Sign in to follow this  
Followers 0
manjupanatt

are we reluctant in making a personality diagnosis

26 posts in this topic

There is always a controversy when to diagnose personality disorders and the validity of the diagnosis.

some say it has to be after atleast a year of follow up without any axis 1 diagnosis. Some say that it could be made after a couple of sessions.

One consultant, few years ago, said there was no point in making a personality diagnosis as it would not affect the management.

I had an American trained Consultant who said that they would make personality diagnosis in one sitting and it was one of the clinical questions for the board exams.

Does a personality diagnosis alter the obligations of the doctor in the event of a critical incident..... i mean is it considered that the patient did it on his free will....like an antisocial personality disorder going on a killing spree(worst nightmare :-/) or a borderline personality disorder taking a serious overdose or killing themselves.

If we are forced to make a personality diagnosis amidst active axis 1 symptoms how can we ensure its validity..... :o

Share this post


Link to post
Share on other sites

a diagnosis of personality disorder doesn't mean that person does not have other diagnoses (eg depression, substance dependance, etc) and can be made on the basis of a single interview (the diagnostic criteria do not include anything about absence of symptoms of other disorders and in fact people with PDs often have higher rates of other consitions than the general population). also, it doesn't remove any of the obligations the doctor has or relate to any concept of 'free will' and may often affect the management.

Share this post


Link to post
Share on other sites

good question.

If I have sufficient information while history taking and current presentation justifies that, I dont hesitate in making a diagnosis of, for example, emotionally unstable PD which is most commonly encountered by all of us, even in my first assessment. This is because sometimes the situation demands it, in terms of decision making and to signpost the patient to right direction. Patients are quite accepting of the diagnosis of personality, if explained in a bit lay terms rather than medical jargon. Also, not only,in American exam system, but over here in OSCEs, there used to be link stations where you have to say to the examiner the diagnosis of personality as well.

I believe it does affect management. Saying that that it does not, is incorrect.

Regarding responsibility, I dont think getting the diagnosis of, for example dissocial PD would absolve that person of responsibity for smacking someone. It would have to be the criminal justice system. Same would apply to borderline taking serious ODs, at the end of the day the person himself would be responsible for what he/ she does to him.

Regarding obligation of the doctor in the event of a critical incident, if the risks have been documented properly, the assessments are documented properly, then it does minimise problems for the concerned doctor. Only the notes are gone through in the event of such an incident.  At the end of the day, u can acknowledge the risk  and act what u think is safe in that situation but then u have to do positive risk taking as well and then it all boils down to the  organisation u work in. It is impossible to eliminate the risk.

Regarding validity, nothing stops us from making the both the diagnosis at the same time, as long as these can be justified on the basis of criteria.

Share this post


Link to post
Share on other sites

I think it is ridiculous to give that definition alone. What do you tell someone with that disorder? ( remember this is a diagnosis driven era). 'So.. you got BPD.. I mean a Borderline .......  '.

yeah right now I know how to handle this high risk taking person  

'Thanx doc. So wht do i need? Or what can you  give me?' 'Hmmm... (tut)(tut)(tut) But then there are sooooo many therapies available to people with your ...'

You have to be able to give a psychological FORMULATION as well ( what does a diagnosis mean to you?)of the person's problems (so that they can disagree as well ) and come to some agreed conclusion of the management to hope for amelioration!!

Share this post


Link to post
Share on other sites

I am still unclear how we document the risks and prepare the safe plan when on call...

Usual presentation is I am going to kill myself; i have a rope in my loft; i know what i am going to do and U ARE GOING TO BE RESPONSIBLE!!

I could probably say that its the same presentation 1 week ago; or the team decision was not to admit her(re read staff says Consultant would kill you if you admit her)....

Any thoughts how you deal with this in an ideal environment.....

Share this post


Link to post
Share on other sites

Document your finding, explain the reasons you are making the decisions you have, discuss with senior staff if you are unsure. Explain to the patient that it is unfortunate if they decide to take their own life, but it is not your responsibility. They have the option to decide to do other things instead of killing themselves, so if they do go ahead, they are the only person that has to take responsibility for the consequences of that act.

We are not a suicide prevention service. If sane people choose to kill themselves it is nothing to do with us.

