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Ovid: Oxford Handbook of Psychiatry

Editors: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew Title: Oxford Handbook of Psychiatry, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 11 – Personality disorders Chapter 11 Personality disorders P.440
Introduction Personality disorder is one of the most contentious diagnoses in psychiatry. Although there are clear diagnostic criteria, the term is often used as a pejorative label for patients whom we dislike, following an inadequate assessment. Diagnostic reliability is poor and current categorical classifications lack validity. The concept has been attacked for being nothing more than medicalisation of socially unacceptable behaviour. Although the vast majority of people with personality disorders are not violent, much discussion has focused on personality disordered offenders and ‘psychopaths’. There have been numerous attempts in various countries to devise legislative measures to protect society from ‘dangerous psychopaths’, and the role of psychiatry in this endeavour has been a point of argument within the profession and between the profession and others (particularly politicians and lawyers) for over a century. There are many psychiatrists who believe that psychiatry has no role in the treatment of people with personality disorders. They argue that:

  • Personality is by definition unchangeable
  • There is no evidence that psychiatry can do anything
  • These people are disruptive and impinge negatively on the treatment of other patients
  • These people are not ill and are responsible for their behaviour
  • Psychiatry is being asked to deal with something that is essentially a social problem.

On the other hand there are those who believe that people with personality disorder clearly fall within the remit of psychiatry, arguing:

  • People with personality disorder suffer from the symptoms of their disorder
  • They have high rates of suicide, other forms of premature death, and of other mental illness
  • There are treatment approaches which are effective
  • Their opponents are rejecting patients because they dislike them
  • The problem is not that these people cannot be helped but that traditional psychiatric services do not provide the type of approach and services that are necessary

The focus of this chapter is on the clinical assessment and management of people with personality disorders. The place of personality disorder in mental health legislation is covered in Chapter 19 and personality disorder and offending is mentioned in Chapter 15. Disorders of sexual preference are also covered in this chapter, as they are grouped with personality disorders in ICD-10. P.441
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The concept of personality disorder Essence ‘Personality’ can be seen as the enduring characteristics and attitudes of an individual. We all recognise, amongst people we know well, some who manifest certain characteristics more than others: shyness, confidence, anger, generosity, tendency to display emotions, sensitivity, and being pernickety to name but a few. When these enduring characteristics of an individual are such as to cause distress or difficulties for themselves or in their relationships with others then they can be said to be suffering from personality disorder. Personality is separate from illness, although the two interact. Definition The following definition is based on ICD-10 and DSM-IV (both are very similar). Personality disorders are enduring (starting in childhood or adolescence and continuing into adulthood), persistent and pervasive disorders of inner experience and behaviour that cause distress or significant impairment in social functioning. Personality disorder manifests as problems in cognition (ways of perceiving and thinking about self and others), affect (range, intensity, and appropriateness of emotional response), and behaviour (interpersonal functioning, occupational and social functioning, and impulse control). To diagnose personality disorder, the manifest abnormalities should not be due to other conditions (such as psychosis, affective disorder, substance misuse, or organic disorder) and should be out of keeping with social and cultural norms. Development of the concept1 The development of clinical concepts of conditions which would today be recognised as personality disorder started in the early 19th Century, at a time when the main two groups of mental conditions acknowledged by psychiatrists were insanity and idiocy. It became clear that there were individuals who were neither insane (not suffering from delusions or hallucinations) nor clearly idiots, imbeciles, or morons (to use the then contemporary terminology for learning disability), but who nevertheless manifested abnormalities in their behaviour. The term ‘moral insanity’ was introduced by Prichard in 1835. ‘Moral’ meant ‘psychological’ (rather than the modern meaning concerning ethics), and amongst the patients described were people who had affective disorders as well as people who were personality disordered. As the concept has developed various labels have been used, but the term ‘psychopathy’ dominated the 20th Century. The term was used in various ways:

  • Broadly and literally, covering any psychopathology at all.
  • More narrowly, covering all personality disorders.
  • More narrowly still, covering personality disorders manifesting antisocial behaviour.
  • At its narrowest, referring to cold, callous, self-centred, predatory individuals.

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Until relatively recently personality disorder manifesting antisocial behaviour has dominated the literature. Clinical developments have been complicated by legal definitions (such as ‘moral imbecile’ in 1913 and ‘psychopathic disorder’ in 1959). Kraeplin (1896) and Schneider (1923) introduced classification systems which can be seen as forerunners of the current categorical approaches in DSM-IV and ICD-10. Key contributions to the development of concepts related to personality disorder

1809 Pinel describes ‘manie sans délire’.
1812 Rush describes ‘perversion of the moral faculties’.
1835 Prichard describes ‘moral insanity’.
1838 Ray describes ‘moral mania’.
1891 Koch describes ‘psychopathic inferiority’.
1896 Kraepelin describes and categorises ‘psychopathic personalities’.
1913 Category ‘moral imbecile’ introduced in Mental Deficiency Act.
1919 Kretschmer suggests relationship between body types and personality.
1923 Schneider describes and categorises ‘psychopathic personalities’.
1930 Partridge describes ‘sociopathy’.
1939 Henderson describes ‘psychopathic states’.
1941 Cleckley publishes Mask of Sanity describing psychopaths.
1959 Category ‘psychopathic disorder’ introduced in Mental Health Act.

