Personality, eating and neurodevelopmental disorders

• Personality disorders: Personality Disorders — Overview | Emotionally Unstable (Borderline) Personality Disorder | Antisocial Personality Disorder | Other Personality Disorders | Personality Disorder in the General Hospital
• Eating disorders: Eating Disorders in Adults | Medical Risk and Refeeding | Treating Eating Disorders
• Neurodevelopmental conditions in adults: ADHD in Adults | Autism in Adults | Learning Disability in Adults | Behaviour That Challenges and STOMP
• Mental health across the lifespan: Mental Health in Older People | Mental Health and Physical Illness | Psychiatric Drugs in Kidney, Liver and Heart Disease
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🧩 Personality, eating and neurodevelopmental disorders — these are long-term conditions that shape how people experience health care. People with personality disorders often have trauma histories and are frequently stigmatised; eating disorders have the highest death rate of any psychiatric illness; and adults with autism or learning disability face major health inequalities. The key is a consistent, compassionate, adjusted approach.
Your four questions for every patient: What long-term pattern of difficulty is this, and since when? Is there immediate physical risk (eating disorder, self-harm)? What reasonable adjustments does this person need? Is medication helping, or could it be part of the problem?

Personality Disorders — Overview

• What they are: Long-standing, pervasive patterns of thinking, feeling and relating to others that differ markedly from cultural expectations, start in adolescence or early adulthood, and cause distress or problems in relationships and functioning. About 1 in 20 adults; much higher in mental health services, prisons and among frequent emergency department attenders.
• ICD-11 approach — rate the severity (mild, moderate, severe) and describe prominent trait domains: negative affectivity, detachment, dissociality, disinhibition, anankastia — plus a "borderline pattern" specifier.
• DSM-5 clusters (still widely used in teaching):
  • Cluster A — "odd or eccentric" — paranoid, schizoid, schizotypal.
  • Cluster B — "dramatic, emotional, erratic" — antisocial, borderline, histrionic, narcissistic.
  • Cluster C — "anxious or fearful" — avoidant, dependent, obsessive-compulsive (anankastic).
• Causes — genetic temperament plus childhood adversity (abuse, neglect, trauma, inconsistent care).
• Diagnosis — by a specialist after careful assessment over time, with collateral history; avoid diagnosing during acute illness or in a single crisis contact.
• Coexisting problems — depression, anxiety, PTSD, substance misuse, eating disorders, self-harm and suicide.
• Stigma — the label can lead to dismissive care; focus on needs, not the diagnosis.

Emotionally Unstable (Borderline) Personality Disorder

• Features:
  • Intense, unstable emotions — rapid mood swings (hours), anger, emptiness.
  • Unstable relationships — idealising then devaluing; intense fear of abandonment.
  • Unstable self-image and identity.
  • Impulsivity — spending, sex, substances, binge eating, reckless driving.
  • Recurrent self-harm and suicidal behaviour (about 1 in 10 die by suicide).
  • Transient stress-related paranoia or dissociation; brief "pseudohallucinations".
• Often a history of childhood trauma or abuse; more often diagnosed in women (men may be misdiagnosed with antisocial PD).
• Differentials — bipolar disorder (mood episodes last days to weeks, not hours), complex PTSD, ADHD, autism (especially in women), substance misuse.
• Treatment (NICE CG78):
  • Psychological therapy — dialectical behaviour therapy (DBT) (especially with recurrent self-harm), mentalisation-based therapy (MBT), schema therapy; structured, long-term, consistent.
  • No drug treatment specifically for the personality disorder or its core symptoms (self-harm, mood instability, impulsivity) — avoid polypharmacy; treat coexisting conditions (depression, anxiety) on their merits.
  • In a crisis — calm, supportive, explore the problem, use the agreed crisis plan; a short-term sedative (e.g. promethazine) for no more than 1 week may be used; avoid prescribing large quantities (overdose).
  • Hospital admission — short and planned where possible (long admissions can increase dependence and self-harm).
  • Consistency — one care coordinator; agreed care plans shared with the emergency department and GP.
• Outlook — many improve substantially with age and treatment; most no longer meet criteria after 10 years.

💡 Clinical Pearl: People with borderline personality disorder are often met with frustration in the emergency department. Treating them with the same respect and care as any other patient, and following their crisis plan, reduces repeat self-harm and the risk of a fatal outcome.

