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Special groups

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.

Keywords assessment; compulsory treatment; epidemiology; personality


disorders; service provision; treatment

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

People with personality disorders present to many different


agencies in the community, including community mental health
teams (CMHTs), social services, primary care, the police and
probation. Although these services have traditionally not prioritized the needs of personality-disordered people, recent policy
developments indicate that attitudes are slowly changing.1 This
contribution provides an overview of the clinical features, epi
demiology, assessment and management of people with personality disorders living in the community.

Paul Moran MD MRCPsych is Clinical Senior Lecturer at the Institute of


Psychiatry, London, UK, and Honorary Consultant Psychiatrist to a
national service for people who self-harm. He qualified in Medicine
from St Bartholomews Hospital, London, and trained in Psychiatry
at the Maudsley Hospital. He has published widely on the subject of
personality disorder. Conflicts of interest: none declared.

Diagnostic features of all personality disorders


The occurrence of maladaptive patterns of behaviour,
thinking and emotions
Enduring and pervasive disturbance that is not limited to
episodes of mental illness
Considerable personal distress and/or significant problems in
occupational and social functioning
The occurrence of early manifestations (e.g. conduct disorder)
appearing in childhood

Marianne Hayward MBBCh MRCPsych is a Specialist Registrar in General


Adult Psychiatry at the Maudsley Hospital, London, UK. She completed
her medical training at Cambridge University and the University
of Wales College of Medicine, and trained in psychiatry at the
Maudsley Hospital. Her research interests include the epidemiology of
personality disorder. Conflicts of interest: none declared.

PSYCHIATRY 6:9

Table 1

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Special groups

follow-up appointments. Many other people with a personality


disorder rely heavily on casualty departments for their primary
healthcare. Casualty departments are also usually the first port
of call in the treatment of deliberate self-harm, accidents and
assaults, all of which occur more commonly in this group of
patients.4
People with cluster B personality disorders may seek help
from CMHTs. Their underlying problems with affective in
stability and poor impulse control may lead them to present in
crisis, threatening deliberate self-harm or aggression to others.
Their presentational style means that they are hard to engage
in standard community treatment programmes and consequently
they are demanding patients to work with, as they can provoke
extreme anxiety and splits within teams.

Ideally, a standardized assessment should be undertaken and


corroborated with information from an informant. Examples of
reliable assessment measures are the Standardised Assessment
of Personality (SAP), the Personality Assessment Schedule (PAS)
and the Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II). An inquiry should also be made into the positive as well as negative aspects of the patients personality, as
this is likely to make the interview more acceptable to the patient
and will also help to guide the management strategy.
Differential diagnosis
Although other mental disorders can occur in the context of a
personality disorder, a primary diagnosis of personality disorder
should be made only in the absence of mental illness. The following differential diagnoses should be considered, particularly
when behaviour is out of character:
an affective disorder depression can be mistaken for
dependent personality disorder and hypomania for histrionic
personality disorder
an anxiety disorder can be difficult to distinguish from
anxious personality disorder (some question whether it is
useful to distinguish between the two)
substance misuse/dependence
a psychotic illness paranoid and schizoid personality disorders
can be confused with a delusional disorder or schizophrenia
a medical condition causing personality change (e.g. head
injury, acute confusional state, dementia).

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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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.