Share this post


Link to post
Share on other sites
Document your finding, explain the reasons you are making the decisions you have, discuss with senior staff if you are unsure. Explain to the patient that it is unfortunate if they decide to take their own life, but it is not your responsibility. They have the option to decide to do other things instead of killing themselves, so if they do go ahead, they are the only person that has to take responsibility for the consequences of that act.

We are not a suicide prevention service. If sane people choose to kill themselves it is nothing to do with us.

Disagree slightly, anyone committing suicide is our business, but the decision to kill oneself carries responsibility for the decision maker first. If known to us, we have to be seen to offer help. 'Insane' people are easier managed as there is a reason for which we can say they cant decide properly for themselves. 'Sane' are difficult to manage in that respect. But all in all, I dont wish anyone to die. One of course the humane reason, the other that the suicide ( and for that matter any SUI)enquiries are Dante's vision of hell on earth!!

Share this post


Link to post
Share on other sites
Disagree slightly, anyone committing suicide is our business, but the decision to kill oneself carries responsibility for the decision maker first. If known to us, we have to be seen to offer help. 'Insane' people are easier managed as there is a reason for which we can say they cant decide properly for themselves. 'Sane' are difficult to manage in that respect. But all in all, I dont wish anyone to die. One of course the humane reason, the other that the suicide ( and for that matter any SUI)enquiries are Dante's vision of hell on earth!!

Anyone committing suicide is our business? No way. If they have capacity, have no mental disorder, and have unimpaired decision making ability, then we have no business in saying what they can or cannot do. I wouldn't want anyone to die particularly, but then I also wouldn't want someone who had a really shitty life and who had come to the sound, logical decision to end it to have to go on suffering indefinitely.

Share this post


Link to post
Share on other sites

Here's my two-penny's worth:

1. There is nothing wrong with arriving at an Axis II diagnosis in the first contact, but it is quite difficult to be confident.

We would need enough corroborative evidence to say that such a set of behaviour is enduring, present in several spheres of life, arose from an early age, has not been episodic and is not the effect of any mental/physical illness or caused by psychoactive substance use.

2. A diagnosis is just a way of grouping a set of symptoms to a particular known catogory for ease of determining course, treatment, outcome and approach. It is not a value judgement.

As clinicians, we should not be worried about making a diagnosis just because of the stigma it would create.

3. We do have a duty of care towards people who access our service, but that does not make us responsible for their life choices and decisions. We are here to see if someone's decision making ability is impaired and advice management of the same, but that does not make us responsible for all deaths. The very assumption that all suicides are preventable does not hold much water.

4. Psychiatry has paternalistic roots, I agree, but we are like any other medical specialty in most ways: for eg. a doctor can advice someone not to smoke, but can not prevent him/her from doing so, if they choose to.

5. Another myth is that one has to admit someone into a secure place in order to prevent suicide. I have not read any convincing evidence that this is the case in the long term. (Please correct me, if I'm wrong: I'd like to read it if such an evidence exists!)

There are equally other interventions like a telephonic helpline, crisis service, befriending, etc. that can offer the ameliorative service.

6. The assumption that we prevent suicides is similar to the assumption on medical/surgical specialties that they prevent deaths!

Neither is the assumption that every person committing suicide should have a mental health problem, true.

Share this post


Link to post
Share on other sites
Disagree slightly, anyone committing suicide is our business, but the decision to kill oneself carries responsibility for the decision maker first. If known to us, we have to be seen to offer help. 'Insane' people are easier managed as there is a reason for which we can say they cant decide properly for themselves. 'Sane' are difficult to manage in that respect. But all in all, I dont wish anyone to die. One of course the humane reason, the other that the suicide ( and for that matter any SUI)enquiries are Dante's vision of hell on earth!!

Anyone committing suicide is our business? No way. If they have capacity, have no mental disorder, and have unimpaired decision making ability, then we have no business in saying what they can or cannot do. I wouldn't want anyone to die particularly, but then I also wouldn't want someone who had a really shitty life and who had come to the sound, logical decision to end it to have to go on suffering indefinitely.

So in some circumstances suicide is ok? or is it that we cant say it?

