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Assessment of Personality Disorders

Overview

Traditionally mental health services have sometimes underdiagnosed personality disorders due to the associated stigma and perceptions of lack of utility of the diagnostic label. However, it is important for a diagnosis to be made, wherever possible, in order to ensure that service users get the right level of care and treatment.

Our care pathways outline treatment for people with Borderline Personality Disorder, because there is established evidence and guidance about the best ways to intervene with this diagnosis. This is not, however, the only type of personality disorder that people in our services may be experiencing. Many of the ideas and guidance developed for BPD will be relevant for other types of personality problems.

Assessment

Indicators that further diagnostic assessment of PDs may be appropriate include:

  • A past history or current presentation of risk of harm to self or others (including current and previous suicidal ideation, plans, intent, suicidal behaviours and preparatory actions)
  • Recurrent depression
  • A past history or current presentation of chaotic or unstable interpersonal relationships (including with services)
  • A past history or current presentation of unstable or impulsive emotional responses
  • A repeated pattern of referral and discharge to community services (i.e. a “revolving door” presentation)
  • A past history or current presentation of sexual, physical or psychological abuse, or neglect
  • A past history or current presentation of substance misuse or forensic issues

If further diagnostic assessment of PDs is indicated, areas that should be assessed, if not already covered in the generic assessment, include:

  • Current and previous risk of harm to self or others (including current and previous suicidal ideation, plans, intent, suicidal behaviours and preparatory actions)
  • Current and previous chaotic or unstable interpersonal relationships (including with services)
  • Current and previous unstable or impulsive emotional responses
  • Current and previous sexual, physical or psychological abuse, or neglect
  • Current and previous substance misuse or forensic issues
  • Current and previous coping strategies
  • Motivation to change and engage with services
  • Obtain a collateral history with the service user’s consent
  • Check electronic records or the repository for information relating to the service user’s history and timeline, if necessary

A diagnostic assessment may take up to 2-3 sessions due to service users being guarded and/or chaotic in presentation, and in order to develop a trusting therapeutic relationship with the service user.

A number of issues should be taken into account when making a diagnosis of PD:

  • If this is the first presentation there should be caution in making a diagnosis of PD, especially if there are significant co-morbid symptoms of anxiety or depression
  • If a previous diagnosis of PD has been made then review the diagnosis, particularly if the original diagnosis was made during a crisis, emergency presentation or episode of depression or anxiety that is in remission
  • Keep in mind that some PD characteristics may present differently across the life span. For example, be aware that older people with BPD may present with less aggressive and impulsive behaviour than younger people, but more psychosomatic, depressive and hypochondriac complaints