Antisocial Personality Disorder

• Features — persistent disregard for others' rights and social norms: deceitfulness, impulsivity, aggression, recklessness, irresponsibility, lack of remorse; repeated offending.
• Diagnosis — age 18 or over, with evidence of conduct disorder before age 15.
• Much more common in men and in prisons; associated with substance misuse, early death (violence, accidents, suicide).
• Psychopathy — a severe form with callousness, superficial charm, lack of empathy and manipulativeness (measured with the PCL-R in forensic settings).
• Management (NICE CG77):
  • Group-based cognitive and behavioural interventions focused on reducing offending.
  • Treat coexisting depression, anxiety and substance misuse.
  • Prevention — parent training programmes for children with conduct problems.
  • No drugs for the disorder itself.
• Risk — assess violence risk; share information with police and probation (MAPPA) when there is a risk of serious harm.

Other Personality Disorders

• Treatment — psychological therapies (CBT, psychodynamic, schema therapy); treat coexisting mental illness.

Personality Disorder in the General Hospital

• Common situations — repeated self-harm, conflict with staff, requests to leave, demanding behaviour, splitting of the team (some staff idealised, others criticised).
• Helpful approaches:
  • Consistency — one plan agreed by the team; regular team discussions; clear, kind boundaries.
  • Validate emotions without endorsing harmful behaviour.
  • Clear communication — explain decisions and what will happen next.
  • Check for an existing crisis or care plan; involve liaison psychiatry and the community team.
  • Assess capacity for each decision (it can fluctuate under acute distress or intoxication); a capacitous person may leave.
  • Avoid unnecessary benzodiazepines and opioids; avoid prescribing large quantities on discharge.
  • Look after staff — debrief after difficult incidents.

Eating Disorders in Adults

• Anorexia nervosa — restriction of energy intake leading to significantly low weight (BMI usually under 18.5), intense fear of weight gain, distorted body image; restricting or binge–purge subtypes. Highest mortality of any psychiatric illness (physical complications and suicide).
• Bulimia nervosa — recurrent binge eating with a sense of loss of control, followed by compensatory behaviour (self-induced vomiting, laxatives, diuretics, fasting, excessive exercise); weight usually normal or above; self-worth tied to shape and weight.
• Binge eating disorder — recurrent binges without regular compensatory behaviour; distress; often with obesity — the commonest eating disorder.
• ARFID (avoidant/restrictive food intake disorder) — restriction from sensory sensitivity, fear of choking or vomiting, or lack of interest, without body-image concerns; common in autism.
• Other — atypical presentations (OSFED), night eating, insulin omission in type 1 diabetes (to lose weight — high risk of DKA and complications).
• Who — any age, sex, ethnicity or body size (men and older people are under-recognised).
• Physical signs:
  • Low weight, bradycardia, hypotension and postural drop, hypothermia, cold blue hands, lanugo hair, dry skin, hair loss, amenorrhoea, delayed puberty, oedema (on refeeding), muscle weakness.
  • Vomiting — Russell's sign (knuckle calluses), dental erosion, parotid swelling, hypokalaemia with metabolic alkalosis, oesophageal tears.
  • Laxative misuse — hypokalaemia, metabolic acidosis, constipation on stopping.
• Complications — arrhythmias (QT prolongation, low potassium), heart failure, osteoporosis (fractures), infertility, anaemia, leucopenia, liver dysfunction, hypoglycaemia, cognitive problems, refeeding syndrome, suicide.
• Screening — SCOFF questionnaire (Sick, Control, One stone, Fat, Food); ask about eating in people with low BMI, amenorrhoea, unexplained hypokalaemia, poorly controlled type 1 diabetes, or frequent weight changes.

Medical Risk and Refeeding

• MEED (Royal College of Psychiatrists — Medical Emergencies in Eating Disorders, replaced MARSIPAN) — assess risk by:
  • BMI and the rate of weight loss (rapid loss is dangerous at any BMI).
  • Heart rate (under 40 is high risk), BP (low systolic, postural drop with dizziness), temperature (under 35.5 °C).
  • Muscle strength — the Sit Up–Squat Stand (SUSS) test.
  • ECG — bradycardia, prolonged QTc, arrhythmias.
  • Bloods — potassium, sodium, phosphate, magnesium, glucose, FBC, LFTs, U&E.
  • Engagement, fluid restriction or water-loading, behaviours (purging, exercise).
• High risk — admit to a medical ward for stabilisation (with eating disorder team input), or a specialist eating disorder unit.
• Refeeding syndrome — after starvation, feeding drives phosphate, potassium and magnesium into cells:
  • Features — low phosphate, low potassium and magnesium, fluid overload, heart failure, arrhythmias, muscle weakness, respiratory failure, confusion, seizures — usually in the first 2–4 days.
  • High risk (NICE CG32) — very low BMI, significant weight loss, little or no intake for over 5–10 days, low electrolytes before feeding, alcohol misuse.
  • Prevention — start feeding promptly (MEED warns that underfeeding is also dangerous), monitor phosphate, potassium, magnesium and glucose daily at first and replace them, give thiamine and vitamins, monitor fluid balance and ECG.
• Legal framework — the Mental Health Act can be used to treat anorexia nervosa, including nasogastric feeding (treating a consequence of the mental disorder); capacity can be impaired by the disorder even if the person seems able to discuss it.