Share this post


Link to post
Share on other sites
Document your finding, explain the reasons you are making the decisions you have, discuss with senior staff if you are unsure. Explain to the patient that it is unfortunate if they decide to take their own life, but it is not your responsibility. They have the option to decide to do other things instead of killing themselves, so if they do go ahead, they are the only person that has to take responsibility for the consequences of that act.

We are not a suicide prevention service. If sane people choose to kill themselves it is nothing to do with us.

Well said

Share this post


Link to post
Share on other sites
Disagree slightly, anyone committing suicide is our business, but the decision to kill oneself carries responsibility for the decision maker first. If known to us, we have to be seen to offer help. 'Insane' people are easier managed as there is a reason for which we can say they cant decide properly for themselves. 'Sane' are difficult to manage in that respect. But all in all, I dont wish anyone to die. One of course the humane reason, the other that the suicide ( and for that matter any SUI)enquiries are Dante's vision of hell on earth!!

Anyone committing suicide is our business? No way. If they have capacity, have no mental disorder, and have unimpaired decision making ability, then we have no business in saying what they can or cannot do. I wouldn't want anyone to die particularly, but then I also wouldn't want someone who had a really shitty life and who had come to the sound, logical decision to end it to have to go on suffering indefinitely.

So in some circumstances suicide is ok? or is it that we cant say it?

Well, if someone tells you that, for example, her partner left her and she wants to kill herself as she cannot live without him, and you cannot find any evidence of depression, adjustment disorder,psychosis or anything that you can offer treatment for, then at least you cannot detain them under MHA. For somebody to be detained under MHA there should be evidence of mental disorder and sufficient risk to self/ others. Somebody can decide to kill themselves for any reason, including existential/ personal, because the world is a terrible place to live in, because they believe in a specific religion, etc, and you cannot deprive them of their liberty if they have capacity.

Of course, if you feel that the suicidal ideation is related to a personality disorder, then there is grounds to detain and treat. What I dont understand, is how you can treat somebody with PD against their will, as Psychological therapies should be our first line treatment. :(

Share this post


Link to post
Share on other sites

People may also choose to commit suicide for good reasons - a soldier throwing himself onto a grenade to save the lives of his comrades, a person running into the road to save someone from being knocked down, a person with a terminal illness who can no longer tolerate the pain, etc. There are many examples of people rationally weighing up the situation and seeing that suicide is a logical thing to do.

So yes, in some circumstances suicide is OK.

Share this post


Link to post
Share on other sites

The MHA 1983 is very broad. I'd argue that wanting to die was not an ordered state of mind. Someone wishing to die after a relationship has ended is not well. Previously they may have had family and friends around but lately it seems psychiatry fills that role. we may not be a suicide prevention service but we are the speciality with the resources to help people like this (through short-term 'respite' admissions, social workers, and HTT).A soldier sacrificing her life is just that - self-sacrifice not suicide. Also - given her job choice (soldier)- it is almost understandable in that context.

Someone with a terminal illness poses more of a quandary. If they wish to die because of the pain (and I haven't heard of people being sectioned for an adjustment disorder) I would guess that, if Hospice and pain relief are maxed out and antidepressants + counselling have been tried and are not beneficial, our role would be limited. I believe a trial of antidepressants and counselling couldn't hurt - if someone is suicidal their mood and biological symptoms are bound to be those of someone with depression - even if this depression would be described as 'reactive' in olden times.

I'm still amazed that, despite different constructs of PDs, we seem to miss that the D in PD is just that - a disorder as opposed to a trait. These patients have usually had terrible childhoods and lack trust. Their disorder makes them unable to tolerate frustration well and they have few friends and family sticking with them - if any. Their behaviour usually leads to a series of temporary work (and thus financial difficulties) and difficulties with boundaries. They often use drugs and alcohol - both as a coping mechanism and because of their destructive personalities.

And we ask them to take responsibility? Seriously? I know we get frustrated with these patients (who GPs call heartsinks) but I avoid using the term PD because IMHO I see services use that label to avoid seeing the untreated recurrent depression and as an excuse to disengage and abandon these patients - which is exactly what happens to the patients over and over again. Also - staff start calling them PDs!

