The diagnosis and treatment of personality disorder are both highly contentious subjects. It is argued in this article that we have misunderstood personality pathology as yet another form of mental illness that should require treatment for its alleviation or removal. But it is not a typical mental illness; personality is a stable persistent component of the self and needs a different treatment approach based on adaptation.

BACKGROUND:Health anxiety, characterised by excessive worry about having or acquiring a serious illness, significantly impacts mental health and well-being. Determining which psychological interventions and components should be considered as first-line treatments requires robust evidence. AIMS:This study aimed to evaluate the efficacy of various psychological interventions and their essential components in managing health anxiety. METHOD:A comprehensive search was conducted across multiple academic databases, including PubMed, Embase, PsyINFO, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials, with updates until 16 January 2025. Randomised clinical trials investigating the efficacy of psychological interventions among adults with substantial levels of health anxiety were included. We employed random-effects network meta-analysis for treatment comparison, and component network meta-analysis to assess the impacts of key therapeutic elements. RESULTS:A total of 35 trials involving 3263 participants (67% female; mean age 37 years, s.d. = 6) were analysed. The results revealed significant effects for several therapies, including cognitive-behavioural therapy (CBT), exposure therapy, acceptance and commitment therapy, metacognitive therapy, and mindfulness-based cognitive therapy, as well as behavioural stress management, compared with a waiting list control. However, cognitive bias modification, imagery therapy and short-term psychodynamic psychotherapy did not show significant effects. Component analysis indicated that exposure and response prevention, cognitive restructuring and mindfulness were linked to improved treatment outcomes. CONCLUSIONS:Both CBT and third-wave CBT are reasonable first-line choices for managing health anxiety. Effective CBT packages for health anxiety should integrate key components such as exposure and response prevention, cognitive restructuring and mindfulness.

BACKGROUND:People with severe COVID anxiety have significant fears of contagion, physiological symptoms of anxiety in response to a COVID stimulus and employ often disproportionate safety behaviours at the expense of other life priorities. AIMS:To characterise the long-term trajectory of severe COVID anxiety, and the factors that influence recovery. METHOD:This prospective cohort study followed 285 people with severe COVID anxiety in the UK over 18 months. A nested randomised feasibility trial tested an online cognitive-behavioural therapy (CBT)-based intervention (no. ISRCTN14973494). Descriptive statistics and linear regression models identified factors associated with change in COVID anxiety over 18 months. RESULTS:Most participants experienced major reductions in COVID anxiety over time (69.8% relative cohort mean decrease, P < 0.001), but a quarter of people (23.7%, 95% CI: 17.8-30.1) continued to worry about COVID every day, and for 13% symptoms remained severe even after the ending of all public health restrictions. Increasing age, being from a minority ethnic background that confers greater risk from COVID-19, and the persistence of high levels of health anxiety and depressive symptoms, predicted slower improvements in severe COVID anxiety after adjusting for other clinical and demographic factors. Neither a trial CBT-based intervention, nor contextual factors including daily case rates, vaccination status or having contracted COVID-19, appeared to affect the trajectory of severe COVID anxiety. CONCLUSIONS:For most people severe COVID anxiety improves significantly with time. However, interventions treating depression and health anxiety, and targeting older people and those from greater-risk minority backgrounds, warrant further investigation in future pandemics.

INTRODUCTION:Personality disorder is the most common of all psychiatric disorders and is best perceived as a diagnostic spectrum extending from no personality dysfunction to severe personality disorder. The position on the spectrum is determined mainly by problems in interpersonal social dysfunction, self-perception and awareness, and dangers to the self and others. AREAS COVERED:We examine psychological and psychodynamic treatments, pharmacotherapy, neuromodulation and other related approaches, environmental treatments, and therapeutic communities. Although many published studies refer to individual categories, these are now linked to the diagnostic spectrum in this review. EXPERT OPINION:There is some evidence that focused psychological treatments linked to problem solving (STEPPS), mentalization based therapy and dialectical behavior therapy, are successful in treating moderately severe personality disorder, especially regarding self-harm, but there is also benefit from well organized standard care that is similarly effective. There is no good evidence that drug treatment is of real value in personality disorder. Brain stimulation approaches have limited evidence. Psychodynamic approaches, environmental interventions, nidotherapy, and therapeutic communities appear to be of some value, but good data are few. Long-term studies of treatment effectiveness are few but some show that personality disorder can respond to treatment and remit.

