The incidence of mental illness has increased steadily in the past decade with many GP surgeries now reporting that more than 30% of appointments are taken up by patients with low-level mental health problems like anxiety and depression.
Practitioners are often called upon to identify and refer patients to specialist mental health services for more serious conditions, such as bipolar disorder and schizophrenia. This can be a daunting prospect for GPs with limited knowledge of mental health and one of the most challenging and misunderstood conditions is personality disorder (PD).
PDs affect around 1% of the population and are centred around an individual's struggle to manage everyday emotional states, such as anger and frustration, particularly when interacting with other people.
Most of us recognise our moods and manage them until they pass while many patients with PDs have a tendency to get stuck in these emotional states which increase in intensity, resulting in behaviour that many of us find unusual.
These limiting patterns of behaviour and response become ingrained like a scratched record, producing feelings of anxiety and frustration. This inevitably leads to fractious interpersonal relationships.
Public understanding of the illness is largely influenced by the media which often portrays it in a negative light, just like so many other mental illnesses.
There is no doubt that those with severe psychopathic traits are dangerous and prone to criminal activity through characteristics such as impulsive self-centred behaviour.
However, these people are in a minority and their impact on society is greatly exaggerated in all but the most extreme cases. In reality, most patients with a PD are a greater danger to themselves than others, with high rates of self-harm and attempted suicide.
The extremes of behaviours seen in PD are something we can all recognise and identify in ourselves but these traits are amplified in patients with PD.
As such, PD may be missed by busy GPs and surgery staff who may dismiss a patient because they are unusually agitated or aggressive, or seem to be ignoring questions put to them.
Recognising the signs
My initial advice to GPs is to be patient and look for some of the following common symptoms of PD before making a referral to the local mental health team:
- Does your patient have rapid mood changes that are reactive to external circumstances? Small negative events can make patients with PD feel suddenly bad. Equally small positive events can make them feel on top of the world.
- How long do the moods last and can you trace the change to interpersonal events? The mood states are generally short-lived and responsive to others.
- How long have the problems lasted? If they have persisted over more than two years, they may be part of the way in which the individual functions and part of their personality, rather than a depressive and anxiety disorder.
- Does the problem occur in a wide variety of contexts? For example, at home, at work or with their peer group? If so, this is indicative of PD.
- Do they manage emotions, particularly anger and irritability and interpersonal sensitivity, with self-harm or the persistent use of drugs?
A brief assessment tool that can be used is the standardised assessment of personality - abbreviated scale (SAPAS).
SAPAS is not recommended for routine screening in primary care settings. However, it may be appropriate for use with patients GPs think have comorbid psychiatric conditions, such as anxiety which has not responded to treatment.
Treatment of disorder types, including borderline PD and obsessive compulsive PD, can be prolonged and complex, involving various talking therapies such as mentalisation or dialectical behaviour therapy. The dichotomy of the condition is that PDs cannot be treated with drugs, but the comorbidities that often accompany them can be treated this way.
The GP's role
The first step is to ensure that a constructive doctor-patient relationship is developed with agreed boundaries about what you can and cannot offer.
The importance of a positive relationship is emphasised for these patients because their problems are manifested within interpersonal interactions and may be present in their interactions with general practice.
Patients may make inappropriate demands and even be threatening. These behaviours must be discussed openly with the patient with agreement about your role in helping them before the second step is undertaken.
The second step is to develop a crisis plan with the patient. What can they expect if they become distressed and suicidal? How quickly can they see you? What happens if you are not in surgery?
In developing this plan it is important to ensure that you do not go beyond what is normal practice for your surgery. During assessment of any crisis a GP needs to maintain a calm state of mind and agree, if indicated, to liaise with local mental health services.
Many patients will calm down with quiet discussion about what is happening to them and may manage well with the promise of a follow-up telephone call the next day.
Once this is agreed, you may wish to go to a third step which is to offer the patient a regular visit time. For example, a brief meeting every few weeks to monitor how they are managing. This makes the patient feel they are being taken seriously and not dismissed.
Finally, monitoring symptoms of comorbid disorders, such as anxiety and depression, is essential and GPs may have a role in specifically supporting the patients in managing alcohol or drug misuse. These two factors alone make treatment of the PD more problematic and less successful even with specialist treatment.
GPs are often isolated on the front line of healthcare and they should be encouraged, where appropriate, to make full use of their colleagues in mental health services.
- Professor Bateman is the clinical lead, Barnet, Enfield and Haringey Mental Health NHS Trust, and a visiting professor in the psychoanalysis unit at University College London.