Patients referred to a Personality Disorder (PD) Service are frequently not offered treatment. This has profound implications for patients (who feel dismissed or rejected), referrers (who are perplexed as they have clearly diagnosed a PD) and the PD services themselves (their raison d'etre being to treat PD patients). A systematic search identified no literature on reasons for non-acceptance. This study aimed to describe reasons for not offering therapy in patients, after a specialist assessment.

We conducted a case series of 50 patients assessed in a specialist PD service. We collected data from routine service notes, using thematic analysis to identify categories of the reasons identified for treatment unsuitability.

Reasons for assessing treatment unsuitability (in descending order) were:

1. 1. (20%) – Lack of engagement (e.g. repeated non-attendance of appointments) and motivation to change (e.g. externalising all responsibility, or believing they completely lacked agency in their actions).

2. 2. (18%) – Extremely harmful substance misuse or dependence.

3. 3. (13%) – The underlying diagnosis (e.g. not meeting diagnostic criteria for a personality disorder or a severe psychopathy) and level of severity (e.g. too mild for a specialist service).

4. 4. (11%) – Identified areas of psychological work has very little to no relation to interpersonal difficulties or relationships.

5. 5. (11%) – A comorbid eating disorder (e.g. BMI < 17.5).

6. 6. (9%) – Another service identified as being more appropriate (e.g. another psychological service).

7. 7. (8%) – Risk of aggression to the therapist.

8. 8. (5%) – Comorbid axis I disorder being the primary problem.

9. 9. (5%) – Extreme self-harming behaviours requiring crisis interventions.

Referrers

1. 1. To accept that many patients with PD will fail to actively engage in psychotherapy.

2. 2. To consider whether severity is of a level requiring specialist PD treatment; or if the patient needs a forensic psychotherapy service rather than a non-forensic PD service.

3. 3. To consider whether the comorbid conditions (e.g. dependent alcohol use) are in fact the primary diagnosis and thus require treatment before the PD service intervention.

PD services

1. 1. Need to develop novel interventions to help patients become more active and engaged in the assessment and thus progress onto treatment.

2. 2. Need to inform referrers on their criteria for not offering treatment, allowing referrers the ability to gauge more accurately when to refer the patient.

As the next generation of doctors, medical students' perception of patients with personality disorder (PD) is critical. Yet a systematic review of the literature shows this has not been studied. The study aims to identify 1) the understanding and perception of medical students about PD and 2) factors that may relate to this knowledge and perception.

A focus group discussion (FGD) was conducted with eight medical students in their sixth year at Amoud University, Somaliland. We presented a case vignette of a patient with typical Borderline PD symptoms (which would meet DSM5 criteria for Borderline PD) and used Barts Explanatory Model Inventory (BEMI) to explore the issue. The FGD was recorded, transcribed, translated and thematically analysed.

The Medical students showed accurate knowledge regarding Borderline PD, recognising features of unstable mood, impulsiveness, and emptiness. Medical students showed binary perception, whether this patient was ‘crazy’ (waali) or not crazy. They perceived their community as a strong African Muslim population. Half the participants believed religious intervention would be helpful “I believe in Islam. So, to some degree it could be managed in certain religious centrs”. Importantly, medical students, when asked to divest of their professional identity, and to describe their personal views as members of the local population, then associated PD with craziness or madness.

The views of PD as craziness or ‘madness’ and the role of religious intervention have important implications for training and service development. The importance of a culturally sensitive training to medical students regarding PD in order to match cultural and religious views, and consideration of development of health services which are sensitive to religious practice is highlighted. We recommend including social and cultural implications in the training of medical students to better prepare them for the complexity of managing PD.