⚠️ Safety Pearl: People with severe anorexia can have normal blood tests until they suddenly collapse. A slow pulse, low temperature, falling BP, failing the SUSS test or a long QTc are signs of high risk — and refeeding needs daily phosphate checks.

Treating Eating Disorders

• Refer early to community eating disorder services; don't wait for a low BMI.
• Anorexia nervosa in adults (NICE NG69) — offer one of:
  • Individual eating-disorder-focused CBT (CBT-ED).
  • MANTRA (Maudsley Anorexia Nervosa Treatment for Adults).
  • SSCM (Specialist Supportive Clinical Management).
  • Eating-disorder-focused focal psychodynamic therapy if these aren't acceptable or effective.
  • Plus dietetic support, physical health monitoring, bone health (DEXA if low weight for a year or more).
  • No medication as the sole treatment; olanzapine is sometimes used for severe anxiety and rumination (specialist).
• Bulimia nervosa — bulimia-focused guided self-help first; then individual CBT-ED if not effective.
• Binge eating disorder — guided self-help, then group or individual CBT-ED; don't offer drugs alone; weight management as a separate issue.
• ARFID — individualised psychological and dietetic approaches.
• Coexisting problems — depression, anxiety, OCD, self-harm, substance misuse; ask about suicide.
• Type 1 diabetes — joint care between the diabetes and eating disorder teams.

ADHD in Adults

• Persists into adulthood in many children with ADHD; many adults (especially women) are diagnosed for the first time.
• Features in adults — inattention (disorganisation, forgetfulness, losing things, missed deadlines), restlessness (rather than overt hyperactivity), impulsivity (interrupting, spending, risky driving), emotional dysregulation; problems at work and in relationships. Symptoms must have started in childhood.
• Associations — anxiety, depression, substance misuse, autism, personality disorder, offending, accidents.
• Diagnosis — specialist assessment (history from childhood, collateral information, rating scales); exclude sleep disorders, thyroid disease, substance misuse, mood disorders.
• Treatment (NICE NG87):
  • Medication first-line in adults with significant impairment — lisdexamfetamine or methylphenidate; then the other; then atomoxetine if stimulants aren't tolerated.
  • Before starting — heart rate, BP, weight; cardiac history and examination (ECG/cardiology if heart disease, family history of sudden death, or palpitations); substance misuse history.
  • Monitoring — BP, pulse and weight every 6 months; sleep, mood, misuse or diversion.
  • Psychological support — CBT, coaching, workplace adjustments.
• Driving — tell the DVLA if ADHD affects safe driving.
• Waiting lists are long; private and "right to choose" providers are common — shared care agreements with GPs.

Autism in Adults

• Autism — lifelong differences in social communication and restricted, repetitive behaviours and interests, with sensory differences; many adults (especially women) are diagnosed late, often after years of anxiety, depression or misdiagnosis (e.g. as borderline personality disorder).
• "Masking" (camouflaging autistic traits) — exhausting; linked to anxiety, depression, burnout and suicide.
• Coexisting conditions — anxiety, depression, ADHD, eating disorders (ARFID, anorexia), OCD, epilepsy, sleep problems, gastrointestinal problems, hypermobility, learning disability (in some).
• Suicide risk — significantly higher in autistic adults; ask directly.
• Diagnosis (NICE CG142) — specialist assessment; history (including childhood development), observation, collateral information.
• Support:
  • Reasonable adjustments — clear, literal communication; written information; quiet waiting areas; extra time; avoiding unexpected changes; asking about sensory needs (lights, noise, touch).
  • Psychological therapies adapted for autism (e.g. CBT with more structure and visual material).
  • Social skills, employment and housing support.
  • No medication for core autistic features; treat coexisting conditions (start low, go slow — more sensitive to side effects).
• Mental health admission — inpatient wards can be overwhelming; community alternatives; under the MHA 2025, autism alone will not be grounds for longer-term detention (once in force).

