Friday, 8 March 2013

Should People with Personality Disorders Ever Be Sectioned?

The DSMV (yes, I am that up-to-date), when discussing the diagnostic criteria for personality disorder, states:
“The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:
  • Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
  • One or more pathological personality trait domains or trait facets.
  • The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
  • The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
  • The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).”
I have to say that this definition is rather harder to understand than the DSMIV criteria, which talks much more clearly about personality disorder as being “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture”. It goes on to talk about how the development of a personality disorder can be traced back at least to adolescence or early adulthood.
Personality disorder essentially comes about as a result of abusive or aversive early life experiences. An event, such as sexual abuse, interferes with the normal development of personality. In an effort to cope with such extreme and difficult life experiences, the child or young person can develop coping strategies which can be perceived as “abnormal”, but which within the context of that person’s experiences may be the only way they can survive. A typical example of this is deliberate self harming through cutting or other means, as a way of relieving the individual of emotional distress.
While a formal diagnosis of personality disorder may not be given too commonly, I would estimate that at least 50% of patients of a typical Community Mental Health Team could be identified as having at least some of the diagnostic features outlined in the DSMV manual. It’s certainly the case in the Charwood CMHT.
Traditionally, and unfortunately too often in the present, the term “personality disorder” has often been used negatively to describe people whose behaviour others find “difficult” or hard to understand. Because personality disorders can be difficult and unrewarding to treat, it has often been the case that doctors make a statement along the lines of: “This person has a personality disorder. They are therefore not mentally ill, are untreatable, and should not therefore receive services.”
Unfortunately, one still hears this sentiment, despite the publication in 2003 of Personality disorder: No longer adiagnosis of exclusion. Published by NIMHE, it remains the principal guidance for the development of services for people with personality disorder in this country.
The introduction is immediately encouraging:
“Personality disorders are common and often disabling conditions. Many people with personality disorder are able to negotiate the tasks of daily living without too much distress or difficulty, but there are others who, because of the severity of their condition, suffer a great deal of distress, and can place a heavy burden on family, friends and those who provide care for them.
As with all forms of mental disorder, the majority of people with a personality disorder who require treatment will be cared for within primary care. Only those who suffer the most significant distress or difficulty will be referred to secondary services. This guidance is designed to ensure that once referred, they receive access to appropriate care.”
The publication states:
“The current 1983 Act is often interpreted as excluding those with personality disorder from compulsory detention because of the requirement that the mental disorder be “treatable”. (i.e. treatment is likely to alleviate or prevent a deterioration in the patient’s condition). Many clinicians have not seen personality disorder as a mental disorder that is treatable. This will change with the new mental health legislation … which removes the treatability clause, and provides a generic description of mental disorder.”
The report makes frequent reference to the appropriateness of use of the MHA for the treatment of people with personality disorder, especially in the forensic area. It has been estimated that up to 80% of prisoners have some form of personality disorder.
Of course, this was written some years before the 2007 Act amendments to the 1983 Act were finalised. So what does the final Act say?
Well, the old definition of “mental disorder” was as follows: “mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind and “mentally disordered” shall be construed accordingly”. The Act also included “mental impairment” and “severe mental impairment”.
The new definition is short and concise, being merely “any disorder or disability of the mind”.
The revised Act did not in fact remove the concept of treatability, and in fact detention under Sec.3 requires that “appropriate medical treatment is available for him
In an attempt to be helpful Sec.3(4) adds: “references to appropriate medical treatment, in relation to a person suffering from mental disorder, are references to medical treatment which is appropriate in his case, taking into account the nature and degree of the mental disorder and all other circumstances of his case.”
The Reference Guide (Para 1.16) adds that “medical treatment” “includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care (as well as medication and other forms of treatment which might more normally be regarded as being “medical”)”. It goes on to say that this medical treatment is “for the purpose of alleviating, or preventing a worsening of, the disorder or one or more of its symptoms or manifestations”.
So where have I got with answering the question posed in this post?
I think I’ve established that detention under the MHA is possible, since a personality disorder is certainly a mental disorder under the MHA.
I’ve also established that personality disorder can be regarded as treatable, and that the legal guidance covers the main sorts of treatment that might be used with personality disorder.
There is therefore no legal reason why someone with a personality disorder cannot be detained under a section of the MHA.
But this is not the same as saying that formal detention should be a routine consideration when an AMHP is presented with someone with a personality disorder.
At least half of my caseload as a CMHT worker are people with personality disorders, in particular, emotionally unstable or borderline personality disorder. I’ve written about some of them on the blog. I even detained one under Sec.2 on one occasion. (although didn’t actually admit her).
Some of the people I work with will spend periods as an inpatient if their emotional instability becomes so severe that they become dangerous to themselves, although the primary thrust of care planning is always to keep them out of hospital.
The care plan of one woman I work with, who frequently engages in self harming and other challenging behaviour, specifically includes a passage stating that, in a crisis, it is unlikely that hospital admission would be helpful.
Hospital, and compulsion under the MHA, does certainly have a place in the treatment of severe personality disorder, especially in the forensic sphere, but the NIMHE guidance encourages the use of specialist resources within the community for most people. It is certainly my experience that it is better to work as much as possible with the wishes of the person, and to respect any advance decisions they may make about the use of hospital and compulsion.
But that does not mean that the MHA should never be used, or only used with forensic cases. I have discussed this issue at length in my post about the Kerrie Wooltorton case, where a patient with a personality disorder was allowed to die after drinking antifreeze, on the basis that that was what she wanted.
In the end, if the requirements for detention are met, then the MHA should be used, if all alternatives, including informal admission, have been exhausted. As well as the basic criteria relating to mental disorder of a nature or degree, for Sec.2, that would be “he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons”, and for Sec.3 “it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section and appropriate medical treatment is available for him”.