References 1 Saß H and Herpertz S (1995) Personality disorders. Clinical section. In A History of Clinical Psychiatry (eds. Berrios G and Porter R). London: Athlone. P.444
‘Normal’ personality The term ‘normal’ personality can be used to refer to an ideal state or that which is statistically normal, but here it describes aspects of personality psychology which offer a descriptive and explanatory framework for the understanding of personality. There are two main approaches: nomothetic and ideographic1. Nomothetic approaches Personality seen in terms of attributes shared by individuals. Two subdivisions: type (or categorical) approaches (discrete categories of personality); and trait (or dimensional) approaches (a limited number of qualities, or traits, account for personality variation). Type approaches dominate the description and classification of personality disorder, but trait approaches are pre-eminent in modern personality psychology. Type approaches These describe individual personality by similarity to a variable number of predefined archetypes. These may attempt to include all aspects of personality and behaviour—the ‘broad’ models—or they may describe one aspect of personality—the ‘narrow’ models. An example of the former is the humoral model of Hippocrates which described four fundamental personality types, (choleric, sanguine, melancholic and phlegmatic); an example of the later is the type A vs. type B model which describes groups of behaviours exhibited by people at higher and lower risk of cardiac disease. Trait approaches These view a variable number of traits as continuous scales along which each person will have a particular position; the positions on all the traits represent a number of dimensions which describe personality. Examples include: Eysenck’s three factor theory (neuroticism, extraversion, psychoticism); Costa and McCrae’s five factor model (neuroticism, extraversion, openness, agreeableness, conscientiousness); Cloninger’s seven factor model (novelty seeking, harm avoidance, reward dependence, persistence, self-directedness, cooperativeness, self-transcendence; originally only first 3 factors); Cattell’s 16 factor theory. A consensus has emerged from personality questionnaire research and from lexical approaches that there are five fundamental traits (the ‘big five’) similar to those of Costa and McCrae. The heritability of personality traits in twin and adoptive studies has been found to be moderately large (about 30%). Ideographic approaches Unlike nomothetic approaches, emphasise individuality and seek to understand an individual’s personality by understanding that individual and their development rather than by reference to common factors. Examples are psychoanalytic, humanistic, and cognitive-behavioural approaches. The first two have little scientific validity and the last has compromised with trait theorists. Is personality stable? Are there traits which are persistent and predict a person’s behaviour over time in a number of situations? Situationists have argued that the situation was a stronger determinant of behaviour than personality traits. P.445
However, more recent research has demonstrated the long-term stability of a number of personality traits and, perhaps unsurprisingly, most now agree that both the situation and personality traits are important in determining behaviour. References 1 Deary I and Power M (1998) Normal and abnormal personality. In Companion to Psychiatric Studies (eds. Johnstone EC, Freeman CPL and Zeally AK). Edinburgh: Churchill Livingstone. P.446
Classification of personality disorder It is largely accepted that normal personality is best described and classified in terms of dimensions or traits. Although this also applies to personality disorder, our current psychiatric classifications are categorical. The various categories of personality disorder described in ICD-10 and DSM-IV have a number of origins: psychodynamic theory, apparent similarities between certain personality disorders and certain mental illnesses, and descriptions of stereotypical personality types. The various categories used come together in a piecemeal and arbitrary fashion and do not represent any systematic understanding or study of personality disorder. The categorical classification of personality disorder is psychiatric classification at its worst. There are a number of important points to bear in mind when using standard categorical approaches in the diagnosis of personality disorders:

  • Due to their heterogeneous origins, there is overlap between the criteria for some categories.
  • It is more common for individuals to meet the criteria for more than one category of personality disorder than to meet only the criteria for a single category.
  • When making a diagnosis one should use all the categories for which a person meets the criteria.
  • If a person meets criteria for more than one category, then they do not suffer from more than one actual disorder. A person has a personality and this may or may not be disordered. If it is disordered it may have various features which are rarely described adequately by a particular category.
  • Clinically it is more important to understand and describe the specific features of a person’s personality than it is to assign them to a particular category.
  • The diagnosis of personality disorder is a particular area where one may believe, wrongly, that one has a better understanding of a person by assigning them to a specific category (an example of ‘tautology’*).

ICD-10 and DSM-IV The personality disorder categories in ICD-10 and DSM-IV are set out opposite. The two schemes are similar, but there are categories that appear in one but not the other, and for some categories different terms are used. Each category has a list of features, a number of which should be present for the person to be diagnosed as manifesting that particular aspect of personality disorder. DSM III (and subsequent editions) placed personality disorder on a separate axis (along with other developmental disorders in axis II) from mental illness (axis I). See p. 9. P.447
ICD-10 and DSM-IV classifications of personality disorder

ICD-10 DSM-IV* Description
Paranoid Paranoid Sensitive, suspicious, preoccupied with conspiratorial explanations, self-referential, distrust of others.
Schizoid Schizoid Emotionally cold, detachment, lack of interest in others, excessive introspection and fantasy.
(Schizotypal disorder classified with schizophrenia and related disorders) Schizotypal Interpersonal discomfort with peculiar ideas, perceptions, appearance, and behaviour.
Dissocial Antisocial Callous lack of concern for others, irresponsibility, irritability, aggression, inability to maintain enduring relationships, disregard and violation of others’ rights, evidence of childhood conduct disorder.
Emotionally unstable—impulsive type — Inability to control anger or plan, with unpredictable affect and behaviour.
Emotionally unstable—borderline type Borderline Unclear identity, intense and unstable relationships, unpredictable affect, threats or acts of self-harm, impulsivity.
Histrionic Histrionic Self-dramatisation, shallow affect, egocentricity, craving attention and excitement, manipulative behaviour.
— Narcissistic Grandiosity, lack of empathy, need for admiration.
Anxious (avoidant) Avoidant Tension, self-consciousness, fear of negative evaluation by others, timid, insecure.
Anankastic Obsessive-compulsive Doubt, indecisiveness, caution, pedantry, rigidity, perfectionism, preoccupation with orderliness and control.
Dependent Dependent Clinging, submissive, excess need for care, feels helpless when not in relationship.
*DSM-IV uses 3 broader clusters to organise the categories of personality disorder—cluster A (odd/eccentric)—paranoid, schizoid, schizotypal cluster B (flamboyant/dramatic)—antisocial, histrionic, narcissistic, borderline; and cluster C (fearful/anxious)—avoidant, dependent, obsessive-compulsive. Although this may seem sensible, there is no particular validity to this clustering.

