The epidemiology and clinical features of personality disorders in later life; a study of secondary care data.

OBJECTIVES: Personality disorders (PDs) are often conceptualised as impacting individuals throughout their life. However, there has been limited study of the disorders in those over the age of 65. We have used the psychiatric secondary care medical records of 21,971 individuals over the age of 65 from Cambridgeshire, UK, who received care between 2014 and 2021 to characterise older patients with a PD diagnosis. METHODS: The data from all patients >65 with a diagnosis of personality disorder (PD) was extracted (n = 217) along with two comparison groups (n = 2170); patients <65 with a diagnosis of PD and patients >65 with a psychiatric diagnosis other than PD or dementia. RESULTS: Compared to younger patients with PD, older patients were more likely to be male, married, suffering from a mixed PD and live in less deprived areas. Compared to patients >65 with diagnoses other than PD, older patients were more likely to be female, single or divorced and had a higher level of social deprivation. Our most striking finding was that older patients with PDs were more likely to experience polypharmacy. A mean of 18.48 different drugs had been prescribed over their lifetime, compared to 9.51 for patients >65 with other mental health diagnoses. CONCLUSION: Here we present the largest ever description of this group of patients and provide insights that could inform clinical practice and future research.

Simulating a Community Mental Health Service During the COVID-19 Pandemic: Effects of Clinician-Clinician Encounters, Clinician-Patient-Family Encounters, Symptom-Triggered Protective Behaviour, and Household Clustering.

Objectives: Face-to-face healthcare, including psychiatric provision, must continue despite reduced interpersonal contact during the COVID-19 (SARS-CoV-2 coronavirus) pandemic. Community-based services might use domiciliary visits, consultations in healthcare settings, or remote consultations. Services might also alter direct contact between clinicians. We examined the effects of appointment types and clinician-clinician encounters upon infection rates. Design: Computer simulation. Methods: We modelled a COVID-19-like disease in a hypothetical community healthcare team, their patients, and patients' household contacts (family). In one condition, clinicians met patients and briefly met family (e.g., home visit or collateral history). In another, patients attended alone (e.g., clinic visit), segregated from each other. In another, face-to-face contact was eliminated (e.g., videoconferencing). We also varied clinician-clinician contact; baseline and ongoing "external" infection rates; whether overt symptoms reduced transmission risk behaviourally (e.g., via personal protective equipment, PPE); and household clustering. Results: Service organisation had minimal effects on whole-population infection under our assumptions but materially affected clinician infection. Appointment type and inter-clinician contact had greater effects at low external infection rates and without a behavioural symptom response. Clustering magnified the effect of appointment type. We discuss infection control and other factors affecting appointment choice and team organisation. Conclusions: Distancing between clinicians can have significant effects on team infection. Loss of clinicians to infection likely has an adverse impact on care, not modelled here. Appointments must account for clinical necessity as well as infection control. Interventions to reduce transmission risk can synergize, arguing for maximal distancing and behavioural measures (e.g., PPE) consistent with safe care.

Embedding Recovery to Transform Inpatient Mental Health Care: The 333 Model.

OBJECTIVE: The 333 model is a radical redesign of acute mental health care. Time-limited inpatient pathways for assessment (≤3 days), treatment (≤3 weeks), and recovery (≤3 months) replaced traditional geographical-sector wards. By making beds available, 333 aspired to improve access, deliver early treatment, and shorten hospital stays-generating savings through reductions in beds and out-of-area placements (OAPs). This article compares the model's performance against national benchmarking and internal targets. METHODS: The complement of general adult beds (2011-2016) was mapped out. Patient flow data (April 2015-March 2017) were extracted from the National Health Service data warehouse and compared with 2016 NHS benchmarking and 333 targets. RESULTS: Between 2012 and 2016, beds were reduced by 44% compared with 17% nationally. OAPs due to bed unavailability became extremely rare. More than 74% (N=2,679) of patients who were admitted to the assessment unit between 2015 and 2017 were discharged back to the community, minimizing fragmentation of care. Median length of stay was one-sixth as long as the national rate, but readmission rates were higher than the national mean because of the model's innovative approach to managing treatment of patients with personality disorders. Bed occupancy was below the national average, with beds available every night for 2 years. CONCLUSIONS: With its recovery-focused approach, 333 has reduced length of stay and ensured that a stay on any ward is meaningful and adds value. The article demonstrates that bed and OAP reduction and the delivery of safe care can be achieved simultaneously.

Amygdala and dlPFC abnormalities, with aberrant connectivity and habituation in response to emotional stimuli in females with BPD.

BACKGROUND: Little is known about the frontolimbic abnormalities thought to underlie borderline personality disorder (BPD). We endeavoured to study regional responses, as well as their connectivity and habituation during emotion processing. METHODS: 14 BPD patients and 14 normal female controls (NC) controlled for menstrual phase underwent emotion-induction during an fMRI task using standardised images in a block design. We then performed psychophysiological interaction (PPI) analysis to investigate functional connectivity. RESULTS: BPD patients reported more disgust in questionnaires compared to controls. Relative to NC, they showed reduced left amygdala and increased dorsolateral prefrontal cortex (dlPFC) activation to all emotions collapsed versus neutral. Habituation of ventral striatal activity to repeated emotional stimuli was observed in controls but not in BPD. Finally, in the context of disgust (but not other emotions) versus neutral, BPD patients displayed enhanced left amygdala coupling with the dlPFC and ventral striatum. LIMITATIONS: Strict inclusion criteria reduced the sample size. CONCLUSIONS: In summary, BPD showed abnormal patterns of activation, habituation and connectivity in regions linked to emotion regulation. Amygdala deactivation may be mediated by abnormal top-down regulatory control from the dorsolateral prefrontal cortex. Aberrant emotion processing may play a unique role in the pathophysiology of BPD.

