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Personality disorders
PSYCHIATRIC DISORDERS
Personality disorders
What’s new?
Tom Fahy C
C
Abstract Personality disorders are common conditions that place a significant burden on the individual sufferer, their carers, and wider society. Patients with personality disorder can be complex to manage and co-morbid personality disorder can impact adversely on the treatment and prognosis of other disorders. Therapeutic advances and changing expectations of healthcare commissioners now challenge the previous reluctance of doctors to engage these patients in treatment, and Department of Health policy emphasizes that service providers must address the needs of this patient population. Despite previous pessimism regarding the treatability of personality disorder, there is a growing body of literature supporting the efficacy of various treatment approaches, especially for problematic behaviours such as self-harming. This article reviews the epidemiology, diagnosis, clinical presentation, assessment and management of personality disorders.
C
The National Institute for Health and Clinical Excellence (NICE) has published treatment guidelines for antisocial and borderline personality disorders1,2 There is increasing evidence that manualized or well-structured psychotherapy programmes, such as mentalization-based treatment (MBT) or dialectical behaviour therapy (DBT), are effective in borderline personality disorder There is limited evidence for the effectiveness of psychological treatment in antisocial personality disorder or psychopathy. Highest risk cases are best managed through a multi-agency approach involving specialist mental health teams and criminal justice agencies
behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’. The DSM-IV (1994), which organizes psychiatric diagnoses into different levels (axes) relating to different aspects of disorder or disability, considers personality disorders on a separate axis (axis II: underlying pervasive or personality conditions) from major mental disorders (axis I). The diagnostic features common to all personality disorders are: maladaptive patterns of thinking, behaviour and emotions an enduring pattern of abnormal behaviour not limited to episodes of mental illness and pervasive to a broad range of social and personal situations manifestation in childhood or adolescence and continuation into adulthood association with considerable personal distress and/or significant problems in social and occupational functioning. Proposals for DSM-5 (www.dsm5.org) suggest a substantial change in approach to diagnosis, by reducing the number of personality disorder categories and introducing dimensional traits and measures of severity of dysfunction attributable to personality. This hybrid between categorical and dimensional approaches may have greater face validity and clinical utility than the current approach.
Keywords assessment; classification; co-morbidity; epidemiology; personality disorders; psychiatry; psychotherapy; treatment
Personality disorders are common conditions and the management of patients with personality disorder is one of the most challenging and at times controversial areas of psychiatry. In the past, people with personality disorders were stigmatized by this diagnostic ‘label’, which frequently excluded them from mental health services on the grounds that they could not be treated or that they were not ill. However, therapeutic advances and changing expectations from healthcare commissioners mean that exclusion is no longer an option. Department of Health policy emphasizes that service providers should address the needs of people with personality disorders, especially those who harm themselves3,4 or who pose a risk to others.5 Greater inclusion of this previously marginalized patient group into mental health services will help to reduce the stigma associated with this diagnosis.
Definition and classification (Table 1) Epidemiology
There is ongoing debate about how best to define and identify personality disorder. The ICD-10 (1992) groups personality disorders with other mental disorders and defines them as: ‘a severe disturbance in the characterological condition and
Research in the UK indicates that 4% of the adult population meet diagnostic criteria for personality disorder.6 A review of international studies suggests a community prevalence rate of 6e10%.7 High rates are found in outpatient and inpatient clinical populations. Prevalence is highest in male, younger, unemployed populations living in urban areas. Schizoid, antisocial, or obsessiveecompulsive personality disorders are overrepresented among men. Dependent or histrionic personality disorders are commoner in women. There is a very high prevalence of personality disorder in the prison population. One review reported a rate of 65%, with antisocial personality disorder being the most common type presenting in 47%.8
Tom Fahy MD MPhil FRCPsych is Professor of Forensic Mental Health at the Institute of Psychiatry, King’s College London, and Consultant Psychiatrist with the South London and Maudsley NHS Foundation Trust, UK. He trained in medicine in Ireland, and in psychiatry at the Maudsley Hospital, London, UK. His clinical work is in community forensic psychiatry. His main research interest is the evaluation of services for patients at high risk of violence. Conflicts of interest: none declared.