Footnote * Tautology (the restatement of the same information using different words) is a particular danger in psychiatry generally, and the diagnosis of personality disorder in particular. For example, saying that someone has ‘borderline’ traits gives a gloss of understanding to the simple fact that a person repeatedly self-harms, without actually communicating any new information (except perhaps the ‘therapeutic despair’ of the psychiatrist). P.448
Psychopathy and ‘severe’ personality disorder Psychopathy The terms ‘psychopathy’, ‘psychopathic personality disorder, ‘psychopathic disorder’ and ‘psychopath’ have dominated much of the personality disorder literature until relatively recently. As mentioned on p. 442, the term has been used in various ways, but there are probably only two legitimate ways in which these terms should be used:

  • The legal category of ‘psychopathic disorder’ under the MHA1983.
  • ‘Psychopathy’ as defined by the Psychopathy Checklist—Revised (PCL-R) as an extreme form of antisocial or dissocial personality disorder.

Psychopathic disorder under the MHA1983 Psychopathic disorder is one of four categories of mental disorder under the MHA1983, defined as ‘a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned’. Patients detained under this category display a range of personality and other pathology. Only a minority are ‘psychopaths’ as defined below. Psychopathy Checklist—revised (PCL-R)1 In The Mask of Sanity Cleckley2 described various features of psychopathy referring to cold, callous, self-centred, predatory, parasitic individuals. This concept has led to the development of the PCL-R, which measures the extent to which a person manifests the features of this prototypical psychopath. The items of the PCL-R are listed opposite. Psychopathy as defined by the PCL-R is strongly correlated with risk of future violence. It defines a narrower group of individuals than antisocial or dissocial personality disorder, and individuals scoring highly commonly fulfil the criteria for antisocial, narcissistic, histrionic, paranoid, and perhaps borderline categories in DSM-IV. Severe personality disorder3 The term ‘severe personality disorder’ is often used but has no clear meaning or definition. Severity of personality disorder has been defined in various ways:

  • In terms of severe impact on social functioning.
  • By using the PCL-R cut-off and being synonymous with psychopathy.
  • By defining severity as the presence of features fulfilling the criteria for multiple categories of DSM-IV or ICD-10 personality disorders (sometimes this is further defined by stating that the categories should be from at least 2 DSM-IV clusters, and perhaps that one must be from cluster B).

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None of these approaches are entirely satisfactory, and each defines different but overlapping groups of individuals. Notes on the PCL-R The items of the PCL-R cover the affective, interpersonal, and behavioural features of psychopathy. Assessment is based on a comprehensive records’ review and in-depth interview(s). Each item is rated 0 (absent), 1 (some evidence but not enough to be clearly present), or 2 (definitely present). There are detailed descriptions of each item in the coding manual. The summed score (out of 40) gives an indication of the extent to which a person is psychopathic and may be converted into a percentile using reference tables for different populations. In the USA a score of 30 or above is used as a cut-off to diagnose ‘psychopathy’; in the UK this cut-off is 25 or above. PCL-R items

  • Glibness/superficial charm
  • Grandiose sense of self-worth
  • Need for stimulation/proneness to boredom
  • Pathological lying
  • Conning/manipulative
  • Lack of remorse or guilt
  • Shallow affect
  • Callous/lack of empathy
  • Parasitic lifestyle
  • Poor behavioural control
  • Promiscuous sexual behaviour
  • Early behaviour problems
  • Lack of realistic, long-term goals
  • Impulsivity
  • Irresponsibility
  • Failure to accept responsibility for own actions
  • Many short-term marital relationships
  • Juvenile delinquency
  • Revocation of conditional release
  • Criminal versatility