mood stabilizers may all have a role to play in the symptomatic


treatment of conditions such as borderline personality disorder.
However, further evidence from well designed, conducted and
reported RCTs is urgently needed: a recent Cochrane review of
pharmacotherapy for borderline personality disorder identified
only ten small trials of moderate quality.7
Service provision
Increasingly, CMHTs are concentrating their efforts and resources
on patients with severe mental illness. In addition, evidence is
emerging to suggest that the needs of patients with personality
disorder are not well met by generic services.10 People suffering
from severe mental illness and comorbid personality disorder are
at higher risk of violent and suicidal behaviour11 and are also
more likely to be victims of violence.12 It is therefore clear that
the policy of care in community settings needs to be modified to
take account of the special needs of this group of people.13
Three types of service model can operate to provide care for
personality-disordered patients in community settings.14
The sole practitioner model involves a mental health practi
tioner as the primary treating health professional. This is often a
psychiatrist who sees the patient in an outpatient clinic. He/she
may conduct psychotherapy, organize social support and prescribe medication. Such a model is probably appropriate only for
less severely disturbed patients, as the professional isolation that
is integral to this model can have hazardous consequences for
both clinician and patient.
The divided functions model divides roles between teams. This
may involve a psychotherapist conducting outpatient therapy,
whilst a community psychiatrist prescribes medication and offers
general support. Such a model can readily lead to splitting and
poorly coordinated treatment.
The specialist team model involves a group of specially trained
health professionals working together as part of one specialist
multidisciplinary team (usually offering a day service). Roles are
divided within the team; for example, one member of the team
may provide individual psychotherapy whilst another is primarily involved in coordinating social care and support. Regular
meetings and team supervision are essential components of this
model as they ensure good communication between the different team members. This model succeeds only if good working
relationships are maintained within the team and treatment is
consistent and delivered according to an agreed policy.
Regional differences in morbidity mean that it is not possible
to recommend one method of service delivery for personalitydisordered patients. However, it is likely that Trusts with high
morbidity levels will need to consider developing specialist day
services for personality-disordered patients, in order to meet the
needs of their local population.

Pharmacological treatment: although medication is not the


mainstay of treatment, it may help to relieve some of the emotional symptoms associated with a personality disorder. In addition, from the perspective of harm minimization, prescribed
medication is generally a safer alternative to drugs and alcohol,
which some personality-disordered patients are at risk of using
in order to relieve their distress. Notwithstanding, it is important
always to be mindful of the risk of overdose in this group of
patients. Antidepressants, atypical antipsychotic medication and

Psychological treatment options for people with


personality disorder
Dialectical behavioural therapy
Psychodynamic psychotherapy
Schema-focused therapy
Cognitive-behaviour therapy
Therapeutic community treatment
Cognitive analytic therapy

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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Special groups

severe personality disorder (DSPD) to be kept in detention in


specialist health facilities for as long as they pose a high risk to
others.15 Although not a psychiatric diagnosis, the term DSPD is
intended to apply to individuals:
who show a significant disorder of personality
who present a significant risk of causing harm from which the
victim would find it difficult or impossible to recover
in whom the risk presented appears functionally linked to the
personality disorder.
Under these proposals, assessment and treatment programmes
for patients with DSPD were established15 and evaluations of
their effectiveness are currently under way.
Following sustained opposition from mental health professionals, service user groups and lawyers, the proposed new Mental
Health Act was abandoned in March 2006 in favour of amending the existing Act. Many of the original proposals have been
retained. Of particular relevance to the compulsory treatment of
personality disorders are:
a simplified single definition of mental disorder throughout
the Act, abolishing the current four categories (including
psychopathic disorder)
the replacement of the current treatability clause (applying
only to psychopathic disorder and mental impairment) with
the requirement for appropriate treatment to be available to
the patient.
Although some of the original concerns about the new Act have
been addressed by the changes, others remain.
The proposals continue to be explicitly directed at improving
public protection.
There is evidence to indicate that even if successfully introduced, the proposals are unlikely to improve public protection. A
systematic review of the accuracy of dangerousness assessments
found that six people with DSPD would need to be detained in
order to prevent one person from acting violently.16
Although the proposals require treatment to be available before a person is detained, there is no requirement for treatment to
be effective. Indeed, the proposals aim to prevent certain groups
of patients being labelled as untreatable and denied the services
they need. This raises the possibility of long periods of detention
in mental health facilities without therapeutic change.
The proposals could result in the further marginalization of an
already disadvantaged section of society.

adequate resources to fund dedicated services. With regard to


compulsory treatment, any changes to mental health legislation
need to be based on sound ethical principles, but the future legal
framework remains unclear.

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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2007 Elsevier Ltd. All rights reserved.