of people with PDs. They argue that: \200 \200 \200 Personality is by de \201 nition unchangeable. There is no evidence that psychiatry helps individuals with PD. These people are disruptive and impinge negatively on the treatment of other patients. These people are not ill and are responsible for their behavior. Psychiatr y is being asked to deal with something that is essentially a social problem. \200 On the other hand there are those who believe that people with PD clearly fall within the r emit of psychiatry, arguing: \200 \200 People with PD suffer from symptoms related to their disorder. They have high rates of suic ide, other forms of premature death, and of other mental illnesses. There are treatment app roaches which are effective. Their opponents are rejecting patients because they dislike th em. 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. \200 \200 13_Semple_Chap13.indd 491 12/7/2012 3:43:10 PM CHAPTER 13 Personality disorders 492 \200\230Normal \200\231 personality Psychologists have sought to conceptualize and describ e the variations in normal personality. There are two main approaches: nomothetic and ideo graphic.1 In general these approaches have developed separately from concepts of abnormal p ersonality and PD. Nomothetic approaches Personality seen in terms of attributes shared by individuals. Two su bdivi- sions: type (or categorical) approaches (discrete categories of personal- ity); and trait (or dimensional) approaches (a limited number of qualities, or traits, account for pe rsonality variation). Type approaches dominate the description and classi \201 cation of P D, but trait approaches are pre-eminent in modern personality psychology. Type approaches T hese describe individual personality by similarity to a variable number of prede \201 ned archetypes. These may attempt to include all aspects of personality and behavior \200\224th e \200\230broad \200\231 models \200\224or they may describe one aspect of personality \200\224the \200\230narrow \200\231 models. An exam- ple of the former is the humoral mode l of Hippocrates which described four fundamental personality types (choleric, sanguine, me lancholic and phlegmatic); an example of the latter is the type A vs. type B model which de scribes groups of behaviors 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 posi- tions on all the traits represent a number of dimensions which describe personality. Examples include: Eysenck \200\231s three- factor theory (neuroticism, extraversion, psychoticism); Costa and McCrae \200\231s \201 ve-factor model (neu- roticism, extraversion, openness, agreeableness, conscientiousness); Cloninger \200\231s seven-factor model (novelty-seeking, harm avoidance, reward dependence, persistence, self-directedness, cooperativeness, self-tran- scendence; originally only \201 rst 3 factors); Cattell \200\231s sixteen-factor theory. A consensus has emerged from personality questionnaire research and from lexical approaches that there are \201 ve fun damental traits (the \200\230big \201 ve \200\231) similar to those of Costa and McCrae. The heritability of personality traits in twin and adoptive studies has been found to be m oderately large (about 30%). Ideographic approaches Unlike nomothetic approaches, these emphasize individuality and seek to understand an individual \200\231s personality by understanding that individual and the ir development rather than by reference to common factors. Examples are psychoanalytic, hum anistic, and cognitive \200\223behavioral approaches. The \201 rst two have little scient i \201 c validity and the last has compromised with trait theorists. 13_Semple_Chap13.indd 492 12/7/2012 3:43:10 PM \200\230NORMAL \200\231 PERSONALITY 493 Is personality stable? Are there traits which are persistent and predict a person \200\231s behavior over time in a number of situations? Situationists have argued that the situation was a stronger determinant of behavior than personality traits. However, more recent resea rch 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 importan t in deter- mining behavior. 1 Deary I and Power M (1998) Normal and abnormal personality. In: Johnstone EC, Freeman CPL , and Zeally AK (eds) Companion to psychiatric studies, 6th edn, pp. 565 \200\22396. Edinbu rgh: Churchill Livingstone. 