The effect of environmental change, planned and unplanned life events on the long-term outcome of common mental disorders.

PURPOSE: To examine the nature of positive and negative environmental change on clinical outcome in 210 patients presenting with anxiety and depression and followed up over 30 years. METHODS: In addition to clinical assessments, major environmental changes, particularly after 12 and 30 years, were recorded in all patients by a combination of self-report and taped interviews. Environmental changes were separated into two major groups, positive or negative, determined by patient opinion. RESULTS: In all analyses positive changes were found to be associated with better outcome at 12 years with respect to accommodation (P = 0.009), relationships (P = 007), and substance misuse (P = 0.003), with fewer psychiatric admissions (P = 0.011) and fewer social work contacts at 30 years (P = 0.043). Using a consolidated outcome measure positive changes were more likely than negative ones to be associated with a good outcome at 12 and 30 years (39% v 3.6% and 30.2% v 9.1%, respectively). Those with personality disorder at baseline had fewer positive changes (P = 0.018) than others at 12 years and fewer positive occupational changes at 30 years (P = 0.041). Service use was greatly reduced in those with positive events with 50-80% more time free of all psychotropic drug treatment (P < 0.001). Instrumental positive change had greater effects than imposed changes. CONCLUSIONS: Positive environmental change has a favourable impact on clinical outcome in common mental disorders. Although studied naturalistically in this study the findings suggest that if harnessed as a therapeutic intervention, as in nidotherapy and social prescribing, it would yield therapeutic dividends.

Matching ICD-11 personality status to clinical management in a community team-The Boston (UK) Personality Project: Study protocol.

Epidemiological studies show 30% to 50% of all patients in community mental health teams have personality disorders. These are normally comorbid with other psychiatric disorders, often as Galenic syndromes, and are seldom identified. In the Boston (UK) Personality Project all patients under a community health service in Boston in Lincolnshire will be asked to agree to have their personality status assessed using scales recording the new ICD-11 classification, together with clinical ratings, social function and satisfaction. A control group of 100 patients from an adjacent service of similar demographics (Spalding) will also have similar ratings but no personality assessments. Changes in clinical status, social function and service satisfaction will be made after 6 and 12 months in both groups. The patients in the Boston group will be offered matched interventions using a stepped care approach for both the severity of disorder and its domain structure. These interventions will include shorter versions of existing psychological treatments, environmental therapies including nidotherapy, adaptive and acceptance models, drug reduction and social prescribing. Full costs of psychiatric care will be measured in both groups. The main hypothesis is that greater awareness of personality function will lead to better clinical outcomes and satisfaction.

Galenic syndromes: combinations of mental state and personality disorders too closely entwined to be separated.

Many mental disorders are linked to personality, but this is rarely recognised in clinical practice. It is suggested here that when the links are very close, the two can be joined. Galenic syndromes are so named because Galen was the first physician to recognise the links between personality and disease.

Specialist teams as constituted are unsatisfactory for treating people with personality disorders.

It is now becoming standard practice in most advanced economies to provide specialist services for those with personality disorder. Such services, almost exclusively, provide complex well-structured psychological interventions lasting many months for a small number of those with borderline personality disorder pathology. The evidence suggests that these treatments are effective but they can only be provided for a small number of people. However, in every area the numbers of patients with significant personality disorder far exceeds those that are treated, and most of these have other personality disorders. It is argued that the current service system is not working efficiently and should be replaced by one that provides resources and expertise within community teams with some external advice from specialists but no transfer of responsibility to a designated team.

A comparison of long-term medium secure patients within NHS and private and charitable sector units in England.