References 1 Hare RD (1991) The Hare Psychopathy Checklist-Revised. Toronto: Multi-Health Systems. 2 Cleckley H (1941) The Mask of Sanity. London: Henry Klimpton. 3 Tyrer P (2004) Getting to grips with severe personality disorder. Criminal Behaviour and Mental Health 14, 1–4. P.450
Aetiology of personality disorder While there is no single, convincing theory explaining the genesis of personality disorder, the following observations are suggestive of possible contributing factors. Genetic Evidence of heritability of ‘normal’ personality traits; some evidence of heritability of cluster B personality disorders; familial relationship between schizotypal personality disorder and schizophrenia, between paranoid personality disorder and delusional disorder, and between borderline personality disorder and affective disorder. No good evidence for relationship between XYY genotype and psychopathy. Neurophysiology ‘Immature’ EEG (posterior temporal slow waves) in psychopathy; functional imaging abnormalities in psychopathy (e.g. decreased activity in amygdala during affective processing task); low 5-HT levels in impulsive violent individuals; autonomic abnormalities in psychopathy (slowed galvanic skin response). Childhood development Difficult infant temperament may proceed to conduct disorder in childhood and personality disorder, ADHD may be a risk factor for later antisocial personality disorder; insecure attachment may predict later personality disorder (particularly disorganised attachment); harsh and inconsistent parenting and family pathology are related to conduct disorder, and may therefore be related to later antisocial personality disorder; severe trauma in childhood (such as sexual abuse) may be a risk factor for borderline personality disorder and other cluster B disorders. Psychodynamic theories Freudian explanations of arrested development at oral, anal, and genital stages leading to dependent, obsessional, and histrionic personalities; ‘borderline personality organisation’ described by Kernberg (diffuse unfiltered reaction to experience prevents individuals from putting adversity into perspective leading to repeated crises); narcissistic and borderline personalities seen as displaying primitive defence mechanisms such as splitting and projective identification; some see antisocial personalities as lacking aspects of superego, but more sophisticated explanation is in terms of a reaction to an overly harsh superego (representing internalisation of parental abuse). Cognitive-behavioural theories There are maladaptive schemata (stable cognitive, affective, and behavioural structures representing specific rules that affect information processing). These schemata represent core beliefs which are derived from an interaction between childhood experience and pre-programmed patterns of behaviour and environmental responses. Schemata are unconditional compared with those found in affective disorders (e.g. ‘I am unlovable’ rather than ‘If someone important criticises me, then I am unlovable’) and are formed early, often pre-verbally. P.451
Theories synthesising cognitive-behavioural and psychodynamic aspects The following are two quite similar models that underlie relatively recently introduced therapies for borderline personality disorder. Cognitive-analytical model (p. 792) Borderline patients experience a range of partially dissociated ‘self-states’, which arise initially as a response to unmanageable external threats and are maintained by repeated threats or internal cues (such as memories). Abusive experiences in childhood lead to internalisation of the harsh parental object leading to intrapsychic conflict which is repressed or produces symptomatic behaviours. Deficits in self-reflection, poor emotional vocabulary, and narrow focus of attention lead to incoherent sense of self and others. Dialectical behavioural model (p. 794) Innate temperamental vulnerability interacts with certain dysfunctional (‘invalidating’) environments leading to problems with emotional regulation. Abnormal behaviours which are manifested represent products of this emotional dysregulation or attempts to regulate intense emotional states by maladaptive problem solving. P.452
Epidemiology of personality disorder1 The measurement of the prevalence of personality disorder of any type and of specific categories of personality disorder in any population has a number of problems: in earlier studies personality disorder and other mental disorders were mutually exclusive, not allowing for the recording of comorbidity; studies differ in the method used to make a diagnosis (interviews/case-notes/informants; clinical diagnosis versus research instruments; emphasis on current presentation or on life history); and in some studies subjects were only allowed to belong to one category of personality disorder. Findings regarding personality disorder of any type will be considered separately from findings related to specific personality disorder categories. Personality disorder of any type Community Rates of personality disorder in the community have been found to be 2–18% (the generally accepted approximate is 10%). It is more prevalent in younger adults, and may be more prevalent in males. Primary care Of patients presenting with conspicous psychiatric morbididty, 5–8% will have a primary diagnosis of personality disorder. The rate of comorbid personality disorder in patients with other primary diagnoses is 20–30%. Psychiatric patients 30–40% of outpatients and 40–50% of inpatients have a personality disorder, not usually as a primary diagnosis. A primary diagnosis of personality disorder occurs in about 5–15% of inpatients. Other populations 25–75% of prisoners have a personality disorder. Antisocial personality disorder is most prevalent, but many prisoners fulfil the criteria for more than one diagnostic category, and many personality disordered prisoners do not meet the criteria for the antisocial category. Specific categories of personality disorder The prevalence rates of the categories of personality disorder (most studies have used DSM categories, so these are used here) in the general population are approximately: P.453

DSM-IV Prevalence
Paranoid 0.5–3%
Schizoid 0.5–7%
Schizotypal 0.5–5%
Antisocial 2–3.5%
Borderline 1.5–2%
Histrionic 2–3%
Narcissistic 0.5–1%
Avoidant 0.5–1%
Dependent 0.5–5%
Obsessive-compulsive 1–2%

References 1 Casey P (2000) The epidemiology of personality disorder. In Personality disorders: diagnosis, management and cause(ed. Tyrer P). Oxford: Butterworth Heinemann. P.454
Relationship between personality disorder and other mental disorders The current state of classification and understanding of the aetiology and pathogenesis of mental disorders is such that most psychiatric diagnoses are based on descriptive criteria. It is common to find that an individual meets the criteria for an axis I disorder along with a personality disorder. At one extreme, both may be a manifestation of the same underlying condition; at the other, they may represent two completely separate aetio-pathogenic entities. The relationship between personality disorder and other mental disorders may be:

  • Mutually exclusive Personality disorder cannot be diagnosed in an individual with another mental disorder. The personality pathology displayed is a manifestation of the other mental disorder, and giving a separate personality diagnosis has no purpose. This was the only approach possible prior to DSM-III’s introduction of multi-axial diagnosis. This approach is not favoured by current classification systems, even where the two appear to be manifestations of the same condition.
  • Coincidental In an individual, personality disorder and another disorder may come together by chance. However, epidemiologically there is support for an association between personality disorder and other mental disorders.
  • Associative Both in individual cases and epidemiologically there are a number of reasons why the coexistence of personality disorder and other mental disorders may be more than just coincidental:
    • Sharing common aetiology (but separate disorder)
    • Prodromal (part of the development of the axis I disorder)
    • Part of a spectrum (a ‘partial’ manifestation of the axis I disorder)
    • Vulnerability (a separate disorder, manifestations of which make an individual more likely to suffer from an axis I disorder)

Problems in assessing personality in patients with other mental disorders A number of problems may arise in the diagnosis of personality disorder in people who appear to have axis I disorders:

  • Underlying personality disorder may be missed as assessment may focus on the current mental state disorder.
  • Personality disorder may be misdiagnosed as axis I disorder and vice versa.
  • In an individual with personality disorder, an axis I disorder may be missed or misconstrued as being part of the personality disorder.

In such cases it is important to remember that axis I pathology is common in people with personality disorders and any change in the presentation of a patient with personality disorder may be due to this. Equally, it is important to base assessment of personality on information (preferably from a number of sources) on the pre-morbid functioning of an individual, rather than on their current functioning or just their own account of their previous functioning (their memory or interpretation of which may be coloured by their current mental state). P.455
Comorbidity between personality disorders and other specific mental disorders1 Strong associations

  • Avoidant personality disorder and social phobia (possibly because they both describe a group of people with the same condition).
  • Substance misuse and cluster B personality disorders.
  • Eating disorders and cluster B and C personality disorders (particularly bulimia nervosa and cluster B).
  • Neurotic disorders and cluster C personality disorders (it has been suggested that these individuals have a ‘general neurotic syndrome’).
  • Somatoform disorders and cluster B and C personality disorders.
  • Habit and impulse disorders and cluster B personality disorders (unsurprisingly).
  • PTSD and borderline personality disorder (this is not borderline personality disorder redefined as chronic PTSD, but is probably due to the increased rate of life events and vulnerability of such individuals).

