International Journal of Social Psychiatry

http://isp.sagepub.com The Burden of Personality Disorder: a District-Based Survey

Charles Montgomery, Keith Lloyd and Jeremy Holmes International Journal of Social Psychiatry 2000; 46; 164 DOI: 10.1177/002076400004600302 The online version of this article can be found at: http://isp.sagepub.com/cgi/content/abstract/46/3/164

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164.

THE BURDEN OF PERSONALITY DISORDER: A DISTRICT-BASED SURVEY

CHARLES MONTGOMERY, KEITH LLOYD &

JEREMY HOLMES

SUMMARY Patients with a clinical diagnosis of personality disorder (PD) often suffer prolonged distress. They are a considerable burden on psychiatric services and they are experienced as difficult to manage by their keyworkers. This paper describes the creation of a community-based case register of patients suffering from PD. It explores the relationship between psychological distress, personality dysfunction, service utilisation and keyworker stress. Mental Health workers were asked to identify those patients on their caseload whose primary problem was PD. This list provided the basis for the case register. Patients completed the revised Personality Diagnostic Questionnaire IV (PDQ 4); the General Health Questionnaire (GHQ); and the Beck Depression Inventory - 21 item (BDI). A brief, semi-structured interview was conducted by Community Psychiatric Nurses to estimate service utilisation and keyworker stress. The mean GHQ was 14.58; the mean BDI score was 28.22. The mean number of PDs per patient was 4.5. One quarter of patients (21/80) had been admitted at least once to a psychiatric ward in the previous year and 17% (13/80) had presented to casualty at least once in the previous two months. 57% of the patients had weekly or more contacts with a helping agency. The number of PD diagnoses per patient as measured by the PDQ 4 was not found to be predictive of stress experienced by CPNs, whereas high BDI and GHQ scores were strongly correlated. Similarly, the number of admissions to a psychiatric ward was associated with high BDI and GHQ scores but not with number of PDs per patient. It is feasible to establish a case register of all patients in the district with PD. There are high levels of depression and distress amorsgst patients with PD being treated as outpatients. Service utilisation and keyworker stress are not predicted by number of PDs per patient but are strongly associated with distress as measured by the GHQ and BDI, The implications of these findings are discussed.

INTRODUCTION
Patients with personality disorder suffer prolonged psychological distress leading to recurrent problems, medical and social as well as psychiatric, all of which seem to be associated with poor outcome (Stone, 1993). Although it has been argued that this group of patients are not well served by the term PD with its pejorative undertones (Blackburn, 1988; Lewis & Appleby, 1988), in recent years the concept of PD has emerged into the mainstream of psychiatric practice (Tyrer et at. 1991). The community prevalence of around 5% rises to

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165

28% when PD is assessed using a structured interview (Casey & Tyrer, 1990) suggesting a large and untreated population suffering distress and morbidity. In British primary care 12% of surgery attenders have been diagnosed as having borderline personality disorder alone (Nvhewell et al. 1995). Between 20 and 40% of psychiatric outpatients have been shown to have an identifiable personality disorder (Morey, 1988) whilst the proportion of inpatients suffering PD is as high as 50% (Dahl, 1986; Loranger et al. 1.987) with over half having a diagnosis of borderline personality disorder (Zanarini et al. 1987; Skodol et al. 1988). Prevalence rates for substance dependence, eating disorder, phobic illness, psychosexual problems and attempted suicide are between four and eight times more common in those with PD compared with those without PD (Zimmerman & Coryell 1990). Clinicians and researchers approach the dilemma of diagnosing PD differently; clinicians with treatment planning in mind tend to make single axis II diagnoses (Gabbard, 1997). When self-report questionnaires and semi-structured interviews are used by researchers, patients receive multiple PD diagnoses, usually between three and six, which, it is suggested, is best understood as &dquo;breadth&dquo; of psychopathology (Dolan et al. 1995). A system for classifying severity of PD has been devised by Tyrer & Johnson (1996) ranging from personal difficulties through to diffuse personality disorder when patients need to score on two or more PDs from different clusters. Clinical impression suggests that in non-specialist centres PD is under-diagnosed which has important therapeutic consequences as it is known that PD alters the presentation, course and response to treatment of comorbid Axis I illness (Reich & Green, 1981; .~lnaes & Torgerson, 1997). This survey is an attempt to (a) create a clinically meaningful case register of patients suffering from PD within a defined and stable population; (b) to estimate the burden represented by these patients on their mental health workers and (c) to explore the relationship between keyworker stress and various psychometric measures of severity of PD.

METHOD
A case register was created of all patients in our predominantly rural district with a diagnosis of PD. Patients of both sexes aged between 18 and 50 were included who had no previous diagnosis of schizophrenia or delusional (paranoid) disorder and who had no evident organic brain damage. The case register was created in the following way: Three Consultant Psychiatrists and all the Community Psychiatric Nurses from their three Community Mental Health Teams received a letter giving details of the survey. They were asked to provide a list of patients under their care whose primary reason for ongoing contact with psychiatric services was the presence of PD. In this way 126 patients were identified who were then asked to complete three self-report questionnaires: 1) The revised Personality Diagnostic Questionnaire IV (Hyler & Rieder, 1987) a screening instrument to assess the presence of criteria for the eleven types of PD described in DSM IV 2) The General Health Questionnaire (GHQ 28 - Goldberg, 1972)

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166

3) The Beck Depression Inventory - 21 item (becks al. 1961)

The mental health workers administered the questionnaires during one of their regular times of contact either at the patients home or at the Community Mental Health Team Clinic. Service utilisation was estimated by asking patients: 1) Frequency of hospital admissions 2) Frequency of attending the Accident & Emergency Department 3) The level of weekly supportive contact they had from day centres, CPNs, social worker, GP The degree of stress each keyworker experienced in dealing with each patient was measured on a Likert five-point scale.