Transference-focused psychotherapy (TFP) is a manualized evidence-based treatment for severe personality disorders (PDs) based on a psychodynamic approach that focuses on object relations theory. It has been used as a teaching tool in different psychiatric settings. Psychiatry trainees are often the “first-responders” in multiple services, and they have to deal with patients with PDs in various settings. Yet there is a documented gap in psychiatry trainees’ education regarding the assessment and management of patients with PD pathology. The aim of our study was to evaluate whether a series of teaching sessions on TFP theory and techniques as applied to PD could improve the attitude and technical confidence of psychiatric trainees in the clinical encounter of a patient with a PD.

Two cohorts of psychiatry trainees in Tower Hamlet's East London Foundation Trust received four teaching sessions, each of one hour duration, on TFP theory and techniques. All the sessions were delivered online, using video teleconferencing software. 14 Trainees completed 2 questionnaires, pre- and post-teaching: the Attitude to Personality Disorder Questionnaire (APDQ) and the Clinical Confidence with Personality Disorder Questionnaire (CCPDQ). The APDQ asks the responder to score from 1–6 the frequency they experience certain feelings towards patients with PD. In the absence of a suitable instrument, we developed the CCPDQ consisting of a set of 13 questions rated on a 6-point Likert scale addressing key issues identified in TFP including establishing and maintaining the treatment frame and in implementing the 4 main techniques. We also conducted a 1-hour focus group post teaching which was videorecorded, transcribed, and analysed thematically.

On quantitative analysis, the Wilcoxon signed-rank test indicated statistically significant improvements in the total APDQ score (P = 0.003, r = 0.81) and in the CCPDQ questionnaires (P = 0.001, r = 0.88).

The thematic analysis showed an overall positive effect of the TFP teaching on trainees’ attitude and confidence: they felt it improved their understanding of the nature of personality disorder, their awareness and management of countertransference, awareness of object relations and relation dyads at play in the encounter.

Training junior doctors about TFP theory and techniques as applied to PD can significantly improve their attitude towards these patients and their technical confidence in the clinical encounter. Of note, our workshop is resource light and can easily be delivered by remote teaching. Based on these findings, teaching of TFP in the core psychiatric training curriculum should be considered.

We aimed to describe the demographic and clinical profile, and management of frequent attenders to a psychiatric liaison service.

Frequent Attenders to emergency departments contribute significantly to the burden on health services and by definition are subjectively highly stressed. It is therefore important that mental health services develop effective responses to this group of patients. A systematic literature search indicated a paucity of information on this group of patients.

We conducted a case series of 49 frequently attending patients to the Psychiatric Liaison service in Tower Hamlets, East London NHS Foundation Trust.

We defined frequent attenders as seeing the Psychiatric Liaison Service 5 or more times in 2018. We excluded 4 patients aged <18 years or >65 years.

For each patient we collected data regarding their demographics; the details of each attendance to the Psychiatric Liaison Service; and their use of other psychiatric services.

We then conducted a multivariate analysis, including stratification of patients based on number of attendances to identify correlation between frequency of attendance and the other information.

Demographic: The 45 patients reviewed had a mean age of 37 and a mean of 7 attendances during the study period.

Clinical: 89% had a history of emotional trauma, 71% of substance misuse, and 49% of any personality disorder. Only 9% of the patients were under the care of the locality Personality Disorder Service.

73% of the patients were under the care of any other psychiatric service. There was no correlation between being under other services and the frequency of attendance.

Only 31% had contact with the locality Frequent Attenders Service during the study period, as this was established recently.

Psychiatric Frequent Attenders have complex needs, which do not fit neatly into existing psychiatric diagnoses and services.

The high frequency of emotional trauma, substance misuse and personality disorder indicates a need for training of clinicians in these services to manage these patients, as well as planning for referral pathways for this group of patients who provide services with major challenges in appropriate pathways to care and follow-up

The aim of this paper is to describe key findings and recommendations of SUI reports regarding patients with a diagnosis of PD in East London NHS Foundation Trust (ELFT). Patients with a diagnosis of PD are often involved in SUIs with regards to risk to themselves or others. Contributing factors might be the nature of their disorder in terms of mood instability and impulsivity, self-harming or antisocial behaviour, and the difficulties posed to assessing clinicians in predicting risk.

