By definition, personality disorders involve persistent characteristics that cannot easily or quickly be eradicated. However, it is wrong to assume that all these patients are untreatable: it may well be possible to contain or even modify undesirable personality traits and their ill-effects. The principles of treatment include the following:

• consistent care, perhaps including:

• identified key worker or therapist

• written contract

• realistic goals - possibly, at first, harm minimization only

• assessment of risk to self and/or others

• proportionate response to manage risk

• sometimes, multiagency working (e.g. probation, substance misuse).

An important recent report, Personality disorder: No longer a diagnosis of exclusion (National Institute for Mental Health, 2003) sets out guidance for treating such patients within existing mental health services.

Case example

A woman in her mid-20s had always privately engaged in self-injurious behaviour. After her divorce, she took overdoses and cut herself much more frequently, at least once a week. Repeated assessments failed to indicate any mental illness. Antidepressant medication had been tried without improvement; admission to acute psychiatric wards seemed to be associated with a worsening of her behaviour. She was admitted to a therapeutic community where self-harm was against the rules and would lead to discharge. Although she was apparently reluctant to address her psychological problems in the daily group sessions, her behaviour became much less troublesome during the year of her membership. Problems did return after she left, but remained at a comparatively low level. The cost of the treatment was less than that of the care she would have otherwise required.

Psychotherapy aiming for greater insight and improved behaviour patterns benefits some cases. However, many patients cannot tolerate in-depth individual work.

Group psychotherapy offers an alternative in which patients can learn from each other. This is the mainstay of therapeutic community treatment, in which the residents are responsible for setting and maintaining the rules (often referred to as 'the boundaries'; for example, a typical rule is that patients must not self-harm - distress must instead be dealt with by talking to others).

Dialectical behaviour therapy is a fairly new type of treatment for borderline personality disorder (Palmer, 2002). It combines elements of CBT with 'dialectical thinking' and 'mindfulness'.

Nidotherapy (derived from Latin nidus, 'nest') is another novel word, at least, and is based on the idea of changing the patient's environment in an effort to produce therapeutic progress (Tyrer and Bajaj, 2005).

Drug treatment is sometimes helpful, in which case it usually needs to be continued on a long-term basis. Antidepressants, low-dose antipsychotics (sometimes given in depot form), and mood stabilizers (lithium or carbamazepine) have been successfully used in some cases. Drugs with a high potential for dependence, such as benzodiazepines, are best avoided in these patients.

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