We never really see the cluster A and C - usually borderlines and dis-socials. And they use up a ot of our resources - not just repeated admissions (admitted overnight by on-call ST, discharged the next day by team to HTT - if they accept the pt!). But these patients also call the ward, HTT, drug and alcohol service, police, psychological services - and in most cases it seems to be either time or getting a stable relationship (usually marriage!) that seems to help.

Psychiatry does seem to be getting overwhelmed -particularly as more and more things get medicalised and as our society gets more and more obsessed with 'health and safety' and being politically correct. People are being referred for their behaviour and more and more psychiatrists shy away from telling people that they have no mental illness - because if they do that person will complain to the CEO/MP who then interferes with the qualified specialist from doing their job!

What is the REAL value in making an ICD10/DSM IV diagnosis for the patient? Does it get them access to more benefits or services? Do all of our patients fit neatly into the criteria designated by consensus? Should we see everyone as an individual and work towards gettng more understanding of them? How many of us GET collateral information in our busy days- or even get a chance to read old [not on the computer!] notes? Yes, some patients like to know and do further research (the miracle of Google!) but, after being told they have features of a PD does the person giving them the weighty bit of news then go on to give a structured plan of treatment or do they say 'Well , so you're responsible for your actions. G'bye!'.

The whole PD issue is going to be even more fascinating in November with the new MHA.

Share this post


Link to post
Share on other sites
People may also choose to commit suicide for good reasons - a soldier throwing himself onto a grenade to save the lives of his comrades, a person running into the road to save someone from being knocked down, a person with a terminal illness who can no longer tolerate the pain, etc. There are many examples of people rationally weighing up the situation and seeing that suicide is a logical thing to do.

So yes, in some circumstances suicide is OK.

Hang on, these are acts of selfless thinking, not the selfish theme that we are talking about. And that's why they aren't classed under 'self harm' as well. If a person were thinking of killing themselves for whatever reason, I would hope that they cold be offered some advice against it. Self preservation is a primary instinct and to go against it in my thinking is unnatural. If you are mentally ill that your judgement is impaired then there are some grounds to treat against someone's will, and if not mentally ill, the choice is with the person, but surely it's not rational to think one should kill oneself (usually to get away from such situation).

BTW agree with the initial part of Freudian's post :)

Share this post


Link to post
Share on other sites
Hang on, these are acts of selfless thinking, not the selfish theme that we are talking about. And that's why they aren't classed under 'self harm' as well. If a person were thinking of killing themselves for whatever reason, I would hope that they cold be offered some advice against it. Self preservation is a primary instinct and to go against it in my thinking is unnatural. If you are mentally ill that your judgement is impaired then there are some grounds to treat against someone's will, [highlight]and if not mentally ill, the choice is with the person,[/highlight] but surely it's not rational to think one should kill oneself (usually to get away from such situation).

BTW agree with the initial part of Freudian's post  :)

So we agree. Someone who is not mentally disordered, but who still chooses to, is not someone who should fall within the remit of psychiatrists. And how do you know it is not rational to think one should kill oneself? I guess until people are in a situation where that becomes a real choice it is not possible to say. And how unusual is it? Well 15% of junior doctors reported suicidal ideation in the wake of the MTAS fiasco just last year. Were they all mentally ill, or not thinking rationally? I hope not, for the sake of all their patients...

Share this post


Link to post
Share on other sites
Hang on, these are acts of selfless thinking, not the selfish theme that we are talking about. And that's why they aren't classed under 'self harm' as well. If a person were thinking of killing themselves for whatever reason, I would hope that they cold be offered some advice against it. Self preservation is a primary instinct and to go against it in my thinking is unnatural. If you are mentally ill that your judgement is impaired then there are some grounds to treat against someone's will, [highlight]and if not mentally ill, the choice is with the person,[/highlight] but surely it's not rational to think one should kill oneself (usually to get away from such situation).

BTW agree with the initial part of Freudian's post  :)

So we agree. Someone who is not mentally disordered, but who still chooses to, is not someone who should fall within the remit of psychiatrists. And how do you know it is not rational to think one should kill oneself? I guess until people are in a situation where that becomes a real choice it is not possible to say. And how unusual is it? Well 15% of junior doctors reported suicidal ideation in the wake of the MTAS fiasco just last year. Were they all mentally ill, or not thinking rationally? I hope not, for the sake of all their patients...