13_Semple_Chap13.indd 493 12/7/2012 3:43:10 PM CHAPTER 13 Personality disorders 494 Classi \201 cation of personality disorder It is largely accepted that normal personality is best described and classi- \201 ed in terms of dimensions or traits. Although this als o applies to PD, our current psychiatric classi \201 cations are categorical. The various categories of PD described in ICD-10 and DSM-IV have a number of origins: psy- chodynamic t heory, apparent similarities between certain PDs and certain mental illnesses, and descript ions of stereotypical personality types. The various categories used come together in a pie cemeal and arbitrary fashion and do not represent any systematic understanding or study of PD. The categorical classi \201 cation of PD is psychiatric classi \201 cation at its wor st. There are a number of important points to bear in mind when using standard categorical approaches in the diagnosis of PDs: \200 Due to their heterogeneous origins, there is overlap between the criteria for some categori es. It is more common for individuals to meet the criteria for more than one category of PD than to meet only the criteria for a single category. When making a diagnosis one should u se 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 pers on 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. Clinicall y it is more important to understand and describe the speci \201 c features of a person \200\231s personality than it is to assign them to a particular category. The diagnosis of PD is a particular area where one may believe, wrongly, that one has a better understanding of a person by assigning them to a speci \201 c category (an example of \200\230tautolog y \200\231).1 ICD-10 and DSM-IV The PD categories in ICD-10 and DSM-IV are set out in Table 13.1. The two schemes are similar, but there are categories that appear in one but not the other, and fo r 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 as pect of PD. DSM III (and subsequent editions) placed PD on a separate axis (along with othe r developmental disorders in axis II) from mental illness (axis I); see b p. 1042. 1 Tautology (the restatement of the same information using different words) is a particular danger in psychiatry generally, and the diagnosis of PD in particular. For example, saying that someone has \200\230borderline \200\231 traits gives a gloss of understanding to the simple fact that a person repeatedly self-harms, without actually communicating any new in formation (except perhaps the \200\230therapeutic despair \200\231 of the psychiatrist!). 13_Semple_Chap13.indd 494 12/7/2012 3:43:10 PM CLASSIFICATION OF PERSONALITY DISORDER 495 Table 13.1 ICD-10 and DSM-IV classi \201 cations 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 fanta sy. (Schizotypal disorder classi \201 ed with schizophrenia and related disorders) Schizotypal Interpersonal discomfort with peculiar ideas, perceptions, appearance, and behavior. Dissocial Antisocial Callous lack of concern for others, irresponsibility, irritability, aggression, inability to maintain enduring relationships, d isregard and violation of others \200\231 rights, evidence of childhood conduct disorder. Emotionally unstable \200\223 impulsive type \200\224 Inability to control anger or plan, with unpredictable affect and behavior. Emotionally unstable \200\223 borderline type Borderline Unclear identity, intense and unstable relationships, unpredictable affect, threats or acts of self-harm, impulsivity. Histrionic Histrionic Self-dramatization, shallow affect, egocentricity, craving attention and excitement, manipu lative behavior. \200\224 Narcissistic Grandiosity, lack of empathy, need for admiration. Anxious (avoidant) Avoidant Tension, self-consciousness, fear of negative evaluation by others, timid, insecure. Anankastic Obsessive \200\223 Doubt, indecisiveness, caution, compulsive 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 three broader clusters to organize the categories of personality disorder \200 \224 cluster A (odd/eccentric) \200\223 \200\223paranoid, schizoid, schizotypal; cluster B (emotional/dramatic) \200\224 antisocial, histrionic, narcissistic, borderline; and cluster C (fearful/anxious) \200\224avoidant, dependent, obsessive \200\223compulsive. Although th is may seem sensible, there is no particular validity to this clustering. 13_Semple_Chap13.indd 495 12/7/2012 3:43:10 PM CHAPTER 13 Personality disorders 496 Psychopathy and \200\230severe \200\231 personality disorder Psychopathy The terms \200 \230psychopathy \200\231, \200\230psychopathic PD, \200\230psychopathic disorder \200\231 , and \200\230psychopath \200\231 have dominated much of the PD literature until relativel y recently. In England and Wales the 2007 revision to the 1983 MHA has removed the descript ion of \200\230psychopathic disorder \200\231 as one of the subcat- egories of mental diso rder. The term should probably now be reserved for individuals meeting criteria as de \201 ned by the Psychopathy Checklist \200\224 Revised (PCL-R) as an extreme form of antisocial or dissocial PD (Box 13.1). Psychopathy Checklist \200\224Revised (PCL-R)1 In The mask of sanity Cleckley2 described va rious features of psychopathy referring to cold, callous, self-centered, predatory, parasit ic individuals. This concept has led to the development of the PCL-R, which measures the ex tent to which a person manifests the features of this prototypical psy- chopath. The items of the PCL-R are listed in Box 13.1. Psychopathy as de \201 ned by the PCL-R is strongly c orrelated with risk of future violence. It de \201 nes a narrower group of individuals tha n antisocial or dissocial PD, and individuals