['I'm in hate with you; epistemic distrust in patients with a severe personality disorder]. / 'Ik haat van jou'; epistemisch wantrouwen bij mensen met een ernstige persoonlijkheidsstoornis.

Background The assessment and treatment of patients with a personality disorder have made considerable progress during the last decades. Unfortunately, this progress is often limited to patients with a personality disorder in general. Patients with a personality disorder who also fulfil criteria for a severe mental illness (SMI-PD) profit less. Aim To describe the relationship between contemporary paradigms about personality disorders and the current treatment practices of patients with SMI-PD, and to assess the added value of the recently introduced paradigm epistemic trust and distrust. Method An expert group of mental health professionals, all members of the Expertise Centre for Personality Disorders, conducted a literature study and in addition organized an invitational conference and consensus meetings, resulting in an analysis and recommendations for treatment of patients with SMI-PD. Results The epistemic trust and distrust paradigm clarifies the learning process of patients with SMI-PD and the way patients benefit from treatment. We conclude with elaborations of this paradigm for five contexts of patients with SMI-PD. Conclusion The epistemic trust and distrust paradigm seems a promising concept to improve the often difficult treatment of patients with SMI-PD.

[Treating chronic suicidality involves taking risks]. / Behandelen van chronische suïcidaliteit vraagt om risico nemen.

BACKGROUND: Chronic suicidality in patients with borderline personality disorder differs substantially from acute suicidality and therefore requires a different approach. On the basis of a case study and a review of the literature, we argue that treatment should definitely involve the taking of short-term risks for the purpose of achieving long-term success. A thorough assessment of the pros and cons is however a prerequisite for this strategy and some precautions need to be taken.

[Diagnostic alertness to patients having a personality disorder with changing symptoms]. / Diagnostische alertheid bij een persoonlijkheidsstoornis met veranderd symptomenbeeld.

The diagnosis of mood disorders in patients with a personality disorder is complex because there may be a significant overlap of symptomatology between both disorders. A 33-year-old man with a borderline personality disorder, for which he had been treated for several years with marginal success, developed a depression that was not recognised and treated until late. Besides the similarity between the two disorders, emotional and personal factors on the part of the physician played an important role in the failure to diagnose the depression. In such complex situations, the use of practice guidelines may be helpful because these prescribe professional attitudes that, in this case, would probably have prevented the non-recognition of the depression.

[Mediocre quality of discharge reports concerning psychiatric patients]. / Matige kwaliteit van ontslagbrieven over psychiatrische patiënten.

OBJECTIVE: Determination of the quality of discharge letters concerning psychiatric patients. DESIGN: Descriptive. SETTING: 29 community mental health clinics in The Netherlands. METHOD: 420 hospital discharge letters were examined according to 13 quality criteria (reply time, legal status of the patient, reason for hospitalization, heteroanamnesis, source of income, alcohol use, drug use, physical findings, approach, structural diagnosis, DSM-III-R diagnosis, number of words, signature by psychiatrist) derived from a Dutch guideline for discharge letters. RESULTS: The letters did not reach the aftercare attendant in time. The length of the letters was usually within 1050 words. Some formal criteria, like classification according to the DSM-III-R and signature were mostly met (in 67.1% and 90.9% of the letters). Important other information (for instance about a heteroanamnesis (24.8%), the source of income (23.1%), the use of alcohol (24%) or drugs (14.7%) and how to cope with the patient (8%)) were not sufficiently mentioned. CONCLUSION: The quality of hospital discharge letters from community mental health clinics in The Netherlands was insufficient. Adequate exchange of information is essential to guarantee good care for psychiatric patients. Improvement of the quality of hospital discharge letters is therefore highly advisable.