As part of the mental health service to general hospitals, liaison psychiatrists frequently assess patients who present to general hospitals following self-harm. Liaison psychiatry also traditionally provides assessment and services for people with physical illnesses and psychiatric comorbidity as well as bodily symptoms which are not adequately explained by underlying physical illness . The morbidity and costs associated with mental health problems in general hospital patients and those with physical illness in the community have led to the development of models of service aimed at supporting general and primary care services in the recognition and management of these disorders . Liaison psychiatry services can improve the health and outcomes of patients in general hospitals and also have been shown to save money in the local health economy. An excellent example of this is the Rapid Assessment Interface Discharge model in Birmingham, United Kingdom [3▪].
The core work of liaison services is the assessment and management of these three patient groups:
- people presenting with self-harm;
- people with medically unexplained symptoms (MUSs) including functional somatic syndromes;
- mental illness in long-term conditions.
It must be noted that, although liaison psychiatrists customarily address these conditions in hospitals and emergency departments, general practitioners and family doctors are intimately involved in the management of patients with these problems.
PATIENTS WITH PERSONALITY DISORDERS AND LIAISON SERVICES
In a 1993 survey of the attitudes of British psychiatrists, over half felt that somatization disorder was a form of personality disorder, and many people with personality disorder, borderline in particular, will frequently engage in self-harm . Despite this, there has been relatively little research on the prevalence of personality disorder and its management in liaison services until recently. Diefenbacher et al. reported data on 3032 patients presenting to consultation–liaison services at Mount Sinai Hospital in New York, United States over a 10-year period. They found that 19.7% of patients exhibited features of a personality disorder, of whom 7.7% were cluster A (odd or eccentric behaviour), 54.3% cluster B (dramatic, emotional or erratic) and 38% cluster C (anxious–fearful). Patients with a personality disorder had a lower rate of somatic illness but higher rates of substance misuse and use of psychiatric services before consultation. The authors concluded that one in five to six patients presenting to liaison services requires psychiatric, psychotherapeutic or social treatments for a personality disorder.
Internationally, liaison services vary in their structure and environment, and yet these findings are consistent with some other studies. Of 1962 patients referred to a liaison psychiatry service from an emergency department in an Italian general hospital , 22% were diagnosed with a personality disorder. There was a similarly high prevalence of personality disorder amongst 541 patients referred to two liaison services in Brazil . A perinatal psychiatric liaison service in France reported a prevalence of 22% of severe personality disorder amongst 430 referrals . However, a study, in Turkey, of patients presenting to a hospital liaison service reported a prevalence of personality disorder of only 2%, although diagnoses were made by nonpsychiatrists and diagnostic accuracy was poor for some diagnoses .
SELF-HARM AND PERSONALITY DISORDERS IN LIAISON PSYCHIATRY
In the United Kingdom, national guidance  recommends that patients who self-harm receive a psychosocial assessment in emergency departments or on medical wards. In practice, this crucial clinical encounter is often undertaken by liaison psychiatric services. It is a clear and often early opportunity to encourage patients to engage with effective treatment. However, many intervention trials in self-harm treat this population as a whole and do not specifically tailor treatments to underlying psychiatric or personality disorders.
A recent Spanish study compared 361 general hospital patients referred to a liaison psychiatric service after a suicide attempt with nearly 5000 other admitted patients referred to the liaison team . Factors predicting risk of suicide attempt were previous suicide attempts, younger age and psychiatric diagnosis. Personality disorder was a significant risk [odds ratio (OR 7.31)], only slightly lower than mood disorders (OR 7.49) and higher than psychotic disorders (OR 5.03). Personality disorder was especially significant in men who attempted suicide. The prevalence of personality disorder amongst those who attempted suicide was 24% compared with 5.4% for other referrals.