Patients with PD present severe challenges to services. SUI findings thus serve as a lightning rod for issues in their management. With the emergence of NICE guidelines for borderline PD [2009] and antisocial PD [2009] regarding risk assessments, there has been greater optimism for management of PDs.

A case series of 50 SUI reports of patients with a diagnosis of PD were identified from the governance and risk management team of ELFT. Themes were categorized as positive practice, contributory factors, and recommendations. Findings are related to guidelines in NICE and RCPsychiatry. Any patient with a diagnosis of PD (of any sub-type) that was involved in a SUI in ELFT met the inclusion criteria. There were no exclusion criteria.

The most frequent themes in positive practice were ‘continuity of care’ and ‘clinical practice’. The most frequent subthemes in clinical practice were ‘assessments’ and ‘follow-up’. ‘Continuity of care’ included examples of collaborative working between various teams, as in joint assessments, good communication, and timely referrals. In contributory factors ‘poor documentation’ was the most frequent theme. 14 reports found no contributory factors. In recommendations the most frequent theme was the need for development and implementation of PD policies and for improved risk management.

NICE guidelines stress the importance of continuity of care and good clinical care and it is commendable that these were findings in positive practice. The importance of documentation being accurate and timely needs underlining in hard pressed time poor clinicians. Services would do well to review PD policies specifically regarding risk management at a wider Trust and local service level. Our findings point to the ongoing need for workforce development as recommended in the RCPSych position statement on PD published in January 2020.

Hypothesis: Personality Disorder (PD) adolescents, compared to non-PD case, have a worse experience at transition.

Aims: To describe the outcomes of referrals of adolescents for transition to adult services and compare PD and non-PD populations to identify potential improvements to allow for better transition experience of the PD patients.

Borderline PD is prevalent in adolescents - although there is a reluctance to make the diagnosis. When patients reach graduation from CAMHS, many fall through the ‘gap’ in services during the transition. Consequently, adding the paucity in research about the transition experience of PD patients, it is important to evaluate what happens to these patients during the transition process to help better understand their experience, and how it can be improved.

Patient's clinical records from Tower Hamlet CAMHS, East London NHS Foundation Trust, were reviewed retrospectively from July 2018 to November 2019, assessing whether optimal transition standards were met. A total of 41 cases that transitioned from CAMHS to AMHS were identified. Transition standards compared were: information sharing – case and risk, parallel care, transition planning and continuity. PD diagnosis was identified based on the recording of this diagnosis or meeting DSM5 criteria from the notes. PD and non-PD transition experience was compared.

36 were given a diagnosis by the CAMHS clinician at transition and 5 had no diagnosis assigned. No cases had a PD diagnosis made by the CAMHS clinician, however 1 case mentioned ‘PD traits’, 1 mentioned ‘EUPD’ as a possible differential and 2 cases were labelled as ‘emotional dysregulation’. The research team found 17 cases that met DSM5 criteria for PD diagnosis.

Comparing transition experience of PD vs non-PD patients, the PD patients had a less optimal transition process. Statistical analysis using Chi Square Tests, showed significantly less optimal transition planning (X2 = 5.103, p < 0.05) and continuity (Fisher's exact test p = 0.049). Cohens W indicated a medium effect for transition planning and continuity.

Adolescents with a diagnosis of PD transition less well to Adult MHS than those without the PD diagnosis. Implications of our findings point to 1) the importance of considering a diagnosis of PD 2) if the diagnosis of PD is made, to anticipate greater difficulties in transition 3) the need to identify specific reasons for transition difficulties related to patient, clinician and system factors and their interrelation.

To evaluate whether a brief training using a Mentalization-Based Treatment (MBT) model improves attitudes of trainee psychiatrists working with patients with personality disorder. Trainee psychiatrists (n = 49) completed the Attitudes to Personality Disorder Questionnaire before and after a training consisting of two 3 h lectures on (a) theory of personality disorder and (b) practical skills using an MBT role-play.

