Abstract
Ms N, a 27-year-old woman has been urgently referred to the community psychiatric service by her General Practitioner. The psychiatrist Dr R feels anxious about the encounter as the receptionist says Ms N has been ‘abusive and challenging’. Ms N informs Dr R she saw her boyfriend Tom talking to his ex-girlfriend and has since had urges to take an overdose.
A Clinical Scenario
Ms N, a 27-year-old woman has been urgently referred to the community psychiatric service by her General Practitioner. The psychiatrist Dr R feels anxious about the encounter as the receptionist says Ms N has been ‘abusive and challenging’. Ms N informs Dr R she saw her boyfriend Tom talking to his ex-girlfriend and has since had urges to take an overdose.
Ms N brightens up in the meeting. On mental state examination she is not clinically depressed. She says she has no further thoughts of harming herself. Dr R spends an hour with Ms N and despite his initial misgivings has found the meeting interesting and pleasant. He informs her he will discharge her as things seem stable and will arrange a follow-up appointment. In a second the atmosphere switches. Ms N becomes furious and says she wants to be admitted. Taken aback, Dr R starts explaining his recommendation. Ms N abruptly stands up, saying ‘You don’t have a clue do you? I’ve got more pills at home why don’t I just go and take them all’.
How can we understand this encounter? What defence mechanisms is Ms N using? What is the short- and longer-term management? What are the options for therapy? What is the prognosis? This chapter will address some of these issues.
Objectives of Chapter
1. To describe the epidemiology of personality disorder (PD) – its distribution and determinants
2. To describe key aspects of assessment and treatment of PD to inform evidence-based clinical practice
Introduction
Personality in all its variety and presentations has captured our interests for a long time – Hippocrates, born 460 BC, was already grappling with the concept through the four humors, black bile, yellow bile, blood and phlegm. An imbalance was thought to influence personality as melancholic, choleric, saguine and phlegmatic. The history of the study of personality is laudable for its attempts at (1) systematising (including through categorisation, resulting in the present ICD and DSM classification systems) (2) interest in psychopathy and (3) attempts at linking personality to biology (with initial forays like phrenology now replaced by significant developments in neuroscience) [1].
Personality consists of the dynamic organisation of enduring patterns of cognition, emotion, behaviour and motivation, and ways of relating to others that characterise an individual [2]. PD may be thought of as occurring when these patterns lead to significant difficulties for the individual or those around them.
The concept of PD has been criticised on several dimensions:
Scientifically: personality is a dimensional entity to which a categorical approach denies reality. There is a lack of an empirical base for existent PD categories.
Clinically: there is considerable overlap between different specific PDs. The classification is polythetic, as not all diagnostic criteria are necessary for making a diagnosis. As only five out of nine criteria need to be met for a diagnosis of borderline PD (BPD) [3], 151 different combinations are possible. Two individuals can have a diagnosis of BPD and only share one out of nine criteria, suggesting considerable differences within this diagnostic group.
Socially: the diagnosis is stigmatising. Psychiatrists have more critical and negative attitudes towards PD than other mental disorders [4, 5].
Problematic as the diagnosis may be, PD is an important condition given its prevalence and impact on the individual with the disorder, their families, services and wider society.
A note on use of the term PD in this chapter. When used PD refers to personality disorders in general. It should be noted however that the evidence base for treatment of PD is based on BPD, and sections of the chapter referring to treatment are referring to treatment of BPD.
Epidemiology of PD
The epidemiology of PD is under-researched and fraught with methodological problems. Table 15.1 summarises key figures [6]. The wide range of prevalence estimates across studies is likely to be due to differences in samples and measurement instruments.
Table 15.1 Median prevalence (per cent) PD in community-based studies using DSM-IV [6]
| Paranoid | Schizoid | Schizotypal | Histrionic | Antisocial | Borderline | Narcissistic | Avoidant | Dependent | Obsessive |
|---|---|---|---|---|---|---|---|---|---|
1.1 | 0.9 | 0.6 | 1.8 | 1.2 | 1.1 | 0.4 | 1.5 | 0.8 | 3.2 |
Community: the prevalence of at least one PD is estimated at 12 per cent [7], and of each specific PD varies between 0.1 per cent (schizoid) and 2.5 per cent (histrionic) [8]. Males and females have a similar rate of diagnosis of at least one PD, although there are gender differences in the diagnosis of specific PDs (e.g. antisocial PD (ASPD) is more common in males). PD is higher in the young, those with low educational achievement, unemployed and divorced [9].
Primary care: patients with PD tend to present with medical symptoms in primary care [10]. Yet when formally studied, PD prevalence is 10 to 30 per cent, with one in four of those attending primary care having a diagnosis of PD [11]. This suggests under-detection in routine practice.