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Classification of personality disorders in ICD-10 and DSM-IV with clustering according to DSM-IV ICD-10
DSM-IV
Cluster A personality disorders Core traits of odd, eccentric behaviour, social withdrawal and paranoid or bizarre thinking Paranoid e tendency to bear grudges, suspiciousness, tendency to interpret others actions as hostile, persistent tendency to self-reference, tenacious sense of personal rights Schizoid e emotional coldness, detachment, lack of interest in other people, insensitivity to social norms and introspective fantasy
Paranoid e persistent interpretation of people’s actions as deliberately threatening Schizoid e lack of interest in social relationships and restricted emotional experience and expression Schizotypal e deficient interpersonal relatedness, odd beliefs and thinking, unusual appearance and behaviour
Cluster B personality disorders Core traits of impulsivity, affective dysregulation and relationship instability Dissocial e callous unconcern for others, disregard for social norms, low tolerance of frustration, incapacity to experience guilt, prone to blaming others Impulsive e affective instability, tendency to outbursts of anger, minimal planning ahead, impulsive actions without thought to the consequences Borderline e affective instability with impulsivity, tendency to become involved in intense, unstable relationships, disturbed self-image, recurrent threats/acts of self harm Histrionic e theatricality and egocentricity, shallow and labile affect, attention-seeking, manipulative to achieve own needs
Antisocial e pervasive pattern of disregard for social norms and violation of the rights of others since the age of 15 years Borderline e pervasive instability of mood, interpersonal relationships and self-image associated with fear of abandonment, identity disturbance and recurrent suicidal behaviour Histrionic e excessive emotionality and attention-seeking, suggestibility and superficiality Narcissistic e grandiosity and arrogance, need for excessive admiration, lack of empathy
Cluster C personality disorders Core traits of fearfulness, anxiety, obsessional behaviour Anankastic e excessive doubt and caution, rigidity, perfectionism and excessive attention to detail at the expense of pleasure, productivity or social relationships Dependent e excessive dependence on others and need for reassurance, subordination of own needs to those of others, fear of abandonment and being alone Anxious e persistent apprehension, feelings of inferiority, hypersensitivity to criticism or rejection and restriction of lifestyle to avoid these
Obsessiveecompulsive e preoccupation with orderliness, inflexibility and perfectionism at the expense of efficiency Dependent e persistent submissiveness to, and dependency on others Avoidant e feelings of discomfort and inadequacy in social situations, fear of negative evaluation, timidity
Table 1
Aetiology
may become evident only in the presence of an environmental trigger such as childhood maltreatment.13,14
There is good empirical evidence to suggest that personality disorders represent maladaptive variants of the core five personality traits e neuroticism, extraversion, openness, agreeableness and conscientiousness (the Five Factor Model). Maladaptive development is traditionally thought to have its origins in childhood environment. Disturbance of early attachment formation (e.g. through sexual or physical abuse) is a key aetiological factor, particularly for cluster B disorders.9 However, there is increasing evidence for genetic influence10 and geneeenvironment interaction.11 Imaging genetics research has demonstrated that certain genotypes underlie variations in brain structure and function, which increase an individual’s vulnerability to personality disorders.12 Recent research has suggested that a certain genotype (MAOA-L allele) confers liability to antisocial behaviour, which
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Clinical presentation Personality disorders manifest in a wide range of psychopathology. Some individuals with personality disorders associated with social withdrawal, such as schizoid or paranoid types, are rarely seen by health services, whereas the impulsive behaviour and emotional instability characteristic of those with cluster B and C traits place a heavier demand on medical services. For many, the first and only point of health service contact is with the GP; repeated crises may lead to a perception of the individual as a difficult or ‘heart-sink’ patient. Others place a heavy burden on emergency departments, especially for treatment for self-harm, assault and problems related to intoxication, which are all more common in this group of
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PSYCHIATRIC DISORDERS
patients. Individuals with personality disorders, particularly of the antisocial, borderline and paranoid types, frequently present within a criminal justice context and some may be subsequently redirected to general adult or forensic psychiatric services.
consultation, and help to diffuse crises. The decision to refer to psychiatric services is likely to be based on: the risk of harm to self and others (see also The principles of risk assessment on pp 574e576 of this issue) the presence and severity of co-morbid mental illness the need for review of diagnosis and medication the degree of distress and burden caused to family and others. Many experienced clinicians will discourage reliance on hospital admission as a crisis management intervention because of concern about undermining self-reliance, promoting dependency and causing difficult staffepatient dynamics. These views receive some support from the literature, which show that brief admissions are more helpful than lengthy ones and that brief admissions are ineffective in managing suicidal threats. Crisis admissions may be more helpful when combined with structured psychotherapeutic interventions.16 Management of these patients within multidisciplinary teams can be difficult, due to their reluctance to engage unless in a crisis and tendency to provoke inconsistency within teams through a psychological process called ‘splitting’. Essential ingredients of safe and effective management include clarity about therapeutic goals, consistency of therapeutic model among all staff dealing with the patient, and good continuity of staff members dealing with the patient. These patients often evoke high levels of anxiety in those around them and therefore it is important that treating clinicians have the prerequisite skills to support and manage these individuals. Competencies required of staff to help them work effectively with such patients include emotional resilience, clarity about personal and interpersonal boundaries, and ability to
Co-morbidity Individuals with personality disorder are more vulnerable to other mental health problems, such as anxiety, somatization, depression, self-harming behaviour, dissociative disorders, substance misuse, eating disorders and brief psychotic episodes. The existence of a co-morbid personality disorder is likely to have an adverse effect on treatment responsivity and the eventual prognosis of most types of mental illness, including psychoses and depression. A co-existing diagnosis of personality disorder also increases the risk of suicide and violent behaviour in severe mental illnesses such as schizophrenia.15
Assessment Any comprehensive assessment of a patient should include potential personality disorder pathology. The assessment of premorbid personality is an essential part of a routine psychiatric history. This should include questions about social and intimate relationships, self-esteem, functioning at school and at work, and history of coping with stressful life experiences such as bereavements and the end of relationships. Information from collateral informants such as parents or partners can be very useful. Personality assessment can be assisted by the use of self-rated assessments such as the Millon clinical multiaxial inventory. However, the most widely used and best-validated instruments are semi-structured interviews, such as the SCID-II or IPDE. Although these are too time-consuming and impractical for routine clinical assessment, they are widely used in treatment studies and in specialist treatment units. The Psychopathy Checklist Revised (PCL-R) is a semi-structured personality assessment that is often used in forensic settings to assess for psychopathic traits and has been shown to be a useful tool in assessing the risk of criminal re-offending.
Differentiating personality disorder from other psychiatric disorders C
Differential diagnosis It can be difficult to establish the presence or absence of a diagnosis of personality disorder in a mentally ill patient. Similarly, diagnostic confusion may arise in distinguishing extreme narcissistic or paranoid personality traits from delusional beliefs, perhaps the most notorious recent case being that of Anders Breivik, the Norwegian right-wing extremist who has admitted to the mass-killing of 77 people in 2011. The important differentiating characteristics are the early manifestation and enduring nature of the problems associated with personality disorders (Table 2). However, it may be difficult to disentangle the prodromal features of severe mental illness from the early manifestations of personality disorder.