Sorry my friend I only agree that suicide is a personal choice. But I think it is a wrong choice which should be challenged in all cases. Whether there is something treatable or whether short time help and support are needed is individual circumstance. If someone had (someone did for the visa issue) killed themselves in the now well agreed MTAS 'fiasco', would you have never tried to help them? Or would they be 'unhelpable' as they didnt have a mental disorder. Where I disagree anyway, extreme stress also produces short term mental decisions, just because they are not classified doesn't mean that the decisions taken at the time are 'sane'. I dont want to medicalise everything but i dont want to deny anyone help for not fitting into a 'criteria'.

Share this post


Link to post
Share on other sites
Sorry my friend I only agree that suicide is a personal choice. But I think it is a wrong choice which should be challenged in all cases. Whether there is something treatable or whether short time help and support are needed is individual circumstance. If someone had (someone did for the visa issue) killed themselves in the now well agreed MTAS 'fiasco', would you have never tried to help them? Or would they be 'unhelpable' as they didnt have a mental disorder. Where I disagree anyway, extreme stress also produces short term mental decisions, just because they are not classified doesn't mean that the decisions taken at the time are 'sane'. I dont want to medicalise everything but i dont want to deny anyone help for not fitting into a 'criteria'.

I concur - wholeheartedly.

F_S

Share this post


Link to post
Share on other sites

I don't think I said they were unhelpable, or that they should not be helped. I just said that it is not within the remit of psychiatry. There are other places they could turn to for help if they wish, like the Samaritans, etc. If they choose not to take up that route, then we can't compel them to.

Share this post


Link to post
Share on other sites

And why not ALSO within our remit? We are supposed to be experts on the mind and its problems. Surely we also can give advice and help. But I think the medicolegal environment today just kills such spirit in a lot of people (me included sometimes). Who wants the hassle!

Share this post


Link to post
Share on other sites
And why not ALSO within our remit? We are supposed to be experts on the mind and its problems. Surely we also can give advice and help. But I think the medicolegal environment today just kills such spirit in a lot of people (me included sometimes). Who wants the hassle!

Because we are here to diagnose and treat severe and enduring mental illness. There are other agencies who are better equipped to deal with sane people who are in despair.

Share this post


Link to post
Share on other sites
Because we are here to diagnose and treat severe and enduring mental illness. There are other agencies who are better equipped to deal with sane people who are in despair.

NWW seems to have come out of the fact that consultant psychiatrists were struggling with the inexorable tide of dissatisfied people who were usually dumped on psychiatry after exhausting the patience of many other services.

A couple of years into psychiatry and my assessments in A&E are taking longer now than they did 2 years ago. I do try and formulate a differential but my plans are less rigid. I've occasionally rung around trying to get a punter a loan or a room for the night. I've had to negotiate with (very lovely) A&E consultants when there's been a massive bed shortage because someone didn't want to go several hours away to the next available bed. And I'm sure we all have.

My argument is that, as far as I can see, sane people do not try and kill themselves. Leaving out the previous arguments (soldier's duty, terminal illness' emotional and physical pain) you have to be pretty desperate to feel that death is the only available option to you.

And who is going to deal with this devastated person? Lifeline? Social services? They don't often have a strong network of friends or family.

I think listening is the most valuable thing I can offer an 'overdose' when I'm on call. If I'm not harassed with idiotic bleeps ['the zopiclone needs re-writing - we forgot to do it in the day!'] I even attempt to get the 'overdose' to look at their cognitions and reactions to stress. Sometimes we just discuss their diagnosis [e.g. the chronic 'borderlines'] and what it means for them and what they plan to do to cope with stress/alcohol/their debts.

Of course there should be other places people can get help but they can't often face dealing with the debt collection letters or getting a CAB appointment. So they cut or OD and wind up in A&E and the psych ST traipses out to see them.

And even if all we do is listen - I think we've done something important. I don't think 90% of our work is to do with severe and enduring mental illness anymore - though NWW seems to want us to ony deal with the complicated , treatment resistant folk- which I think is a potent recipe for job dissatisfaction.

F_S

(who is trying to resist being jaded - just a little longer!)

Share this post


Link to post
Share on other sites

FS, i liked that bit where u said:

And we ask them to take responsibility? Seriously?