Crisis intervention amongst patients with emotionally unstable (or borderline) personality disorders who present to emergency departments can reduce self-harm episodes and psychiatric hospitalization, while reducing costs. A Swiss study comparing crisis intervention with treatment as usual (TAU) between two cohorts (totalling 200 patients) showed rates of 8% for repeat deliberate self-harm and 8% for hospitalization for the intervention group compared with 17 and 56% in the TAU group . In separate articles [13,14], the clinicians from Switzerland have observed that, although dialectic behavioural therapy, mentalization-based treatment, transference-focussed psychotherapy, schema-focussed therapy and other therapies have been shown to help suicidal behaviour in randomized controlled trials in patients with an emotionally unstable personality disorder, the patients were not recruited after a suicide attempt in an emergency department. If further research is able to demonstrate that patients recognized as having a personality disorder following self-harm can be engaged in these treatments, and these therapies are widely available and accessible, then the practice of liaison psychiatrists will begin to focus on the early recognition of these disorders, particularly in patients attending more than once.
MEDICALLY UNEXPLAINED SYMPTOMS AND PERSONALITY DISORDERS IN LIAISON PSYCHIATRY
Some people are afflicted by chronic physical symptoms that do not have an identifiable physical cause or are out of proportion to the underlying physical disease . They account for 20% of new presentations in primary care, and 20–40% of patients presenting to hospital outpatient departments, which is a huge number of people . The term medically unexplained symptom (MUS) is one that, most liaison psychiatrists find, has little clinical utility. However, the recognition of the costs to healthcare systems of patients with MUS has meant that its use to describe a broad group of patients using health services has become more widely accepted. Patients with MUS may have a variety of psychiatric diagnoses. Over 40% of people with MUS have anxiety or depression , and hypochondriacal, somatoform and factitious disorders remain important clinical issues. The costs are significant, with $256 billion per annum being spent in the United States  and £3.1 billion in the United Kingdom . Looking at associated and aetiological factors, patients with MUSs share the high rates of childhood neglect and abuse common in personality disorders . Therefore, in terms of providing both good clinical care and sustainable health services, there are two pressing clinical questions. What are the rate and impact of personality disorder in the presentation of MUSs? And, are currently available treatments for personality disorder effective in MUS patients with personality disorder?
Fallon et al. in a very recent study from the United States assessed the prevalence of personality disorder comorbidity in hypochondriasis, comparing the rate with patients with obsessive compulsive disorder and social anxiety disorder [20▪]. They observed that most studies on the prevalence of personality disorders in hypochondriasis use self-report measures that can overestimate the prevalence of personality disorder. They used a more comprehensive Structured Clinical Interview for DSM Disorders (SCID) interview. They also used a community sample recruited for research rather than patients recruited through hospital attenders. They found that 40.3% of 62 patients with hypochondriasis had a personality disorder, of which 19.4% were paranoid, 14.5% obsessive and 17.7% avoidant. However, they observe that this suggests the majority of patients with hypochondriasis do not have a personality disorder (the rate was not significantly greater than those for the two comparison anxiety disorders) and conclude that clinicians should avoid assuming that personality disorder is the primary source of hypochondriacal distress. This is consistent with a past German study showing 25% of patients with somatoform disorders having a personality disorder, 48% in a study of 56 patients with persistent somatization in Denmark , although a higher rate of 76% was found in a UK study of 25 women with the same condition .
We could find no controlled trials specifically addressing the use of psychological therapies aimed at personality disorder in the context of MUS.
Functional somatic syndromes
Functional somatic symptoms and syndromes are an important health issue. They are conditions characterized by patterns of persistent bodily complaints for which adequate examination does not reveal sufficient explanatory disorder. Common, costly, persistent and disabling, functional somatic syndromes include fibromyalgia, chronic fatigue syndrome (CFS) and irritable bowel syndrome.
Uguz et al. in a study in Turkey compared the prevalence of axis I and axis II (personality) disorders in 103 patients with fibromyalgia and 83 controls through structured clinical interviews. The rates for axis II disorders in fibromyalgia patients were 31% and in controls 13.3%. Rose et al. in France found that 47% of patients with fibromyalgia had at least one Diagnostic and Statistical Manual of Mental Disorders (DSM) IV personality disorder using the SCID, although only 30 patients were interviewed.
