Summary Personality disorders are common and ubiquitous in all medical settings, so every medical practitioner will encounter them frequently. People with personality disorder have problems in ...interpersonal relationships but often attribute them wrongly to others. No clear threshold exists between types and degrees of personality dysfunction and its pathology is best classified by a single dimension, ranging from normal personality at one extreme through to severe personality disorder at the other. The description of personality disorders has been complicated over the years by undue adherence to overlapping and unvalidated categories that represent specific characteristics rather than the core components of personality disorder. Many people with personality disorder remain undetected in clinical practice and might be given treatments that are ineffective or harmful as a result. Comorbidity with other mental disorders is common, and the presence of personality disorder often has a negative effect on course and treatment outcome. Personality disorder is also associated with premature mortality and suicide, and needs to be identified more often in clinical practice than it is at present.
The nomenclature of personality disorders in the 11th revision of the
International Classification of Diseases and Related Health Problems
represents the most radical change in the classification ...history of personality disorders. A dimensional structure now replaces categorical description. It was argued by the Working Group that only a dimensional system was consistent with the empirical evidence and, in the spirit of clinical utility, the new system is based on two steps. The first step is to assign one of five levels of severity, and the second step is to assign up to five prominent domain traits. There was resistance to this structure from those who feel that categorical diagnosis, particularly of borderline personality disorder, should be retained. After lengthy discussion, described in detail here, there is now an option for a borderline pattern descriptor to be selected as a diagnostic option after severity has been determined.
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.
Ethnic minority service users with schizophrenia and schizoaffective disorders may experience inequalities in care. There have been no recent studies assessing access to evidence-based treatments for ...psychosis amongst the main ethnic minority groups in the UK.
Data from nationally representative surveys from England and Wales, for 10,512 people with a clinical diagnosis of schizophrenia or schizoaffective disorders, were used for analyses. Multi-level multivariable logistic regression analyses were used to assess ethnic minority inequalities in access to pharmacological treatments, psychological interventions, shared decision making and care planning, taking into account a range of potential confounders.
Compared with white service users, black service users were more likely prescribed depot/injectable antipsychotics (odds ratio 1.56 (95% confidence interval 1.33-1.84)). Black service users with treatment resistance were less likely to be prescribed clozapine (odds ratio 0.56 (95% confidence interval 0.39-0.79)). All ethnic minority service users, except those of mixed ethnicity, were less likely to be offered cognitive behavioural therapy, compared to white service users. Black service users were less likely to have been offered family therapy, and Asian service users were less likely to have received copies of care plans (odds ratio 0.50 (95% confidence interval 0.33-0.76)), compared to white service users. There were no clinician-reported differences in shared decision making across each of the ethnic minority groups.
Relative to white service users, ethnic minority service users with psychosis were generally less likely to be offered a range of evidence-based treatments for psychosis, which included pharmacological and psychological interventions as well as involvement in care planning.
To make informed choices, patients need information about negative as well as positive effects of treatments. There is little information about negative effects of psychological interventions.
To ...determine the prevalence of and risk factors for perceived negative effects of psychological treatment for common mental disorders.
Cross-sectional survey of people receiving psychological treatment from 184 services in England and Wales. Respondents were asked whether they had experienced lasting bad effects from the treatment they received.
Of 14 587 respondents, 763 (5.2%) reported experiencing lasting bad effects. People aged over 65 were less likely to report such effects and sexual and ethnic minorities were more likely to report them. People who were unsure what type of therapy they received were more likely to report negative effects (odds ratio (OR) = 1.51, 95% CI 1.22-1.87), and those that stated that they were given enough information about therapy before it started were less likely to report them (OR = 0.65, 95% CI 0.54-0.79).
One in 20 people responding to this survey reported lasting bad effects from psychological treatment. Clinicians should discuss the potential for both the positive and negative effects of therapy before it starts.
The association of workplace factors on mental health of healthcare workers (HCWs) during the COVID-19 pandemic needs to be urgently established. This will enable governments and policy-makers to ...make evidence-based decisions. This international study reports the association between workplace factors and the mental health of HCWs during the pandemic.
An international, cross-sectional study was conducted in 41 countries. The primary outcome was depressive symptoms, derived from the validated Patient Health Questionnaire-2 (PHQ-2). Multivariable logistic regression identified factors associated with mental health outcomes. Inter-country differences were also evaluated.
