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Management of personality disorder 

Management of personality disorder
Management of personality disorder

Giles Newton-Howes

and Kate Davidson

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date: 01 July 2022

Some years ago that most sceptical of academic psychiatrists, Michael Shepherd, in referring to the contents of a book entitled Recent Advances in Psychiatry commented that the content was more accurately defined as ‘recent activities’, as ‘advances’ was too generous a word. Whilst not going quite as far as this in regard to advances in the treatment of personality disorder it is fair to add that the promise of effective therapies across the spectrum of personality dysfunction remains a long way off and we must be very careful not to oversell the evidence. The complexity of personality disorders often requires complex intervention, however, until we are confident that single treatments are effective the arguments for evaluating them in combination have to be very strong on theoretical grounds to justify the cost. We are still at the stage in which explanatory trials (ones demonstrating efficacy under optimal conditions) are at least as necessary as pragmatic ones (demonstrating benefit in conditions of ordinary practice). These need to be carried out with adequate numbers of patients (at least 50 in each treatment arm rather than an artificially derived sample size to justify a small number) and with good independent assessments carried out by research workers who are masked as much as possible from disclosure of treatment. These requirements are exacting but can be achieved. We also need better pragmatic trials of patients seen in ordinary mental health practice whose treatment and characteristics are both representative and from whom it is possible to generalize findings with confidence. Currently there are very few studies that satisfy this requirement; one recent study combining an educational intervention with problem-solving is an exception. Despite the caution of these statements these are exciting times in the management of personality disorder. We are no longer listening to the once powerful lobby that claimed that patients with these conditions should not be treated by psychiatric services, or to the pessimists that still regard these conditions as untreatable. We are in the equivalent position as those in the early 1950s who suddenly became aware of the possibility that powerful treatments for severe mental illness were ready and waiting to be used. They do indeed appear to be within reach, but we must use them wisely.

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