BACKGROUND: In England, forensic psychiatric hospital services are provided at three security levels: high, medium and low. All are publicly funded and similarly regulated, but medium and low secure services are provided in the private and charitable (PCS) sector as well as the National Health Service (NHS). Originally, medium secure hospital services were conceived as for up to 2 years' inpatient stay, but numbers of longer stay patients have been rising. Little is known about their characteristics or whether they differ between NHS and PCS settings. AIMS: To describe and compare characteristics of long-stay patients in NHS and in PCS medium security hospital units. METHODS: Data were extracted from clinical records in 14 NHS and 9 PCS hospital units for all patients fulfilling criteria for long stay: having been in high security for more than 10 years or medium security for more than 5 years or in a mix of both for more than 15 years in total. RESULTS: 178 NHS and 107 PCS patients were eligible for inclusion, respectively, 16 and 22% of the total patient populations in these settings. The mean length of stay in a medium or high secure setting was similar: 163 and 164 months. Characteristics of the patients, however, differed between unit type. NHS services admitted more patients from prison and PCS services more from other hospitals. NHS services included a lower proportion of patients with personality disorder or intellectual disability. 'Challenging behaviour' was more prevalent in PCS; a history of absconding was found more often among NHS patients. CONCLUSIONS: The two systems of service appear to be used differently. More research is needed to explain why patients apparently without behavioural disturbances remain in specialist secure facilities for such a long time and whether their needs are truly being met in the least restrictive environment possible.

Looking from the outside: No substitute for rigorous evaluation.

Looking in from the outside, what would the ordinary person expect of forensic mental health services? I suggest that there are three questions he or she would ask: (a) Are there public health measures that can be introduced to prevent those with mental disorder going on to commit crimes? (b) Can we identify in advance the individual who is likely to go on and commit a violent act because of his or her mental health difficulties, and prevent that or limit damage? (c) If a seriously harmful act has already been committed, what interventions might prevent a repetition? All of these questions are about prevention of an untoward event in the future and anticipate knowledge. How secure can we be that current forensic mental health practitioners can make adequately evidenced responses? I fear that examination of current literature would indicate that they and their academic colleagues would fall short of these expectations. Reasons for this are undoubtedly numerous. The issues are complex, with the interplay of many variables from the vagaries of human nature through varying presentations of disorders, still often classified rather than diagnosed, to widely differing environments which, further, may suddenly change in a critical way. The impact of a serious offence can be so catastrophic that officialdom often decides that "something must be done." Yet, without a good evidence base, such decision-making is often ineffective and wasteful of resources. The limited evidence base has not been helped by the virtual extinction of an academic forensic psychiatry infrastructure and funding within British universities and the National Health Service. This does not bode well for the future.

Executive function, attention, and memory deficits in antisocial personality disorder and psychopathy.

Antisocial personality disorder (ASPD) and psychopathy attempt to represent individuals demonstrating callousness and disregard for others. ASPD has been criticized for capturing a heterogeneous population whilst missing the essence of the diagnosis by neglecting interpersonal/affective deficits which measures of psychopathy include. This heterogeneity in operationalizations has led to diverse findings without clear understanding of what characterizes this broader population. This study sought to clarify the neuropsychological profiles of ASPD and psychopathy. The Cambridge Neuropsychological Test Assessment Battery was administered to 85 adult male offenders in a personality disorder secure service and to 20 healthy controls. Of patients with ASPD, 46% met criteria for psychopathy. Of those with psychopathy, 89% met criteria for ASPD. There were two sets of comparisons: ASPD versus other personality disorders versus controls and psychopathy versus other personality disorders versus controls. ASPD showed deficits across executive functions, visual short-term and working memory, and attention (compared with controls). Psychopathy showed deficits limited to attention, complex planning, inhibitory control, and response reversal. Response reversal and visual search deficits appeared specific to ASPD and psychopathy versus other personality disorders and may underpin antisocial traits. Additional deficits in inhibitory control and working memory appeared to distinguish ASPD from other personality disorders.

Characteristics and Pathways of Long-Stay Patients in High and Medium Secure Settings in England; A Secondary Publication From a Large Mixed-Methods Study.

Background: Many patients experience extended stays within forensic care, but the characteristics of long-stay patients are poorly understood. Aims: To describe the characteristics of long-stay patients in high and medium secure settings in England. Method: Detailed file reviews provided clinical, offending and risk data for a large representative sample of 401 forensic patients from 2 of the 3 high secure settings and from 23 of the 57 medium secure settings in England on 1 April 2013. The threshold for long-stay status was defined as 5 years in medium secure care or 10 years in high secure care, or 15 years in a combination of high and medium secure settings. Results: 22% of patients in high security and 18% in medium security met the definition for "long-stay," with 20% staying longer than 20 years. Of the long-stay sample, 58% were violent offenders (22% both sexual and violent), 27% had been convicted for violent or sexual offences whilst in an institutional setting, and 26% had committed a serious assault on staff in the last 5 years. The most prevalent diagnosis was schizophrenia (60%) followed by personality disorder (47%, predominantly antisocial and borderline types); 16% were categorised as having an intellectual disability. Overall, 7% of the long-stay sample had never been convicted of any offence, and 16.5% had no index offence prompting admission. Although some significant differences were found between the high and medium secure samples, there were more similarities than contrasts between these two levels of security. The treatment pathways of these long-stay patients involved multiple moves between settings. An unsuccessful referral to a setting of lower security was recorded over the last 5 years for 33% of the sample. Conclusions: Long-stay patients accounted for one fifth of the forensic inpatient population in England in this representative sample. A significant proportion of this group remain unsettled. High levels of personality pathology and the risk of assaults on staff and others within the care setting are likely to impact on treatment and management. Further research into the treatment pathways of longer stay patients is warranted to understand the complex trajectories of this group.