A total of 2527 responses were received, from 41 countries, including China (n = 1213; 48.0%), UK (n = 891; 35.3%), and USA (n = 252; 10.0%). Of all participants, 1343 (57.1%) were aged 26 to 40 years, and 2021 (80.0%) were female; 874 (34.6%) were doctors, and 1367 (54.1%) were nurses. Factors associated with an increased likelihood of depressive symptoms were: working in the UK (OR = 3.63; CI = 2.90-4.54; p < 0.001) and USA (OR = 4.10; CI = 3.03-5.54), p < 0.001); being female (OR = 1.74; CI = 1.42-2.13; p < 0.001); being a nurse (OR = 1.64; CI = 1.34-2.01; p < 0.001); and caring for a COVID-19 positive patient who subsequently died (OR = 1.20; CI = 1.01-1.43; p = 0.040). Workplace factors associated with depressive symptoms were: redeployment to Intensive Care Unit (ICU) (OR = 1.67; CI = 1.14-2.46; p = 0.009); redeployment with perceived unsatisfactory training (OR = 1.67; CI = 1.32-2.11; p < 0.001); not being issued with appropriate personal protective equipment (PPE) (OR = 2.49; CI = 2.03-3.04; p < 0.001); perceived poor workplace support within area/specialty (OR = 2.49; CI = 2.03-3.04; p < 0.001); and perceived poor mental health support (OR = 1.63; CI = 1.38-1.92; p < 0.001).
This is the first international study, demonstrating that workplace factors, including PPE availability, staff training pre-redeployment, and provision of mental health support, are significantly associated with mental health during COVID-19. Governments, policy-makers and other stakeholders need to ensure provision of these to safeguard HCWs' mental health, for future waves and other pandemics.
Evidence is beginning to emerge that music therapy can improve the mental health of people with depression. We examine possible mechanisms of action of this complex intervention and suggest that ...music therapy partly is effective because active music-making within the therapeutic frame offers the patient opportunities for new aesthetic, physical and relational experiences.
The authors examined whether lamotrigine is a clinically effective and cost-effective treatment for people with borderline personality disorder.
This was a multicenter, double-blind, ...placebo-controlled randomized trial. Between July 2013 and November 2016, the authors recruited 276 people age 18 or over who met diagnostic criteria for borderline personality disorder. Individuals with coexisting bipolar affective disorder or psychosis, those already taking a mood stabilizer, and women at risk of pregnancy were excluded. A web-based randomization service was used to allocate participants randomly in a 1:1 ratio to receive either an inert placebo or up to 400 mg/day of lamotrigine. The primary outcome measure was score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. Secondary outcome measures included depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment, and adverse events.
A total of 195 (70.6%) participants were followed up at 52 weeks, at which point 49 (36%) of those in the lamotrigine group and 58 (42%) of those in the placebo group were taking study medication. The mean ZAN-BPD score was 11.3 (SD=6.6) among those in the lamotrigine group and 11.5 (SD=7.7) among those in the placebo group (adjusted difference in means=0.1, 95% CI=-1.8, 2.0). There was no evidence of any differences in secondary outcomes. Costs of direct care were similar in the two groups.
The results suggest that treating people with borderline personality disorder with lamotrigine is not a clinically effective or cost-effective use of resources.
People with severe COVID anxiety have had experiences of the COVID-19 pandemic which are overwhelming, and have led to patterns of behaviours that add little protective benefit but are at the expense ...of other priorities in life. It appears to be a complex social and psychological phenomenon, influenced by demographic and social factors. Identifying subgroups of people with severe COVID anxiety would better place clinicians to assess and support this distress where indicated.
Measurement tools assessing depression, generalised and health anxiety, obsessive-compulsive symptoms, personality difficulty and alcohol use from 284 people living in United Kingdom with severe COVID anxiety were explored with latent profile analysis. Further analyses examined the associations of identified clusters with demographic and social factors and daily functioning, quality of life and protective behaviours.
A model with 4 classes provided the best fit. Distinct patterns of psychopathology emerged which were variably associated with demographic factors and COVID behaviours.
Given the complex aetiology of COVID anxiety a number of factors which might better cluster subgroups are likely to have gone uncollected. Moreover, using data collected at a single time-point limits these results' ability to conclude whether observed relationships were the product of the pandemic or longstanding.
People living with severe COVID anxiety are a heterogenous group. This analysis adds to evidence that certain health behaviours and demographic factors are inextricably linked to poor mental health in people with COVID anxiety, and that targeting health behaviours with specific intervention might be beneficial.
•Severe COVID anxiety is a heterogenous experience, with distinct psychopathological subgroups.•These subgroups are differentially related to demographic and social factors, COVID protective behaviours and clinicaloutcomes.•Targeting specific COVID behaviours with interventions may offer benefit to mental distress.
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