Rates of personality disorder in CFS have been found to be 29% amongst 113 sufferers in the United States (compared with 7% of well controls) , and 39% amongst 61 patients at a tertiary centre in London, United Kingdom (compared with 4% of medical students) . However, 50 female patients in Belgium with CFS were compared with 50 controls. Both groups had a prevalence of 12% of a personality disorder using the Assessment of DSM-IV Personality Disorders questionnaire . Contrastingly, in a recent study in China, 75% of 83 patients with irritable bowel syndrome showed some personality dysfunction .
These prevalence rates mostly, but not always, suggest greater personality disorder morbidity in patients with a functional somatic syndrome compared with the general population, but for people with a functional somatic syndrome the majority do not have a personality disorder, and it should not be assumed that patients with these problems have a personality disorder. Liaison psychiatrists may be involved in their assessment and management, either through patients presenting to the general hospital or in specific clinical services, such as those for chronic fatigue syndrome.
As such, it is likely that more complex or disabled patients will be seen in liaison services. It has been demonstrated that the common experience of childhood abuse is linked with the later development of some functional somatic syndromes . This again raises the relevance of the detection of personality disorder, particularly in this group of patients seen by liaison psychiatry, and whether, particularly in the severely disabled groups, the additional application of treatments effective in personality disorder will be efficacious.
Patients with long-term conditions such as heart disease, arthritis, diabetes and chronic obstructive pulmonary disease are more likely to develop a psychiatric disorder by three to four-fold. Having both a physical and a psychiatric condition delays recovery from both disorders . Patients with a personality disorder often live more chaotic lives, and, if they have a long-term condition, they may be less able to manage their disorder or fail to manage their care as an act of deliberate self-harm. Personality disorder with a long-term condition may mean the patient presents with complexity and uncertainty in their management, requiring skill and patience in communication .
In a Norwegian study of patients with personality problems defined by the Iowa Personality Disorder Screen, there were higher rates of pain, use of analgesics and frequency of attendance in primary care, suggesting more somatic morbidity among patients with personality disorder .
In a large population survey of over 34 000 people in Canada, people with a borderline personality disorder had greater rates of arteriosclerosis, liver disease, cardiovascular disease, gastrointestinal disease and arthritis compared with the general population . Comorbidity could increase the likelihood of suicide attempts. A similar population survey in the United Kingdom also showed higher rates of ischaemic heart disease and stroke with any personality disorder, the highest odds ratios being associated with emotionally unstable personality disorder .
Psychotherapy has been provided in holistic environments for people with long-term conditions. An example is the diabetes centre at Guy's and St Thomas’ Hospital, London, United Kingdom. They provide brief cognitive analytic therapy to patients and also refer patients to the local longer-term psychotherapy department if necessary. A senior psychotherapist has stated:
‘I’m looking at their early relationships and how that impacts on their ability to self-care. If someone has experienced neglect and deprivation in their childhood, if they’ve grown up feeling they weren’t noticed, or their primary carer wasn’t emotionally available to them, or if they grew up feeling abandoned or they weren’t somehow good enough, they will often act out these patterns of relating towards themselves’ .
This illustrates an understanding of how personality development can impact on self-care for long-term conditions. Research into psychotherapies for long-term conditions suggests that cognitive behavioural therapy approaches may be effective in depression and anxiety, but it is difficult to research more complex psychotherapeutic approaches that may be needed for patients with comorbid personality disorders and chronic physical illnesses, such as transactional analysis, cognitive analytical therapy and psychodynamic psychotherapies. It has been argued that a range of therapies is needed for complex patients with long-term conditions and psychiatric difficulties .