Psychoeducation and Problem Solving (PEPS) Therapy for Adults With Personality Disorder: A Pragmatic Randomized-Controlled Trial.

We compared psychoeducation and problem solving (PEPS) therapy against usual treatment in a multisite randomized-controlled trial. The primary outcome was social functioning. We aimed to recruit 444 community-dwelling adults with personality disorder; however, safety concerns led to an early cessation of recruitment. A total of 154 people were randomized to PEPS and 152 to usual treatment. Follow-up at 72 weeks was completed for 68%. PEPS therapy was no more effective than usual treatment for improving social functioning (adjusted difference in mean Social Functioning Questionnaire scores = -0.73; 95% CI [-1.83, 0.38]; p = 0.19). PEPS therapy is not an effective treatment for improving social functioning of adults with personality disorder living in the community.

A systematic review and synthesis of outcome domains for use within forensic services for people with intellectual disabilities.

BACKGROUND: There is limited empirical information on service-level outcome domains and indicators for the large number of people with intellectual disabilities being treated in forensic psychiatric hospitals. AIMS: This study identified and developed the domains that should be used to measure treatment outcomes for this population. METHOD: A systematic review of the literature highlighted 60 studies which met eligibility criteria; they were synthesised using content analysis. The findings were refined within a consultation and consensus exercises with carers, patients and experts. RESULTS: The final framework encompassed three a priori superordinate domains: (a) effectiveness, (b) patient safety and (c) patient and carer experience. Within each of these, further sub-domains emerged from our systematic review and consultation exercises. These included severity of clinical symptoms, offending behaviours, reactive and restrictive interventions, quality of life and patient satisfaction. CONCLUSIONS: To index recovery, services need to measure treatment outcomes using this framework. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Managing uncertainty in the clinical prediction of risk of harm: Bringing a Bayesian approach to forensic mental health.

Predicting the likelihood of harm posed by mentally disordered offenders remains controversial. It is proposed that a Bayesian approach may help quantify the uncertainty surrounding such prediction. An example of this approach quantifying the risk of breast cancer in the event of a positive mammogram is provided. Copyright © 2017 John Wiley & Sons, Ltd.

Psychoeducation with problem-solving (PEPS) therapy for adults with personality disorder: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manualised intervention to improve social functioning.