scoring highly commonly ful \201 l the crite ria for antisocial, narcis- sistic, histrionic, paranoid, and perhaps borderline categories in DSM-IV. Severe personality disorder3 The term \200\230severe personality disorder \200\231 is ofte n used but has no clear meaning or de \201 nition. Severity of PD has been de \201 ned in various ways: \200 \200 \200 In terms of severe impact on social functioning. By using the PCL-R cut-off and being synon ymous with psychopathy. By de \201 ning severity as the presence of features ful \201 lli ng the criteria for multiple categories of DSM-IV or ICD-10 PDs (sometimes this is further de \201 ned by stating that the categories should be from at least two DSM-IV clusters, an d perhaps that one must be from cluster B). None of these approaches is entirely satisfacto ry, and each de \201 nes differ- ent but overlapping groups of individuals. 13_Semple_Chap13.indd 496 12/7/2012 3:43:11 PM PSYCHOPATHY AND \200\230SEVERE \200\231 PERSONALITY DISORDER 497 Box 13.1 Notes on the PCL-R The items of the PCL-R cover the affective, interpersonal, and behav- ioural features of ps ychopathy. 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 (de \201 nitely present). There are detailed descriptions of each item in the coding man ual. The summed score (out of 40) gives an indication of the extent to which a person is ps ychopathic and may be converted into a percent- ile using reference tables for different po pulations. In the USA a score of 30 or above is used as a cut-off to diagnose \200\230psyc hopathy \200\231; in the UK this cut-off is 25 or above. PCL-R items 1. Glibness/super \201 cial charm 2. Grandiose sense of self-worth 3. Need for stimulation/proneness to boredom 4. Pathological lying 5. Conning/manipulative 6. Lack of remorse or guilt 7. Shallow affect 8. Callous/lack of empathy 9. Parasitic lifestyle 10. Po or behavioral control 11. Promiscuous sexual behavior 12. Early behavior problems 13. Lack of realistic, long-term goals 14. Impulsivity 15. Irresponsibility 16. Failure to accept re sponsibility for own actions 17. Many short-term marital relationships 18. Juvenile delinqu ency 19. Revocation of conditional release 20. Criminal versatility 1 Hare RD (1991) The Hare psychopathy checklist-revised. Toronto: Multi-Health Systems. 2 C leckley H (1941) The mask of sanity. London: Henry Klimpton. 3 Tyrer P (2004) Getting to gr ips with severe personality disorder. Crim Behav Ment Hlth 14: 1 \200\2234. 13_Semple_Chap13.indd 497 12/7/2012 3:43:11 PM CHAPTER 13 Personality disorders 498 Etiology of personality disorder While there is no single, convincing theory explaining the genesis of PD, the following observations are suggestive of possible contributing factors. Genetic Evidence of heritability of \200\230normal \200\231 personality traits; some evide nce of heritability of cluster B PDs; familial relationship between schizotypal PD and schi zophrenia, between paranoid PD and delusional disorder, and between borderline PD and affec tive disorder. There is no good evidence for a relationship between XYY genotype and psycho pathy. Neurophysiology \200\230Immature \200\231 EEG (posterior temporal slow waves) in psychopat hy; func- tional imaging abnormalities in psychopathy (e.g. decreased activity in amyg dala during affective processing task); low 5-HT levels in impulsive violent individuals; auton omic abnormalities in psychopathy (slowed gal- vanic skin response). Childhood development Dif \201 cult infant temperament may proceed to conduct disorder in child- hood and PD; ADHD may be a risk factor for later antisocial PD; insecure attachment may predict later PD (particularly disorganized attachment); harsh and inconsistent parenti ng and family pathology are related to con- duct disorder, and may therefore be related to later antisocial PD; severe trauma in childhood (such as sexual abuse) may be a risk factor for bor- derline PD and other cluster B disorders. Psychodynamic theories Freudian explanations of arrested development at oral, anal, and gen ital stages leading to dependent, obsessional, and histrionic personalities; \200\230bor- derline personality organization \200\231 described by Kernberg (diffuse un \201 ltered re action to experience prevents individuals from putting adversity into perspective leading t o repeated crises); narcissistic and borderline per- sonalities seen as displaying primitiv e defense mechanisms such as splitting and projective identi \201 cation; some see antisoc ial personalities as lacking aspects of superego, but more sophisticated explanation is in terms of a reaction to an overly harsh superego (representing internalization of parental a buse). 