Secondary care: between 40 per cent and 92 per cent of psychiatric outpatients [12] and about 50 per cent of psychiatric inpatients [13] meet criteria for a PD.
There is considerable co-morbidity. Over half of people with PD also meet criteria for at least one other major psychiatric disorder, for example mood disorders and anxiety disorders [9]. All PD clusters are significantly associated with increased rates of anxiety, mood, externalising (i.e. conduct disorder, attention-deficit hyperactivity disorder) and substance use disorders [9]. Nearly half of those meeting criteria for any PD also met criteria for a second PD diagnosis and 14 per cent met four or more individual PD diagnoses [14].
Self-Harm
Compared with individuals without PD, those with PD are significantly more likely to engage in intentional self-harm in all its forms, namely suicidal deaths, suicidal attempts and non-suicidal self-injury [15]. PD is very high among patients presenting to treatment following intentional self-harm (23–55%) and suicidal deaths (13–56%) [15]. The odds of dying by suicide is 15–38 times higher for people with PD than for those in the general population [15]. This wide range is due to being based on different samples (primary care and hospitalised patients). PD has been found to be present in nearly 30 per cent of suicide attempts [15] and 10 per cent of BPD patients do eventually kill themselves [16].
Across the Life Cycle
Children and youth: there is a firm basis for establishing early diagnosis and treatment of BPD in adolescents. This basis includes: (1) BPD is as valid and reliable diagnosis in adolescence as it is in adults based on phenomenology, stability, risk factors, separation of course and outcome from other disorders and efficacy of treatment for BPD [17]. (2) It has an estimated prevalence of 1–3 per cent in the community, 11–22 per cent in outpatients and 33–49 per cent in inpatients [17].
Old age: PD is a condition that seems to improve with age, the prevalence of PD among older people in the community is estimated to be about 10 per cent [18].
Culture
Culture is relevant in both the expression and assessment of PD. Regarding expression, ICD-11’s description of PD acknowledges the role of culture by specifying ‘The patterns of behaviour characterizing the disturbance cannot be explained primarily by social or cultural factors’ [19]. Regarding assessment the ICD and DSM systems make cultural assumptions as they are framed by Western norms of personality functioning, putting self before relational aspects. Differences in expression, and assessment, of PD may be a factor in epidemiological findings regarding PD as in the two following studies. A systematic review of ethnic variations in prevalence and treatment of PD found significantly lower prevalence and range of treatment offered in non-white versus white subjects [20]. A study of inpatients found that compared with white subjects, PD was significantly less prevalent in non-white ethnic groups [21].
Aetiology
PD is a developmental disorder, and development occurs within a social context. Thus rather than focussing on isolated aetiological mechanisms it is more appropriate to incorporate multiple levels of analysis at individual (e.g. genetics, temperament and adversity), family and socioeconomic levels [22]. Specific genetic mechanisms have not been identified and are unlikely to be found, as PD is influenced by multiple genes each having a small effect. Epigenetics indicates the need for a more transactional model whereby the potential for genetic expression is shaped through environmental influences [23]. Disruptions in early attachment, in combination with biological vulnerability, contribute to problems with sense of self and other disturbances of identity characteristic of PD. The dynamic nature of personality as understood by psychodynamic theory thus becomes linked to our biology.
Assessment in PD
Accurate assessment and diagnosis of PD is problematic, given the wide range of non-discriminant symptoms and extensive co-morbidity. It is therefore essential to retain what the key purpose of the assessment is, namely to identify:
1. What is the problem? The problem is usefully seen as having two components – caseness (what is the diagnosis – at both psychiatric and psychological (i.e. the formulation) levels) and impact (which may be seen as a measure of severity and therefore determining what level of treatment is required)
2. What is the treatment based on (1) the problem as described above and (2) on the ability of the patient to make use of what is offered? Is one thinking of management at primary, psychiatric and/or psychological level?
Thus, when assessing PD it is useful to keep the concepts of caseness (the psychiatric diagnosis), impact (of the individual’s difficulties on himself and others) and frame (how ready is the patient to benefit from psychotherapy in terms of e.g. stability of living conditions, level of chaos in their lives, psychoactive drug dependence) in mind. Caseness and impact help in determining what is the problem, and impact and frame help determine what is the appropriate treatment.
ICD-11 and DSM-5
ICD-11
A version of ICD-11 was released on 18 June 2018 and it is planned that Member States will start reporting using ICD-11 on 1 January 2022.
