I was interested to read an article in The Independent recently where psychologist Oliver James wrote that of comic peformers ‘most but not all – are either depressive or personality disordered’.
James is a psychologist of some experience or, failing that, exposure. Clearly it takes a particular sort of person to wish to earn their living by entertaining other people – and to subject themselves to the scrutiny this entails – but to make a blanket diagnosis of this nature cannot be right or fair. Psychiatrists are often almost as guilty, it is a term often used in my by my colleagues to refer to patients or professionals we find difficult or do not like.
Here’s an introduction to this difficult area.
ICD-10 defines personality disorder as follows:
‘A severe disturbance in the character logical condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’
‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’
There are nine categories of ICD-10 personality disorder and ten of DSM-IV. DSM-IV divides its personality disorder classifications into three ‘clusters’.
(F60.) Specific personality disorders
(F60.0) Paranoid personality disorder
(F60.1) Schizoid personality disorder
(F60.2) Dissocial personality disorder
(F60.3) Emotionally unstable personality disorder
(F60.4) Histrionic personality disorder
(F60.5) Anankastic personality disorder
Obsessive-compulsive personality disorder
(F60.6) Anxious (avoidant) personality disorder
(F60.7) Dependent personality disorder
(F60.8) Other specific personality disorders
Cluster A (odd or eccentric disorders)
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder
Cluster B (dramatic, emotional, or erratic disorders)
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder
Cluster C (anxious or fearful disorders)
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder
Problems with the diagnosis
The diagnosis and treatment of people with personality disorder is one of the trickiest areas of psychiatric practice. Although established as a diagnosis and enshrined in both the ICD-10 and DSM IV, there is not a consensus concerning to what extent behaviours of a negative social and moral value should be considered psychiatric disorders and as a diagnosis personality disorder has a number of problems.
- There is no definitive definition of ‘personality’ to be disordered, and it is at best a semi-technical term. Most definitions are based on personality being an enduring combination of traits that serve to characterize an individual’s thoughts feelings and actions which are relatively consistent over a range of situations. Some people would argue that personality is not a stable entity, but varies with time and situation.
- Few personality types would fit into a single category listed above. With its three clusters, DSM-IV goes some way to address this.
- There is an instability between raters when trying to diagnose personality disorder – this occurs even when rating scales are used.
- There is a large overlap of the behaviour of people with personality disorders with those of ‘normal’ people. ICD-10 and DSM-IV offer categorical diagnoses, whereas in fact personalities exist on a spectrum i.e. they are dimensional.
- It is a hard area to conduct research into, partly due to the changing definitions of personality disorder over time and changing emphasis on personality traits not asked about on entry to the study.
- There is a great deal of stigma attached to the diagnosis
- This diagnosis allows significant deviance from societal norms, such as conscientious objection to a social regime, to be classified as a mental disorder. There is concern that this will be used to justify treatment of political dissidents as though they were psychologically disturbed.
Problems aside, people fitting the criteria for personality disorders are very prevalent in society, between 7 and 13 per cent in the general population and of 20 to 30 per cent in general medical practice. It is also believed that 40% psychiatric outpatients and 50% inpatients would qualify for a personality disorder diagnosis. Personality disorders rarely present to services in isolation and are associated with a high co-morbidity frequently being associated with alterations of eating behaviour, alcohol and substance abuse, other mental disorders, antisocial behaviour, and sexual promiscuity. When someone meeting the criteria for personality disorder presents to health services an in-patient length of stay is likely to be longer and costs higher.
What causes Personality disorder?
As with a lot of mental illnesses, the answer to this question is not clear and genetic and social factors have been implicated. There is evidence for the involvement of difficult upbringing with people having suffered physical or sexual abuse being over represented in personality disordered people. Behaviour problems in childhood are also implicated, including severe aggression, disobedience, and repeated temper tantrums.
It was felt for a long time that people with personality disorders were not treatable. There has been a perception that people with difficult personality traits can change themselves if they really wish and that it is therefore their fault if they do not. We therefore tend to blame people who have a personality disorder. The tide has turned somewhat these days, and people are engaging those with a diagnosis of personality disorder in a number of ways. These include trials of drug treatment, for example for comorbid depression, psychotherapy including dialectical behavioural therapy and therapeutic communities.
What research has been conducted suggests that over 10-30 years the outcome for people with personality disorders is generally favourable, with two-thirds improved at follow up with milder residual symptoms. The severity of symptoms decreases with age and only one quarter would retain a diagnosis of boarderline personality disorder age 50. Whilst employment is fairly common, marriage rates are half the average and odds of having children one quarter.