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Under-identification of personality disorder among in-patient mental health service users: implications for CBT therapists

Published online by Cambridge University Press:  01 April 2008

Fiona C. Kennedy  and
Sara Thomas
Fiona C. Kennedy*
Affiliation:
Isle of Wight Clinical Psychology Service, St Mary's Hospital, Newport, Isle of Wight, UK
Sara Thomas
Affiliation:
Southampton University Doctoral Programme in Clinical Psychology, School of Psychology, University of Southampton, UK
*
*Author for correspondence: Dr F. Kennedy, The Boulders, Quarr Road, Ryde, Isle of Wight PO33 4EL, UK. (email: drkennedy@email-therapy.co.uk)
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Abstract

The identification of personality disorder among mental health service users is problematic but important because it is associated with high levels of comorbidity and possibly ineffective service delivery. This study assessed the prevalence of personality disorder using the Millon Clinical Multiaxial Inventory – 3rd edition (MCMI-III) compared with prevalence using frequency of assignment of diagnosis in people referred to an in-patient CBT clinical psychology service. Prevalence rates differed from 85% (MCMI-III) to 16% (diagnosis) using these different measures. Reasons for this difference and implications for CBT therapists' practice are discussed.

Keywords

CBTdetectionin-patientpersonality disordertreatment
Type
Service models and forms of delivery
Information
the Cognitive Behaviour Therapist , Volume 1 , Issue 1 , April 2008 , pp. 55 - 66
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2008

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References

Recommended follow-up reading

Craig, RJ (2002). Essentials of MCMI-III assessment. In: Essentials of Millon Inventories Assessment, 3rd edn (ed.Strack, S.). San Francisco: Wiley.Google Scholar
Kennedy, F (2008). The use of formulation in inpatient settings. In: Cognitive Behaviour Therapy for Acute Psychiatric Inpatient Units; Working with Clients, Staff and the Milieu (ed.Clarke, I. and Wilson, H.), pp. 39–62. London: Routledge.Google Scholar
Linehan, MM (1993). Cognitive Behavioural Treatment of Borderline Personality Disorder. New York: Guilford.Google Scholar
NIMHE (2003). Personality Disorder: No Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the Development of Services for People with Personality Disorder. National Institute for Mental Health in England. Department of Health.Google Scholar
Young, JE (1990). Cognitive Therapy for Personality Disorders: A Schema-focused Approach. Sarasota, FL: Professional Resource Exchange.Google Scholar
APA (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association.Google Scholar
Arntz, A, Van Den Hoorn, M, Cornelis, J, Verheul, R, Van Den Bosch, WMC, de Bie, AJHT (2003). Reliability and validity of the borderline personality disorder severity index. Journal of Personality Disorders 17, 45–59.CrossRefGoogle ScholarPubMed
Bateman, A, Fonagy, P (1999). The effectiveness of partial hospitalisation in the treatment of borderline personality disorder – a randomised controlled trial. American Journal of Psychiatry 156, 1563–1569.CrossRefGoogle Scholar
Bender, DS, Dolan, RT, Skodol, AE, Sanislow, CA, Dyck, IR, McGlashan, TH, Shea, MT, Zanarini, MC, Oldham, JM, Gunderson, JG (2001). Treatment utilization by patients with personality disorders. American Journal of Psychiatry 159, 295–302.CrossRefGoogle Scholar
Braun, DL, Sunday, SR, Halmi, KA (1994). Psychiatric comorbidity in patients with eating disorders. Psychological Medicine 24, 859–869.CrossRefGoogle ScholarPubMed