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Management Referral to mental health services A number of personality disordered patients gain useful help and support from their GP who, in the ideal situation, may be able to bring a longstanding knowledge of the patient to the
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Anxiety disorder e the distinction between anxious personality disorder and an anxiety disorder can be difficult. Early manifestation, enduring nature and pervasiveness are features which would favour a diagnosis of personality disorder over an anxiety disorder Affective disorder e dependent personality disorder can be confused with depression and borderline or histrionic personality disorder with hypomania Psychotic illness e borderline personality disorder can present with transient pseudo-psychotic symptoms and paranoid and schizoid personality disorders can be confused with a delusional disorder or schizophrenia Substance misuse e erratic, impulsive or irresponsible behaviour and emotional liability caused by substance misuse/ dependence can be mistaken for personality disorder Medical conditions e organic illness or injury can cause enduring personality change or present with uncharacteristic changes to personality and behaviour, such as head injury, brain tumours or cerebrovascular disease (especially affecting the frontal lobe), epilepsy (particularly temporal lobe epilepsy), multiple sclerosis and systemic lupus erythematosus
Table 2
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Psychotherapies evaluated in the treatment of personality disorder Treatment
Description
Type of study
Results
Psychodynamic psychotherapy/ mentalization based therapy (þ/ day hospital treatment)
Long-term treatment that uses the relationship between the patient and therapist as a way to understand how the internal world of the individual affects relationships Adaptation of cognitive therapy, including functional analysis of behaviour, skills training and support Emphasis on changing core beliefs and maladaptive behaviours
Randomized controlled trials20,21 (mainly BPD3)
Superior to treatment as usual for self harm, hospital admissions, costs and symptoms, but benefit more delayed
Randomized controlled trials22 (mainly BPD)
Significant reduction in self-harm and hospitalization, less change in other clinical symptoms
Randomized controlled trials23 (cluster B with recurrent self harm)
Postulates that switching between partially dissociated ‘self states’ accounts for clinical features of borderline personality disorder (BPD) and therapy aims to understand and control these processes Intensive psychosocial treatments provided but the therapeutic environment itself is seen as the primary agent of change and community members take a significant role in decision-making and the everyday running of the unit.
‘Pre-post studies’ and randomized controlled trial24 (mainly BPD)
Reduction in frequency of self harm but no difference in repetition over 1 year; cost effective Improvement seen over time but may not be more effective than other psychological therapies
Dialectical behaviour therapy
Cognitive behavioural therapy
Cognitive analytical therapy
Therapeutic communities
One ‘controlled’ trial in UK but inadequate comparison group25 (all sub-types)
Evaluation of therapeutic efficacy is difficult but the general consensus is favourable
Table 3
patients and keeping them engaged in treatment, and the quality of the therapeutic alliance achieved, are crucial factors in determining treatment outcome. A well-designed randomized trial of such a treatment programme demonstrated the sustained clinical benefits of a partial hospitalization programme with psychodynamic-oriented psychotherapy.20 Dialectical behaviour therapy (DBT) aims to equip patients with skills in preventing emotional crises and self-harming by promoting mindfulness, interpersonal efficacy, emotional regulations and distress tolerance. DBT was developed by the American psychologist Marsha Linehan, partly relying on her own psychological struggles.26 DBT has demonstrated efficacy in the treatment of self-harming behaviour in borderline personality disorder.27
tolerate the intense emotional impact these patients can have on them.17 Clinical supervision of staff working with individuals with personality disorder plays an important role in maintaining a clear therapeutic agenda and in supporting staff in what may be challenging and emotionally draining work. Treatment A range of treatment interventions is available for personality disorder, including psychological treatments and drug therapy. Despite previous pessimism there is now a growing body of literature supporting the efficacy of various treatment approaches.18,19 In general a combination of psychological treatments reinforced by drug therapy at critical times is the consensus view of treatment.3
Pharmacological treatment: it is not thought that any psychotropic drug treatment is specific to any single personality disorder, rather that certain types of medication can help to relieve some of the symptomatic distress associated with certain personality disorders. These are usually prescribed in psychiatric secondary care settings after a thorough assessment. There are varying levels of evidence for the use of the following agents: antidepressants (mainly selective serotonin reuptake inhibitors) to reduce impulsivity, anger and aggression mostly in borderline and antisocial subtypes25,28
Psychological therapy: most treatment studies have focused on patients with borderline personality disorder (Table 3). There is no clear evidence of the superiority of one type of treatment approach over another or for a particular method of service delivery (inpatient, outpatient, or day programme). However, treatment benefits appear particularly evident when treatment is intensive, long-term, theoretically coherent, well structured and well integrated with other services, and where follow-up to residential care is provided.20 The efforts made in engaging
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atypical antipsychotics (olanzapine and risperidone) in low doses to reduce anxiety, paranoid ideation and anger in borderline and schizotypal personality disorder29,30 mood stabilizers to help with affective instability and aggression in borderline and antisocial personality disorders respectively.31e33 None of these drugs is specifically licensed for use in individuals with personality disorder, and the risks of overdosage should always be considered before they are prescribed.
