Personality disorder

From Ganfyd

Personality disorder is a very contentious issue. Rather than delve into the debates surrounding the concept, this page is intended to give a pragmatic overview of what is meant by the term.

Personality disorder Is a continuum but can be divided as No personality disorder Personality difficulty Simple disorder Complex(diffuse) disorder Severe disorder Is real Research criteria correlates with occupation[1] and social setting Evidence base for drugs limited other than for short term symptom control Borderline personality disorder is treatable (proven treatments tend to be resource intensive) Dialectic behaviour therapy Mentalisation-based therapy Cognitive behavioural therapy Schema-focused therapy Transference-focused therapy Cognitive analytical therapy Success in assertive outreach team intervention targeting the most severe treatment resisting personality disorders with nidotherapy [2] has been claimed

It is usually helpful to think of personality as a spectrum, ranging across various domains (e.g introversion, extroversion). Individuals vary in their tendency towards certain responses to situations and in their characteristic personality traits. There are a number of models of personality, which can be broadly classified into nomothetic and idiographic approaches. The concept of personality disorder is one in which an individual lies at one or more extremes of personality expression. Their behaviour is thus maladaptive in certain situations. It is this mal-adaptivity which allows personality to be classified as abnormal. Much debate centres on whether this abnormality should be treated as a mental illness. The origins of personality disorder are complex, but it is clear that child abuse plays a significant part in the aetiology of many cases.

Subtyping

A person may be classified as having more than one personality disorder at a time.

In addition, other psychiatric co-morbidities are common.

Classification

That used now in ICD-10 and DSM-IV are based on DSM-III of 1980. The artificial classification cut off of not allowing an official label before age 18 years should be noted. A clustering approach with cluster C of DSM-IV split into a 4th obsessive-compulsive cluster would map better to the 4 main personality dimensions of the normal population^[3]. These clusters are thus:

1. Odd, eccentric
2. Flamboyant, erratic or dramatic
3. Anxious or fearful
4. Obsessive or compulsive

Some more commonly encountered subtypes are:

• Borderline personality disorder
• Dissocial personality disorder
• Narcissistic personality disorder
• Anankastic personality disorder
• Schizotypal personality disorder

Clinical & Social context

On research based criteria patients who seek contact with health services for any reason appear to be more likely to meet the criteria for a diagnosis of personality disorder than the background population. Therefore there may be an issue of perception in all healthworkers that fuels some of the contentions. Against a background rate of no more than 12% in community studies the rates in other health relevant settings are:

Clinical vignettes

For an ICD-10 compliant diagnostic description, please see individual articles as listed above. The following are some vignettes. They are not based on any particular patient and are for illustrative purposes only.

Borderline personality disorder

A twenty-one year old, unmarried female student has frequently attended A+E in the last six months with a series of paracetamol overdoses and self-harm via cutting her forearms and legs. She has a background of sexual assault as a minor and was fostered from age 6 years old. On questioning, she admits to chronic feelings of emptiness and self-loathing, with frequent mood swings and an inability to form lasting relationships.

Dissocial personality disorder

A forty year old unemployed male describes a pattern of witnessing violence towards his mother at the hands of an abusive, alcoholic father from the age of 3 onwards. He has had two periods in prison for assault, for which he does not feel responsible. He describes his actions as "provoked". He is superficially charming and seems to have no difficulties forming attachments with women, although he has never had a relationship which lasted more than a few weeks at a time.

Narcissistic personality disorder

A thirty-three year old male, who was arrested by Police for breach of the peace, described himself as a great artist, whom society does not value, in spite of his immense talents. He blamed his difficult relationship with his mother on her frequent changes of partner when he was younger. He treated custody staff in an abusive fashion and demanded to know his rights, but at interview was mildly obsequious to the interviewing psychiatrist.

Anankastic personality disorder

A fifty year old accountant developed a depressive episode following promotion to a new role. He stated that he was finding it impossible both to perform at an adequate level at work and to manage staff working with him. Collateral history revealed a man with an excessively rigid approach towards his colleagues, living alone in an immaculate flat.

Treatment

Treatment for personality disorder is equally contentious. However, the most promising approaches so far appear to be the psychological therapies, rather than drug-based treatment.

References