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Personality disorders
Clinical features
Diagnosis and classification
The diagnostic features of all personality disorders are given in
Table 1.
Whilst ICD-10 continues to retain personality disorder within
the main rubric of mental disorders, DSM has, since its third
revision in 1980, placed personality disorders on a separate axis,
Axis II. DSM-IV recognizes three clusters of personality disorder:
Cluster A paranoid, schizoid and schizotypal personality
disorder. These disorders are characterized by odd, eccentric
behaviour, difficulty mixing with others and paranoid thinking.
Cluster B histrionic, narcissistic, antisocial and borderline
personality disorders. These disorders are characterized by problems with impulse control, affect regulation and relationship
instability.
Cluster C obsessivecompulsive, avoidant and dependent.
These disorders are characterized by fearfulness, excessive
dependency on others and obsessional behaviour.
The current classification of personality disorders, which is
based on a categorical model of abnormal personality, is unsatisfactory. Criteria for categories of personality disorder frequently
overlap and clinicians often disagree on whether categories are
present or not. In fact, personality is probably more accurately
conceptualized using a dimensional model.2 Nevertheless, cat
egories lead more readily to treatment decisions and convey more
vividly the disturbance demonstrated by people with personality
problems. It is therefore likely that future classification schemes
will attempt to hybridize categorical and dimensional models of
abnormal personality.
Paul Moran
Marianne Hayward
Abstract
Personality disorders are a major public health issue. They are common conditions, with approximately 4% of UK adults being affected. The
nature of the problems experienced by personality-disordered people
varies considerably, and referral to mental health services is not always
necessary. Nevertheless, for those who do seek help from mental health
services, there is now growing evidence that some of their problems are
eminently treatable; over the past two years, there have been important
developments in the field of personality disorder treatment research. In
addition, the essential components of dedicated personality disorder
services are now well described, a series of innovative services have
been funded and evaluations of these services are currently under way.
This contribution summarizes some of the most important recent developments in the field.
Clinical presentation
The term personality disorder covers a wide range of psycho
pathology. Consequently, the nature of the problems experienced by people with personality disorder in the community
varies considerably. Many people with a personality disorder
are able to negotiate life reasonably successfully. However, there
are others who suffer considerably and place a heavy burden on
those around them.
For some people with a personality disorder, the first point
of contact with the health service will be their GP. In general
practice, the presentation is usually that of a difficult or heartsink patient with multiple problems.3 They are more likely
to attend when in a crisis, but may then fail to re-attend for
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Table 1
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Special groups
Epidemiology
Epidemiological surveys in Europe and the USA have shown
that the point prevalence of unspecified personality disorder in
the community lies somewhere between 4% and 13%. Recent
research has shown that in the UK, the weighted prevalence of
personality disorder is approximately 4%, with prevalence being
highest among men, those who are separated, the unemployed,
and people living in urban locations.5 The differences in pre
valence reported in different studies paints a confusing picture,
and this is likely to reflect:
methodological differences: diagnostic criteria used, sampling
strategy used and assessment method used
differences in the populations from which samples are drawn
changes in the prevalence of personality disorder over time
real differences in the prevalence of personality disorder between geographical settings.
Most studies have detected gender differences in the prevalence
of specific categories of personality disorder. This has been most
clearly demonstrated for antisocial personality disorder, which
is 56 times more common in men than women. Surveys have
generally found an excess of prevalence of personality disorder
among those aged less than 40 years. The cross-sectional finding
of a decline with age may reflect: selection bias, a cohort effect
(individuals born in earlier generations might be less likely to
have a personality disorder), or possibly a higher mortality rate
among those with personality disorder.
Management
Referral to psychiatric services
Disturbed behaviour and interpersonal conflict can bring a person
with a personality disorder to the attention of health professionals. However, immediate referral to psychiatric services may not
be the appropriate course of action for all people with a personality disorder. For some (particularly for those with more egosyntonic disorders, such as paranoid or obsessional personality
disorders), it may be more appropriate to accept the personality
as abnormal and to minimize the problems created in the outside
world. This involves changing the focus of treatment from patient
to environment (nidotherapy) and may create less conflict than
attempts to alter personality or behaviour.6
Other personality-disordered people derive useful support
and help from their GPs, who may have a detailed knowledge
of the patient since childhood. However, a substantial number
of people with personality disorder will require referral to psychiatric services. Triggers for referral and acceptance are usually
determined by an assessment of risk of harm to self or to others,
the presence and severity of accompanying mental illness and
the degree of burden and distress caused to family and others.1
Assessment
The assessment of pre-morbid personality should form part of a
routine psychiatric interview. Indeed, failure to undertake such
an assessment can lead to the omission of important clinical
information, which may guide later treatment. It is difficult to
make absolute recommendations about the assessment of personality disorder in community settings, as although a number of
reliable assessment procedures now exist, there is no single gold
standard. The choice of method will ultimately be determined by
time constraints and the availability of sources of information.
Three methods are available for the assessment of personality
disorders:
clinical interview
standardized assessment
self-report questionnaire.