RESULTS
were returned from 80 patients (63% of 126). 75% (n 60) of the case register were female, 25% (n = 20) were male. The mean age of females patients was 39, the mean age of males was 43. The mean GHQ score was 14.58 (SD = 8.75) and there was no significant difference between males and females. The mean BDI score was 28.22 (SD 12.23) and there was no significant difference between males and females. All cases scored at least one PD on the PDQ IV. The mean PD diagnosis per patient was 4.57 (range 1-10. SI) 2.13). Forty-seven percent (38/80) of patients had fortnightly or more contact with their CPI~s. In 50% of cases CPNs related their contacts with the patient as above averagely stressful. A quarter (21/80) of patients had been admitted to a psychiatric ward at least once over the previous year and 17% (13/80) had presented to casualty at least once over the previous two months (range 0-20). 57% (46/80) of patients were having weekly or more contact with a

Completed questionnaires
on

agency. The number of PD diagnoses per patient as detected by the PDQ 4 (i.e., measure of severity of personality dysfunction) was not found to be associated with stress experienced by Clots. The mean GHQ and BDI scores among patients whom the CPNs found stressful was significantly higher than among those they did not find stressful (Table 1). The number of times CPNs made contact with each patient was not significantly associated with any of the instruments. A high GHQ score almost reached statistical significance for predicting the number of times patients presented at casualty. High BDI scores similarly showed a trend towards an association with visits to casualty. There was no association with the number of PDs per patient. Patients who were admitted were younger and had
Table 1

helping

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167 Table 2

(1) T = -2.86 p = 0.0005 1 (2) T = 2.60 p=0.0~1

higher BDI

scores than those who number of admissions (Table 2).

were

not

admitted.

PDQ 4

was

not associated with

DISCUSSION There were several limitations to this study. The way in which the case register was created relied upon clinicians judgement which, especially for the less severely disordered patients, would have led to variations as to who was included; on the other hand, such clinical judgement meant that the diagnosis of &dquo;personality disorder&dquo; had clinical validity as distinct from questionnaire-based diagnosis. Several patients were untraceable and presumably had left the area during the six months after the survey was running. Despite these drawbacks findings from the survey highlight a number of issues: Firstly, it is feasible to create a meaningful case register of all patients suffering from PD in contact with psychiatric services in any district. Secondly, depression (as detected by the BDI) is a common finding within this patient group with a mean score of 28. 36 (45%) patients had BDI scores >30 (&dquo;extremely severe&dquo;) whilst 27 (33%) scored 19 to 29 (&dquo;moderately severe&dquo;). These findings are comparable to other studies. Shapiro et al. (1994) found patients in a treatment group with a diagnosis of major depression had a mean BDI score of 24.50. Awes (1996) looked at patients on a psychotherapy waiting list and found mean BDI scores of 24.32. The number of PD diagnoses per patient was 4.5 which corresponds to other studies (see Table 3) that had used an earlier version of the screening questionnaire. The clinical
Table 3

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168

usefulness of this is called into question by the somewhat unexpected finding that the GHQ and to a lesser extent the BDI were found to be much better predictors of service utilisation and keyworker stress than the PDQ IV. There are two possible explanations for these findings: firstly, it may be that as a screening instrument the PDQ IV has low construct validity; further research involving the use of structured interviews is needed to clarify this. A second explanation is that global personality dysfunction as measured by the PDQ IV does not equate with personal distress. It is possible that patients with even serious PD reach a stable state whereby they become adjusted to their psychopathology. The combination of having PD and being distressed (as measured by the GHQ or BDI) is a more potent factor in increasing both service utilisation and stress levels amongst carers than purely a diagnosis of PD. Evidence about effective treatments for Personality Disorder is scant although it does seem that intensive psychotherapy can be effective in selected cases (Linehan (1987); Bateman (1997); Monsen et al. 1995). In a recent paper Dolan, Warren & Norton (1997) claim that a year of inpatient psychotherapy reduced the number of personality disorders as detected on a PDQ IV equivalent measure. Given the widespread prevalence of PD the question of selection for such treatment is clearly an important issue. This study suggests that levels of distress as measured by the GHQ and BDI rather than numbers of PDs as measured by the PDQ, is a better guide to the relevance of intensive treatment. A case register of PDs provides a first step towards a co-ordinated and dedicated service for such patients. In a district service their management will be based on triage. Some, well adapted, however disturbed patients, are best helped by low-intensity support. There are undoubtedly some highly distressed and disturbed people who resist all attempts at engagement and treatment. Between them are a group for whom intensive psychotherapeutic efforts should be concentrated. Simple measures of distress can make a useful contribution to this process of selection. In summary this survey suggests it is not the severity of P.D. but rather the severity of accompanying affective disturbance that determines the burden such patients place on services. Not all patients with even severe P.D. need intensive treatment. However, a sub-group of PD patients who are severely distressed with high BDI and GHQ scores and with high and generally unproductive service utilisation do urgently warrant more refined intervention. Prospective studies of the &dquo;natural history&dquo; of PD are urgently required to further clarify outcome and treatment response in this challenging group of patients.
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Dr. Charles Montgomery, Locum Consultant Devon EX2 5AF

Psychiatrist,

Wonford House

Hospital, Dryden Road, Exeter,

Department of Postgraduate

Dr. Keith Lloyd, Consultant Psychiatrist & Senior Lecturer, Medicine & Health Studies, Wonford House Hospital Dr.

University

of Exeter,

Jeremy Holmes, Consultant Psychiatrist/Psychotherapist, Barnstaple, Devon EX31 4JB Correspondence to Dr. Montgomery

North Devon District

Hospital, Raleigh Park,

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