Learning Disability in Adults

• Learning disability — significantly reduced intellectual ability (IQ under 70) and reduced social or adaptive functioning, starting in childhood. About 1.5 million people in the UK.
• Health inequalities — people with a learning disability die on average about 20 years younger; many deaths are avoidable (LeDeR) — respiratory infection and aspiration pneumonia, constipation (bowel obstruction), epilepsy (SUDEP), sepsis, cancer diagnosed late.
• Common physical problems — epilepsy, dysphagia, reflux, constipation, obesity or underweight, sensory impairment (hearing and vision), dental disease, thyroid disease (Down syndrome), early-onset dementia (Down syndrome — Alzheimer's from the 40s–50s).
• Mental health — higher rates of anxiety, depression, psychosis and behaviour that challenges; may present as changes in behaviour (withdrawal, aggression, sleep or appetite change, self-injury).
• Diagnostic overshadowing — attributing new symptoms to the learning disability; always look for pain, illness, constipation, dental problems, infection or side effects.
• Good care:
  • Reasonable adjustments (Equality Act 2010) — longer appointments, easy-read information, a quiet space, the first appointment of the day.
  • Hospital passport; involve carers and learning disability liaison nurses.
  • Annual health check from age 14 and a health action plan.
  • Mental Capacity Act — support decision-making; best interests decisions; don't assume lack of capacity.
  • DNACPR decisions must never be based on learning disability alone.
  • Oliver McGowan Mandatory Training for all health and care staff.

Behaviour That Challenges and STOMP

• Behaviour that challenges — aggression, self-injury, destruction, withdrawal — usually communicates an unmet need (pain, distress, sensory overload, boredom, change in routine).
• Assessment (NICE NG11) — look for physical causes (pain, constipation, infection, dental pain, seizures, medication side effects), mental illness, communication difficulties, environment and routine changes.
• Management — positive behaviour support (functional assessment, changing the environment, teaching new skills); communication aids; treat physical and mental health problems.
• Medication — antipsychotics only when psychological approaches haven't worked or the risk is severe; lowest dose, short term, with regular review.
• STOMP (Stopping Over-Medication of People with a learning disability, autism or both) — NHS England programme: many people are on antipsychotics, antidepressants or sedatives without a diagnosed mental illness; review and reduce with the person and carers.
• Side effects to watch for — weight gain, diabetes, sedation, constipation, falls, movement disorders, dysphagia.

Mental Health in Older People

• Depression — common, under-recognised; may present with physical complaints, anxiety, agitation, cognitive impairment ("pseudodementia"), weight loss, or self-neglect; older men have high suicide rates. Look for physical causes and drugs; SSRIs (sertraline) or mirtazapine; check sodium; psychological therapies work as well as in younger people; ECT for severe or psychotic depression.
• Anxiety — often with depression or physical illness; first-onset anxiety in older age — look for physical causes (thyroid, arrhythmia, drugs, early dementia).
• Delirium and dementia — see the Dementia and Cognitive Disorders chapter; always consider delirium in a sudden change.
• Late-onset psychosis — see the Psychosis chapter (sensory impairment, isolation).
• Alcohol and prescribed drug misuse — often hidden (falls, confusion, interactions).
• Prescribing in older people — "start low, go slow"; avoid anticholinergic burden (TCAs, oxybutynin, older antihistamines — confusion, falls, dementia risk); avoid long-term benzodiazepines and Z-drugs (falls); antipsychotics in dementia increase stroke and death.
• Safeguarding — elder abuse (financial, physical, neglect), self-neglect (Diogenes syndrome — squalor, hoarding, refusing help).
• Loneliness and bereavement — social prescribing; carers' support.

Mental Health and Physical Illness

• Depression and anxiety are 2–3 times more common in people with long-term conditions (heart disease, diabetes, COPD, cancer, stroke, chronic pain) and worsen outcomes and self-care.
• Screen and treat — Whooley questions, PHQ-9, GAD-7; psychological therapies (including integrated NHS Talking Therapies for long-term conditions); antidepressants chosen with care (interactions — e.g. SSRIs with anticoagulants).
• Liaison psychiatry — self-harm, delirium, capacity, psychiatric illness in medical inpatients, medically unexplained symptoms, perinatal problems, alcohol and drugs.
• Specific links:
  • Post-stroke depression — common; affects rehabilitation.
  • Parkinson's disease — depression, anxiety, apathy, psychosis (drug-related), impulse-control disorders, dementia.
  • Cardiac disease — depression after MI worsens prognosis; sertraline is safe.
  • Cancer — depression, anxiety, adjustment disorder, steroid-induced mood changes.
  • ICU survivors — PTSD, depression, cognitive problems.
  • Diabetes — depression worsens control; eating disorders (insulin omission).
• Perioperative care — continue most psychiatric drugs (avoid abrupt stopping — withdrawal, relapse); lithium is usually stopped 24 hours before major surgery and restarted when eating, drinking and renal function are stable; check clozapine plans; MAOIs need anaesthetic planning.