The ICD-11 classification of PD [24] is groundbreaking and was developed in response to problems identified with PD diagnosis as described above. It does away with the specific PD diagnoses, instead adopting a dimensional approach to personality and focussing on personality traits. The steps are:
1. identify if a PD is present (problems in functioning of aspects of self and/or with others which are ‘pervasive’, ‘enduring’ and have significant impact)
2. assess level of severity (mild, moderate or severe)
3. assess which is the predominant trait domain (negative affectivity, disinhibition, detachment, dissociality and anankastia). Given the importance many clinicians place on BPD, the ICD-11 task group have accepted that this diagnosis will be retained
DSM-5
While the original specific classifications have been retained as they were in DSM-IV, there is an alternative model for PD which translates well with ICD-11 in its emphasis on self and other, levels of personality functioning, and trait domains identified [25].
These developments in ICD-11 and DSM-5 are an important step. They are ‘clinically near’ as they focus on personality functioning through the prism of self or interpersonal (i.e. ‘other’) dysfunction. This is consistent with psychoanalytic theories of personality, in particular contemporary object relations theory with its emphasis of the individual’s internal representation of himself and of others [26]. Secondly, the dimensional nature of personality and PD is accepted through the focus on severity. This not only makes clinical sense but is also backed by research, for example, generalised severity is the most important single predictor of current and prospective dysfunction [27]. The above-mentioned importance for the busy clinician of establishing caseness and impact is borne out by the ICD-11 and DSM-5 guidelines.
Screening for PD
The standardised Assessment of Personality – Abbreviated Scale (SAPAS) [28] is a useful screening tool. It has eight items as below.
In general, do you have difficulty making and keeping friends?
Would you normally describe yourself as a loner?
In general, do you trust other people?
Do you normally lose your temper easily?
Are you normally an impulsive sort of person?
Are you normally a worrier?
In general, do you depend on others a lot?
In general, are you a perfectionist?
A score of three items correctly identified the presence of DSM-IV PD in 90 per cent of participants. It is recommended as feasible for routine use in clinical settings where a high prevalence of PD is expected and is thus suitable for psychiatric, not primary care, settings.
A more sophisticated screening tool, used widely in the PD services, is the Structured Clinical Interview for DSM (SCID), which is a semi-structured interview that takes around 90 minutes to complete.
The Function of Assessment at Different Levels of Care
The different function of assessment at different levels of care is a useful guide for clinicians.
At primary care and general psychiatry level: the function is PD detection and the decision whether to manage or refer on. If management is to occur at either of these levels, more specific formulation and diagnosis is required.
At psychotherapy service or PD service level: the function here is confirmation whether PD is present and the decision whether to offer therapy. If therapy is to be offered, is the level of psychological intervention supportive (shoring up defences) or to enable psychic change (challenging defences)? As personality can be seen as the organisation of defence mechanisms, achieved by dint of hard work by the individual to get him/her through life (or not), he/she resists giving up these mechanisms – whether consciously or unconsciously. If the syntonic component of his/her defences is too great, he/she may not be up for psychic change (even if he/she claims to be).
The treatment contract is a critical component of treating patients with more severe PD. It sets the treatment frame (essential for this patient group whose chaotic presentation directs all therapeutic activity to symptom fighting rather than tackling the underlying issues) and defines the responsibility of the patient (e.g. regular attendance, undertaking to address self-harming behaviour) and service (e.g. providing a safe and stable environment). While different evidence-based treatments place different emphases on the treatment contract, how the patient responds to the expectations of the treatment contract is in itself a useful part of the assessment.
Treatment
Psychological and Psychiatric Management
There is an evidence base for the treatment of PD but it is small and exists for BPD [29] (see Table 15.2). No single therapy stands out as more effective [30]. Recent meta-analysis of specialist therapy for BPD suggests outcome changes are modest and unstable [16].
Table 15.2 Evidence-based treatments for borderline personality disordera
| Transference- focussed psychotherapy (TFP) | Mentalisation-based treatment (MBT) | Cognitive analytic treatment (CAT) | Schema-focussed therapy (SFT) | Dialectical behavioural therapy (DBT) | |
|---|---|---|---|---|---|
| Theoretical background |
|
|
| Cognitive behavioural therapy (CBT) |
|
| Key concepts |
|
|
|
|
|
| Mechanisms of change |
| Increased mentalisation | Change in reciprocal procedures | Change in maladaptive schemas |
|
| Patient–therapist relationship |
|
| Non-collusive |
| Dialectical relationship – acceptance and change |
| Treatment goals |
|
| Recognise and revise unhelpful patterns | Identify and modify schema |
|
| Techniques |
|
|
|
|
|
| Framework |
|
|
|
|
|
a The columns from left to right are in the order from most psychoanalytic to least psychoanalytic in approach.
b Mentalising is both an implicit and explicit process by which we make sense of others andourselves, in terms of intentional mental states.
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