Personality Disorder Personality Disorder Services in NHS Highland: Services in NHS Highland:

Challenges and Challenges and DevelopmentsDevelopments

Dr Tim Agnew, Consultant Dr Tim Agnew, Consultant Psychiatrist and Lead in NHS Psychiatrist and Lead in NHS Highland Personality Disorder Highland Personality Disorder

Service.Service.

OverviewOverview

NHS HighlandNHS Highland Services available as of 2009Services available as of 2009 ChallengesChallenges Recent developmentsRecent developments Future developmentsFuture developments QuestionsQuestions

NHS HighlandNHS Highland

41% of landmass of Scotland41% of landmass of Scotland 33,000km² 33,000km² Only 6% of Scottish population (300 000)Only 6% of Scottish population (300 000) Two thirds in very low population densitiesTwo thirds in very low population densities Biggest centre of population Inverness (40 Biggest centre of population Inverness (40

000)000) Difficult terrainDifficult terrain Limited infrastructureLimited infrastructure

NHS HighlandNHS Highland

4 Community Health Partnerships 4 Community Health Partnerships (CHPs)(CHPs)

Services for North, Mid and South-Services for North, Mid and South-East Highland CHPsEast Highland CHPs

Argyll and Bute CHP has its own Argyll and Bute CHP has its own major process of service redesign major process of service redesign ongoing including psychological ongoing including psychological therapy servicestherapy services

Situation in 2009 in 3 Situation in 2009 in 3 Northern CHPsNorthern CHPs

Specific services for Borderline PDSpecific services for Borderline PD Generic services for all other PDsGeneric services for all other PDs

Specific services for BPDSpecific services for BPD

Structured admission programStructured admission program

Dialectical Behaviour Therapy (DBT)Dialectical Behaviour Therapy (DBT) CBT-BPD (Davidson)CBT-BPD (Davidson)

Services for all PDsServices for all PDs

Clinical psychologyClinical psychology Primary care Primary care CMHTs CMHTs In-patient servicesIn-patient services Liaison psychiatryLiaison psychiatry

DBT serviceDBT service

DBT has been mainstay for BPDDBT has been mainstay for BPD First group of therapists trained in 2006First group of therapists trained in 2006 Three groups trained to date (24 in total)Three groups trained to date (24 in total) 18 therapists amounting to 2 WTE18 therapists amounting to 2 WTE Anyone meeting DSM IV criteria offered 1 Anyone meeting DSM IV criteria offered 1

year of DBTyear of DBT Very intensiveVery intensive

DBT serviceDBT service

Problems with increasing waiting Problems with increasing waiting timestimes

Limited capacity, large referral Limited capacity, large referral numbersnumbers

Situation unsustainableSituation unsustainable

DBT ServiceDBT Service

BPD is a polymorphic disorderBPD is a polymorphic disorder 256 varieties256 varieties Severity was measured using Severity was measured using

number of DSM IV criterianumber of DSM IV criteria DBT is over-intensive intervention for DBT is over-intensive intervention for

somesome

DBT serviceDBT service

Evidence suggests DBT is best at Evidence suggests DBT is best at reducing parasuicidal behaviour and reducing parasuicidal behaviour and hospital admissionshospital admissions

Stage 1 DBT – behavioural Stage 1 DBT – behavioural stabilisationstabilisation

Decided to prioritise on basis of:Decided to prioritise on basis of: parasuicidal behaviour parasuicidal behaviour psychiatric hospital admissionspsychiatric hospital admissions

DBT serviceDBT service

Allows quicker response for these Allows quicker response for these individualsindividuals

What to offer everyone else?What to offer everyone else? Some patients seemed to prefer skills Some patients seemed to prefer skills

groups to individual workgroups to individual work Skills group work twice as efficient in Skills group work twice as efficient in

terms of therapist time as individual terms of therapist time as individual workwork

What about a skills group What about a skills group standalone?standalone?

Oft-quoted (but unpublished) study by Oft-quoted (but unpublished) study by Linehan does not suppport utility of skills Linehan does not suppport utility of skills training alonetraining alone

Some emerging evidence for DBT-ST (Soler, Some emerging evidence for DBT-ST (Soler, 2009)2009) Single centre, randomised, two-group trialSingle centre, randomised, two-group trial DBT-ST or “Standard Group Therapy” for 13 weeksDBT-ST or “Standard Group Therapy” for 13 weeks 63 patients63 patients Seemed to have an impact on affective symptomsSeemed to have an impact on affective symptoms No effect on parasuicidal behaviourNo effect on parasuicidal behaviour

Other considerationsOther considerations

STEPPS (Systems Training for STEPPS (Systems Training for Emotional Predictability and Problem Emotional Predictability and Problem Solving) RCTSolving) RCT

All DBT therapists already trained to All DBT therapists already trained to deliver skills groupsdeliver skills groups

Existing supervision system (DBT Existing supervision system (DBT consult groups)consult groups)

Theoretical coherenceTheoretical coherence

DrawbacksDrawbacks

No really robust evidence for No really robust evidence for approachapproach

No individual therapyNo individual therapy FormulationFormulation Skills generalisationSkills generalisation ValidationValidation DialecticsDialectics Problem solvingProblem solving