8 Fazel S, Danesh J. Serious mental disorder in 23,000 prisoners: a systematic review of 62 surveys. Lancet 2002; 359: 545e50. 9 Bender DS, Farber BA, Geller JD. Cluster B personality traits and attachment. J Am Acad Psychoanal 2001; 29: 551e63. 10 Livesley MD. Practical management of personality disorder. Chapter 3. Guildford Publications Incorporated, 2003. 11 Cloninger CR. Genetics of personality disorder. In: Oldham JM, Skodol AE, Bender DS, eds. The American Psychiatry Publishing Textbook of Personality Disorders. Washington, DC: American Psychiatric Publishing, 2005. 12 Meyer-Lindenberg A, Weinberger DR. Intermediate phenotypes and genetic mechanisms of psychiatric disorders. Nat Rev Neurosci 2006; 7: 818e27. 13 Kim-Cohen J, Caspi A, Taylor A, et al. MAOA, maltreatment, and gene environment interaction predicting children’s mental health: new evidence and a meta-analysis. Mol Psychiatry 2006; 11: 903e13. 14 Ferguson DM, Boden JM, Horwood LJ, et al. MAOA, abuse exposure and antisocial behaviour: 30-year longitudinal study. Br J Psychiatry 2011; 198: 457e63. 15 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: 129e34. 16 Fonaghy P, Bateman A. Progress in the treatment of borderline personality disorders. Br J Psychiatry 2006; 188: 1e3. 17 Duggan M. Developing services for people with personality disorder: the training needs of staff and services. NIMHE. Available at: http:// www.nimhe.org.uk/downloads/ReportJuly112002.doc; 2002. 18 Bateman A, Tyrer P. Psychological treatment for personality disorders. Advan Psychiatr Treat 2004; 10: 378e88. 19 Bateman A, Tyrer P. Drug treatment for personality disorders. Advan Psychiatr Treat 2004; 10: 389e98. 20 Bateman A, Fonaghy P. Treatment of borderline personality disorder with psychoanalytically orientated partial hospitalisation: an 18 month follow-up. Am J Psychiatry 2001; 158: 36e42. 21 Bateman A, Fonagy P. Randomised controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009; 166: 1355e64. 22 Binks CA, Fenton M, McCarthy I, Lee T, Adams CE, Duggan C. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2006. Issue 1. Art. No.: CD005652. 23 Tyrer P, Thompson S, Schmidt U, et al. Randomised controlled trial of brief cognitive behaviour therapy vs treatment as usual in deliberate self harm: the POPMACT study. Psychol Med 2003; 33: 969e76. 24 Ryle A. The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. J Personal Disord 2004; 73: 197e210. 25 Rutter D, Tyrer P. The value of therapeutic communities in the treatment of personality disorder: a suitable place for treatment? J Psychiatr Pract 2003; 9: 291e302. 26 http://www.nytimes.com/2011/06/23/health/23lives.html?_r¼1. 27 Linehan MM, Comtois KA, Murray AM, et al. Two year randomised controlled trial and follow-up of dialectical behaviour therapy vs therapy by experts for suicidal behaviour and borderline personality disorder. Arch Gen Psychiatry 2006; 63: 757e66. 28 Coccaro EF, Kavoussi RJ. Fluoxetine and impulsive aggressive behaviour in personality-disordered subjects. Arch Gen Psychiatry 1997; 54: 1081e8.
Severe personality disorder and public protection There is strong evidence that personality disorder is commonplace among prison populations and that offenders with personality disorders have a higher risk of re-offending including for violent crime.34 Currently in the UK, people with personality disorder can be detained in hospital if it is thought that treatment will alleviate their condition. In forensic settings, treatment interventions for personality disorder are aimed not just at relieving the symptoms of mental distress, but also at reducing the risk of re-offending. Interventions within forensic populations have favoured social learning and cognitiveebehavioural models. Prognosis It is a widely held view that some personality disorders ‘mellow’ with time. There are insufficient longitudinal data to support this in any of the sub-types other than borderline personality disorder, in which it has been shown that, after 10 years, 85% achieve remission by standard diagnostic criteria, recurrences are rare but social functioning remained poor.1 This is in contrast to many Axis I disorders where improvement may be more rapid but recurrence is common. Recognition of the natural progression of the disorders and the emergence of effective psychosocial interventions brings optimism to the management of a previously marginalized group of patients. A
REFERENCES 1 Borderline personality disorder: treatment and management. The British Psychological Society and The Royal College of Psychiatrists, 2009. 2 Antisocial personality disorder: treatment, management and prevention. The British Psychological Society and The Royal College of Psychiatrists, 2010. 3 National Institute of Mental Health 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. 4 National Collaborating Centre for Mental Health. Self harm: the shortterm physical and psychological management and secondary prevention of self-harm in primary and secondary care (Clinical Guideline 16). London: National Institute for Health and Clinical Excellence, 2004. 5 Home Office and Department of Health. Managing dangerous people with severe personality disorder. Proposals for policy development. London: Home Office & Department of Health, 1999. 6 Coid J, Yang M, Tyrer P, et al. Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry 2006; 188: 423e31. 7 Samuels J. Personality disorders: epidemiology and public health issues. Int Rev Psychiatry.
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29 Zanarini MC, Frankenburg FR. Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebocontrolled pilot study. J Clin Psychiatry 2001; 62: 849e54. 30 Koenigsberg HW, Reynolds D, Goodman M, et al. Risperidone in the treatment of schizotypal personality disorder. J Clin Psychiatry 2003; 64: 628e34. 31 Sheard MH, Martin JL, Bridges CI, et al. The effect of lithium on unipolar aggressive behaviour in man. Am J Psychiatry 1976; 133: 1409e13. 32 Frankenburg FR, Zanarini MC. Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder. A double blind placebo controlled pilot study. J Clin Psychiatry 2002; 63: 442e6. 33 Binks CA, Fenton M, McCarthy I, Lee T, Adams CE, Duggan C. Pharmacological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2006. Issue 1. Art. No.: CD005653. 34 Gunderson JG, Stout RL, McGlashan TH, et al. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorder study. Arch Gen Psychiatry 2011; 68: 827e37.
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Practice points C
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Comprehensive patient assessment should include assessment of personality (by clinical interview, standardized assessment, or semi-structured interview) Awareness of the existence of co-morbid personality disorder is important as it can adversely impact on the treatment responsiveness and prognosis of other mental disorders Important aspects of management include a coherent treatment model, clear therapeutic goals, continuity of staff members and consistency of treatment model among all those dealing with the patient, clarity of interpersonal boundaries and maintenance of engagement and therapeutic alliance Treatment should be long term and integrated with other services available to the patient Clinical supervision of staff and reflective practice is important in managing difficult patients Maintain optimism
Ó 2012 Elsevier Ltd. All rights reserved.
Personality disorders
What’s new?