  1. Good post. I'm afraid that in some parts of the world the so-called 'treatability test' lingers on regardless of legislation and guidance. Have heard the new test about the potentially low threshold of 'appropriate treatment' (as opposed to the prospect of successful treatment) compared to buying a lottery ticket, the purpose of the purchase being to win £lots while the likelihood of this actually happening is quite low. And anyway how often are people with what the unelightended regard as 'proper' mental illnesses are admitted to hospital in expectation of a complete cure? That said, I think acknowledging that an admission can be particularly damaging for some patients with PD presentations is no more than honest.

  2. Isn't it troubling that if personality disordered traits become normative for a culture, then those displaying them no longer are considered as having a personality disorder? Imagine if we applied that standard to diabetes or obesity.

    1. Again commenting very late... but thinking about this.

      In a way, everyone DOES have personality disorder traits. We're all different, we all have our own thoughts and feelings and ways of doing things. However there seems to be a vague 'acceptable' range considered 'normal' and only those functioning outside of this range are considered disordered by the majority.

      Anyway, let's imagine everyone had the traits of BPD. For a start, if EVERYONE felt like that people would understand each other, things would be set up to allow that range and depth of emotion. Also, some of the traits would probably not exist anymore, eg. suicidal tendencies - because others would understand and support each other through emotional pain, and the person wouldn't feel trapped and alone. Other traits wouldn't exist in terms of being considered problematic; for example the perception that people with BPD are 'OVERreacting'.

      Also, the whole of society, workplaces and the legal system would be different, would have developed differently. Some things that are currently seen as inconsequential may be considered serious abuse because of the emotional fallout. You could legitimately get compassionate leave from work if you'd had a relationship breakup or a friend had seriously betrayed you - and have sympathy and support from colleagues when you returned.

      Personally I think BPD exists in individuals with a much greater capacity for empathy and compassion, due to high sensitivity, which unfortunately means they are far more easily damaged. So if EVERYONE was like that, the damage and subsequent lack of support would be much less likely to happen.

      Actually, I like the sound of a society like that!

  3. In the case of Kerrie Wooltorton how would detention under the MHA have 'helped' her or, more significantly, prevented her from dying?

    1. She could then have received life saving treatment for the poisoning -- which she had successfully received in the past when presenting in similar circumstances.