13_Semple_Chap13.indd 498 12/7/2012 3:43:11 PM etiology OF PERSONALITY DISORDER 499 Cognitive \200\223behavioral theories There are maladaptive schemata (stable cognitive, aff ective, and behav- ioural structures representing speci \201 c rules that affect informati on processing). These schemata represent core beliefs which are derived from an interaction between childhood experience and pre-programmed patterns of behavior and environmental res ponses. Schemata are uncon- ditional compared with those found in affective disorders (e.g. \200\230I am unlov- able \200\231 rather than \200\230If someone important criticizes me , then I am unlovable \200\231) and are formed early, often pre-verbally. Theories synthesizing cognitive \200\223behavioral and psychodynamic aspects The following are two quite similar models that underlie relatively recently introduced therapies for bor derline PD. Cognitive \200\223analytical model (see b p. 858) Borderline patients experienc e a range of partially dissociated \200\230self-states \200\231, which arise initially as a response to unmanageable external threats and are maintained by repeated threats or inter nal cues (such as memories). Abusive experiences in childhood lead to internalization of th e harsh parental object leading to intrapsychic con \202 ict which is repressed or produce s symptomatic behaviors. De \201 cits in self-re \202 ection, poor emotional vocabulary, and narrow focus of atten- tion lead to incoherent sense of self and others. Dialectical be havioral model (see b p. 856) Innate temperamental vul- nerability interacts with certain d ysfunctional ( \200\230invalidating \200\231) environments leading to problems with emotion al regulation. Abnormal behaviors which are manifested represent products of this emotional dysregulation or attempts to regulate intense emotional states by maladaptive problem- sol ving. 13_Semple_Chap13.indd 499 12/7/2012 3:43:11 PM CHAPTER 13 Personality disorders 500 Epidemiology of personality disorder1 The measurement of the prevalence of PD of any type a nd of speci \201 c categories of PD in any population has a number of problems: in earlier studies PD and other mental disorders were mutually exclusive, not allow- ing for the reco rding of comorbidity; studies differ in the method used to make a diagnosis (interviews/cas e notes/informants; clinical diagnosis versus research instruments; emphasis on current pre sentation or on life history); and in some studies subjects were only allowed to belong to one category of PD. Findings regarding PD of any type will be considered separately from \201 ndings related to speci \201 c PD categories (see Table 13.2). Personality disorder of any type \200 Community: 2 \200\22318% (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 conspicuous psychiatric morbidity, 5 \200\2238% will have a primary diagnosis of PD. The rate of comorbid PD in patients with other primary diagnoses is 20 \200\22330%. Psychia tric patients: 30 \200\22340% of outpatients and 40 \200\22350% of inpatients have a PD, no t usually as a primary diagnosis. A primary diagnosis of PD occurs in about 5 \200\22315% o f inpatients. Other populations: 25 \200\22375% of prisoners have a PD. Antisocial PD is mo st prevalent, but many prisoners ful \201 l the criteria for more than one diagnostic cate gory, and many personality disordered prisoners do not meet the criteria for the antisocial category. rates of PD in the community have been found to be 1 Casey P (2000) The epidemiology of personality disorder. In: P Tyrer (ed.), Personality d isorders: diagnosis, management and course, pp. 71 \200\2239. Oxford: Butterworth Heinemann . 13_Semple_Chap13.indd 500 12/7/2012 3:43:11 PM EPIDEMIOLOGY OF PERSONALITY DISORDER 501 Table 13.2 Speci \201 c 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: DSM-IV Prevalence (%) Paranoid 0.5 \200\2233 Schizoid 0.5 \200\2237 Schizotypal 0.5 \200\2235 Antisocial 2 \200\2233.5 Borderline 1.5 \200\2232 Histrionic 2 \200\2233 Narcissistic 0.5 \200\2231 Avoidant 0.5 \200\2231 Dependent 0.5 \200\2235 Obsessive \200\223compulsive 1 \200\2232 13_Semple_Chap13.indd 501 12/7/2012 3:43:11 PM CHAPTER 13 Personality disorders 502 Relationship between personality disorder and other mental disorders The current state of c lassi \201 cation and understanding of the etiology and pathogenesis of mental disorders i s such that most psychiatric diagnoses are based on descriptive criteria. It is common to \201 nd that an individual meets the criteria for an axis I disorder along with a PD. At o ne extreme, both may be a manifestation of the same underlying condition; at the other, the y may represent two completely separate aetio-pathogenic entities. The relationship between PD and other mental disorders may be: Mutually exclusive Personality disorder cannot be di agnosed in an individual with another mental disorder. The personality pathology displayed is a manifestation of the other mental disorder, and giving a separate personality diagnosi s has no purpose. This was the only approach possible prior to DSM-III \200\231s introducti on of multi-axial diagnosis. This approach is not favored by current classi \201 cation sy stems, even where the two appear to be manifestations of the same condition. Coincidental t ogether by