Abstract Nidotherapy is the collaborative and systematic manipulation of the environment, including physical, social, and personal aspects, to make a better fit between a person and his or her setting. It does not aim to treat symptoms, only to effect environmental change so that both behavior and symptoms improve as they are no longer in conflict with the environment. It is a transdiagnostic form of care and so it does not slot easily into treatment manuals, but its most effective contribution is in the management of personality disorder, where it can treat many problems that other treatment strategies fail to touch. Examples are given of its effectiveness, including the results of two controlled trials. It can be understood further by looking at www.nidotherapy.com.

OBJECTIVE:To examine the factors that predict the development of bipolar disorder in a population presenting with anxiety and depressive disorders. METHOD:In a 30-year study, the Nottingham Study of Neurotic Disorder, the personality status, life events, service data, and early course of patients recruited to a randomised controlled trial were compared in patients who developed bipolar pathology and those who had no bipolar symptoms. RESULTS:Over 30 years, 5 (2.5%) of 200 patients assessed at baseline developed unequivocal bipolar disorder, one within the first 10 weeks of the study, and three (1.5%) had bipolar II pathology. Analysis of these data showed that those patients who had some degree of bipolarity had an increase in anxiety and depressive symptoms and general psychopathology, most pronounced in the second year of the study, that was not found with patients who had no bipolar pathology. CONCLUSIONS:Patients treated for anxiety and depressive disorders who remain unwell after initial treatment are more at risk of developing bipolar disorder than others.

OBJECTIVE:Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions that stop repetition is lacking. This individual participant data (IPD) meta-analysis of randomized controlled trials (RCTs) aimed to provide robust estimates of therapeutic intervention effects and explore which treatments are best suited to different subgroups. METHOD:Databases and trial registers to January 2022 were searched. RCTs compared therapeutic intervention to control, targeted adolescents ages 11 to 18 with a history of self-harm and receiving clinical care, and reported on outcomes related to self-harm or suicide attempt. Primary outcome was repetition of self-harm 12 months after randomization. Two-stage random-effects IPD meta-analyses were conducted overall and by intervention. Secondary analyses incorporated aggregate data from RCTs without IPD. RESULTS:The search identified 39 eligible studies; 26 provided IPD (3,448 participants), and 7 provided aggregate data (698 participants). There was no evidence that interventions were more or less effective than controls at preventing repeat self-harm by 12 months in IPD (odds ratio 1.06 [95% CI 0.86, 1.31], 20 studies, 2,949 participants) or IPD and aggregate data (odds ratio 1.02 [95% CI 0.82, 1.27], 22 studies, 3,117 participants) meta-analyses and no evidence of heterogeneity of treatment effects on study and treatment factors. Across all interventions, participants with multiple prior self-harm episodes showed evidence of improved treatment effect on self-harm repetition 6 to 12 months after randomization (odds ratio 0.33 [95% CI 0.12, 0.94], 9 studies, 1,771 participants). CONCLUSION:This large-scale meta-analysis of RCTs provided no evidence that therapeutic intervention was more, or less, effective than control for reducing repeat self-harm. Evidence indicating more effective interventions in youth with 2 or more self-harm incidents was observed. Funders and researchers need to agree on a core set of outcome measures to include in subsequent studies. PLAIN LANGUAGE SUMMARY:Self-harm is common in adolescents and linked to higher risks of repeated self-harm and suicide. This meta-analysis of 33 randomized controlled trials involving 4,146 adolescents found that therapeutic interventions were no more effective than standard care at preventing repeat self-harm at 12 months. However, interventions were more effective in youth with 2 or more self-harm incidents. The authors discuss limitations posed by the lack of uniform outcome measures for self-harm. CLINICAL GUIDANCE:STUDY PREREGISTRATION INFORMATION: Reducing Self-harm in Adolescents: An Individual Participant Data Meta-analysis; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=152119.