Cheng, AT, Mann, AH, Chan, KA (1997). Personality disorder and suicide. British Journal of Psychiatry 170, 441–446.CrossRefGoogle ScholarPubMed
Corruble, E, Ginestet, D, Guelfi, JD (1996). Comobidity of personality disorders and unipolar major depression: a review. Journal of Affective Disorders 37, 157–170.CrossRefGoogle Scholar
Craig, RJ (2002). Essentials of Millon Inventories Assessment, 3rd edn (ed. Strack, S.) San Francisco: Wiley.Google Scholar
de Girolamo, G, Dotto, P (2000). Epidemiology of personality disorders. In: New Oxford Textbook of Psychiatry, vol. 1 (ed.Gelder, M. G., Lopez-Ibor, J. J. and Andreasen, N. C.), pp. 959–964. New York: Oxford University Press.Google Scholar
Giesen-Bloo, J, van Dyck, R, Spinhoven, P, van Tilburg, W, Dirksen, C, van Asselt, T, Kremers, I, Nadort, M, Arntz, A (2006). Outpatient therapy for borderline personality disorder: randomized trial of schema-focused therapy versus transference-focused psychotherapy. Archives of General Psychiatry 63, 649–658.CrossRefGoogle Scholar
Hayward, M, Slade, M, Moran, PA (2006). Personality disorders and unmet needs among psychiatric inpatients. Psychiatric Services 57, 538–543.CrossRefGoogle ScholarPubMed
Kennedy, F (2008). The use of formulation in inpatient settings. In: Cognitive Behaviour Therapy for Acute Psychiatric Inpatient Units; Working with Clients, Staff and the Milieu (ed.Clarke, I. and Wilson, H.), pp. 39–62. London: Routledge.Google Scholar
Kennedy, F, Thomas, S (2007). A DBT service on the Isle of Wight. Clinical Psychology Forum 171, 28–32.CrossRefGoogle Scholar
Lesage, AD, Boyer, R, Grunberg, F, Vanier, C, Morissette, R, Menard-Buteau, L, Loyer, M (1994). Suicide and mental disorders: a case control study of young men. American Journal of Psychiatry 151, 1063–1068.Google ScholarPubMed
Linehan, MM, Heard, HL, Armstrong, HE (1993). Naturalistic follow-up of a behavioural treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry 50, 971–974.CrossRefGoogle ScholarPubMed
McGowan, J (2008). Working with personality disorders in an acute psychiatric ward. In: Cognitive Behaviour Therapy for Acute Psychiatric Inpatient Units; Working with Clients, Staff and the Milieu (ed Clarke, I. and Wilson, H.), pp. 92–111. London: Routledge.Google Scholar
Millon, T (1997). Millon Clinical Multiaxial Inventory – III manual, 2nd edn. Minneapolis: National Computer Systems.Google Scholar
Narrow, WE, Regier, DA, Rae, DS, Manderscheid, RW, Locke, BZ (1993). Use of services by people with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry 50, 95–107.CrossRefGoogle ScholarPubMed
NICE (2008)a. Borderline personality disorder: treatment and management. NICE guideline. Consultation document, June 2008, National Institute for Clinical Exellence. (http://www.nice.org.uk/nicemedia/pdf/BorderlinePersonalityDisorderNICEGuidelineForConsultation.pdf). Accessed October 2008.Google Scholar
NICE (2008)b. Antisocial personality disorder: treatment, management and prevention. NICE guideline. Consultation document, August 2008, National Institute for Clinical Exellence. (http://www.nice.org.uk/nicemedia/pdf/ASPDNICEGuidelineConsultation.pdf). Accessed October 2008.Google Scholar
NIMHE (2003)a. Breaking the Cycle of Rejection: The Personality Disorder Capabilities Framework. National Institute for Mental Health in England. Department of Health.Google Scholar
NIMHE (2003)b. Personality Disorder: No Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the Development of Services for People with Personality Disorder. National Institute for Mental Health in England. Department of Health.Google Scholar