chance. However, epidemiologically there is support for an association between P D and other mental disorders. Associative Both in individual cases and epidemiologically th ere are a number of reasons why the coexistence of PD and other mental disorders may be mor e than just coincidental: \200 \200 \200 \200 In an individual, PD and another disorder may come Sharing common etiology (but separate disorder). Prodromal (part of the development of the axis I disorder). Part of spectrum (a \200\230partial \200\231 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 probl ems may arise in the diagnosis of PD in people who appear to have axis I disorders: \200 Underlying PD may be missed as assessment may focus on the current mental state disorder. P D may be misdiagnosed as axis I disorder and vise versa. In an individual with PD, an axis I disorder may be missed or misconstrued as being part of the PD. \200 In such cases it is important to remember that axis I pathology is com- mon in people with PDs and any change in the presentation of a patient with PD may be due to this. Equally, it is important to base assessment of personality on information (preferably from a number of sources) on the premorbid functioning of an individual, rather than on their current funct ioning or just their own account of their previous functioning (their memory or interpretat ion of which may be colored by their current mental state). 13_Semple_Chap13.indd 502 12/7/2012 3:43:11 PM RELATIONSHIP BETWEEN PD AND OTHER MENTAL DISORDERS 503 Comorbidity between personality disorders and other speci \201 c mental disorders1 Strong associations \200 Avoidant PD and social phobia (possibly because they both describe a group of people with t he same condition). Substance misuse and cluster B PDs. Eating disorders and cluster B and C PDs (particularly bulimia nervosa and cluster B). Neurotic disorders and cluster C PDs (i t has been suggested that these individuals have a \200\230general neurotic syndrome \200 \231). Somatoform disorders and cluster B and C PDs. Habit and impulse disorders and cluste r B PDs (unsurprisingly). PTSD and borderline PD (this is not borderline PD rede \201 ned as chronic PTSD, but is probably due to the increased rate of life events and vulnerability of such individuals). \200 \200 \200 Moderate associations \200 Schizotypal PD and schizophrenia (also a weaker association between schizophrenia and antis ocial PD). Depression and cluster B and C PDs. Delusional disorder and paranoid PD. \200 Impact of personality disorders on manifestation, treatment, and outcome of other mental di sorders Although the concept of \200\230comorbid PD \200\231 may seem spurious from an aet io- pathological perspective, its presence has an impact on the presentation, treatment, an d outcome of axis I disorders, and it is therefore useful to recognize such comorbidity fro m a clinical perspective. \200 Presentation exaggerated, or masked by the presence of an underlying PD. Treatment and outc ome make treatment more dif \201 cult and worsens the outcome of axis I disorders. This ma y be due to problems in the following areas: help- seeking behaviors, compliance with treat ment, coping styles, risk- taking, lifestyle, social support networks, therapeutic alliance , alcohol and substance misuse. The presentation of axis I disorders may be distorted, The presence of comorbid PD will usually Some contend that it is the presence of this comorbidity which makes it more likely for a p erson to fail to respond to standard primary care treat- ment approaches, therefore necessi tating referral to psychiatric services. 1 Tyrer P (2000) Comorbidity of personality disorder and mental state disorders. In: Tyrer P (ed.), Personality disorders: diagnosis, management and course, pp. 71 \200\2239. Oxford: Butterworth Heinemann. 13_Semple_Chap13.indd 503 12/7/2012 3:43:11 PM CHAPTER 13 Personality disorders 504 Assessment of personality disorder1 Potential pitfalls There are a number of potential pitf alls in the assessment and diagnosis of personality disordered patients: \200 Relying on diagnoses made by others (psychiatrists are notoriously poor at diagnosing PD). Failing to recognize comorbidity. Misdiagnosing PD as mental illness, and vise versa. Inade quate information. Negative countertransference (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 PD). Applying ICD-10 or DSM-IV categories without a broader asses sment of personality. \200 \200 \200 Making the diagnosis of personality disorder \200 A clinical diagnosis of PD should be based on an accurate assessment of a person \200\231s enduring and pervasive patterns of emotional expression, interpersonal relationships, socia l 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); observat ion (usually repeated); previous records (medical, prison, school, social work); independen t accounts (perhaps from several sources such as relatives and other professionals). Inform ation 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 \200\231s personality and whether it may be disordered. In addition, speci \201 c enquiry can be made regarding the following aspects of personality: interests and activities; relationships; mood/ emotions; attitudes (religio us, moral, health); self-concept; coping with dif \201 culties; speci \201 c characterist ics or traits (perhaps based on PD categories); include both positive and negative aspects. In describing personality and PD, \201 rst the features of a person \200\231s personalit y 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 PD, then th e features that are pathological should be described. If one wants to make categorical diag noses then the category or categories for which the criteria are met may be stated. 