BACKGROUND: If effective, less intensive treatments for people with personality disorder have the potential to serve more people. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of psychoeducation with problem-solving (PEPS) therapy plus usual treatment against usual treatment alone in improving social problem-solving with adults with personality disorder. DESIGN: Multisite two-arm, parallel-group, pragmatic randomised controlled superiority trial. SETTING: Community mental health services in three NHS trusts in England and Wales. PARTICIPANTS: Community-dwelling adults with any personality disorder recruited from community mental health services. INTERVENTIONS: Up to four individual sessions of psychoeducation, a collaborative dialogue about personality disorder, followed by 12 group sessions of problem-solving therapy to help participants learn a process for solving interpersonal problems. MAIN OUTCOME MEASURES: The primary outcome was measured by the Social Functioning Questionnaire (SFQ). Secondary outcomes were service use (general practitioner records), mood (measured via the Hospital Anxiety and Depression Scale) and client-specified three main problems rated by severity. We studied the mechanism of change using the Social Problem-Solving Inventory. Costs were identified using the Client Service Receipt Inventory and quality of life was identified by the European Quality of Life-5 Dimensions questionnaire. Research assistants blinded to treatment allocation collected follow-up information. RESULTS: There were 739 people referred for the trial and 444 were eligible. More adverse events in the PEPS arm led to a halt to recruitment after 306 people were randomised (90% of planned sample size); 154 participants received PEPS and 152 received usual treatment. The mean age was 38 years and 67% were women. Follow-up at 72 weeks after randomisation was completed for 62% of participants in the usual-treatment arm and 73% in the PEPS arm. Intention-to-treat analyses compared individuals as randomised, regardless of treatment received or availability of 72-week follow-up SFQ data. Median attendance at psychoeducation sessions was approximately 90% and for problem-solving sessions was approximately 50%. PEPS therapy plus usual treatment was no more effective than usual treatment alone for the primary outcome [adjusted difference in means for SFQ -0.73 points, 95% confidence interval (CI) -1.83 to 0.38 points; p = 0.19], any of the secondary outcomes or social problem-solving. Over the follow-up, PEPS costs were, on average, £182 less than for usual treatment. It also resulted in 0.0148 more quality-adjusted life-years. Neither difference was statistically significant. At the National Institute for Health and Care Excellence thresholds, the intervention had a 64% likelihood of being the more cost-effective option. More adverse events, mainly incidents of self-harm, occurred in the PEPS arm, but the difference was not significant (adjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.64). LIMITATIONS: There was possible bias in adverse event recording because of dependence on self-disclosure or reporting by the clinical team. Non-completion of problem-solving sessions and non-standardisation of usual treatment were limitations. CONCLUSIONS: We found no evidence to support the use of PEPS therapy alongside standard care for improving social functioning of adults with personality disorder living in the community. FUTURE WORK: We aim to investigate adverse events by accessing centrally held NHS data on deaths and hospitalisation for all PEPS trial participants. TRIAL REGISTRATION: Current Controlled Trials ISRCTN70660936. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 52. See the NIHR Journals Library website for further project information.

Iatrogenic harm from psychological therapies--time to move on.

The problem of adverse effects of psychotherapy has been recognised for decades, yet research on causes and prevention of harm has failed to progress. There is confusion between different definitions and a lack of systematic recording and reporting. A new framework for moving this field forward is proposed.

Pharmacological interventions for those who have sexually offended or are at risk of offending.