Paris, J (1993). The treatment of borderline personality disorder in light of the research on its long term outcome. Canadian Journal of Psychiatry 38 (Suppl. 1), 528–534.Google ScholarPubMed
Perry, JC, Lavori, PW, Hoke, L (1987). A Markov model for predicting levels of psychiatric service use in borderline and antisocial personality disorders and bipolar type II affective disorder. Journal of Psychiatric Research 21, 215–232.CrossRefGoogle ScholarPubMed
Reich, JH, Green, AI (1991). Effect of personality disorders on outcome of treatment. Journal of Nervous and Mental Diseases 179, 74–82.CrossRefGoogle ScholarPubMed
Robins, LN (1998). The intimate connection between antisocial personality disorder and substance abuse. Social Psychiatry and Psychiatric Epidemiology 33, 393–399.CrossRefGoogle ScholarPubMed
Ryle, A (1995). Cognitive analytic therapy: history and recent developments. In: Cognitive Analytic Therapy: Developments in Theory and Practice (ed.Ryle, A.), pp. 1–22. Chichester: Wiley.Google Scholar
Saarento, O, Hakko, H, Joukamaa, M (1998). Repeated use of psychiatric emergency out-patient services among new patients: a 3-year follow up study. Acta Psychiatrica Scandinavica 98, 276–282.CrossRefGoogle ScholarPubMed
Sanderson, WC, Wetzler, S, Beck, AT, Betz, F (1994). Prevalence of personality disorders among patients with anxiety disorders. Psychiatry Research 51, 167–174.CrossRefGoogle ScholarPubMed
Swenson, CR, Sanderson, C, Dulit, RA, Linehan, MM (2001). The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units. Psychiatric Quarterly 72, 307–324.CrossRefGoogle ScholarPubMed
Turkington, D, Dudley, R, Warman, DM, Beck, AT (2004). Cognitive-behavioral therapy for schizophrenia: a review. Journal of Psychiatric Practice 10, 5–16.CrossRefGoogle ScholarPubMed
Turkington, D, Kingdon, D, Chadwick, P (2003). Cognitive-behavioural therapy for schizophrenia: filling the therapeutic vacuum. British Journal of Psychiatry 183, 98–99.CrossRefGoogle ScholarPubMed
Tyrer, P, Seivewright, H (2000). Studies of outcome. In: Personality Disorders: Diagnosis, Management, and Course, 2nd edn (ed.Tyrer, P.), pp. 105–125. Oxford: Butterworth-Heinemann.Google Scholar
Tyrer, P, Thompson, S, Schmidt, U, Jones, V, Knapp, M, Davidson, K, Knapp, K, Davidson, J, Catalan, J, Airlie, S, Baxter, S, Byford, G, Byrne, S, Cameron, R, Caplan, S, Cooper, B, Ferguson, C, Freeman, S, Frost, J, Godley, J, Greenshields, J, Henderson, N, Holden, P, Keech, L, Kim, K, Logan, C, Manley, A, Macleod, R, Murphy, L, Patience, L, Ramsay, S, De Munroz, J, Scott, H, Seivewright, K, Sivakumar, P, Tata, S, Thornton, O, Ukoumunne, C, Wessely, S (2003). Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychological Medicine 33, 969–976.CrossRefGoogle ScholarPubMed
World Health Organisation (WHO) (1992). ICD-10: International Statistical Classification of Diseases and Related Health Problems. Washington, DC: American Psychiatric Publishing.Google Scholar
Young, JE (1990). Cognitive Therapy for Personality Disorders: A Schema-focused Approach. Sarasota, FL: Professional Resource Exchange.Google Scholar
Zubin, J, Spring, B (1977). Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology 86, 103–126.CrossRefGoogle ScholarPubMed
APA (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association.Google Scholar
Arntz, A, Van Den Hoorn, M, Cornelis, J, Verheul, R, Van Den Bosch, WMC, de Bie, AJHT (2003). Reliability and validity of the borderline personality disorder severity index. Journal of Personality Disorders 17, 45–59.CrossRefGoogle ScholarPubMed
Bateman, A, Fonagy, P (1999). The effectiveness of partial hospitalisation in the treatment of borderline personality disorder – a randomised controlled trial. American Journal of Psychiatry 156, 1563–1569.CrossRefGoogle Scholar