    2. If you need a liver transplant following paracetemol overdose and have capacity and say no, then they can't give you it under the MHA Act. How could Kerrie Wooltorton have had treatment forced on her under the MHA? (Or MCA?)

    3. You need to read this post as well as the Kerrie Wooltorton post -- and other stuff I've written on the blog. Legally, the MHA allows a patient to be treated compulsorily if they have a mental disorder and they need treatment. Treatment can include life saving medical treatment if it arises from their mental disorder. Kerrie's swallowing of a lethal poison was a consequence of her mental disorder. She could therefore legally be treated in order to save her life. She could also have been legally treated under common law -- in order to save her life. I would personally always go for an option that led to someone's life being saved, even if they didn't want it to -- I would rather they sued me for saving their life (and what sort of compensation would they be seeking?) than have to juastify to an inquest why I did not act to save their life.

    4. I had enough capacity to manage to almost end my life whilst sectioned on an acute ward, yet being on a section 3 they had the power to save my life with a blood transfusion.

    5. I read the post on Kerrie and I'm not convinced that "Kerrie's swallowing of a lethal poison was a consequence of her mental disorder". It's just that attempted suicide is automatically assumed to be caused by mental illness, and that happened to Kerrie, too, in the past, thus the diagnosis. If anything, persistently trying to commit suicide and having the courage to refuse treatment and to put up with the pain and suffering caused by the suicide method may actually show that she was perfectly rational and firmly determined to kill herself no matter what. Moreover, she had tried the same method in the past, so she was fully aware of the consequences. If she was so determined to die, I don't see why the society had a right or a duty to save her. I can see that, maybe, a crying person committing some impulsive gesture for the first time could, or should, be stopped, but this woman was obviously not in that situation. She clearly knew what she was doing and really wanted it.

    6. The thing is that if you have a BPD diagnosis it's virtually impossible to get appropriate treatment and support. People are retraumatised by the system and professionals who interpret their requests for help with the unbearable pain they carry as "attention-seeking". Everything is interpreted as a malicious or manipulative act, and the human suffering is forgotton. (Not saying you do this Masked AMHP! But so many do.)
      In light of this I can see why Kerrie might have felt suicide was the only course of action, in a rational way.

      Society has a duty to save people like Kerrie because they are victims of the same society - often of childhood abuse or other traumatising circumstances (in fact their is a school of though that suggests BPD is a form of PTSD). This is compounded by adverse life events that spring from their problems (eg. homelessness or being preyed on by abusive partners who exploit vulnerabilities).
      A diagnosis of BPD shouldn't have been slapped on her if she didn't fulfill the criteria - just attempting suicide shouldn't be enough for diagnosis (although snap judgements are made and reinforced as I mentioned above).
      It is very likely that someone who commits suicide will be diagnosable with a mental health problem. If that's not the case - why do they want to kill themselves? Financial circumstances? Hopelessness? Why are we as a society happy that they end their lives prematurely in this miserable way, when we could alleviate their suffering? - whether offically 'mental' or not.

  4. This was a really interesting post to read, I am in two minds about whether hospitalisation (both voluntary and under section) is helpful for people with a PD diagnosis. From my own personal experience (I have BPD), I think in moments of very extreme distress it is important that short admission is considered. No, mental health wards are not a therapeutic place to be, but it can be a relief to be 'kept safe' and also really importantly give carers and family a break, even if this means being detained under section. Of course this depends on severity and I do think history of self harm should be considered. If someone is likely to self harm in a way that would be very damaging, require extensive and obtrusive treatment (operations for example) or life-threatening, it's better they were in hospital or a crisis/recovery house. It's difficult though...I had an experience of being handcuffed and bundled into the back of a police van under section 136 because I was in a highly dissociative and suicidal state and was trying to run in front of cars. Obviously something had to be done, but the physical and mental trauma of the event had its own repercussions.

    1. I totally agree that the trauma of admissions and hospitalisation can cause more issues. I've always said that i think the sections etc caused PTSD. Really interesting to hear someone else say that.