BACKGROUND: Sexual offending is a serious social problem, a public health issue, and a major challenge for social policy. Victim surveys indicate high incidence and prevalence levels and it is accepted that there is a high proportion of hidden sexual victimisation. Surveys report high levels of psychiatric morbidity in survivors of sexual offences.Biological treatments of sex offenders include antilibidinal medication, comprising hormonal drugs that have a testosterone-suppressing effect, and non-hormonal drugs that affect libido through other mechanisms. The three main classes of testosterone-suppressing drugs in current use are progestogens, antiandrogens, and gonadotropin-releasing hormone (GnRH) analogues. Medications that affect libido through other means include antipsychotics and serotonergic antidepressants (SSRIs). OBJECTIVES: To evaluate the effects of pharmacological interventions on target sexual behaviour for people who have been convicted or are at risk of sexual offending. SEARCH METHODS: We searched CENTRAL (2014, Issue 7), Ovid MEDLINE, EMBASE, and 15 other databases in July 2014. We also searched two trials registers and requested details of unidentified, unpublished, or ongoing studies from investigators and other experts. SELECTION CRITERIA: Prospective controlled trials of antilibidinal medications taken by individuals for the purpose of preventing sexual offences, where the comparator group received a placebo, no treatment, or 'standard care', including psychological treatment. DATA COLLECTION AND ANALYSIS: Pairs of authors, working independently, selected studies, extracted data, and assessed the risk of bias of included studies. We contacted study authors for additional information, including details of methods and outcome data. MAIN RESULTS: We included seven studies with a total of 138 participants, with data available for 123. Sample sizes ranged from 9 to 37. Judgements for categories of risk of bias varied: concerns were greatest regarding allocation concealment, blinding of outcome assessors, and incomplete outcome data (dropout rates in the five community-based studies ranged from 3% to 54% and results were usually analysed on a per protocol basis).Participant characteristics in the seven studies were heterogeneous, but the vast majority had convictions for sexual offences, ranging from exhibitionism to rape and child molestation.Six studies examined the effectiveness of three testosterone-suppressing drugs: cyproterone acetate (CPA), ethinyl oestradiol (EO), and medroxyprogesterone acetate (MPA); a seventh evaluated two antipsychotics (benperidol and chlorpromazine). Five studies were placebo-controlled; in two, MPA was administered as an adjunctive treatment to a psychological therapy (assertiveness training or imaginal desensitisation). Meta-analysis was not possible due to heterogeneity of interventions, comparators, study designs, and other issues. The quality of the evidence overall was poor. In addition to methodological issues, much evidence was indirect. PRIMARY OUTCOME: recividism. Two studies reported recidivism rates formally. One trial of intramuscular MPA plus imaginal desensitisation (ID) found no reports of recividism at two-year follow-up for the intervention group (n = 10 versus one relapse within the group treated by ID alone). A three-armed trial of oral MPA, alone or in combination with psychological treatment, reported a 20% rate of recidivism amongst those in the combined treatment arm (n = 15) and 50% of those in the psychological treatment only group (n = 12). Notably, all those in the 'oral MPA only' arm of this study (n = 5) dropped out immediately, despite treatment being court mandated.Two studies did not report recidivism rates as they both took place in one secure psychiatric facility from which no participant was discharged during the study, whilst another three studies did not appear directly to measure recividism but rather abnormal sexual activity alone. SECONDARY OUTCOMES: The included studies report a variety of secondary outcomes. Results suggest that the frequency of self reported deviant sexual fantasies may be reduced by testosterone-suppressing drugs, but not the deviancy itself (three studies). Where measured, hormonal levels, particularly levels of testosterone, tended to correlate with measures of sexual activity and with anxiety (two studies). One study measured anxiety formally; one study measured anger or aggression. Adverse events: Six studies provided information on adverse events. No study tested the effects of testosterone-suppressing drugs beyond six to eight months and the cross-over design of some studies may obscure matters (given the 'rebound effect' of some hormonal treatments). Considerable weight gain was reported in two trials of oral MPA and CPA. Side effects of intramuscular MPA led to discontinuation in some participants after three to five injections (the nature of these side effects was not described). Notable increases in depression and excess salivation were reported in one trial of oral MPA. The most severe side effects (extra-pyramidal movement disorders and drowsiness) were reported in a trial of antipsychotic medication for the 12 participants in the study. No deaths or suicide attempts were reported in any study. The latter is important given the association between antilibidinal hormonal medication and mood changes. AUTHORS' CONCLUSIONS: We found only seven small trials (all published more than 20 years ago) that examined the effects of a limited number of drugs. Investigators reported issues around acceptance and adherence to treatment. We found no studies of the newer drugs currently in use, particularly SSRIs or GnRH analogues. Although there were some encouraging findings in this review, their limitations do not allow firm conclusions to be drawn regarding pharmacological intervention as an effective intervention for reducing sexual offending.The tolerability, even of the testosterone-suppressing drugs, was uncertain given that all studies were small (and therefore underpowered to assess adverse effects) and of limited duration, which is not consistent with current routine clinical practice. Further research is required before it is demonstrated that their administration reduces sexual recidivism and that tolerability is maintained.It is a concern that, despite treatment being mandated in many jurisdictions, evidence for the effectiveness of pharmacological interventions is so sparse and that no RCTs appear to have been published in two decades. New studies are therefore needed and should include trials with larger sample sizes, of longer duration, evaluating newer medications, and with results stratified according to category of sexual offenders. It is important that data are collected on the characteristics of those who refuse and those who drop out, as well as those who complete treatment.

Development and validation of a treatment progress scale for personality disordered offenders.

BACKGROUND: There is a need for a measure to evaluate change in treatment for offenders with a personality disorder, and the Progress Rating Scale (PRS) was developed to meet this need taking account of multiprofessional input. METHOD: The PRS comprises six process and five non-process items developed via thematic analysis of routine CPA patient treatment reports at a forensic Personality Disorder Service. Rating for items was fully standardized and operationalized with revisions aiming to maximize inter-rater agreement reflecting good face and content validity. Psychometric properties were examined using PRS ratings for 147 patients at three different time points in conjunction with relevant psychometrics. RESULTS: Following refinement, the instrument demonstrated good content validity. Intra-class correlations suggested moderate to substantial inter-rater agreement (intraclass correlations: 0.63-0.92). Item analyses indicated good internal consistency for process items (Cronbach's alpha: 0.82-0.88). Correlations with relevant psychometrics revealed meaningful relationships between PRS scores, defence styles and social problem solving. PRS score trajectories were in line with previously known treatment outcomes supporting predictive validity. CONCLUSION: The PRS shows promise as process measure in clinical settings but requires further testing on other samples to confirm initial findings and demonstrate its utility.