13_Semple_Chap13.indd 504 12/7/2012 3:43:12 PM ASSESSMENT OF PERSONALITY DISORDER 505 Instruments to assess personality disorder There are a number of instruments available for assessing PD. Such instru- ments are mainly used in research, and are rarely seen in clinic al practice. Most require training and some take a considerable amount of time to complete. Self-report questionnaires Millon Clinical Multiaxial Inventory (MCMI), Personality Disord er Questionnaire (PDQ-IV), Wisconsin Personality Inventory (WISPI). Structured clinical int erviews with patient only Structured Clinical Interview for DSM-IV Personality Disorder (SC ID-II), Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Structured clinica l interviews with informant only Standardized Assessment of Personality (SAP). Structured c linical interviews with patient and/or informant Personality Assessment Schedule (PAS), Str uctured Interview for DSM-IV Personality Disorders (SIDP-IV). for Instruments assessing spe ci \201 c personality disorders Schedule Interviewing Borderlines (SIB), Diagnostic Interv iew for Borderline Patients (DIB), Borderline Personality Disorder Scale (BPD-Scale), Psych opathy Checklist-Revised (PCL-R), Psychopathy Checklist-Screening Version (PCL-SV), Schedul e for Schizotypal Personalities (SSP). Diagnostic instruments including an assessment of an tisocial personality disorder Diagnostic Interview Schedule (DIS), Feigner Diagnostic Crite ria. Functional assessment The functional assessment of personality and associated problems has been proposed as a useful clinical approach which can produce a formula- tion identifying i ssues to be addressed in management. \200 List abnormal personality traits \200\224thoughts about self and others (e.g. identity pro blems, 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), behavior (e.g. stubbornne ss, quarrelsomeness, sadism, self-destructiveness, compliance, impulsivity, theatricality, attention-seeking), social functioning (e.g. social isolation, controlling others, dependen ce on others, mistrust of others, inviting rejection, forming unstable intense relationship s, manipulating and using others), insight (including the ability to understand and integra te one \200\231s thoughts, feelings, and actions). Describe associated distress and comorbi d axis I disorders. Describe interference with functioning relationships, offending/violenc e. \200 \200\224occupational, family and 1 Gunn J (2000) Personality disorder: a clinical suggestion. In Tyrer P (ed.), Personality disorders: diagnosis, management and cause, pp. 44 \200\22350. Oxford: Butterworth Heineman n. 13_Semple_Chap13.indd 505 12/7/2012 3:43:12 PM CHAPTER 13 Personality disorders 506 Management of personality disorder 1: general aspects It is generally felt that PD is resis tant to speci \201 c psychiatric treatment. However, there is no good evidence to either r efute or support this state- ment. Patients often present at a time of crisis and/or when t hey develop a comorbid axis I disorder. Although some may wish to, psychiatrists cannot avo id having to manage patients with PD. Principles of successful management plans1 A successful management plan in PD is tailored t o the individual \200\231s needs andjj 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, recognizing that change, if it comes, will only be observable over a long period. Possible management goals Potential management goals include: psychological and practical s upport; monitoring and supervision; intervening in crises; increasing motivation and compli ance; increasing understanding of dif \201 culties; building a thera- peutic relationship; limiting harm; reducing distress; treating comorbid axis I disorders; treating speci \201 c areas (e.g. anger, self-harm, social skills); and giving practical support (e.g. housing , \201 nance, childcare). Managing comorbid axis I disorders It is important to recognize and treat comorbid axis I p athology in patients with PD. Standard treatment approaches should be used, taking into acc ount aspects of the patient \200\231s personality (e.g. impulsivity and an anti- authoritar ian attitude may lead to non-compliance with medication). Understanding and managing the relationship between the patient and staff2 Rejection