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 (
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”.