and by standard case management (Walsh et al, 2001) the additional measurement of personality status adds an extra dimension. In the UK700 study, violent episodes were found to be more frequent in those with personality disorder (P. Moran, personal communication, 2002). What is abundantly clear is that treatment policies of those with comorbid personality disorder and severe mental illness should not be assumed to be the same as for those with severe mental illness alone, and that further work is needed on specific interventions for this group.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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