The management of individuals with personality disorder is one of the most challenging and sometimes controversial areas of psychiatry. This paper describes the principles involved in identifying the clinical problems and formulating a management plan for patients with personality disorder in everyday clinical practice. It demonstrates that the principles of assessing and managing personality disorders and the clinical skills required are no different from those of treating any other chronic mental disorder.

The concept of borderline personality disorder (BPD) seems to include, almost by definition, the idea that people described by the term are difficult to help. The broad picture portrayed by the diagnostic criteria (Box 1) is likely to be familiar to most clinicians and to cause the hearts of many to sink. A core issue for those with BPD is difficulty of relationship, and this will inevitably – even especially – include clinical and therapeutic relationship. It is all too common for distress to be met with much therapeutic effort but for little to change. Indeed, there is often a nagging sense that attempts at treatment may be making matters worse. The care of people with BPD presents an important challenge to mental health services. At the individual level, the patient continues to be at risk and to suffer and the clinician feels frustrated. At the service level, substantial resources may be expended to little apparent benefit.

The extraordinary events of 1994 in Rwanda touched the world, and the extent and brutality of the atrocities committed scarred it (Anderson, 1998). There are no simple explanations or solutions for such human tragedy. Societies are shattered by war, and societal interventions are required to heal the physical and psychological wounds. The final outcome of such interventions is, however, difficult to predict. Psychiatric involvement in Rwanda's suffering has been small and examination of the literature reveals a paucity of data. Most of the data that are available are qualitative, as that is the only way of understanding what happened. Everyone involved in Rwanda in 1994 was changed by their experiences. Rwanda was a catastrophe.

A substantial body of research indicates that, for people from Black and Asian ethnic minorities, access to, utilisation of and treatments prescribed by mental health services differ from those for White people (Lloyd & Moodley, 1992; for a review see Bhui, 1997). Pathways to mental health care are important, and the widely varying pathways taken in various societies may reflect many factors: the attractiveness and cultural appropriateness of services; attitudes towards services; previous experiences; and culturally defined lay referral systems (Goldberg, 1999). Contact with mental health care services may be imposed on the individual, but people who choose to engage with services usually do so only if they think that their changed state of functioning is health-related and potentially remediable through these services. In such cases, they will contact whoever they perceive to be the most appropriate carer, and these carers are often not part of a national health care network.

Group psychotherapy is one of the most widely practised treatment methods in psychiatry, with an extensive literature, but it has long been regarded as the poor relation to individual therapy. Nineteenth-century ideas about the primacy of the individual, taken up by psychoanalysis, continue to dominate Western culture. Mrs Thatcher's famous remark “I don't believe in society. There is no such thing, only individual people, and there are families” (Women's Own, 31 October 1987) typifies the extreme view in which the self and the individual's needs are paramount and are set above those of the group. Foulkes in the 1950s had put forward the opposite position, arguing that there is no such thing as an individual that exists apart from and outside the social (Foulkes, 1948; Foulkes & Anthony, 1957).

It is estimated that 29% of adults in the UK smoke (Office for National Statistics, 2000). Each year smoking kills 120 000 people (13 deaths per hour), making it the single most common preventable cause of death in Britain (Callum, 1998). Around half of all smokers will die prematurely because of their addiction (Peto et al, 1994). Their overall life expectancy is, on average, 8 years less than for non-smokers (Callum, 1998). Smoking also costs the National Health Service (NHS) £1500 million, with around 1000 admissions every day for smoking-related illnesses (Parrott et al, 1998). (However, the UK treasury earns £8 billion in tax on tobacco sold in the UK alone, in addition to the enormous revenue from overseas markets.)

Antipsychotic drugs are among the most widely prescribed psychotropic medications for elderly people, particularly for the 5–8% of patients who are in institutions. The antipsychotics are indicated for treating psychotic disorders, including schizophrenia, delusional disorder, psychotic symptoms in mood disorders and for a number of organic psychoses.

Home visits by old age psychiatrists remain popular with elderly patients, their carers and general practitioners (GPs). Home assessments by various disciplines working with older people have been endorsed as a sign of good practice by the Audit Commission (2000) in their recent national report on mental health services for older people:

Children who have a learning disability are at increased risk of sexual and physical abuse and neglect. They and their families are more likely to be socially isolated and to suffer material and emotional poverty. The range of emotional reactions in carers can vary at different times from extreme overprotection, through relative equanimity, to sometimes outright hatred and rejection of the child. Society largely reflects this, only rarely viewing the individual with learning disability in a positive way, choosing often to pity, patronise, ignore, ridicule or openly despise. These attitudes are internalised by children with the disability, who invariably suffer from low self-esteem. All of these factors combine to facilitate abuse.

Getting to grips with critical appraisal is not easy. To some extent, it is a metaphorical bandwagon, overloaded with dogma, misinformation and mathematics. Its introduction into the MRCPsych curriculum (Royal College of Psychiatrists, 2001) has left many trainers trying to catch up with their trainees' skills. This paper attempts to demystify some of the concepts, provide a balanced overview of the advantages and drawbacks of critical appraisal, and discuss ways of developing skills in critical appraisal.