No individual therapistNo individual therapist

4 individual sessions before group 4 individual sessions before group workwork Crisis planCrisis plan Written formulation Written formulation

Extra module (Foundation module)Extra module (Foundation module) Psycho-educationPsycho-education Validation, dialectics, problem solvingValidation, dialectics, problem solving

3 final group sessions3 final group sessions Agenda set by groupAgenda set by group

No RCT evidenceNo RCT evidence

Service-based evidenceService-based evidence Same regular assessment/ outcome Same regular assessment/ outcome

tools as full DBT tools as full DBT Pilot onlyPilot only Re-evaluate after one run-throughRe-evaluate after one run-through

Skills Training Program Skills Training Program (STP)(STP)

Starts next weekStarts next week 33 week run (plus 4 weeks individual 33 week run (plus 4 weeks individual

work)work) Closed group of 8 patientsClosed group of 8 patients 2 skills trainers2 skills trainers Good feedback for individual sessionsGood feedback for individual sessions

Personality Disorder ServicePersonality Disorder Service

Name change from DBT serviceName change from DBT service PDS offers:PDS offers:

DBTDBT STPSTP CBT-BPDCBT-BPD

Still only for people with BPD as Still only for people with BPD as primary presentationprimary presentation

Allows flexibility to develop further Allows flexibility to develop further

Life after DBTLife after DBT

Some feedback from individuals that Some feedback from individuals that there is a service gap after completion of there is a service gap after completion of DBTDBT

What is available after finishing DBT?What is available after finishing DBT? User-led “graduate” group not activeUser-led “graduate” group not active Possible DBT skills informed “graduate” Possible DBT skills informed “graduate”

group, CPN inputgroup, CPN input Some people wish to move away from Some people wish to move away from

this type of service after completing DBTthis type of service after completing DBT

Other perspectivesOther perspectives

Recent visit by Tom MullenRecent visit by Tom Mullen Multidisciplinary and service user Multidisciplinary and service user

attendanceattendance Stakeholders meeting plannedStakeholders meeting planned OTs keen to adapt Journey program locallyOTs keen to adapt Journey program locally Multidisciplinary visit to Leeds being Multidisciplinary visit to Leeds being

plannedplanned Volunteering HighlandVolunteering Highland

FutureFuture

PDS to expand educational role to PDS to expand educational role to CMHTs, primary care and in-patient CMHTs, primary care and in-patient wardswards

PDS to offer consultation service to PDS to offer consultation service to CMHTs, in-patient wardsCMHTs, in-patient wards

Expand CBT-PD provision within PDSExpand CBT-PD provision within PDS Specific provision in the localitiesSpecific provision in the localities Training in other approachesTraining in other approaches

Don’t forgetDon’t forget

AdministrationAdministration Overhaul of referral processOverhaul of referral process Overhaul assessment processOverhaul assessment process Revised prioritisationRevised prioritisation Standardised admin guidanceStandardised admin guidance New computerised database New computerised database

Main challengesMain challenges

Too much geographyToo much geography Not enough therapists with not Not enough therapists with not

enough timeenough time Increasing referralsIncreasing referrals

Main developmentsMain developments

Revision of prioritising factorsRevision of prioritising factors Skills Training ProgramSkills Training Program Database and admin overhaulDatabase and admin overhaul

Thank youThank you

Questions or comments?Questions or comments?

ReferenceReference

Soler J. et al, Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial. Behaviour Research and Therapy 47 (2009) 353-358

Blum et al., Systems Training for Emotional Predictability and Blum et al., Systems Training for Emotional Predictability and Problem Solving (STEPPS) for Outpatients With Borderline Problem Solving (STEPPS) for Outpatients With Borderline Personality Disorder A Randomized Controlled Trial and 1-Year Personality Disorder A Randomized Controlled Trial and 1-Year Follow-Up. Follow-Up. American Journal of PsychiatryAmerican Journal of Psychiatry 165 (4) 468 -- Am J 165 (4) 468 -- Am J PsychiatryPsychiatry

K. Davidson, J. Norrie, P. Tyrer, A. Gumley, P. Tata and H. Murray K. Davidson, J. Norrie, P. Tyrer, A. Gumley, P. Tata and H. Murray et al., The effectiveness of cognitive behavior therapy for et al., The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial, personality disorder study of cognitive therapy (BOSCOT) trial, Journal of Personality DisordersJournal of Personality Disorders 2020 (2006), pp. 450–465. (2006), pp. 450–465.

M.M. Linehan, H.E. Amstrong, A. Suarez, D. Allmon and H.L. Heard, M.M. Linehan, H.E. Amstrong, A. Suarez, D. Allmon and H.L. Heard, Cognitive-behavioral treatment of chronically parasuicidal Cognitive-behavioral treatment of chronically parasuicidal borderline patients, borderline patients, Archives of General PsychiatryArchives of General Psychiatry 4848 (1991), pp. (1991), pp. 1060–1064 1060–1064