    2. Yeah, I think that's why the say on the whole admission/admission under section for people with BPD won't be helpful..because the person will typically be so sensitive and most likely succeptible to traumatisation/PTSD. Also you can get into the bad cycle of needing to go to hospital every time you experience an intense emotional's tricky

    3. Reading this has been enlightening I fully agree. After a lifetime of hospitalisations in my childhood I was recently detained by the police under section 136 as I had overdosed and was suicidal and was traumatised by being in a hospital where no one knew or cared about my psch history, was treated as an idiot and being put on a ward in an NHS hospital was the worst possible thing they could do.

  5. So basically, even if an individual is perfectly rational and is not psychotic, his or her personality alone can be used as an excuse to use psychiatry as a tool for social control and extralegal imprisonment. Face it: this is not about treatment at all but about controlling people who are deemed difficult, bizarre, troublemakers or who may have committed crimes. At least, when they were not sectioned because they were not deemed treatable, there was a measure of protection against such abuses. Now, psychiatrists can simply find some pretext based on personality traits or social functioning to get anybody they want under their control. If any of the people with so-called personality disorders want help with their social functioning or other problems, that's all right. It's their choice, although the treatment is basically a form of self-improvement, concrete help with life's problems, learning to stay out of trouble a little more, etc., not the real treatment of an illness. However, using personality disorder excuses for purposes of social control is outrageous! And since personality traits tend to be stable, one cannot even argue, like a schizophrenic might, for example, that the "illness" has clear symptoms such as hallucinations and delusions that were, in fact, induced by drugs, were never really present or have been absent for many years. What may or may not happen, for example, is that the patient won't behave in certain ways any more, but that may have more to do with the normal aging process, with punishment and unpleasant consequences, including unwanted "treatment", and perhaps with increased opportunities for the "patient" to simply do as he or she pleases without repercussions or to avoid people. For instance, if a student was answering back to teachers and parents and did not wear his uniform properly, that won't happen any more once the student is legally adult and out of school, and even the student's own parents, let alone the teachers, can simply be avoided at that point.

    1. Monica, i'm glad you've said it. I've just completed my AMHP training and that is what i tried to argue in my last essay. it is my opinion that the mental health act (just like any other legislation for that matter) is a tool of social control, construction and modeling and as you said it is particularly evident when "undesirable" behaviour is seen as a mental disorder that needs to be corrected through empirically unsupported medical (or psychological) treatments. PD is a perfect example.

  6. Call me cynical, but I doubt Kerrie would have been allowed to die without the BPD diagnosis. Most mental health staff wouldn't mind if we evil, manipulative, attention-seeking BPD-ers all killed ourselves off and saved the NHS resources.

  7. And I include you 'masked AMHP' for even asking the question, and your tedious, ignorant witterings that people unfortunate enough to be labelled with PDs should only be admitted for a short time. Cos we are all the same. Yep we all sit around WANTING to be ill - we ARE ill- and are so dependent and attention-seeking that we want to be admitted at every little upset. Um, no. This stigma is what kills. Kerrie would be alive if she had had proper treatment - not the punitive, victim-blaming shit the NHS serves up. If we attention-seekers can get any treatment at all.

  8. I was sectioned (section 136 and then a 2) a few years ago for being actively suicidal. I have suffered from BPD for many years and had experienced many hospital admissions (the others were all voluntary) and other medical/psychiatric/psychological treatments. The admission probably saved my life and the staff on the ward were very sensitive to my needs.

    I was referred for specialist therapy during that admission. I waited around nine months for that to become available and in that time I had one more long-ish admission, during which I was put on a medication which made a huge difference to my functioning.

    Since going on the medication, alongside the highly recommended therapy in a therapeutic community, I have had no hospital admissions. My involvement with mental health services in now comparatively minimal and I am much more able to deal with stressful situations. I am not without the personality traits, especially during difficult times, and not without the odd crisis. But because I have had appropriate treatment (during which I worked very hard - and continue to do so) they are generally dealt with via slightly increased input from outpatient/community services.