Psychiatric Drugs in Kidney, Liver and Heart Disease

Drug Reference Table

Spot the Diagnosis

Exam-style Scenarios

1. A 24-year-old woman attends the emergency department for the fifth time this month after cutting her arms. She has a diagnosis of emotionally unstable personality disorder and asks for diazepam.
Answer: Crisis in borderline personality disorder.

• Treat wounds with respect; psychosocial assessment by liaison psychiatry; follow her crisis plan.
• Avoid benzodiazepines; short-term promethazine (up to 1 week) if sedation is needed.
• Link with her community team for DBT or MBT; avoid long admissions.

2. A 21-year-old student has a BMI of 13.2, heart rate 38, temperature 35.3 °C and can't stand from squatting without using her hands.
Answer: High-risk anorexia nervosa (MEED red flags).

• Admit to a medical ward with eating disorder team input; ECG, electrolytes including phosphate and magnesium.
• Start feeding promptly with daily electrolyte monitoring and replacement; thiamine; avoid underfeeding.
• Consider the Mental Health Act if she refuses life-saving treatment.

3. A 35-year-old man with a moderate learning disability has become aggressive and stopped eating over 2 weeks. His carers say he keeps holding his face.
Answer: Behaviour change — look for a physical cause (likely dental pain).

• Full physical assessment with reasonable adjustments (dental, ears, abdomen — constipation, urine).
• Involve carers and the learning disability liaison nurse; hospital passport.
• Avoid starting antipsychotics for "behaviour" without a cause (STOMP).

4. A 28-year-old man says he has always been disorganised, impulsive and unable to concentrate, has lost several jobs, and was in trouble at school for the same.
Answer: Possible adult ADHD.

• Refer for specialist assessment (childhood history, collateral information).
• If confirmed — lisdexamfetamine or methylphenidate, after baseline BP, pulse, weight and cardiac history.
• Screen for substance misuse, anxiety and depression; DVLA advice.

5. A 70-year-old man with CKD stage 4 and depression is on lithium for bipolar disorder.
Answer: Lithium is nephrotoxic and renally excreted — review urgently with psychiatry and renal teams.

• Consider switching to an alternative mood stabiliser (e.g. an antipsychotic such as quetiapine or aripiprazole).
• Check lithium level, eGFR, TFTs and calcium; avoid NSAIDs and dehydration.
• Choose a renally safe antidepressant if needed (e.g. sertraline).

Key Points

• Personality disorders are long-standing patterns from adolescence; often linked to childhood trauma.
• Borderline PD: DBT or MBT; no drugs for core features; short-term sedation (up to 1 week) in crisis only.
• Antisocial PD needs conduct disorder before 15; group CBT for offending.
• In hospital: consistency, clear boundaries, crisis plans, assess capacity for each decision.
• Anorexia has the highest mortality of any psychiatric illness.
• MEED: BMI and rate of loss, heart rate, BP, temperature, SUSS test, ECG, electrolytes.
• Refeeding syndrome: low phosphate in the first days — start feeding promptly and monitor electrolytes daily.
• The MHA can authorise nasogastric feeding in anorexia.
• Adult anorexia: CBT-ED, MANTRA or SSCM; bulimia: guided self-help, then CBT-ED.
• Adult ADHD: lisdexamfetamine or methylphenidate first-line; monitor BP, pulse and weight.
• Autistic adults: reasonable adjustments, adapted therapies, no drugs for core features; high suicide risk.
• Learning disability: die about 20 years earlier; beware diagnostic overshadowing; annual health checks; STOMP.
• Older people: depression may mimic dementia; start low, go slow; avoid anticholinergics.
• Kidney disease: avoid lithium; heart disease: sertraline; liver disease: low-dose short-acting benzodiazepines.

Guidelines and Further Reading

• NICE CG78: Borderline personality disorder — recognition and management
• NICE CG77: Antisocial personality disorder — prevention and management
• NICE NG69: Eating disorders — recognition and treatment
• RCPsych CR233: Medical emergencies in eating disorders (MEED)
• NICE CG32: Nutrition support for adults (refeeding syndrome)
• NICE NG87: Attention deficit hyperactivity disorder — diagnosis and management
• NICE CG142: Autism spectrum disorder in adults — diagnosis and management
• NICE NG11: Challenging behaviour and learning disabilities
• NHS England: STOMP — stopping over-medication of people with a learning disability, autism or both
• LeDeR: Learning from lives and deaths — annual reports
• Maudsley Prescribing Guidelines in Psychiatry
• BNF — for current doses