for tr eatment of patients with PD (even when they present with mental illness) is often due to th e intense negative feelings these patients may engender, and the disruptive and uneasy rela tionships they form with those that try to help them. Just as they do in many of their inte rpersonal relationships, patients with PDs display disordered attachment in their relations hips with staff (whether with individuals or with a service). When dealing with such patien ts this needs to be recognized, acknowledged, and managed. An acceptance of, and tolerance for, these dif \201 culties needs to be combined with continuing commitment to the patient . However, patients, staff, and other agencies need to realize there are no instant solutio ns and that psychiatric services cannot take responsibility for all adverse behaviors. Admission to hospital Patients with PD bene \201 t little from prolonged admissions to con ventional psychiatric units. Admission to such units may be necessary when there is a speci \201 c crisis (usually in the short term) or when the patient presents with an axis I dis order. Longer-term admission for the treatment of PD 13_Semple_Chap13.indd 506 12/7/2012 3:43:12 PM MANAGEMENT OF PD 1: GENERAL ASPECTS 507 could be undertaken in a therapeutic community. Involuntary long-term hospitalization of pa tients with PD primarily to prevent harm to others where there is little prospect of clinic al bene \201 t to the patient is ethically dubious. Managing crises Individuals with PD often present in crisis. This may follow life events, r elationship 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 relative ly minor or non-existent stressor. Where patients repeatedly present in crisis it can be he lpful for the various professionals involved to plan what the response should be in such si tu- ations. A consistent response is important, but there should be suf \201 cient \202 exibility to deal with changes in circumstances. For example, where a patient repeatedly pr esents with self-harm it may be appropriate for out- patient treatment to continue followin g any necessary medical treatment; however, if this patient presents threatening suicide fo llowing 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 t o manipulative patients are covered on b p. 994. 1 Davison SE (2002) Principles of managing patients with personality disorder. Advances in Psychiat Treat 8: 1 \200\2239. 2 Adshead G (1998) Psychiatric staff as attachment \201 gu res. Understanding management problems in psychiatric services in the light of attachment t heory. Br J Psychiat 172: 64 \200\2239. 13_Semple_Chap13.indd 507 12/7/2012 3:43:12 PM CHAPTER 13 Personality disorders 508 Management of personality disorder 2: speci \201 c treatments1,2 Medication3 The main indi cation for medication in patients with PD is the development of comorbid mental illness. Th ere is no good evidence that medication has any effect on PD itself. The positive \201 nd ings from studies have been short-term, and probably due to the effects of medication on co morbid disorders rather than on the PD itself. Bearing this in mind, the following have bee n suggested: \200 Antipsychotics borderline) and cluster A (particularly schizotypal and perhaps paranoid) disorders. Antidepressants harming patients (particularly borderline), an d in cluster C (particularly avoidant and obsessive \200\223compulsive) disorders. Anticonv ulsants and lithium affective instability or impulsivity. may be of some bene \201 t in cluster B (particularly may be of bene \201 t in impulsive, depressed, or self- have been suggested where there is Therapeutic community A therapeutic community is a consciously designed social environment and program within a residential or day unit, in which the social and group process is harn essed with therapeutic intent. It is an intense form of psychosocial treatment in which eve ry aspect of the environment is part of the treatment setting, in which interpersonal behav ior can be challenged and modi \201 ed. The main principles are democratization, permissiv eness, communalism, and reality confrontation. There are various interactions between patie nts 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 treat ment is effective with some patients with PDs. Dialectical behavioral therapy (DBT) (b p. 8 56) Combination of individual and group therapy lasting at least 12mths. In stage 1, indivi dual therapy focuses on a detailed cognitive \200\223behavioral approach to self-harm and o ther \200\230therapy interfering \200\231 behaviors. 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. \200\230Mindfulne ss training \200\231 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 develo ped. 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 hel p them apply skills when dif \201 culties arise. There is evidence that DBT may be an effe ctive therapy for out- patients with borderline PD. 13_Semple_Chap13.indd 508 12/7/2012 3:43:12 PM MANAGEMENT OF PD 2: SPECIFIC TREATMENTS 509