It reminds me of what is finally being said about the so called 'knife culture' ie parents should be resonsible for their children. Indignant parents have been heard saying why should the government tell me how to raise my children. I am a good citizen I pay my taxes. The government should do something about it - they should put my money into good use.

It's so easy to put the onus on responsibility on others. THe pd's are good at it, but the rest of us aren't far behind! If we ask a pd to take some responsibility, it should be a sort of mentalisation process. It doesn;t end by saying it's ur fault if u die. It should be followed up with a discussion on what they can do to keep themselves safe, what resources they have to help them with their crisis etc. It's acknowledging that they are feeling stuck and that they cant solve the problem on their own. it should come with the suggestion that there are ways in which the problem can be tackled without an admission. Some pd also take on board the concept of a 'rebound phenomenon' - ie the problem hits u harder when u are discharged.

I have voted in favour of making a diagnosis only after a thorough histroy and collateral. I am wary of making a hasty decision due to many reasons:

- often it tends to make professionals dismissive about a patient's problems

- we are aware of the sinking feeling we have, and tend to forget just how miserable it might be for the person himself

- in an a n e situation, i would take into account current circumstances and the potential risks. even if a patient were a known pd, i would as has already been said - listen to the patient. I would also try and admit such a patient if need be.

- I haven't seen the statistics, but those of u who have working in the same area for 2-3 years may agree that most pd patients do manage without turning up to the a n e every friday. The revolving door phenomenon comes in tides and ebbs. They will come only when there is a percieved crisis...after which either the crisis is solved, or else they slowly get so fed up of the admit-discharge cycle that they try and modify their behaviour - they up the ante, then settle down or wind up in hosptial or attempt suicide] or even cope without coming to the a n e. So not all pd are trying to make our lives miserable.

I can recall a few pd patients, who have been responsible for how i feel. Sure there are many agencies out there who could be seen doing the job. Very few of them would do it out of hours, and even fewer would be held responsible if something did go wrong. If we can't be a**sed to talk to these people, then can we really expect much from less psychologicaly minded colleagues? Sometimes we just have to pick up the lose ends and present them to our professional colleagues, and sometimes this process will have to start in the a n e.

Share this post


Link to post
Share on other sites

thought this might be of interest to people- the guidance on criminal responsibility in personality disorder by british psychological society :)

[highlight]Should people with personality disorder be held criminally responsible?[/highlight]

Legal determination of guilt is based on the law’s view that people are autonomous agents who

can be held morally, and hence criminally responsible. The law’s concern with ‘insanity’ as an

excuse from legal blame assumes that only in serious mental disorders is the ability to make ‘free’

choices impaired. Personality disorders are not considered sufficient to impair free choice, and

few legal systems currently recognise these disorders as grounds for excusing a person from

criminal responsibility.

In contrast to the law, psychology assumes that all behaviour is determined. In its extreme

form, determinism negates the notion that people are blameworthy, but differing philosophical

positions are identifiable (Blackburn, 1993). Hard determinism holds that human behaviour is

completely determined by factors outside the conscious person: choice is irrelevant and is at best

an illusion. Soft determinism accepts the reality of human choice, but argues that choices

themselves are determined. Recent psychological views, however, see human agency as the basis

for purposeful, intentional choices. Bandura (1986), for example, argues that although humans

are never wholly autonomous, and behaviour is always constrained by an individual's experience

and circumstances, self-regulating processes allow people to be partial authors of their situations.

Differences between the law and psychology may therefore lie less in acceptance of the human

capacity for autonomy and free choice than in the extent to which constraints on choice and

behaviour are recognised. Most psychological disorders impose constraints on people that

seriously limit their options in making choices. Personality disorder is one such constraint.

However, the insanity defence is no longer of practical significance in Britain, and a finding of

guilt is not incompatible with diversion to the mental health system. Most psychologists would

argue that personality disorders are psychological impairments that impair freedom of choice and

this should be taken into account by the courts in determining the most appropriate

disposal/sentencing.

References

Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, N. J.: Prentice-Hall.

Blackburn, R. (1993). The psychology of criminal conduct: Theory, research and practice. Chichester: Wiley

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!


Register a new account

Sign in

Already have an account? Sign in here.


Sign In Now
Sign in to follow this  
Followers 0