Bender, DS, Dolan, RT, Skodol, AE, Sanislow, CA, Dyck, IR, McGlashan, TH, Shea, MT, Zanarini, MC, Oldham, JM, Gunderson, JG (2001). Treatment utilization by patients with personality disorders. American Journal of Psychiatry 159, 295–302.CrossRefGoogle Scholar
Braun, DL, Sunday, SR, Halmi, KA (1994). Psychiatric comorbidity in patients with eating disorders. Psychological Medicine 24, 859–869.CrossRefGoogle ScholarPubMed
Cheng, AT, Mann, AH, Chan, KA (1997). Personality disorder and suicide. British Journal of Psychiatry 170, 441–446.CrossRefGoogle ScholarPubMed
Corruble, E, Ginestet, D, Guelfi, JD (1996). Comobidity of personality disorders and unipolar major depression: a review. Journal of Affective Disorders 37, 157–170.CrossRefGoogle Scholar
Craig, RJ (2002). Essentials of Millon Inventories Assessment, 3rd edn (ed. Strack, S.) San Francisco: Wiley.Google Scholar
de Girolamo, G, Dotto, P (2000). Epidemiology of personality disorders. In: New Oxford Textbook of Psychiatry, vol. 1 (ed.Gelder, M. G., Lopez-Ibor, J. J. and Andreasen, N. C.), pp. 959–964. New York: Oxford University Press.Google Scholar
Giesen-Bloo, J, van Dyck, R, Spinhoven, P, van Tilburg, W, Dirksen, C, van Asselt, T, Kremers, I, Nadort, M, Arntz, A (2006). Outpatient therapy for borderline personality disorder: randomized trial of schema-focused therapy versus transference-focused psychotherapy. Archives of General Psychiatry 63, 649–658.CrossRefGoogle Scholar
Hayward, M, Slade, M, Moran, PA (2006). Personality disorders and unmet needs among psychiatric inpatients. Psychiatric Services 57, 538–543.CrossRefGoogle ScholarPubMed
Kennedy, F (2008). The use of formulation in inpatient settings. In: Cognitive Behaviour Therapy for Acute Psychiatric Inpatient Units; Working with Clients, Staff and the Milieu (ed.Clarke, I. and Wilson, H.), pp. 39–62. London: Routledge.Google Scholar
Kennedy, F, Thomas, S (2007). A DBT service on the Isle of Wight. Clinical Psychology Forum 171, 28–32.CrossRefGoogle Scholar
Lesage, AD, Boyer, R, Grunberg, F, Vanier, C, Morissette, R, Menard-Buteau, L, Loyer, M (1994). Suicide and mental disorders: a case control study of young men. American Journal of Psychiatry 151, 1063–1068.Google ScholarPubMed
Linehan, MM, Heard, HL, Armstrong, HE (1993). Naturalistic follow-up of a behavioural treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry 50, 971–974.CrossRefGoogle ScholarPubMed
McGowan, J (2008). Working with personality disorders in an acute psychiatric ward. In: Cognitive Behaviour Therapy for Acute Psychiatric Inpatient Units; Working with Clients, Staff and the Milieu (ed Clarke, I. and Wilson, H.), pp. 92–111. London: Routledge.Google Scholar
Millon, T (1997). Millon Clinical Multiaxial Inventory – III manual, 2nd edn. Minneapolis: National Computer Systems.Google Scholar
Narrow, WE, Regier, DA, Rae, DS, Manderscheid, RW, Locke, BZ (1993). Use of services by people with mental and addictive disorders. Findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry 50, 95–107.CrossRefGoogle ScholarPubMed
NICE (2008)a. Borderline personality disorder: treatment and management. NICE guideline. Consultation document, June 2008, National Institute for Clinical Exellence. (http://www.nice.org.uk/nicemedia/pdf/BorderlinePersonalityDisorderNICEGuidelineForConsultation.pdf). Accessed October 2008.Google Scholar
NICE (2008)b. Antisocial personality disorder: treatment, management and prevention. NICE guideline. Consultation document, August 2008, National Institute for Clinical Exellence. (http://www.nice.org.uk/nicemedia/pdf/ASPDNICEGuidelineConsultation.pdf). Accessed October 2008.Google Scholar