Moderate associations

  • Schizotypal personality disorder and schizophrenia (also a weaker association between schizophrenia and antisocial personality disorder).
  • Depression and cluster B and C personality disorders.
  • Delusional disorder and paranoid personality disorder.

Impact of personality disorders on manifestation, treatment, and outcome of other mental disorders Although the concept of ‘comorbid personality disorder’ may seem spurious from an aetio-pathological perspective, its presence has an impact on the presentation, treatment, and outcome of axis I disorders, and it is therefore useful to recognise such comorbidity from a clinical perspective.

  • Presentation The presentation of axis I disorders may be distorted, exaggerated, or masked by the presence of an underlying personality disorder.
  • Treatment and outcome The presence of comorbid personality disorder will usually make treatment more difficult and worsens the outcome of axis I disorders. This may be due to problems in the following areas: help-seeking behaviours, compliance with treatment, coping styles, risk-taking, lifestyle, social support networks, therapeutic alliance, alcohol and substance misuse.

Some contend that it is the presence of this comorbidity which makes it more likely for a person to fail to respond to standard primary care treatment approaches, therefore necessitating referral to psychiatric services. References 1 Tyrer P (2000) Comorbidity of personality disorder and mental state disorders. In Personality disorders: diagnosis, management and cause (ed. Tyrer P). Oxford: Butterworth Heinemann. P.456
Assessment of personality disorder1 Potential pitfalls There are a number of potential pitfalls in the assessment and diagnosis of personality disordered patients:

  • Relying on diagnoses made by others (psychiatrists are notoriously poor at diagnosing personality disorder).
  • Failing to recognise comorbidity.
  • Misdiagnosing personality disorder as mental illness and vice versa.
  • Inadequate information.
  • Negative counter-transference (basing diagnosis on your negative reaction to a patient rather than on an objective assessment; transference and countertransference may be a part of this but negative feelings towards an individual should not be the primary basis for a diagnosis of personality disorder).
  • Applying ICD-10 or DSM-IV categories without a broader assessment of personality.

Making the diagnosis of personality disorder

  • A clinical diagnosis of personality disorder should be based on an accurate assessment of a person’s enduring and pervasive patterns of emotional expression, interpersonal relationships, social functioning, and views of self and others when they are not suffering from another mental disorder.
  • In many cases information from sources other than the patient will be essential. Potential sources of information include:clinical interviews (perhaps repeated); observation (usually repeated); previous records (medical, prison, school, social work); independent accounts (perhaps from several sources such as relatives and other professionals).
  • Information from various areas of the psychiatric history (childhood and adolescence; work record; forensic history/other aggression or violence; relationship history; psychiatric contact/self-harm) will give an indication of a person’s personality and whether it may be disordered.
  • In addition, specific enquiry can be made regarding the following aspects of personality:interests and activities; relationships; mood/emotions; attitudes (religious, moral, health); self-concept; coping with difficulties; specific characteristics or traits (perhaps based on personality disorder categories); include both positive and negative aspects.
  • In describing personality and personality disorder, first the features of a person’s personality should be described, then a decision should be made as to whether the degree of distress and disruption due to personality traits is such as to indicate the presence of personality disorder, then the features that are pathological should be described. If one wants to make categorical diagnoses then the category or categories for which the criteria are met may be stated.

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Instruments to assess personality disorder There are a number of instruments available for assessing personality disorder. Such instruments are mainly used in research and are rarely seen in clinical practice. Most require training and some take a considerable amount of time to complete. Self-report questionnaires Millon Clinical Multiaxial Inventory (MCMI), Personality Disorder Questionnaire (PDQ-IV), Wisconsin Personality Inventory (WISPI) Structured clinical interviews with patient only Structured Clinical Interview for DSM-IV Personality Disorder (SCID-II), Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) Structured clinical interviews with informant only Standardized Assessment of Personality (SAP) Structured clinical interviews with patient and/or informant Personality Assessment Schedule (PAS), Structured Interview for DSM-IV Personality Disorders (SIDP-IV), International Personality Disorder Examination (IPDE) Instruments assessing specific personality disorders Schedule for Interviewing Borderlines (SIB), Diagnostic Interview for Borderline Patients (DIB), Borderline Personality Disorder Scale (BPD-Scale), Psychopathy Checklist-Revised (PCL-R), Psychopathy Checklist-Screening Version (PCL-SV), Schedule for Schizotypal Personalities (SSP). Diagnostic instruments including an assessment of antisocial personality disorder Diagnostic Interview Schedule (DIS), Feigner Diagnostic Criteria. Functional assessment The functional assessment of personality and associated problems has been proposed as a useful clinical approach which can produce a formulation identifying issues to be addressed in management.

  • List abnormal personality traits—thoughts about self and others (e.g. identity problems, paranoia, grandiosity, magical thinking, exaggerating, suggestibility, preoccupation with death, obsessionality, self-esteem), feelings and emotions (e.g. depression, elation, mood instability, callousness, loneliness, anger, irritability), behaviour (e.g. stubbornness, quarrelsomeness, sadism, self-destructiveness, compliance, impulsivity, theatricality, attention seeking), social functioning (e.g. social isolation, controlling others, dependence on others, mistrust of others, inviting rejection, forming unstable intense relationships, manipulating and using others), insight (including the ability to understand and integrate one’s thoughts, feelings and actions).
  • Describe associated distress and comorbid axis I disorders.
  • Describe interference with functioning—occupational, family and relationships, offending/violence.