The recording of adverse events from psychological treatments in clinical trials: evidence from a review of NIHR-funded trials.

BACKGROUND: There is a concern in the literature that harm from interventions is insufficiently documented in clinical trials in general, and in those assessing psychological treatments in particular. A recent decision by a trial steering committee to stop recruitment into a randomized controlled trial (RCT) of a psychological intervention for personality disorder led to an investigation of the recording of harm in trials funded by the National Institute for Health Research (NIHR). METHODS: The protocols and final reports of all 82 NIHR trials funded between 1995 and 2013 were examined for the reporting of adverse events. These were subdivided by category of intervention. RESULTS: None of the psychological intervention trials mentioned the occurrence of an adverse event in their final report. Trials of drug treatments were more likely to mention adverse events in their protocols compared with those using psychological treatments. When adverse events were mentioned, the protocols of psychological interventions relied heavily on severe adverse events guidelines from the National Research Ethics Service (NRES), which were developed for drug rather than psychological interventions and so may not be appropriate for the latter. CONCLUSIONS: This survey supported the belief that the reporting of adverse events in psychological treatments is weak and the criteria used may not be appropriate. Recommendations are made as to how current practice might be improved.

Defence styles in a sample of forensic patients with personality disorder.

BACKGROUND: Ego defences, often considered central to clinical work, have received surprisingly little attention in the forensic literature. METHOD: In this exploratory study, 114 male inpatients completed the Defence Style Questionnaire (DSQ) following their admission to a specialist personality disorder (PD) service. Change in DSQ scores over time was examined using mixed effects models for those (n = 48) remaining in treatment for at least 18 months. RESULTS: Defensive functioning at baseline was less mature in comparison with non-clinical norms, with two other non-forensic PD samples, and with a male paedophile sample, but was unrelated to criminal history. Axis II severity was negatively associated with overall defensive functioning (ODF). Antisocial PD was positively associated with a maladaptive defence style. Borderline PD was negatively associated with self-sacrificing defences. Avoidant PD was negatively associated with both self-sacrificing and adaptive styles. Non-completion of treatment was predicted by low ODF scores and high maladaptive defence style scores at baseline. ODF improved significantly over time in treatment and was predicted by strong antisocial and weak schizotypal PD pathologies. CONCLUSIONS: Defence style, as measured by the DSQ, appears to have the potential to inform assessment and measure change in this group of offenders.

Personality disorder traits and self-reported target problems in a treatment-seeking sample.

BACKGROUND: Assessments of personality disorder (PD) by clinicians or researchers are not always congruent with the problems that clients view as most salient. This can result in disagreement over areas for change, leading to dissatisfaction and the risk of treatment attrition. METHOD: The sample comprised 141 treatment-seeking adults with PD. Each described the five things they most wanted to change about themselves. These target problems were compared with PD diagnoses obtained from the International Personality Disorder Examination. RESULTS: The congruence between the clients' target problems and PD traits identified by the professionals was generally weak. Disagreement arose where a client's target problem was not a PD trait and, less frequently, where the client and the professional agreed on the presence of a trait but not on its importance. Surprisingly, doubting the trustworthiness of others was the most commonly reported target problem in this treatment-seeking sample even though many such participants did not qualify for that particular paranoid trait. CONCLUSION: Personality disorder diagnoses were generally poor indicators of the problems these clients cited as most important. This lack of correspondence may explain some of the lack of effectiveness of interventions for PD. KEY PRACTITIONER MESSAGE: The problem that a client with personality disorder (PD) views as most important may only be weakly identified in a formal diagnostic assessment. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PD traits are insufficient to describe fully the things clients most want to change about themselves. Many clients with PD consider difficulty trusting others to be their most important problem, despite not qualifying for that particular paranoid trait. Risk of disagreement between the clinician and the client might be reduced if both parties can engage in a discussion about the results of any formal diagnostic assessment.