ObjectivesSleep disturbance is commonly reported by people with anxiety, depressive, and personality disorders, but longitudinal studies exploring the interplay of the three with disturbed sleep have not previously been described.MethodsIn this study, sleep disturbance was examined among 89 patients initially presenting with anxiety or depressive disorders who provided follow-up at 12- and 30-year time points in the Nottingham Study of Neurotic Disorder. Multilevel models were used to identify factors most predictive of changes in sleep quality over time.ResultsThere were strong associations between poor sleep and contemporaneous severity of personality disorder and the presence of other mental disorders at 12 and 30 years follow-up, but not with disorder presence at other time points. Improvements in personality disorder were associated with improvements in sleep between time points and attenuated the positive unadjusted effects of recovery from anxiety or depressive disorders to non-significance. Relapse into further episodes of mental disorder predicted poorer sleep, whereas worsening personality disorder was not predictive of significant changes when adjusting for other factors.ConclusionsThis study demonstrates the complex interplay between anxiety, depressive, and personality disorders and sleep disturbance over a long follow-up period. Future research might look to examine the relationship between personality disorder and disturbed sleep with interventional studies and by integrating personality trait research.

The temporal relationship between childhood trauma and personality status using the ICD-11 classification was examined in 75 adults (65%F) aged between 19 and 72 selected by constrained procedure to ensure the full range of personality disturbance. Trauma history was assessed using the Childhood Traumatic Events Scale, past and recent versions and personality status using scales to assess the severity and domains of the ICD-11 system, PDS-ICD-11 and PAQ-11. The PDS-ICD-11 findings showed 52 (59.3%) had some personality disturbance with 17 (22.7%) having moderate or severe personality disorder. There was a significant association between childhood sexual trauma and ICD-11 personality severity ( p  = 0.005) and a lessened association with recent trauma ( p  = 0.02). Apart from the borderline composite score, the PAQ-11 negative affectivity domain was significantly associated with childhood sexual trauma ( p  = 0.003), but other domains were not linked. The Anankastia domain was significantly associated with early major physical illness ( p  = 0.012), and physical illness both in early life ( p  = 0.005) and recent exposure ( p  = 0.024) were associated with personality disorder. Other forms of childhood abuse and illness or injury in childhood did not differ with regard to later personality disorder. The results confirm a significant but not overwhelming relationship between childhood sexual trauma and severity of ICD-11 personality disturbance in adult life that is greater than for other classes of trauma.

The WPA Section on Personality Disorders has promoted greater understanding of personality dysfunction since 20031. This subject is highly relevant to mental pathology. Personality disorders affect at least 10% of the general population2, and their high levels of comorbidity with other mental disorders (Galenic syndromes)3 means that many doctors in a variety of specialties are likely to come across these patients repeatedly in their everyday practice. In the last fifteen years, much of the work of the Section has been devoted to the development of the new classification of personality disorder in the ICD-11. A radical revision was suggested that eliminated all the existing categories in the ICD-10 and replaced them with a single dimensional spectrum of severity4. In other terms, it was proposed that, once the diagnosis of a personality disorder has been established, it should be described in terms of its level of severity: mild, moderate or severe personality disorder, or personality disorder of unspecified severity. Also described was "personality difficulty", not classified as a mental disorder but listed in the grouping of problems associated with interpersonal interactions. It was also proposed that personality disorder and personality difficulty could be further described using five trait domain specifiers: negative affectivity, detachment, dissociality, disinhibition, and anankastia. Although this solution came under criticism as being too radical and apparently ignoring recent advances in the field, particularly in relationship to work on borderline personality disorder5, the scientific justification for the change was a strong one6 and has been embraced with increasing enthusiasm over time. There are now many studies suggesting that this classification is superior to that of the ICD-10 in terms of clinical utility, internal consistency and acceptability7, 8, and it has received international support by its full incorporation into the ICD-11 Clinical Descriptions and Diagnostic Requirements for Mental Disorders. Many studies are currently in progress to establish its psychometric properties and clinical value in selecting treatment. Over the next few years, under initiatives developed by R. Mulder and Y.-R. Kim (current and future Chair of the Section), we hope to expand the knowledge base of the ICD-11 classification, facilitate its introduction in all countries covered by the WPA, and obtain research data that will guide clinical practice in an area where we currently have grossly lopsided empirical evidence. With these goals in mind, Section members are developing clinical measures of ICD-11 personality disorder severity and the five trait domain specifiers. Notably, B. Bach and M. Sellbom are working on a Diagnostic Interview for Personality Pathology in ICD-11 (DIPP-11). One of the important roles of our Section is to promote the message that all psychiatrists (and physicians, for that matter) should be familiar with the concept of personality disorder and to realize that most of the patients they see will have some form of personality disturbance. This is not an academic extra; such knowledge will help them in choosing treatment, predicting outcomes, and planning care. We need to be rid of the notion that personality disorder is an outré subject only useful to specialists. The Section will also be watching carefully and contributing to the current debate over the status of borderline personality disorder. The borderline option was included as a "pattern specifier" in the ICD-11 classification, following pressure from the large group who felt that this diagnosis was too valuable to be discarded9. But the pattern specifier is not a diagnosis; it is an option to be added to the appropriate severity diagnosis in the ICD-11, from personality difficulty to severe personality disorder. If, as it seems possible, all the categorical diagnoses of personality disorder will be abandoned in future revisions of the DSM, the status of borderline personality disorder will become increasingly uncertain. As research into all aspects of borderline pathology is currently more active than research into all other areas of personality pathology, it is understandable that many would like to see the borderline group retained in some form. There is no reason why it cannot cohabit with the current ICD-11 approach in both clinical and research practice, but improvements are needed to achieve better harmonization. We also hope that, by emphasizing that personality dysfunction is on a spectrum, and that most people in the population have some dysfunction, we can remove much of the stigma that surrounds the diagnosis. The stigma will also be reduced by showing that those with personality problems can get better, and that this can be achieved avoiding deceptively simple solutions such as changing their name.