Tom Fahy C
C
Abstract Personality disorders are common conditions that place a significant burden on the individual sufferer, their carers, and wider society. Patients with personality disorder can be complex to manage and co-morbid personality disorder can impact adversely on the treatment and prognosis of other disorders. Therapeutic advances and changing expectations of healthcare commissioners now challenge the previous reluctance of doctors to engage these patients in treatment, and Department of Health policy emphasizes that service providers must address the needs of this patient population. Despite previous pessimism regarding the treatability of personality disorder, there is a growing body of literature supporting the efficacy of various treatment approaches, especially for problematic behaviours such as self-harming. This article reviews the epidemiology, diagnosis, clinical presentation, assessment and management of personality disorders.
C
The National Institute for Health and Clinical Excellence (NICE) has published treatment guidelines for antisocial and borderline personality disorders1,2 There is increasing evidence that manualized or well-structured psychotherapy programmes, such as mentalization-based treatment (MBT) or dialectical behaviour therapy (DBT), are effective in borderline personality disorder There is limited evidence for the effectiveness of psychological treatment in antisocial personality disorder or psychopathy. Highest risk cases are best managed through a multi-agency approach involving specialist mental health teams and criminal justice agencies
behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’. The DSM-IV (1994), which organizes psychiatric diagnoses into different levels (axes) relating to different aspects of disorder or disability, considers personality disorders on a separate axis (axis II: underlying pervasive or personality conditions) from major mental disorders (axis I). The diagnostic features common to all personality disorders are: maladaptive patterns of thinking, behaviour and emotions an enduring pattern of abnormal behaviour not limited to episodes of mental illness and pervasive to a broad range of social and personal situations manifestation in childhood or adolescence and continuation into adulthood association with considerable personal distress and/or significant problems in social and occupational functioning. Proposals for DSM-5 (www.dsm5.org) suggest a substantial change in approach to diagnosis, by reducing the number of personality disorder categories and introducing dimensional traits and measures of severity of dysfunction attributable to personality. This hybrid between categorical and dimensional approaches may have greater face validity and clinical utility than the current approach.
Keywords assessment; classification; co-morbidity; epidemiology; personality disorders; psychiatry; psychotherapy; treatment
Personality disorders are common conditions and the management of patients with personality disorder is one of the most challenging and at times controversial areas of psychiatry. In the past, people with personality disorders were stigmatized by this diagnostic ‘label’, which frequently excluded them from mental health services on the grounds that they could not be treated or that they were not ill. However, therapeutic advances and changing expectations from healthcare commissioners mean that exclusion is no longer an option. Department of Health policy emphasizes that service providers should address the needs of people with personality disorders, especially those who harm themselves3,4 or who pose a risk to others.5 Greater inclusion of this previously marginalized patient group into mental health services will help to reduce the stigma associated with this diagnosis.
Definition and classification (Table 1) Epidemiology
There is ongoing debate about how best to define and identify personality disorder. The ICD-10 (1992) groups personality disorders with other mental disorders and defines them as: ‘a severe disturbance in the characterological condition and
Research in the UK indicates that 4% of the adult population meet diagnostic criteria for personality disorder.6 A review of international studies suggests a community prevalence rate of 6e10%.7 High rates are found in outpatient and inpatient clinical populations. Prevalence is highest in male, younger, unemployed populations living in urban areas. Schizoid, antisocial, or obsessiveecompulsive personality disorders are overrepresented among men. Dependent or histrionic personality disorders are commoner in women. There is a very high prevalence of personality disorder in the prison population. One review reported a rate of 65%, with antisocial personality disorder being the most common type presenting in 47%.8
Tom Fahy MD MPhil FRCPsych is Professor of Forensic Mental Health at the Institute of Psychiatry, King’s College London, and Consultant Psychiatrist with the South London and Maudsley NHS Foundation Trust, UK. He trained in medicine in Ireland, and in psychiatry at the Maudsley Hospital, London, UK. His clinical work is in community forensic psychiatry. His main research interest is the evaluation of services for patients at high risk of violence. Conflicts of interest: none declared.
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Ó 2012 Elsevier Ltd. All rights reserved.