References 1 Gunn J (2000) Personality disorder: a clinical suggestion. In Personality disorders: diagnosis, management and cause (ed. Tyrer P). Oxford: Butterworth Heinemann. P.458
Management of personality disorder (1)—general aspects It is generally felt that personality disorder is resistant to specific psychiatric treatment. However, there is no good evidence to either refute or support this statement. Patients often present at a time of crisis and/or when they develop a comorbid axis I disorder. Although some may wish to, psychiatrists cannot avoid having to manage patients with personality disorder. Principles of successful management plans A successful management plan in personality disorder is tailored to the individual’s needs and explicitly states jointly agreed and realistic goals. The approach to these patients should be consistent and agreed across the services having contact with the patient. Plans should take a long-term view, recognising that change, if it comes, will only be observable over a long period. Possible management goals Potential management goals include: psychological and practical support; monitoring and supervision; intervening in crises; increasing motivation and compliance; increasing understanding of difficulties; building a therapeutic relationship; limiting harm; reducing distress; treating comorbid axis I disorders; treating specific areas (e.g. anger, self-harm, social skills); and giving practical support (e.g. housing, finance, child care). Managing comorbid axis I disorders It is important to recognise and treat comorbid axis I pathology in patients with personality disorder. Standard treatment approaches should be used, taking into account aspects of the patient’s personality (e.g. impulsivity and an anti-authoritarian attitude may lead to non-compliance with medication). Understanding and managing the relationship between the patient and staff2 Rejection for treatment of patients with personality disorder (even when they present with mental illness) is often due to the intense negative feelings these patients may engender, and the disruptive and uneasy relationships they form with those that try to help them. Just as they do in many of their interpersonal relationships, patients with personality disorders display disordered attachment in their relationships with staff (whether with individuals or with a service). When dealing with such patients this needs to be recognised, acknowledged, and managed. An acceptance of, and tolerance for these difficulties needs to be combined with continuing commitment to the patient. However, patients, staff, and other agencies need to realise there are no instant solutions and that psychiatric services cannot take responsibility for all adverse behaviours. P.459
Admission to hospital Patients with personality disorder benefit little from prolonged admissions to conventional psychiatric units. Admission to such units may be necessary when there is a specific crisis (usually in the short term) or the patient presents with an axis I disorder. Longer-term admission for the treatment of personality disorder could be undertaken in a therapeutic community. Involuntary long-term hospitalisation of patients with personality disorder primarily to prevent harm to others where there is little prospect of clinical benefit to the patient is ethically dubious. Managing crises Individuals with personality disorder often present in crisis. This may follow life events, relationship problems, or occur in the context of the development of comorbid mental illness. In some cases the crisis may follow what appears to the outside observer to be a relatively minor or non-existent stressor. Where patients repeatedly present in crisis it can be helpful for the various professionals involved to plan what the response should be in such situations. A consistent response is important, but there should be sufficient flexibility to deal with changes in circumstances. For example, where a patient repeatedly presents with self-harm it may be appropriate for outpatient treatment to continue following any necessary medical treatment; however, if this patient presents threatening suicide following the death of a partner, then it may be appropriate to arrange admission to hospital. Other approaches to individuals presenting with threats of self-harm or of violence and to manipulative patients are covered on pp. 902, 903, 904, 905. References 1 Davison SE (2002) Principles of managing patients with personality disorder. Advances in Psychiatric Treatment 8: 1–9. 2 Adshead G (1998) Psychiatric staff as attachment figures. Understanding management problems in psychiatric services in the light of attachment theory. BJP 172, 64–9. P.460
Management of personality disorder (2)—specific treatments1,2 Medication3 The main indication for medication in patients with personality disorder is the development of comorbid mental illness. There is no good evidence that medication has any effect on personality disorder itself. The positive findings from studies have been short-term, and probably due to the effects of medication on comorbid disorders rather than on the personality disorder itself. Bearing this in mind, the following have been suggested:

  • Antipsychotics may be of some benefit in cluster B (particularly borderline) and cluster A (particularly schizotypal and perhaps paranoid) disorders.
  • Antidepressants may be of benefit in impulsive, depressed, or self-harming patients (particularly borderline), and in cluster C (particularly avoidant and obsessive-compulsive) disorders.
  • Anticonvulsants and lithium have been suggested where there is affective instability or impulsivity.