Another example is the Primary Care Psychotherapy Consultation Service, set up in 2009 to support general practitioner practices in the management of complex cases, training staff and providing a direct clinical service. There is a strong focus on patients with long-term conditions and/or MUSs with complex needs and it has a psychoanalytic model of care. The service has recently been described and evaluated [35▪]. Outcome scores were improved after treatment, although the effect sizes were less for patients with MUS.
There remain many outstanding questions regarding the impact of personality disorder on patients attending the general hospital or with physical illness that will be of interest to liaison psychiatrists. The prevalence of personality disorder in patients presenting to liaison psychiatrists has been estimated and seems to be around 20%, but it is less clear on prevalence amongst discrete groups, including those presenting with MUSs. We need to establish what the impact of personality disorder is in terms of symptom presentation and interpretation, individuals’ self-care and health outcomes. If the prevalence of personality disorder is understood together with the impact it has, then the further question is whether evidence-based treatments, either those that are currently available or new approaches, can be applied and developed for this group of patients. If so, then liaison psychiatry services with their close relationships with general health services and developing roles in primary care will be well placed to raise the important health and economic issues around personality disorder in general health and to recommend or deliver the necessary evidence-based treatments.
It is well established that self-harm is part of the diagnostic criteria for borderline personality disorder, and therefore such presentations will be common to the general hospital. However, although evidence-based therapies have been shown to be effective for patients with personality disorders, there is little evidence on how these patients might be engaged with treatment after presenting to liaison services with self-harm. This would be a useful research endeavour.
In population surveys, people with personality disorders have been shown to have higher rates of pain, they use analgesic medication more and see their primary care physician more than the general population. They are also more likely to be diagnosed with functional syndromes such as fibromyalgia, and people with functional somatic syndromes have similarly high rates of abusive childhood experiences common in personality disorder. This interrelation is not fully understood and will benefit from further research. The majority of people with MUSs/somatoform disorders and functional syndromes do not have personality disorders and should not be presumed to be suffering from a personality disorder. Nevertheless, in both groups of patients, the rate of personality disorder is probably higher than in the general population and patients with established organic disorder. For patients with personality disorder and MUS or functional somatic syndromes, understanding the role that personality disorder has on symptom management, distress tolerance, disability and illness behaviour would be likely to lead to the development of more effective treatments. There remains the question of how best to apply existing treatments that are effective in patients with personality disorder to this patient group and whether targeting interventions for personality disorder in these groups will lead to better outcomes.
Population surveys suggest that patients with personality disorders have higher rates of certain long-term conditions, including cardiovascular disease. This link and the suggestion that people with complex problems, including personality disorders, may self-manage long-term conditions less well requires further understanding through research. An example would be in considering diabetes. This is a condition that requires careful self-monitoring and personal discipline. The complications of diabetes are profound, including renal failure, blindness and limb loss. Understanding the impact of personality disorder in patients with diabetes and improving self-management could have a considerable health and economic impact.
Through the evolution of technical biomedicine and longevity, more is expected of patients in terms of both self-management and contact with the broader system of healthcare. Conditions that psychiatrists are familiar with, such as personality disorder, that fundamentally have their basis in sense of self and interrelationships need to be closely considered in terms of assisting people towards the health outcomes that they desire. It is the anecdotal experience of many liaison psychiatrists that people with personality disorder engage in a dysfunctional manner with general health services, often as a means of addressing their emotional needs, thereby placing themselves at considerable, often iatrogenic, risk. This risk is not considered commonly in general psychiatric assessment. Through a deeper understanding of the links to and impact of personality disorder on the general care of long-term conditions, functional somatic syndromes and other somatoform disorders, more effective treatments can be developed. Some appropriate psychotherapeutic interventions for patients with long-term conditions and personality disorders have been developed in primary and secondary care. If these can be made systematically available and evaluated within evolving healthcare services, then this aspect of liaison psychiatry can be at the vanguard of integrating mental and physical healthcare and demonstrating to biomedical services how applying a greater understanding of the patient can improve outcomes.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 129).
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