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Classification of personality disorders in ICD-10 and DSM-IV with clustering according to DSM-IV ICD-10
DSM-IV
Cluster A personality disorders Core traits of odd, eccentric behaviour, social withdrawal and paranoid or bizarre thinking Paranoid e tendency to bear grudges, suspiciousness, tendency to interpret others actions as hostile, persistent tendency to self-reference, tenacious sense of personal rights Schizoid e emotional coldness, detachment, lack of interest in other people, insensitivity to social norms and introspective fantasy
Paranoid e persistent interpretation of people’s actions as deliberately threatening Schizoid e lack of interest in social relationships and restricted emotional experience and expression Schizotypal e deficient interpersonal relatedness, odd beliefs and thinking, unusual appearance and behaviour
Cluster B personality disorders Core traits of impulsivity, affective dysregulation and relationship instability Dissocial e callous unconcern for others, disregard for social norms, low tolerance of frustration, incapacity to experience guilt, prone to blaming others Impulsive e affective instability, tendency to outbursts of anger, minimal planning ahead, impulsive actions without thought to the consequences Borderline e affective instability with impulsivity, tendency to become involved in intense, unstable relationships, disturbed self-image, recurrent threats/acts of self harm Histrionic e theatricality and egocentricity, shallow and labile affect, attention-seeking, manipulative to achieve own needs
Antisocial e pervasive pattern of disregard for social norms and violation of the rights of others since the age of 15 years Borderline e pervasive instability of mood, interpersonal relationships and self-image associated with fear of abandonment, identity disturbance and recurrent suicidal behaviour Histrionic e excessive emotionality and attention-seeking, suggestibility and superficiality Narcissistic e grandiosity and arrogance, need for excessive admiration, lack of empathy
Cluster C personality disorders Core traits of fearfulness, anxiety, obsessional behaviour Anankastic e excessive doubt and caution, rigidity, perfectionism and excessive attention to detail at the expense of pleasure, productivity or social relationships Dependent e excessive dependence on others and need for reassurance, subordination of own needs to those of others, fear of abandonment and being alone Anxious e persistent apprehension, feelings of inferiority, hypersensitivity to criticism or rejection and restriction of lifestyle to avoid these
Obsessiveecompulsive e preoccupation with orderliness, inflexibility and perfectionism at the expense of efficiency Dependent e persistent submissiveness to, and dependency on others Avoidant e feelings of discomfort and inadequacy in social situations, fear of negative evaluation, timidity
Table 1
Aetiology
may become evident only in the presence of an environmental trigger such as childhood maltreatment.13,14
There is good empirical evidence to suggest that personality disorders represent maladaptive variants of the core five personality traits e neuroticism, extraversion, openness, agreeableness and conscientiousness (the Five Factor Model). Maladaptive development is traditionally thought to have its origins in childhood environment. Disturbance of early attachment formation (e.g. through sexual or physical abuse) is a key aetiological factor, particularly for cluster B disorders.9 However, there is increasing evidence for genetic influence10 and geneeenvironment interaction.11 Imaging genetics research has demonstrated that certain genotypes underlie variations in brain structure and function, which increase an individual’s vulnerability to personality disorders.12 Recent research has suggested that a certain genotype (MAOA-L allele) confers liability to antisocial behaviour, which
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Clinical presentation Personality disorders manifest in a wide range of psychopathology. Some individuals with personality disorders associated with social withdrawal, such as schizoid or paranoid types, are rarely seen by health services, whereas the impulsive behaviour and emotional instability characteristic of those with cluster B and C traits place a heavier demand on medical services. For many, the first and only point of health service contact is with the GP; repeated crises may lead to a perception of the individual as a difficult or ‘heart-sink’ patient. Others place a heavy burden on emergency departments, especially for treatment for self-harm, assault and problems related to intoxication, which are all more common in this group of
614
Ó 2012 Elsevier Ltd. All rights reserved.
PSYCHIATRIC DISORDERS
patients. Individuals with personality disorders, particularly of the antisocial, borderline and paranoid types, frequently present within a criminal justice context and some may be subsequently redirected to general adult or forensic psychiatric services.
consultation, and help to diffuse crises. The decision to refer to psychiatric services is likely to be based on: the risk of harm to self and others (see also The principles of risk assessment on pp 574e576 of this issue) the presence and severity of co-morbid mental illness the need for review of diagnosis and medication the degree of distress and burden caused to family and others. Many experienced clinicians will discourage reliance on hospital admission as a crisis management intervention because of concern about undermining self-reliance, promoting dependency and causing difficult staffepatient dynamics. These views receive some support from the literature, which show that brief admissions are more helpful than lengthy ones and that brief admissions are ineffective in managing suicidal threats. Crisis admissions may be more helpful when combined with structured psychotherapeutic interventions.16 Management of these patients within multidisciplinary teams can be difficult, due to their reluctance to engage unless in a crisis and tendency to provoke inconsistency within teams through a psychological process called ‘splitting’. Essential ingredients of safe and effective management include clarity about therapeutic goals, consistency of therapeutic model among all staff dealing with the patient, and good continuity of staff members dealing with the patient. These patients often evoke high levels of anxiety in those around them and therefore it is important that treating clinicians have the prerequisite skills to support and manage these individuals. Competencies required of staff to help them work effectively with such patients include emotional resilience, clarity about personal and interpersonal boundaries, and ability to
Co-morbidity Individuals with personality disorder are more vulnerable to other mental health problems, such as anxiety, somatization, depression, self-harming behaviour, dissociative disorders, substance misuse, eating disorders and brief psychotic episodes. The existence of a co-morbid personality disorder is likely to have an adverse effect on treatment responsivity and the eventual prognosis of most types of mental illness, including psychoses and depression. A co-existing diagnosis of personality disorder also increases the risk of suicide and violent behaviour in severe mental illnesses such as schizophrenia.15
Assessment Any comprehensive assessment of a patient should include potential personality disorder pathology. The assessment of premorbid personality is an essential part of a routine psychiatric history. This should include questions about social and intimate relationships, self-esteem, functioning at school and at work, and history of coping with stressful life experiences such as bereavements and the end of relationships. Information from collateral informants such as parents or partners can be very useful. Personality assessment can be assisted by the use of self-rated assessments such as the Millon clinical multiaxial inventory. However, the most widely used and best-validated instruments are semi-structured interviews, such as the SCID-II or IPDE. Although these are too time-consuming and impractical for routine clinical assessment, they are widely used in treatment studies and in specialist treatment units. The Psychopathy Checklist Revised (PCL-R) is a semi-structured personality assessment that is often used in forensic settings to assess for psychopathic traits and has been shown to be a useful tool in assessing the risk of criminal re-offending.
Differentiating personality disorder from other psychiatric disorders C
Differential diagnosis It can be difficult to establish the presence or absence of a diagnosis of personality disorder in a mentally ill patient. Similarly, diagnostic confusion may arise in distinguishing extreme narcissistic or paranoid personality traits from delusional beliefs, perhaps the most notorious recent case being that of Anders Breivik, the Norwegian right-wing extremist who has admitted to the mass-killing of 77 people in 2011. The important differentiating characteristics are the early manifestation and enduring nature of the problems associated with personality disorders (Table 2). However, it may be difficult to disentangle the prodromal features of severe mental illness from the early manifestations of personality disorder.
