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The purpose of this paper is to describe the evolution of the field of personality disorder since the publication of “Personality disorder: no longer a diagnosis of exclusion” in 2003.

A review of both the academic literature contained within relevant databases alongside manual searches of policy literature and guidance from the key stakeholders was undertaken.

The academic and policy literature concentrates on treating borderline and antisocial personality disorders. It seems unlikely that evidence will resolutely support any one treatment modality over another. Criticism has arisen that comparison between modalities misses inter and intra patient heterogeneity and the measurement of intervention has become conflated with overall service design and the need for robust care pathways. Apparent inconsistency in service availability remains, despite a wealth of evidence demonstrating the availability of cost-effective interventions and the significant inequality of social and health outcomes for this population.

The inclusion of heterogeneous sources required pragmatic compromises in methodological rigour.

This paper charts the recent developments in the field with a wealth of wide-ranging evidence and robust guidance from institutions such as NICE. The policy literature has supported the findings of this evidence but current clinical practice and what patients and carers can expect from services remains at odds. This paper lays bare the disparity between what we know and what is being delivered. The authors argue for the need for greater research into current practice to inform the setting of minimum standards for the treatment of personality disorder.

Abstract This article summarises criteria that can lead to a diagnosis of personality disorder before considering the impact on personality disorder of specific interventions and policy initiatives designed to ensure that services respond to need.

Abstract Steps have been taken towards improving the support given by the mental health workforce to those with personality disorder. But there is more to be done. This article argues that personality disorder is a significant public health challenge and not simply an issue for mental health and criminal justice services.

It is recognised that training is required for staff working with people with a diagnosis of personality disorder, as it poses challenges requiring particular skills and abilities (National Institute for Mental Health in England, 2003a). The proposal to train graduate primary care mental health workers (GPCMHWs) to work with the client group met with some scepticism by senior clinicians. However, the experience of providing training and supervision to the graduate primary care mental health workers to work with clients with personality disorder in Camden and Islington has proved positive. Several characteristics of the GPCMHWs identified in the training literature might contribute to this positive experience. Those factors include cognitive ability, motivation to learn, age, and attitudes. Initial findings from the evaluation of the training shows that graduate workers respond positively to the training, showing improvements in self‐rated knowledge and skills relating to working with the client group, and an eagerness to learn more. The relevance of this to the personality disorder capabilities framework are described.

Personality disorders manifest themselves in a variety of ways and there is also debate about the extent to which these conditions can be treated. The author debates the definition of personality disorder and considers the stigma that this diagnosis can attach to individuals. A new approach to the treatment of people with personality disorders is proposed, using the person‐centred approach and placing the individual at the centre of services. With regards to personality disorder, this person‐centred approach is able to treat the condition as well as addressing the negative effects of how it manifests itself.

This paper describes two different services within the UK, both of which aim to better address the needs of offenders with personality disorder. Both services have been developed in the light of recent policy and practice guidance, which recognises the need to develop new ways of working with this hard‐to‐reach population.The importance of developing boundaries and optimistic therapeutic relationships in order to foster motivation and engagement is emphasised. It is within these that assessment and interventions to address risk, mental health and social integration issues can be undertaken. In addition, the need for different agencies to work together in partnership to better address these needs is also emphasised.Resettle is a stand‐alone service in the pilot stage whilst the probation link‐work role is a resource within an established community personality disorder service.

Abstract This article looks at the benefits of and obstacles to using a whole systems approach to plan and deliver personality disorder services. It does so using the example of the Leeds Managed Clinical Network, a community pilot service that employs whole system working to support people with personality disorder.

Previous studies have demonstrated high rates of psychiatric morbidity in the female prison population and difficulty in transferring women to psychiatric hospital. This study examines whether female prisoners found by consultant forensic psychiatrists to need hospital are admitted and explores the factors affecting this. All women referred to a specialist prison forensic mental health in‐reach service during 2003 were identified and written documentation from assessing consultant forensic psychiatrists was obtained. This was used to identify demographic, offence, clinical and outcome data. Missing data were sought from the prison database, and individual clinicians were interviewed to clarify clinical records. 119 women were referred for assessment. Of these, 50% of those with personality disorder were rejected compared with only 38% of those with a psychotic illness. A sizeable minority of those identified by specialist forensic mental health in‐reach services as needing treatment in hospital were not transferred. There appears to be a particular problem for those with personality disorders. Long delays in transfer to hospital remain a problem for prison mental health services.