    I would question that PDs are necessarily less treatable than some of the major mental health issues. Someone with chronic schizophrenia may be treated very effectively in an in-patient environment with the correct medications and other inputs, but may still have trouble functioning as well as someone with their age and background without the diagnosis when in the community. Their condition would, to some extent, be considered 'treatable'. I would question that people with PDs aren't similarly treatable (obviously each case is different) in that, whilst full recovery may not be possible, huge improvements can be made. But this is rather dependent on the right treatments being available, which just is often not the case!

    I would love to see evidence-based psychological therapies available to everyone who wanted them, whether that was in an in-patient, day patient or outpatient setting. Unfortunately, let's face it, there isn't the money.

    For those who do get that opportunity, take it if you want it, but make the most of it.

    I am now living independently, by and large without medication, in a relationship, have a good group of wonderful friends and have my first part-time job. Yay :)

  9. I still think that it is weird to have a mental health 'professional' adopt such a guise as a 1940's type Hollywood Western Cowboy. Seems there is a need to have some special recognition and seems not to take the AMHP role seriously and respectfully towards service users. Interesting to know what drives this!

    1. I started out wanting to be anonymous, as it also protected the anonymity of people I wrote about, just as you have chosen to comment anonymously.

  10. i have a diagnosis of borderline emotionaly unstable personality dissorder .Earlier this year i had 4 suicide attempts and on 2 of them was admitted and sectioned.It was the best thing they could have done at the time as i was a danger to my self and others. It has to be asesed on a person to person basis not on the overall diagnosis as like me i have other mental problems its just the bpd is the main diagnosis.i have a diagnosis of harmfull use of stimulants for one and have had a order to prevent sexual harm placed on me for a period .If the pdoc`s only look at the primary diagnosis and jump to automatic non admission then they can be missing a serious problem espesially if like i do i wont be in a mind to calmly state my history infact i have been told by my pdoc i dont accept ive done anything wrong and can be very convincing..i have been admited to a&e for a serious mental health incident and been sent home when no pdoc was available and the duty doc has deemed it just part of my condition as i had apparently calmed down.later with my pdoc he worked out i had lost insight to my actions but was in a mind to stay out of hospitalization when actually i should have been detained so basicaly conned the doctor who was so buisy he misssed the actual story..The diagnosis title is just a guide but it seems that its used as a reason to not look properly at what the patient is doing.

  11. I work in an acute mental health ward and I can see this as a double edged sword with many of the patients we see within the hospital. I do feel that with this particular mental health illnesses behaviors increase within the hospital as it absolves the individual of responsibility and can become a place that many people want to be due to the care they receive whilst in hospital. I also find that many of our patients prefer to be sectioned rather than be an informal patient because they have more responsibility as an informal patient compared to when they are formal patients. I find that hospital stays in an acute setting are longer than they should be causing the individual to pick up behaviors from other patients increasing their risks. A patient may be admitted with a very minimal cutting behavior but after talking to other patients who are very happy to share information on what they did to get sectioned or remain in the hospital also escalates their behavior. I do find that many patients feel proud that their behavior has escalated enough to warrant them a section (I am not talking about forensic patients) I find that a lot of patients will escalate their behavior so that they can be placed on an observations level 1:1 is usually a preference of the patients I work with.

    I do feel that within an acute setting there is very little guidance of how best to treat an individual with a personality disorder. When an individual ligatured we used to be encouraged to spend time with the patient to talk through the reasons as to why they ligatured however this seemed to escalate behavior in a type of pavlovian conditioning where we were technically reinforcing the behavior, Ligature = 1:1 time. Now we are being encouraged to cut the ligatures and leave but if a patient asks for support prior to a self harm attempt we have to ensure we give it however this is quite haphazard because there are no strict guidelines.

    On the other end of the scale I do feel that the mental health of loved ones is just as important as the mental health of the individual with a personality disorder because this is a very stressful illness for those around the patient. No one should have to walk in to their child or loved one attempting to commit suicide despite many patients alerting someone prior to their attempt. I could not imagine how hard this could be on family members and friends. Who wouldn't want to ensure their loved one is cared for in a safe and more knowledgeable environment.

    At the end of the day it is a very tough call from both sides. I have seen patients reside in an acute setting for 18 months and I really do not feel that is the place for them.