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Education And Debate

Education and debatePsychotherapy for severe personality disorder: exploring the limits of evidence based purchasingCommentary: Mix of perspectives needed in purchasing of care

BMJ 1999; 318 doi: (Published 22 May 1999) Cite this as: BMJ 1999;318:1410

Psychotherapy for severe personality disorder: exploring the limits of evidence based purchasing

  1. Steve Kisely (, senior lecturer in psychiatry
  1. Primary Care Mental Health Unit, University of Western Australia, 16 The Terrace, Fremantle, WA 6160, Australia
  2. Department of Psychiatry, Hairmyres Hospital, East Kilbride G75 8RG

    The growing emphasis on practising evidence based medicine has led to debate about how generalisable the findings from experimental studies are to clinical practice. Patients with severe personality disorders, who often pose difficult management problems in both primary and secondary care, illustrate the potential limits of practising evidence based medicine in the commissioning of services. The Department of Health has recently announced the development of therapeutic communities as part of providing a specialist service in England for patients with severe personality disorders (Department of Health, press release, 23 October 1997). This paper looks at the evidence for the option chosen by the department, examines alternatives, and discusses possible consequences.

    Summary points

    Patients with severe personality disorders can pose management problems in both primary and secondary care

    Much of the literature on treating these disorders has been descriptive or qualitative rather than quantitative, and there have been few randomised controlled trials

    Consensus statements by expert groups have come to contradictory conclusions about the best ways to treat patients with severe personality disorders

    When the decision to favour one treatment modality is made in the absence of evidence from randomised controlled trials, the development of alternative, and possibly more cost effective, approaches will be hampered

    What are personality disorders?

    Individuals with a personality disorder show an enduring pattern of inner experience and behaviour that deviates markedly from cultural expectations. These patterns are inflexible and pervasive across a wide range of social and personal situations and lead to clinically significant distress or impairment in social, occupational, and other important areas of functioning.1 Cluster B personality disorders (also termed “dramatic” or severe personality disorders) are one of three clusters of personality disorders. Individuals with severe personality disorders have major difficulties in establishing and maintaining adequate social relationships because of their emotional lability and impulsive behaviour. This cluster includes individuals …

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