Background Environmental changes can be positive in mental illness. Systematic, planned and guided environmental change in all its aspects is called nidotherapy. It has shown some benefit but has not been extended to whole communities. Aims A cluster-randomised step-wedge trial is planned in six village communities in Nottinghamshire, England, covering an adult population of 400. Method Adults in six villages will be offered a full personal environmental assessment followed by agreed change in different 3-month periods over the course of 1 year. All six villages have populations between 51 and 100 residents and are similar demographically. Assessments of mental health, personality status, social function, quality of life and environment satisfaction will be made. After the initial baseline period of 3 months, two villages will be randomised to nidotherapy for 3 months, a further two at 6 months and the last two at 9 months. Results The primary outcome will be change in social function; secondary outcomes include health-related quality of life, anxiety and depressive symptoms, personality status, costs of nidotherapy and life satisfaction. Adverse events will also be recorded. The analysis will be carried out using a multimodal statistical approach examining (a) the change in scores of the primary outcome (social function); (b) change in scores of all secondary outcomes, including costs; and (c) changes in environmental satisfaction. Conclusions The findings of this study should help to determine whether nidotherapy has a place in the early detection and treatment of mental pathology.

Drama therapy is a popular form of management in mental illness, as it reaches out beyond many other therapies. Few studies have examined both the advantages and disadvantages of this medium. This qualitative study examines both, and finds gains and hazards.

Potential competing interests: No competing

SUMMARY:Prominent clinical perspectives posit that the interface of autism and (borderline) personality disorder manifests as either a misdiagnosis of the former as the latter or a comorbidity of both. In this editorial, we integrate these disparate viewpoints by arguing that personality difficulties are inherent to the autistic spectrum.

Personality and Mental HealthVolume 18, Issue 1 p. 3-3 EDITORIAL Changes in the journal Peter Tyrer, Corresponding Author Peter Tyrer [email protected] Imperial College, London, UKSearch for more papers by this authorRoger Mulder, Roger Mulder Imperial College, London, UKSearch for more papers by this authorCarla Sharp, Carla Sharp Imperial College, London, UKSearch for more papers by this author Peter Tyrer, Corresponding Author Peter Tyrer [email protected] Imperial College, London, UKSearch for more papers by this authorRoger Mulder, Roger Mulder Imperial College, London, UKSearch for more papers by this authorCarla Sharp, Carla Sharp Imperial College, London, UKSearch for more papers by this author First published: 11 February 2024 https://doi.org/10.1002/pmh.1594Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume18, Issue1February 2024Pages 3-3 RelatedInformation