Therapeutic community A therapeutic community is a consciously designed social environment and programme within a residential or day unit, in which the social and group process is harnessed with therapeutic intent. It is an intense form of psychosocial treatment in which every aspect of the environment is part of the treatment setting, in which interpersonal behaviour can be challenged and modified. The main principles are democratisation, permissiveness, communalism, and reality confrontation. There are various interactions between patients and staff both individually and in groups, particularly in the daily community groups, which contribute towards achieving these principles. There is some evidence that such treatment is effective with some patients with personality disorders. Dialectical behavioural therapy (DBT) (p. 794) Combination of individual and group therapy lasting at least 12 months. In stage 1, individual therapy focuses on a detailed cognitive-behavioural approach to self-harm and other ‘therapy interfering’ behaviours. Internal and external antecedents are explored, and alternative problem-solving strategies are developed. Group therapy focuses on tolerance of distress, emotional regulation and interpersonal skills. ‘Mindfulness training’ based on Eastern meditation techniques is a key part of this. In stage 2, patients are helped to process previous trauma, but only when stage 1 skills are developed. In stage 3, the focus is on developing self-esteem and realistic future goals. Another aspect of DBT is that patients may contact therapists by telephone between sessions to help them apply skills when difficulties arise. There is evidence that DBT may be an effective therapy for outpatients with borderline personality disorder. P.461
Cognitive-analytic therapy (pp. 792, 793) May be appropriate for some patients with borderline personality disorder. Aims to identify different ‘self states’ and associated ‘reciprocal role procedures’ (patterns of relationships learned in early childhood). Patients are helped to observe and change thinking and behaviour related to these ‘self states’. Countertransference helps provide useful information about ‘reciprocal role relationships’ either through identification with the patient or reacting to their projections. The aim is for patients to be able to recognise their various ‘self states’ and to be aware of them without dissociating. Psychodynamic therapy (pp. 776–81) Classic Freudian or Jungian psychoanalysis is of no proven benefit for patients with personality disorder, and is probably contraindicated in patients with severe personality disorders. However, psychodynamic concepts are extremely useful in understanding personality disordered patients and the reactions they provoke in others, including ourselves. Modified psychodynamic approaches for patients with borderline and narcissistic personality disorders have been developed. Cognitive-behavioural therapy (pp. 786, 787). Schema-focused therapy concentrates on identifying and modifying early maladaptive schemas and related behaviours. Patients are educated about schemas and led to expect that they will be difficult to change (for example, patients will distort new information to fit in with their existing schemas). ‘Empathic confrontation’ is used to help patients to repeatedly and persistently challenge their core beliefs about themselves and others. Issues related to interpersonal schemas may arise in the therapeutic relationship and be used as ‘data’ for dealing with these schemas. There are other models used in cognitive-behavioural therapy to treat personality disorder, but all have in common: the goal-directed problem-solving approach; the teaching of specific skills; a longer time-scale than the relatively brief length of therapy for most other disorders; emphasis on developing, maintaining, and utilising the therapeutic relationship; a focus on underlying core beliefs (schemas) regarding self and others; and, a longer-term historical perspective in therapy as opposed to the here-and-now focus with many other disorders. References 1 Davidson K and Tyrer P (2000) Psychosocial treatment in personality disorder. In Personality disorders: diagnosis, management and cause (ed. Tyrer P). Oxford: Butterworth Heinemann. 2 Deary I and Power M (1998) Normal and abnormal personality. In Companion to Psychiatric Studies (eds. Johnstone EC, Freeman CPL, Zeally AK). Edinburgh: Churchill Livingstone. 3 Tyrer P (2000) Drug treatment of personality disorder. In Personality disorders: diagnosis, management and cause (ed. Tyrer P). Oxford: Butterworth Heinemann. P.462
Outcome of personality disorder1 Morbidity and mortality High rates of accidents, suicide, and violent death, particularly where cluster B features are prominent. As mentioned already, there are high rates of other mental disorders (see p. 454). Outcome of other disorders in patients with personality disorder The outcome of mental illness and physical illness is worse in patients with personality disorders. The potential reasons for this are covered on p. 455. Persistence of personality disorder Some contend that personality disorder is by definition life-long and therefore has a poor prognosis, but the evidence for this is far from conclusive. Comparison between different age groups Personality disorder is less prevalent in older adults than younger adults, particularly for cluster B disorders. In terms of ‘normal’ personality, compared with young adults the elderly are more likely to be cautious and rigid, and less likely to be impulsive and aggressive. However, cross-sectional studies looking at different age groups at one point in time tell us little about the development of personality in individuals over time. Follow-up of individuals over time Antisocial/dissocial Children presenting to child services with antisocial behaviour are 5–7 times as likely to develop antisocial personality disorder as those presenting with other problems. May show some improvement in antisocial behaviour by fifth decade. However, may just change with time from ‘overt’ criminal behaviour to more ‘covert’ antisocial behaviour such as domestic violence and child abuse. There is contra-dictory evidence as to whether ‘burn-out’ or ‘maturation’ in later life really does occur. Borderline A third to a half of patients fulfilling the criteria for borderline personality disorder do not have personality disorder at all when followed up after 10–20 years. About a third continue to have borderline personality disorder and others have other predominating personality disorders. Poor prognostic indicators are severe repeated self-harm and ‘comorbid’ antisocial personality; a good prognostic indicator may be an initial presentation with comorbid affective disorder. Schizotypal Generally have poorer prognosis than borderline patients. About 50% may develop schizophrenia. Obsessional May worsen with age. More likely to develop depression than OCD. Clusters There is some evidence that cluster A traits worsen with age, cluster B traits improve, and cluster C traits remain unchanged. References 1 Tyrer P and Seivewright H (2000) Outcome of personality disorder. In Personality disorders: diagnosis, management and cause (ed. Tyrer P). Oxford: Butterworth Heinemann. P.463
P.464
Disorders of sexual preference (1)—general aspects1 Essence Disorders of sexual preference (the term used in ICD-10) or paraphilias (the term used in DSM-IV) are disorders in which an individual is sexually aroused by inappropriate stimuli. Other terms used include sexual deviation and perversion. There is some overlap between these disorders, sex offending, and inappropriate sexual behaviour, but the three are separate concepts (see p. 636). Homosexuality was previously included, but this is no longer the case. Disorders of sexual preference are one of three broad types of sexual disorders. The others are gender identity disorders and sexual dysfunctions (see opposite). In some cases two or more of these are present. Definition DSM-IV defines each paraphilia as at least 6 months of recurrent, intense, sexually arousing fantasies, sexual urges, or behaviours involving a particular inappropriate act or object. These fantasies, urges, or behaviours must cause clinically significant distress or impairment in social functioning. ICD-10 has less strict and less detailed criteria, referring to the particular object or act as being the most important source of sexual arousal or essential for satisfactory sexual response. Classification There are many different objects and acts that may be the focus of disorders of sexual preference. Most of the defined categories are extreme forms of behaviours that are common parts of ‘normal’ sexual activity. The classification systems in DSM-IV and ICD-10 are very similar (see opposite). A disorder of sexual preference may be present in addition to other mental disorders. Aetiology Physiological factors These may include genetic factors, prenatal influence of hormones in utero, hormonal abnormalities in adults, and perhaps brain abnormalities. Psychological theories These include absence of effective father with over-protective/close binding/intimate mother; failure of successful resolution of oedipal conflict; modelling and conditioning; masculine insecurity. The various factors may lead to sexual deviation by (a) preventing normal sexual development and relationships, and/or (b) promoting deviant sexual interest. Epidemiology It is difficult to estimate the prevalence of these disorders as many individuals do not present for help and are unlikely to admit to sexually deviant P.465
arousal in surveys. Rates of sexual offending do not give a good approximation of rates of disorders of sexual preference, as these disorders represent one of many factors that may lead to such offending (see p. 636). There is probably a wide range of sexual practices in the ‘normal’ population. Disorders of sexual preference are more common in males than females (perhaps 30 times more common). From clinical samples, age of onset is usually between 16 and 20, and many individuals have multiple paraphilias, in series and/or in parallel. Classification of disorders of sexual preference