C
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Management Referral to mental health services A number of personality disordered patients gain useful help and support from their GP who, in the ideal situation, may be able to bring a longstanding knowledge of the patient to the
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Anxiety disorder e the distinction between anxious personality disorder and an anxiety disorder can be difficult. Early manifestation, enduring nature and pervasiveness are features which would favour a diagnosis of personality disorder over an anxiety disorder Affective disorder e dependent personality disorder can be confused with depression and borderline or histrionic personality disorder with hypomania Psychotic illness e borderline personality disorder can present with transient pseudo-psychotic symptoms and paranoid and schizoid personality disorders can be confused with a delusional disorder or schizophrenia Substance misuse e erratic, impulsive or irresponsible behaviour and emotional liability caused by substance misuse/ dependence can be mistaken for personality disorder Medical conditions e organic illness or injury can cause enduring personality change or present with uncharacteristic changes to personality and behaviour, such as head injury, brain tumours or cerebrovascular disease (especially affecting the frontal lobe), epilepsy (particularly temporal lobe epilepsy), multiple sclerosis and systemic lupus erythematosus
Table 2
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Psychotherapies evaluated in the treatment of personality disorder Treatment
Description
Type of study
Results
Psychodynamic psychotherapy/ mentalization based therapy (þ/ day hospital treatment)
Long-term treatment that uses the relationship between the patient and therapist as a way to understand how the internal world of the individual affects relationships Adaptation of cognitive therapy, including functional analysis of behaviour, skills training and support Emphasis on changing core beliefs and maladaptive behaviours
Randomized controlled trials20,21 (mainly BPD3)
Superior to treatment as usual for self harm, hospital admissions, costs and symptoms, but benefit more delayed
Randomized controlled trials22 (mainly BPD)
Significant reduction in self-harm and hospitalization, less change in other clinical symptoms
Randomized controlled trials23 (cluster B with recurrent self harm)
Postulates that switching between partially dissociated ‘self states’ accounts for clinical features of borderline personality disorder (BPD) and therapy aims to understand and control these processes Intensive psychosocial treatments provided but the therapeutic environment itself is seen as the primary agent of change and community members take a significant role in decision-making and the everyday running of the unit.
‘Pre-post studies’ and randomized controlled trial24 (mainly BPD)
Reduction in frequency of self harm but no difference in repetition over 1 year; cost effective Improvement seen over time but may not be more effective than other psychological therapies
Dialectical behaviour therapy
Cognitive behavioural therapy
Cognitive analytical therapy
Therapeutic communities
One ‘controlled’ trial in UK but inadequate comparison group25 (all sub-types)
Evaluation of therapeutic efficacy is difficult but the general consensus is favourable
Table 3
patients and keeping them engaged in treatment, and the quality of the therapeutic alliance achieved, are crucial factors in determining treatment outcome. A well-designed randomized trial of such a treatment programme demonstrated the sustained clinical benefits of a partial hospitalization programme with psychodynamic-oriented psychotherapy.20 Dialectical behaviour therapy (DBT) aims to equip patients with skills in preventing emotional crises and self-harming by promoting mindfulness, interpersonal efficacy, emotional regulations and distress tolerance. DBT was developed by the American psychologist Marsha Linehan, partly relying on her own psychological struggles.26 DBT has demonstrated efficacy in the treatment of self-harming behaviour in borderline personality disorder.27
tolerate the intense emotional impact these patients can have on them.17 Clinical supervision of staff working with individuals with personality disorder plays an important role in maintaining a clear therapeutic agenda and in supporting staff in what may be challenging and emotionally draining work. Treatment A range of treatment interventions is available for personality disorder, including psychological treatments and drug therapy. Despite previous pessimism there is now a growing body of literature supporting the efficacy of various treatment approaches.18,19 In general a combination of psychological treatments reinforced by drug therapy at critical times is the consensus view of treatment.3
Pharmacological treatment: it is not thought that any psychotropic drug treatment is specific to any single personality disorder, rather that certain types of medication can help to relieve some of the symptomatic distress associated with certain personality disorders. These are usually prescribed in psychiatric secondary care settings after a thorough assessment. There are varying levels of evidence for the use of the following agents: antidepressants (mainly selective serotonin reuptake inhibitors) to reduce impulsivity, anger and aggression mostly in borderline and antisocial subtypes25,28
Psychological therapy: most treatment studies have focused on patients with borderline personality disorder (Table 3). There is no clear evidence of the superiority of one type of treatment approach over another or for a particular method of service delivery (inpatient, outpatient, or day programme). However, treatment benefits appear particularly evident when treatment is intensive, long-term, theoretically coherent, well structured and well integrated with other services, and where follow-up to residential care is provided.20 The efforts made in engaging
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atypical antipsychotics (olanzapine and risperidone) in low doses to reduce anxiety, paranoid ideation and anger in borderline and schizotypal personality disorder29,30 mood stabilizers to help with affective instability and aggression in borderline and antisocial personality disorders respectively.31e33 None of these drugs is specifically licensed for use in individuals with personality disorder, and the risks of overdosage should always be considered before they are prescribed.