There was a significant improvement on composite scores of attitude, with small to moderate effect size (Wilcoxon signed-rank test Z = 3.961, P < 0.001, r = 0.40).

Brief MBT-informed teaching oriented to the clinical situation appears to have a positive effect on attitudes towards people with personality disorder.

Research drives innovation and improved practice in psychotherapy. We describe views of members of the Faculty of Medical Psychotherapy of the Royal College of Psychiatrists (RCPsych) regarding their knowledge, experience and perspectives on psychotherapy research. We sent questionnaires to the Faculty membership emailing list.

In total, 172 psychiatrists from all levels of training returned fully complete responses. Respondents considered knowledge of psychotherapy research to be important to clinical work. Many have qualifications and experience in research but lack current opportunities for research involvement and would welcome the Faculty doing more to promote psychotherapy research. Perceived obstacles to research involvement included lack of competence, competing demands and wider organisational factors.

The lack of research opportunities for medical psychotherapists may lead to their underrepresentation in psychotherapy research and a less medically informed research agenda. Providing support at academic, RCPsych and National Health Service organisational levels will allow more clinically relevant research not only in psychotherapy but in other psychiatric disciplines as well.

Learning psychotherapy can be difficult and stressful. We explore core trainees’ (n = 5) views on undertaking a psychodynamic psychotherapy training case using transference-focused psychotherapy (TFP), in an East London NHS Foundation Trust supervision group. We used framework analysis of focus group interviews to examine trainees’ concerns, their views about this experience and its impact on general psychiatric practice.

Trainees described various concerns on starting: providing an effective intervention, insufficient experience and training-related pressures. However, they found that TFP addressed some of them and was helpful for learning psychodynamic psychotherapy. Difficulties around the countertransference remained at end-point. Trainees suggested that introductory teaching and learning through observation might be worthwhile.

Trainees’ experience suggests that an evidence-based operationalised approach such as TFP can be integrated into the core psychiatry curriculum as a psychodynamic psychotherapy learning method. Trainees report benefits extending to other areas of their practice.

After reading this article you will be able to:

• • Apply an understanding of object relations theory to interactions with patients with Borderline Personality Disorder (BPD)

• • Describe the use of the treatment contract and technical neutrality

• • Understand and better manage the countertransference in working with patients with BPD

None.

In 1988, Lewis and Appleby demonstrated that psychiatrists hold negative attitudes towards patients with personality disorder. We assessed the attitudes of psychiatry trainees towards patients with borderline personality disorder and depression, expecting an improvement. 166 trainees were block randomised to receive one of four case vignettes that varied by diagnosis and ethnic group. We used Lewis and Appleby's original questionnaire and the Attitudes to Personality Disorder Questionnaire (APDQ).

We received 76 responses. Lewis and Appleby's questionnaire showed more negative attitudes towards personality disorder than depression, with no significant patient ethnic group effects, and the APDQ also showed a (weak) trend towards more negative attitudes to personality disorder. In subgroup analysis, only in the White British patient group were there significantly more negative attitudes to personality disorder. Factor analysis showed significantly less sense of purpose when working with personality disorder.

The perceived greater lack of purpose in working with personality disorder should be the target of clinical training and intervention. Targeted interventions that include training in managing personality disorder, supervision and practice in non-specialist, general psychiatry settings are important.

To select staff for a personality disorder service by exposing applicants to anticipated challenges. Applicants took part in a role play, an unstructured group with fellow applicants and numbers of the interviewing panel, and a panel interview. A service user representative was involved from the initial planning stage.

Multiple assessment methods enabled fine discrimination between applicants. Appointed staff said they felt the interviews were a valid test of required skills and have been well regarded by patients in the programme.

Selecting staff for a personality disorder service benefits from using multiple interview methods. The service user representative and role-play actor can contribute crucially by representing the patient's perspective. Key domains to assess include the applicant's psychological qualities, psychiatric skills and ability to work in a team.