Hedonic and disgust taste perception in borderline personality disorder and depression.

Depression and borderline personality disorder (BPD) are both thought to be accompanied by alterations in the subjective experience of environmental rewards. We evaluated responses in women to sweet, bitter and neutral tastes (juice, quinine and water): 29 with depression, 17 with BPD and 27 healthy controls. The BPD group gave lower pleasantness and higher disgust ratings for quinine and juice compared with the control group; the depression group did not differ significantly from the control group. Juice disgust ratings were related to self-disgust in BPD, suggesting close links between abnormal sensory processing and self-identity in BPD.

Self-relevant disgust and self-harm urges in patients with borderline personality disorder and depression: a pilot study with a newly designed psychological challenge.

BACKGROUND: Borderline personality disorder (BPD) is a common psychiatric condition associated with self-harm. Self-harm is poorly understood and there is currently no treatment for acute presentations with self-harm urges. OBJECTIVES: By using a new task (Self-relevant Task; SRT), to explore emotions related to one's own person (PERSON task) and body (BODY task), to study the correlations of these emotions, specifically disgust, with self-harm urge level changes, and to test the task's potential to be developed into an experimental model of self-harming for treatment trials. METHODS: 17 BPD patients, 27 major depressive disorder (MDD) patients, and 25 healthy volunteers performed the SRT. Emotion labels were extracted from task narratives and disgust and self-harm urge level changes measured by visual analogue scales. We used validated rating scales to measure symptom severity. RESULTS: The SRT was effective at inducing negative emotions and self-harm urge changes. Self-harm urge changes correlated with borderline symptom severity. Post-task disgust levels on the visual analogue scales were higher in BPD patients than in healthy controls in the PERSON task, and higher than in both control groups in the BODY task. Changes in disgust levels during the task were significantly greater in the patient groups. Post-task disgust levels or changes in disgust were not associated with self-harm urge changes (except the latter in MDD in the PERSON task), but self-harm urge changes and disgust (but no other emotion) narrative labels were on a whole sample level. CONCLUSION: Although associations with the analogue scale measures were not significant, self-disgust reported in the narrative of patients may be associated with a higher probability of self-harm urges. Further research with larger sample sizes is needed to confirm this relationship and to examine whether reducing self-disgust could reduce self-harm urges. The SRT was effective and safe, and could be standardized for experimental studies.

A study of psychotic symptoms in borderline personality disorder.

Patients with borderline personality disorder (BPD) report psychotic symptoms, but it has been questioned whether they are intrinsic to BPD. Thirty patients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria for BPD were drawn from a specialist personality disorder service. Exclusion criteria included a preexisting clinical diagnosis of nonaffective psychotic disorder. Participants underwent structured psychiatric interview using the Present State Examination (PSE), lifetime version. Approximately 60% of the patients reported psychotic symptoms unrelated to drugs or affective disorder. Auditory hallucinations were the most common symptom (50%), which were persistent in the majority of cases. A fifth of the patients reported delusions, half of whom (three patients) also met DSM-IV criteria for schizophrenia, who were previously undiagnosed. The form of auditory hallucinations was similar to that in schizophrenia; the content was predominantly negative and critical. Persistent auditory hallucinations are intrinsic symptoms of BPD. This may inform current diagnostic criteria and have implications for approaches to treatment, both pharmacological and psychological. The presence of delusions may indicate a comorbid axis I disorder.

The organization and delivery of psychological treatments.

This article reviews the major issues which face health providers when they seek to organise the delivery of psychological treatments to best effect. A lack of consensus on efficacy, efficiency and acceptability makes policy decisions difficult. Streamlined focused services offering evidence based interventions for a limited target group are compared with broader enterprises offering comprehensive provision of a range of therapies. The dilemmas that the relative strengths and weaknesses of these two models pose are compared in relation to setting, cost efficiency, patient acceptability, equitable access and the pragmatics of staff training, service delivery and clinical governance. It is suggested that changes in the structure of health service provision more generally and the potential inherent in new technology and innovative ways of working may provide new solutions to some of these difficulties and the successive restructurings of a department of psychological treatments are adduced as an example.

Cognitive analytic therapy: comparing two measures of improvement.

A sample group of 49 patients began a course of cognitive analytic therapy and completed two questionnaires at the end of the first session. The 32 patients who completed the course completed the same two questionnaires at the penultimate session, and the 30 patients who attended a 3-month follow-up completed the questionnaires again then. The two questionnaires were the Person's Relating to Others Questionnaire (PROQ2) and the Clinical Outcomes in Routine Evaluation (CORE). There was a high positive correlation between the total scores of these two measures and between the CORE and two, three and four of the PROQ2 scales at the start of therapy, the end of therapy and at follow-up respectively. By the end of therapy there were significant drops in scores on three of the eight PROQ2 scales and on the total score, and on the CORE. By follow-up there were significant drops on four PROQ2 scales and the CORE, but only two of these were the same as at the end of therapy. There was no obvious explanation why some patients registered a greater drop on one questionnaire than on the other.