Mental capacity and borderline personality disorder

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Abstract

The use of the Mental Capacity Act 2005 in assessing decision-making capacity in patients with borderline personality disorder (BPD) is inconsistent. We believe this may stem from persisting confusion regarding the nosological status of personality disorder and also a failure to recognise the fact that emotional dysregulation and characteristic psychodynamic abnormalities may cause substantial difficulties in using and weighing information. Clearer consensus on these issues is required in order to provide consistent patient care and reduce uncertainty for clinicians in what are often emergency and high-stakes clinical scenarios.

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Most cited references 17

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Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study.

John Markowitz, B. Ansell, T H McGlashan … (2011)

Borderline personality disorder (BPD) is traditionally considered chronic and intractable. To compare the course of BPD's psychopathology and social function with that of other personality disorders and with major depressive disorder (MDD) over 10 years. A collaborative study of treatment-seeking, 18- to 45-year-old patients followed up with standardized, reliable, and repeated measures of diagnostic remission and relapse and of both global social functioning and subtypes of social functioning. Nineteen clinical settings (hospital and outpatient) in 4 northeastern US cities. Three study groups, including 175 patients with BPD, 312 with cluster C personality disorders, and 95 with MDD but no personality disorder. The Diagnostic Interview for DSM-IV Personality Disorders and its follow-along version (the Diagnostic Interview for DSM-IV Personality Disorders-Follow-Along Version) were used to diagnose personality disorders and assess changes in them. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Longitudinal Interval Follow-up Evaluation were used to diagnose MDD and assess changes in MDD and in social function. Eighty-five percent of patients with BPD remitted. Remission of BPD was slower than for MDD (P < .001) and minimally slower than for other personality disorders (P < .03). Twelve percent of patients with BPD relapsed, a rate less frequent and slower than for patients with MDD (P < .001) and other personality disorders (P = .008). All BPD criteria declined at similar rates. Social function scores showed severe impairment with only modest albeit statistically significant improvement; patients with BPD remained persistently more dysfunctional than the other 2 groups (P < .001). Reductions in criteria predicted subsequent improvements in DSM-IV Axis V Global Assessment of Functioning scores (P < .001). The 10-year course of BPD is characterized by high rates of remission, low rates of relapse, and severe and persistent impairment in social functioning. These results inform expectations of patients, families, and clinicians and document the severe public health burden of this disorder.

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Treatment utilization by patients with personality disorders.

Mary C Zanarini, I Dyck, T H McGlashan … (2001)

Utilization of mental health treatment was compared in patients with personality disorders and patients with major depressive disorder without personality disorder. Semistructured interviews were used to assess diagnosis and treatment history of 664 patients in four representative personality disorder groups-schizotypal, borderline, avoidant, and obsessive-compulsive-and in a comparison group of patients with major depressive disorder. Patients with personality disorders had more extensive histories of psychiatric outpatient, inpatient, and psychopharmacologic treatment than patients with major depressive disorder. Compared to the depression group, patients with borderline personality disorder were significantly more likely to have received every type of psychosocial treatment except self-help groups, and patients with obsessive-compulsive personality disorder reported greater utilization of individual psychotherapy. Patients with borderline personality disorder were also more likely to have used antianxiety, antidepressant, and mood stabilizer medications, and those with borderline or schizotypal personality disorder had a greater likelihood of having received antipsychotic medications. Patients with borderline personality disorder had received greater amounts of treatment, except for family/couples therapy and self-help, than the depressed patients and patients with other personality disorders. These results underscore the importance of considering personality disorders in diagnosis and treatment of psychiatric patients. Borderline and schizotypal personality disorder are associated with extensive use of mental health resources, and other, less severe personality disorders may not be addressed sufficiently in treatment planning. More work is needed to determine whether patients with personality disorders are receiving adequate and appropriate mental health treatments.

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Life expectancy at birth and all-cause mortality among people with personality disorder.

Marcella Fok, Richard D. Hayes, Chin-Kuo Chang … (2012)

It is well established that serious mental illness is associated with raised mortality, yet few studies have looked at the life expectancy of people with personality disorder (PD). This study aims to examine the life expectancy and relative mortality in people with PD within secondary mental health care. We set out to examine this using a large psychiatric case register in southeast London, UK. Mortality was obtained through national mortality tracing procedures. In a cohort of patients with a primary diagnosis of PD (n=1836), standardised mortality ratios (SMRs) and life expectancies at birth were calculated, using general population mortality statistics as the comparator. Life expectancy at birth was 63.3 years for women and 59.1 years for men with PD-18.7 years and 17.7 years shorter than females and males respectively in the general population in England and Wales. The SMR was 4.2 (95% CI: 3.03-5.64) overall; 5.0 (95% CI: 3.15-7.45) for females and 3.5 (95% CI: 2.17-5.47) for males. The highest SMRs were found in the younger age groups for both genders. People with PD using mental health services have a substantially reduced life expectancy, highlighting the significant public health burden of the disorder. Copyright © 2012 Elsevier Inc. All rights reserved.

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Author and article information

Journal

Journal ID (nlm-ta): BJPsych Bull

Journal ID (iso-abbrev): BJPsych Bull

Journal ID (hwp): pbrcpsych

Title: BJPsych Bulletin

Publisher: Royal College of Psychiatrists

ISSN (Print): 2056-4694

ISSN (Electronic): 2056-4708

Publication date (Print): February 2017

Volume: 41

Issue: 1

Pages: 33-36

Affiliations

[1 ]South London and Maudsley NHS Foundation Trust, London

[2 ]Institute of Psychiatry, Psychology and Neuroscience, King's College London

[3 ]University of Bristol

Author notes

Correspondence to Karyn Ayre ( karyn.ayre@ 123456slam.nhs.uk )

Karyn Ayre is an Academic Clinical Fellow, South London and Maudsley NHS Foundation Trust, London; Gareth S. Owen is a Clinical Senior Lecturer and Honorary Consultant Psychiatrist, Institute of Psychiatry, Psychology and Neuroscience, King's College London; Paul Moran is a Reader and Honorary Consultant Psychiatrist, Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol.

Article

DOI: 10.1192/pb.bp.115.052753

PMC ID: 5288091

PubMed ID: 28184315

SO-VID: 05b835ba-d8b5-4fee-b319-b2dc6675a388

License:

This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 30 September 2015

Date revision received : 2 February 2016

Date accepted : 24 February 2016

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Mental capacity and borderline personality disorder

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Social Behavior and Personality: an international journal

Most cited references 17

Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study.

Treatment utilization by patients with personality disorders.

Life expectancy at birth and all-cause mortality among people with personality disorder.

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