Summary of the impact

Over the last 20 years Imperial College research on the assessment and treatment of personality disorder has led to important changes in healthcare policy and the provision of services for people with these mental disorders. Our introduction of the first reliable assessment of the severity of personality disorder made it a much better understood and accepted diagnosis and led to current plans for changing the World Health Organisation (WHO) international classification of this disorder. Our research highlighting the impact of personality disorder contributed to the development of new services and our evaluation of these services led to them becoming more widely available throughout the NHS. In contrast, our evaluation of an intensive assessment and treatment programme for a select group of offenders with personality disorder showed that it was not cost effective. This programme has now been stopped and resources have been diverted to help treat a far wider group of people with personality disorder and offending behaviour.

Underpinning research

Key Imperial College London researchers:
Professor Peter Tyrer, Professor of Community Psychiatry (1991 to present)
Professor Mike Crawford, Professor of Mental Health Research (1999 to present)
Dr Tim Weaver, Reader in Mental Health Services Research (1995 to present)

Professor Tyrer and colleagues' research demonstrated in 1996 the importance of assessing the severity of personality disorder and the development and validation of a clinically acceptable method for assigning levels of severity (1). This led to new research at Imperial which showed the impact of personality disorder on health and social functioning (2). We demonstrated that untreated personality disorder was associated with long-term morbidity (3), and that the presence of personality disorder reduces the impact of treatments for other mental health problems.

In collaboration with colleagues at the University of Glasgow, we developed psychological treatments for people with personality disorder and conducted randomised clinical trials examining the effectiveness of these interventions (4). The results of these studies contributed to new investment in services for people with personality disorder.

In 2002 the Department of Health (DoH) funded 11 new community-based services for people with personality disorder in England. We were commissioned to conduct a comprehensive evaluation of these new services. Our evaluation showed that they succeeded in engaging large numbers of patients and helped their health (5). We used data from this evaluation to conduct a Delphi study of 89 patients and providers of services for people with personality disorder which we used to develop consensus-based guidelines about how services for people with personality disorder should be delivered in the future.

In contrast, our clinical trial of a specialist service for the assessment of a select group of offenders with personality disorder, the `Dangerous and Severe Personality Disorder programme,' and a mixed method evaluation of the treatment process that was used concluded that this programme failed to improve the care of offenders with personality disorder and was not providing a cost-effective use of resources (6). This work involved randomising 75 prisoners with severe personality disorder to the specialist units or a waiting list control. One year later, those referred for specialist assessment had increased aggression and poorer social functioning compared to those who remained on the waiting list for the programme.

References to the research

Details of the impact

Impacts include: health and welfare, practitioners and services Main beneficiaries include: patients, WHO, Mental Health Professionals/Trust, DoH, NICE

Over the last 20 years, considerably influenced by our research, personality disorder has achieved a level of awareness and understanding that has become integrated into mainstream mental health services. In 1996, we introduced a simple classification system, based on severity, which enabled the condition to be more reliably rated and assessed and also treated much more economically. This approach has been adopted by the two international systems for classifying mental disorders; Section III of the American Psychiatric Association's Diagnostic and Statistical Manual of mental disorders (5th ed., 2013) [1] and the WHO International Classification of Diseases (version 11, 2011) [2].

Our research, improving the reliability of the assessment of personality disorder, led to greater acceptance and awareness of the importance of this condition and contributed to the expansion of specialist services for people with personality disorder. Eleven years ago a national survey of mental health Trusts in England reported that four out of five did not provide specialist services to people with personality disorder and one third stated that they provided `no service' at all for people with these problems. Our national evaluation of specialist services for people with personality disorder concluded that they were providing a valuable service provision that was highly valued by service users and providers and recommended that they should be expanded. Since then the DoH has set up a dedicated website on personality disorder for users and providers of mental health services. This includes a directory of specialist services for people with personality disorder. Over 100 such services are now provided throughout the UK [3].

Our recommendations on the treatment of people with personality disorder (research reference 5), which were based on a Delphi study of service users, providers and experts in this field were incorporated into NICE guidelines on the treatment of people with borderline personality disorder in 2009 [4]. These include specific recommendations about the process of referral to specialist services and the content and structure of psychological treatments which were based on our conclusions. Qualitative data collected from people with personality disorder as part of this evaluation formed the basis of the service user experience chapter of these guidelines.

Our research demonstrating that people with antisocial personality disorder were rarely offered support and treatment from mental health services was highlighted in NICE guidelines on the treatment of people with this condition that were published in 2009 [5] and influenced their recommendation that mental health services should offer treatment for comorbid mental health problems referral for psychological treatment.

Between 2003 and 2010 we tested the clinical and cost effectiveness of a modified form of cognitive behaviour therapy for people with borderline and antisocial personality disorder. This research was also referenced in NICE guidelines and contributed to the decision, in 2011, to expand the `Increasing Access to Psychological Therapies' programme to include treatment for people with personality disorder [6].

In contrast, our highly critical evaluation of the Dangerous and Severe Personality Disorder programme was instrumental in the decision in 2009 to close this programme and replace it with a less intensive programme of care for a much larger number of offenders with personality disorder. This programme is estimated to have cost over £200,000,000 [7], but our work demonstrating the small numbers of people who were treated, the length and burden of the assessments used, and the lack of clear evidence of patient benefit, led to a decision to abandon this programme and invest these resources into providing more focussed psychologically-informed treatment for a far larger number of personality disordered offenders [8].

Sources to corroborate the impact

[1] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

[2] Tyrer P, Crawford M, Mulder R; on behalf of the ICD-11 Working Group for the Revision of Classification of Personality Disorders (2011). Reclassifying personality disorders. Lancet, 377, 1814-1815. DOI.

[3] Department of Health http://www.personalitydisorder.org.uk/services/#map_top. Archived on 7^th November 2013.

[4] NICE Borderline Personality Disorder: Treatment and Management (2009) http://www.nice.org.uk/nicemedia/pdf/cg78niceguideline.pdf (pages 20, 21, 29, 27, 33, 84, 85, 88, 91, 117, 121, 123, 190, 306). Archived on 7^th November 2013.

[5] NICE Antisocial personality disorder treatment, management and prevention (2009). http://www.nice.org.uk/nicemedia/pdf/cg77niceguideline.pdf (pages 60, 61, 62, 69, 70, 71, 197). Archived on 7^th November 2013.

[6] Department of Health. Talking therapies: A four-year plan of action 2011. https://www.gov.uk/government/publications/talking-therapies-a-4-year-plan-of-action. Archived on 7^th November 2013.

[7] Tyrer, P., Duggan, C., Cooper, S., Crawford, M., Seivewright, H., Rutter, D., Maden, T., Byford, B., Barrett, B. (2010). The successes and failures of the DSPD experiment: the assessment and management of severe personality disorder. Medicine Science and the Law, 50, 95-100. DOI

[8] Details of the new Offender Personality Disorder Pathway can be found at: http://www.personalitydisorder.org.uk/criminal-justice/about-dspd-programme/. Archived on 7^th November 2013.