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Treatment
The evidence base for the treatment of personality disorder is
extremely limited and therefore it is not yet possible to make
prescriptive statements about what constitutes appropriate treatment. However, a number of small clinical trials now indicate
that both psychological and pharmacological treatments have
a place in management and a combination of these is the con
sensus view of treatment in personality disorder.1
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Special groups
Psychological treatment forms the central component of treatment. A number of psychological treatments are now available
and these are listed in Table 2. Some treatments have a more
robust evidence base than others, although it is premature to
conclude that other forms of psychological treatment are ineffective. A Cochrane review of psychological treatments for borderline personality disorder identified seven randomized controlled
trials (RCTs), six of dialectical behavioural therapy (DBT) and
one of psychoanalytically orientated partial hospitalization. The
review concluded that some of the problems encountered by
people with borderline personality disorder may be amenable to
talking/behavioural treatments. In particular, DBT was reported
to be effective in reducing self-harm and suicidality, and partial hospitalization was reported to reduce hospital admissions,
psychotropic medication use, and symptoms of depression and
anxiety, as well as increasing social functioning.7
More recently, a multi-centre RCT of schema-focused therapy
compared with transference-focused psychotherapy for borderline
personality disorder found that both are effective in reducing the
severity of psychopathology and improving quality of life, with
schema-focused therapy having the larger effect size.8 Although
the above evidence is encouraging, to date the studies are too
few and small to inspire full confidence in their results, and further replicative work is required. In addition, rigid adherence to
one particular treatment model is likely to be unhelpful and consultative work with service users has highlighted the importance
of offering choice from a range of treatment options.1
Despite the differences between psychological treatments,
successful treatment programmes seem to share a number of
common features.9 Such programmes tend to be:
well structured
well integrated with other services
relatively long-term
encouraging of treatment compliance
clearly focused
understandable to both therapist and patient.
Compulsory treatment
Currently in the UK, people with personality disorder can be
detained in hospital under the category of psychopathic dis
order only if they are thought to be treatable. In 2000, as part of
general reforms to the Mental Health Act, the government proposed a new legal framework to allow for dangerous people with
Table 2
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References
1 National Institute for Mental Health in England. Personality disorder:
no longer a diagnosis of exclusion. Policy implementation guidance
for the development of services for people with personality disorder.
London: Department of Health, 2003.
2 Moran P, Coffey C, Mann A, et al. Dimensional characteristics of
DSM-IV personality disorders in a large epidemiological sample.
Acta Psychiatr Scand 2006; 113: 23336.
3 Moran P, Rendu A, Jenkins R, et al. The impact of personality
disorder in UK primary care: a 1-year follow- up of attenders.
Psychol Med 2001; 31: 144754.
4 Hiroeh U, Appleby L, Mortensen PB, et al. Death by homicide,
suicide, and other unnatural causes in people with mental illness:
a population-based study. Lancet 2001; 358: 211012.
5 Coid J, Yang M, Tyrer P, et al. Prevalence and correlates of personality
disorder in Great Britain. Br J Psychiatry 2006; 188: 42331.
6 Tyrer P. Nidotherapy: a new approach to the treatment of
personality disorder. Acta Psychiatr Scand 2002; 105: 46971.
7 Binks CA, Fenton M, McCarthy I, Lee T, Adams CE, Duggan C.
Psychological therapies for people with borderline personality
disorder (review). The Cochrane Collaboration, 2006.
8 Giesen-Bloo J, van Dyck R, Spinhoven P, et al. Outpatient
psychotherapy for borderline personality disorder: randomized trial
of schema-focused therapy vs transference-focused psychotherapy.
Arch Gen Psychiatry 2006; 63: 64958.
9 Bateman AW, Fonagy P. Effectiveness of psychotherapeutic treatment
of personality disorder. Br J Psychiatry 2000; 177: 13843.
10 Hayward M, Slade M, Moran PA. Personality disorders and unmet
needs among psychiatric inpatients. Psychiatr Serv 2006; 57: 53843.
11 Moran P, Walsh E, Tyrer P, et al. Impact of comorbid personality
disorder on violence in psychosis: report from the UK700 trial.
Br J Psychiatry 2003; 182: 12934.
12 Walsh E, Moran P, Scott C, et al. Prevalence of violent victimisation
in severe mental illness. Br J Psychiatry 2003; 183: 23338.
13 Tyrer P, Simmonds S. Treatment models for those with severe
mental illness and comorbid personality disorder. Br J Psychiatry
2003; 182(suppl 44): S1518.
14 Bateman A, Tyrer P. Services for personality disorder: organisation
for inclusion. Advan Psychiatr Treat 2004; 10: 42533.
15 Home Office, HM Prison Service, Department of Health. Dangerous
and severe personality disorder (DSPD) high secure services:
planning and delivery guide. London: Home Office, HM Prison
Service, Department of Health, 2004.
16 Buchanan A, Leese M. Detention of people with dangerous severe
personality disorders: a systematic review. Lancet 2001; 358:
195559.
Conclusion
In conclusion, personality disorders are common conditions
that are associated with a significant burden to the individual,
those around them and society as a whole. Recently there has
been greater acknowledgement of the need for specialist mental
health services for personality-disordered people. Psychological and pharmacological treatments are emerging as promising
management tools and the essential components of the dedicated personality disorder service are now well described. Further progress will be contingent on the sustained provision of
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