Personality Disorder Services
in NHS Highland: Challenges
and Developments
Dr Tim Agnew, Consultant
Psychiatrist and Lead in NHS
Highland Personality Disorder
Service.
Overview
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NHS Highland
Services available as of 2009
Challenges
Recent developments
Future developments
Questions
NHS Highland
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41% of landmass of Scotland
33,000km²
Only 6% of Scottish population (300 000)
Two thirds in very low population densities
Biggest centre of population Inverness (40 000)
Difficult terrain
Limited infrastructure
NHS Highland
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4 Community Health Partnerships (CHPs)
Services for North, Mid and South-East
Highland CHPs
Argyll and Bute CHP has its own major
process of service redesign ongoing
including psychological therapy services
Situation in 2009 in 3 Northern
CHPs
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Specific services for Borderline PD
Generic services for all other PDs
Specific services for BPD
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Structured admission program
Dialectical Behaviour Therapy (DBT)
CBT-BPD (Davidson)
Services for all PDs
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Clinical psychology
Primary care
CMHTs
In-patient services
Liaison psychiatry
DBT service
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DBT has been mainstay for BPD
First group of therapists trained in 2006
Three groups trained to date (24 in total)
18 therapists amounting to 2 WTE
Anyone meeting DSM IV criteria offered 1
year of DBT
Very intensive
DBT service
Problems with increasing waiting
times
 Limited capacity, large referral
numbers
 Situation unsustainable
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DBT Service
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BPD is a polymorphic disorder
256 varieties
Severity was measured using number of
DSM IV criteria
DBT is over-intensive intervention for
some
DBT service
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Evidence suggests DBT is best at reducing
parasuicidal behaviour and hospital
admissions
Stage 1 DBT – behavioural stabilisation
Decided to prioritise on basis of:
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parasuicidal behaviour
psychiatric hospital admissions
DBT service
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Allows quicker response for these
individuals
What to offer everyone else?
Some patients seemed to prefer skills
groups to individual work
Skills group work twice as efficient in
terms of therapist time as individual work
What about a skills group
standalone?
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Oft-quoted (but unpublished) study by Linehan
does not suppport utility of skills training alone
Some emerging evidence for DBT-ST (Soler,
2009)
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Single centre, randomised, two-group trial
DBT-ST or “Standard Group Therapy” for 13 weeks
63 patients
Seemed to have an impact on affective symptoms
No effect on parasuicidal behaviour
Other considerations
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STEPPS (Systems Training for Emotional
Predictability and Problem Solving) RCT
All DBT therapists already trained to
deliver skills groups
Existing supervision system (DBT consult
groups)
Theoretical coherence
Drawbacks
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No really robust evidence for approach
No individual therapy
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Formulation
Skills generalisation
Validation
Dialectics
Problem solving
No individual therapist
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4 individual sessions before group work
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Extra module (Foundation module)
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Crisis plan
Written formulation
Psycho-education
Validation, dialectics, problem solving
3 final group sessions
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Agenda set by group
No RCT evidence
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Service-based evidence
Same regular assessment/ outcome tools
as full DBT
Pilot only
Re-evaluate after one run-through
Skills Training Program (STP)
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Starts next week
33 week run (plus 4 weeks individual
work)
Closed group of 8 patients
2 skills trainers
Good feedback for individual sessions
Personality Disorder Service
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Name change from DBT service
PDS offers:
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DBT
STP
CBT-BPD
Still only for people with BPD as primary
presentation
Allows flexibility to develop further
Life after DBT
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Some feedback from individuals that there
is a service gap after completion of DBT
What is available after finishing DBT?
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User-led “graduate” group not active
Possible DBT skills informed “graduate” group,
CPN input
Some people wish to move away from this
type of service after completing DBT
Other perspectives
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Recent visit by Tom Mullen
Multidisciplinary and service user attendance
Stakeholders meeting planned
OTs keen to adapt Journey program locally
Multidisciplinary visit to Leeds being planned
Volunteering Highland
Future
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PDS to expand educational role to CMHTs,
primary care and in-patient wards
PDS to offer consultation service to
CMHTs, in-patient wards
Expand CBT-PD provision within PDS
Specific provision in the localities
Training in other approaches
Don’t forget
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Administration
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Overhaul of referral process
Overhaul assessment process
Revised prioritisation
Standardised admin guidance
New computerised database
Main challenges
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Too much geography
Not enough therapists with not enough
time
Increasing referrals
Main developments
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Revision of prioritising factors
Skills Training Program
Database and admin overhaul
Thank you
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Questions or comments?
Reference
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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 Problem
Solving (STEPPS) for Outpatients With Borderline Personality Disorder A
Randomized Controlled Trial and 1-Year Follow-Up. American Journal of
Psychiatry 165 (4) 468 -- Am J Psychiatry
K. Davidson, J. Norrie, P. Tyrer, A. Gumley, P. Tata and H. Murray et al., The
effectiveness of cognitive behavior therapy for borderline personality
disorder: results from the borderline personality disorder study of cognitive
therapy (BOSCOT) trial, Journal of Personality Disorders 20 (2006), pp.
450–465.
M.M. Linehan, H.E. Amstrong, A. Suarez, D. Allmon and H.L. Heard,
Cognitive-behavioral treatment of chronically parasuicidal borderline
patients, Archives of General Psychiatry 48 (1991), pp. 1060–1064