8 Fazel S, Danesh J. Serious mental disorder in 23,000 prisoners: a systematic review of 62 surveys. Lancet 2002; 359: 545e50. 9 Bender DS, Farber BA, Geller JD. Cluster B personality traits and attachment. J Am Acad Psychoanal 2001; 29: 551e63. 10 Livesley MD. Practical management of personality disorder. Chapter 3. Guildford Publications Incorporated, 2003. 11 Cloninger CR. Genetics of personality disorder. In: Oldham JM, Skodol AE, Bender DS, eds. The American Psychiatry Publishing Textbook of Personality Disorders. Washington, DC: American Psychiatric Publishing, 2005. 12 Meyer-Lindenberg A, Weinberger DR. Intermediate phenotypes and genetic mechanisms of psychiatric disorders. Nat Rev Neurosci 2006; 7: 818e27. 13 Kim-Cohen J, Caspi A, Taylor A, et al. MAOA, maltreatment, and gene environment interaction predicting children’s mental health: new evidence and a meta-analysis. Mol Psychiatry 2006; 11: 903e13. 14 Ferguson DM, Boden JM, Horwood LJ, et al. MAOA, abuse exposure and antisocial behaviour: 30-year longitudinal study. Br J Psychiatry 2011; 198: 457e63. 15 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: 129e34. 16 Fonaghy P, Bateman A. Progress in the treatment of borderline personality disorders. Br J Psychiatry 2006; 188: 1e3. 17 Duggan M. Developing services for people with personality disorder: the training needs of staff and services. NIMHE. Available at: http:// www.nimhe.org.uk/downloads/ReportJuly112002.doc; 2002. 18 Bateman A, Tyrer P. Psychological treatment for personality disorders. Advan Psychiatr Treat 2004; 10: 378e88. 19 Bateman A, Tyrer P. Drug treatment for personality disorders. Advan Psychiatr Treat 2004; 10: 389e98. 20 Bateman A, Fonaghy P. Treatment of borderline personality disorder with psychoanalytically orientated partial hospitalisation: an 18 month follow-up. Am J Psychiatry 2001; 158: 36e42. 21 Bateman A, Fonagy P. Randomised controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009; 166: 1355e64. 22 Binks CA, Fenton M, McCarthy I, Lee T, Adams CE, Duggan C. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2006. Issue 1. Art. No.: CD005652. 23 Tyrer P, Thompson S, Schmidt U, et al. Randomised controlled trial of brief cognitive behaviour therapy vs treatment as usual in deliberate self harm: the POPMACT study. Psychol Med 2003; 33: 969e76. 24 Ryle A. The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. J Personal Disord 2004; 73: 197e210. 25 Rutter D, Tyrer P. The value of therapeutic communities in the treatment of personality disorder: a suitable place for treatment? J Psychiatr Pract 2003; 9: 291e302. 26 http://www.nytimes.com/2011/06/23/health/23lives.html?_r¼1. 27 Linehan MM, Comtois KA, Murray AM, et al. Two year randomised controlled trial and follow-up of dialectical behaviour therapy vs therapy by experts for suicidal behaviour and borderline personality disorder. Arch Gen Psychiatry 2006; 63: 757e66. 28 Coccaro EF, Kavoussi RJ. Fluoxetine and impulsive aggressive behaviour in personality-disordered subjects. Arch Gen Psychiatry 1997; 54: 1081e8.
Severe personality disorder and public protection There is strong evidence that personality disorder is commonplace among prison populations and that offenders with personality disorders have a higher risk of re-offending including for violent crime.34 Currently in the UK, people with personality disorder can be detained in hospital if it is thought that treatment will alleviate their condition. In forensic settings, treatment interventions for personality disorder are aimed not just at relieving the symptoms of mental distress, but also at reducing the risk of re-offending. Interventions within forensic populations have favoured social learning and cognitiveebehavioural models. Prognosis It is a widely held view that some personality disorders ‘mellow’ with time. There are insufficient longitudinal data to support this in any of the sub-types other than borderline personality disorder, in which it has been shown that, after 10 years, 85% achieve remission by standard diagnostic criteria, recurrences are rare but social functioning remained poor.1 This is in contrast to many Axis I disorders where improvement may be more rapid but recurrence is common. Recognition of the natural progression of the disorders and the emergence of effective psychosocial interventions brings optimism to the management of a previously marginalized group of patients. A
REFERENCES 1 Borderline personality disorder: treatment and management. The British Psychological Society and The Royal College of Psychiatrists, 2009. 2 Antisocial personality disorder: treatment, management and prevention. The British Psychological Society and The Royal College of Psychiatrists, 2010. 3 National Institute of Mental Health 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. 4 National Collaborating Centre for Mental Health. Self harm: the shortterm physical and psychological management and secondary prevention of self-harm in primary and secondary care (Clinical Guideline 16). London: National Institute for Health and Clinical Excellence, 2004. 5 Home Office and Department of Health. Managing dangerous people with severe personality disorder. Proposals for policy development. London: Home Office & Department of Health, 1999. 6 Coid J, Yang M, Tyrer P, et al. Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry 2006; 188: 423e31. 7 Samuels J. Personality disorders: epidemiology and public health issues. Int Rev Psychiatry.
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29 Zanarini MC, Frankenburg FR. Olanzapine treatment of female borderline personality disorder patients: a double-blind, placebocontrolled pilot study. J Clin Psychiatry 2001; 62: 849e54. 30 Koenigsberg HW, Reynolds D, Goodman M, et al. Risperidone in the treatment of schizotypal personality disorder. J Clin Psychiatry 2003; 64: 628e34. 31 Sheard MH, Martin JL, Bridges CI, et al. The effect of lithium on unipolar aggressive behaviour in man. Am J Psychiatry 1976; 133: 1409e13. 32 Frankenburg FR, Zanarini MC. Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder. A double blind placebo controlled pilot study. J Clin Psychiatry 2002; 63: 442e6. 33 Binks CA, Fenton M, McCarthy I, Lee T, Adams CE, Duggan C. Pharmacological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2006. Issue 1. Art. No.: CD005653. 34 Gunderson JG, Stout RL, McGlashan TH, et al. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorder study. Arch Gen Psychiatry 2011; 68: 827e37.
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Practice points C
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Comprehensive patient assessment should include assessment of personality (by clinical interview, standardized assessment, or semi-structured interview) Awareness of the existence of co-morbid personality disorder is important as it can adversely impact on the treatment responsiveness and prognosis of other mental disorders Important aspects of management include a coherent treatment model, clear therapeutic goals, continuity of staff members and consistency of treatment model among all those dealing with the patient, clarity of interpersonal boundaries and maintenance of engagement and therapeutic alliance Treatment should be long term and integrated with other services available to the patient Clinical supervision of staff and reflective practice is important in managing difficult patients Maintain optimism
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