NIMHE (2003)a. Breaking the Cycle of Rejection: The Personality Disorder Capabilities Framework. National Institute for Mental Health in England. Department of Health.Google Scholar
NIMHE (2003)b. Personality Disorder: No Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the Development of Services for People with Personality Disorder. National Institute for Mental Health in England. Department of Health.Google Scholar
Paris, J (1993). The treatment of borderline personality disorder in light of the research on its long term outcome. Canadian Journal of Psychiatry 38 (Suppl. 1), 528–534.Google ScholarPubMed
Perry, JC, Lavori, PW, Hoke, L (1987). A Markov model for predicting levels of psychiatric service use in borderline and antisocial personality disorders and bipolar type II affective disorder. Journal of Psychiatric Research 21, 215–232.CrossRefGoogle ScholarPubMed
Reich, JH, Green, AI (1991). Effect of personality disorders on outcome of treatment. Journal of Nervous and Mental Diseases 179, 74–82.CrossRefGoogle ScholarPubMed
Robins, LN (1998). The intimate connection between antisocial personality disorder and substance abuse. Social Psychiatry and Psychiatric Epidemiology 33, 393–399.CrossRefGoogle ScholarPubMed
Ryle, A (1995). Cognitive analytic therapy: history and recent developments. In: Cognitive Analytic Therapy: Developments in Theory and Practice (ed.Ryle, A.), pp. 1–22. Chichester: Wiley.Google Scholar
Saarento, O, Hakko, H, Joukamaa, M (1998). Repeated use of psychiatric emergency out-patient services among new patients: a 3-year follow up study. Acta Psychiatrica Scandinavica 98, 276–282.CrossRefGoogle ScholarPubMed
Sanderson, WC, Wetzler, S, Beck, AT, Betz, F (1994). Prevalence of personality disorders among patients with anxiety disorders. Psychiatry Research 51, 167–174.CrossRefGoogle ScholarPubMed
Swenson, CR, Sanderson, C, Dulit, RA, Linehan, MM (2001). The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units. Psychiatric Quarterly 72, 307–324.CrossRefGoogle ScholarPubMed
Turkington, D, Dudley, R, Warman, DM, Beck, AT (2004). Cognitive-behavioral therapy for schizophrenia: a review. Journal of Psychiatric Practice 10, 5–16.CrossRefGoogle ScholarPubMed
Turkington, D, Kingdon, D, Chadwick, P (2003). Cognitive-behavioural therapy for schizophrenia: filling the therapeutic vacuum. British Journal of Psychiatry 183, 98–99.CrossRefGoogle ScholarPubMed
Tyrer, P, Seivewright, H (2000). Studies of outcome. In: Personality Disorders: Diagnosis, Management, and Course, 2nd edn (ed.Tyrer, P.), pp. 105–125. Oxford: Butterworth-Heinemann.Google Scholar
Tyrer, P, Thompson, S, Schmidt, U, Jones, V, Knapp, M, Davidson, K, Knapp, K, Davidson, J, Catalan, J, Airlie, S, Baxter, S, Byford, G, Byrne, S, Cameron, R, Caplan, S, Cooper, B, Ferguson, C, Freeman, S, Frost, J, Godley, J, Greenshields, J, Henderson, N, Holden, P, Keech, L, Kim, K, Logan, C, Manley, A, Macleod, R, Murphy, L, Patience, L, Ramsay, S, De Munroz, J, Scott, H, Seivewright, K, Sivakumar, P, Tata, S, Thornton, O, Ukoumunne, C, Wessely, S (2003). Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychological Medicine 33, 969–976.CrossRefGoogle ScholarPubMed
World Health Organisation (WHO) (1992). ICD-10: International Statistical Classification of Diseases and Related Health Problems. Washington, DC: American Psychiatric Publishing.Google Scholar
Young, JE (1990). Cognitive Therapy for Personality Disorders: A Schema-focused Approach. Sarasota, FL: Professional Resource Exchange.Google Scholar
Zubin, J, Spring, B (1977). Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology 86, 103–126.CrossRefGoogle ScholarPubMed
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