ICD-10 DSM-IV Sexually arousing object or act
Fetishism Fetishism Non-living object (e.g. clothing, shoes, rubber).
Fetishistic transvestism Transvestic fetishism Cross-dressing (not few articles but complete outfit, perhaps with wig and make-up). Clear association with sexual arousal distinguishes from transsexual tranvestism. However, may be an early phase in some transsexuals.
Exhibitionism Exhibitionism Exposure of genitals to strangers.
Voyeurism Voyeurism Watching others who are naked, disrobing, or engaging in sexual acts.
Paedophilia Paedophilia Children (usually prebubertal or early pubertal). May be specified as attracted to males, females, or both, or as limited to incest.
Sadomasochism Sexual masochism Being humiliated, beaten, bound, or made to suffer.
Sexual sadism
Psychological or physical suffering of others.
— Frotteurism Touching and rubbing against non-consenting person.
Other disorders of sexual preference Paraphilia not otherwise specified Includes telephone scatalogia (obscene phone calls), necrophilia (corpses), partialism (exclusive focus on part of body), zoophilia (animals), coprophilia (faeces), urophilia (urine), klismaphilia (enemas), autoerotic asphyxia (self asphyxiation).
Multiple disorders of disorders of sexual preference — Many individuals manifest multiple disorders. Term ‘polymorphous perversity’ has been used. Most common combination is fetishism, transvestism, and sadomasochism.

References 1 Abel GG and Osborn CA (2000) The paraphilias. In New Oxford Textbook of Psychiatry (eds. Gelder MG, López-Ibor, Andreasen N). Oxford: Oxford University Press. P.466
Disorders of sexual preference (2)—assessment and management1 Assessment Why is the person presenting now?

  • May present directly or at request of spouse when behaviour is discovered or starts to cause problems in relationships. Occasionally present as sexual dysfunction, with disorder of preference coming to light on further assessment.
  • May present at own request, or more likely at request of court, prosecutor, or solicitor, after committing offence.

Is there another mental disorder? Various psychiatric disorders may lead to release of sexually deviant behaviour, perhaps in individuals who have experienced fantasies but not acted on them previously. Particularly important to exclude in someone presenting for first time in middle age or later. So full psychiatric history, MSE, and perhaps neurological examination/investigation important. Psycho-sexual assessment Full psycho-sexual assessment essential in anyone presenting with sexual problems. Interviewer should put person at ease and be able to facilitate by being open, sensitive, and able to discuss sexual matters. Involvement of sexual partner in assessment (either at the same time or through another interview) is usually helpful. Following areas should be covered: • Sexual knowledge and sources of information • Sexual attitudes to self and others • Age of onset and development of sexual interest, masturbation, dating, sexual intercourse • Relationship history, including: age of self and partner, gender of partners, duration, quality, problems, abuse • Fantasy (content/use/development) • Orientation • Drive (frequency of masturbation/intercourse) and dysfunction (specific inquiry about arousal, impotence, premature ejaculation) • Experience (range of sexual behaviours with specific enquiry about paraphilias) • Current sexual practices: mood, thoughts, visual images, material used, and conditions for arousal during both intercourse and masturbation (many men with paraphilias report ‘normal’ intercourse although at the time they are imagining deviant scenarios); where various forms of arousal are reported estimate proportion of sexual practice devoted to each. What does the person want from treatment?

  • Do they want help at all or have they just come as they have been forced to (by spouse, courts, etc.)?
  • Do they want to change the focus of their sexual arousal and/or desist from the overt behaviour?
  • Do they want to adapt better to the behaviour without changing it?
  • Are they motivated to engage in treatment?

Further investigations Physical examination and investigations may be indicated, particularly if sexual dysfunction coexists. Penile plethysmography, polygraphy, and visual reaction times may be useful in assessing paraphilias. P.467
Management General issues Treatment should not be imposed on people who do not want it. Patients should realise that treatment will take considerable effort on their part. The aims of treatment should be clear from the beginning. Broadly, there are three possible aims:

  • Better adjustment without changing the behaviour.
  • Desisting from overtly problematic behaviour but retaining ‘deviant’ arousal.
  • Changing the focus of the arousal.

Where treatment is aimed at change, the following may need to be addressed:

  • Encouraging development of ‘normal’ relationships.
  • Addressing sexual inadequacy (perhaps using approaches similar to those for sexual dysfunction).
  • Develop interests, activities, and relationships that will fill the time previously taken up by fantasising about, preparing for, and taking part in the deviant activity.
  • Decreasing masturbation to deviant fantasies and encouraging masturbation to more appropriate fantasies.

Specific treatment approaches Physical treatments Neurosurgery and bilateral orchidectomy (‘castration’) of historical interest only. Various medications have been used: antipsychotics, oestrogens, progestogens, luteinising-hormone releasing analogue, antiandrogens, and SSRIs. There is evidence for the efficacy of cyproterone acetate (an antiandrogen) and medroxyprogesterone acetate (a progestogen) in the treatment of hypersexuality and paraphilias. Recently, SSRIs have been used increasingly, and some use them first-line due to their relative lack of side-effects. Psychodynamic psychotherapy Individual and group approaches have been used, ranging from sophisticated psychoanalysis to primarily supportive therapy. Cognitive-behavioural therapy Specific techniques may be used to decrease deviant (covert sensitisation, aversive therapy, masturbatory satiation, biofeedback) and increase ‘normal’ arousal (orgasmic reconditioning, shaping, fading, exposure to explicit stimuli, biofeedback, systematic desensitisation). Controversially used to treat homosexuality until the 1970s. Social skills training, assertiveness training, sexual education, and relapse prevention can also be helpful. Addressing cognitive distortions regarding sex, women, or children may also be important. References 1 Brockman B and Bluglass R (1996) A general psychiatric approach to sexual deviation. In Sexual Deviation (ed. Rosen I). Oxford: Oxford University Press.

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