Aims and method In 1988, Lewis and Appleby demonstrated that psychiatrists hold negative attitudes towards patients with personality disorder. We assessed the attitudes of psychiatry trainees towards patients with borderline personality disorder and depression, expecting an improvement. 166 trainees were block randomised to receive one of four case vignettes that varied by diagnosis and ethnic group. We used Lewis and Appleby's original questionnaire and the Attitudes to Personality Disorder Questionnaire (APDQ).Results We received 76 responses. Lewis and Appleby's questionnaire showed more negative attitudes towards personality disorder than depression, with no significant patient ethnic group effects, and the APDQ also showed a (weak) trend towards more negative attitudes to personality disorder. In subgroup analysis, only in the White British patient group were there significantly more negative attitudes to personality disorder. Factor analysis showed significantly less sense of purpose when working with personality disorder.Clinical implications The perceived greater lack of purpose in working with personality disorder should be the target of clinical training and intervention. Targeted interventions that include training in managing personality disorder, supervision and practice in non-specialist, general psychiatry settings are important.
In this article, we discuss the impact of migration and acculturation processes on the cultural, personal identity, and mental health of children who immigrate to a Western, multicultural environment, and the challenges clinicians in such environments face, when confronted with non-Western idioms of distress and healing practices. We do that by presenting a challenging clinical case of an 8-year-old girl who presented with very disorganized behavior, which matches a culturally accepted construct of spirit possession, in the context of migration trauma, acculturative stress, and new sibling transition. We identify cultural conflict in school and bullying as major mediators between acculturative stress and mental distress. We also aim at identifying vulnerability, risk and protective factors, and the importance of cultural coping resources. We explore in depth the patient's cultural background and the family's belief system and culturally shaped narratives, in order to arrive at a cultural formulation, which focuses on the significance of idioms of distress in shaping psychopathology and influencing the personal and interpersonal course of trauma- and stress-related disorders. We also call attention to the finding that in children, idioms of distress may manifest themselves in a somatic manner. We argue, together with other researchers, that spirit possession deserves more interest as an idiom of distress and a culture-specific response to traumatizing events. We finally emphasize the importance of an anti-reductionist clinical stance, that is able to use different levels of understanding processes of distress and healing, and seeks to reconciliate cultural divides and integrate different explanatory frameworks and help-seeking practices.
SUMMARY
We describe the importance of relational factors in prescribing practices and discuss how they may influence treatment outcomes. Although relational factors play a part in every clinician–patient interaction, they are particularly relevant when managing patients with complex emotional needs. We discuss how relational prescribing can add value when incorporated into standard practice. We introduce psychodynamic theory principles, and we suggest a framework to facilitate reflection and support decision-making when clinicians are faced with complex prescribing decisions.
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