1 Heiman JR and LoPiccolo J (1988) Becoming orgasmic. London: Piatkus Books. 12_Semple_Chap12.indd 477 12/7/2012 3:42:32 PM CHAPTER 12 Reproductive psychiatry and sexuality 478 Sexual dysfunction 4: problems speci \201 c to men Erectile failure (failure of genital re sponse) Inability to develop or maintain an erection, leading to failure of coitus or sexua l intercourse. Subtypes Primary Never been able to sustain an erection; Secondary Able to d o so in the past; Situational Only successful under certain circumstances; Total Not under any circumstances. Contributing factors Moral/religious views on sex and masturbation; prev ious negative sexual experiences (may undermine sexual con \201 dence and increase \200 \230performance anxiety \200\231); sec- ondary to other sexual dysfunction (e.g. premature ejaculation); use of alcohol and drugs; stress and fatigue. Management Physical assessment to exclude organic causes (disease or surgery affecting the blood supply of the penis, side-effects of drugs or medication) especially in older men; re fer to expert on sexual problems if primary, total, long-standing (years), or not associate d with obvious trig- gers. General Education (about physical and psychological factors that may contribute to erectile failure) and self-help exercises1,2 (better if part- ner involv ed). Physical Sildena \201 l (Viagra); training in self-administration of papaverine or pr ostaglandin E1 into the penis prior to intercourse; use of a vacuum constriction device; su rgical implantation of semi-rigid or in \202 at- able penile prostheses. Note: relapse com mon (775%), usually related to clear triggers, and will improve naturally or through use of previously suc- cessful techniques. (Seeing this as a \200\230normal \200\231 situation m ay help relieve anxiety and reduce the sense of failure which might otherwise prolong probl ems further.) Orgasmic dysfunction (or \200\230inhibited ejaculation \200\231) Relatively rare in men. O rgasm delayed/does not occur at all, despite normal sexual excitement and arousal. Situatio nal dysfunction usually has a psychological cause (see Common triggers b p. 473); total dys function may have a variety of causes. Management Main aims: reducing \200\230performance anxiety \200\231, increasing arousal an d physical stimulation, i.e. addressing any common triggers, rela- tionship problems, assoc iated feelings of anxiety or guilt, or memories of past traumatic/unpleasant sexual experie nces. Education (dispelling myths, understanding \200\230normal \200\231 physiology, the e ffects of alcohol); use of sensate focus techniques. Persistent problems should be referred to an expert. Premature ejaculation The inability to control ejaculation adequately for both partners to enjoy the sexual interaction. Ejaculation may occur immediately after penetration, or in th e absence of an erection. Differential diagnosis Delayed erection (prolonged stimulation needed to achieve adequate e rection; short time to ejaculation); organic impairment (esp. pain); \200\230normal \200 \231 rapid ejaculation in young or sexually inexperienced men (control is learned with prac tice); secondary to psychological stres- sors; transient problem following a period of redu ced sexual activity. Management Expert advice should be sought for complex cases or where there is associated or gasmic dysfunction/lack or loss of sexual desire. 12_Semple_Chap12.indd 478 12/7/2012 3:42:32 PM SEXUAL DYSFUNCTION 4: PROBLEMS SPECIFIC TO MEN 479 Sympathetic partner is crucial to successful management. General education (speci \201 c i ssues of \200\230normal \200\231 time before ejaculation occurs). Reduction of \200\230pe r- formance anxiety \200\231 (as for Orgasmic dysfunction). Use of self-help guides.2 Speci \201 c exercises may include: the \200\230stop \200\223start \200\231 technique (see Box 12.6), the \200\230squeeze technique \200\231 (see Box 12.7), and sensate focus (see b p. 475). Non-organic dyspareunia Pain during intercourse in men; usually has a physical cause (e.g. urethral infection, scarring secondary to STD, tight foreskin) that can be directly treated. If psychological factors are the root cause, reassurance, education, and use of re laxation and cognitive tech- niques may be helpful. Complex cases require expert management . Box 12.6 The stop \200\223start technique (Semans \200\231 technique) Developed by Masters and Johnson;1,2 effective in up to 90% of cases of premature ejaculati on. Aims: To increase the frequency of sexual contact and increase the sensory threshold of the penis. Setting: Best performed in the context of sensate focus exercises \200\224to ensure non-gen ital areas are focused on \201 rst (less threatening for anx- ious individuals, allowing the recognition of sensations leading up to ejaculation, and may make the \200\230quality \200\231 of the sexual experience better), to limit the number of \200\230accidental \200 \231 ejaculations (that may discourage cou- ples early on), and increase good communication and cooperation. Technique: \200 Stimulation of the penis until high arousal (but not the ejaculation threshold) is achieved . Cessation of stimulation for a few minutes to allow arousal to subside. Repetition 4 \200 \2235 times until ejaculation is permitted. \200 Box 12.7 Squeeze technique If control does not develop using the \200\230stop \200\223start \200\231 technique, this method may be used to inhibit the ejaculatory re \202 ex: \200 Stimulation of the penis until high arousal (but not the ejaculation threshold) is achieved . The man (or his partner) applies a \201 rm squeeze to the head of the penis for 15 \200 \22320 seconds. (Fore \201 nger and middle \201 nger are placed over the base of the gla ns and shaft of the penis, and the thumb applies pressure on the opposite side at the base of the undersurface of the glans.) Note: this technique should be practiced before high arousal occurs to establish how \201 rmly the penis may be squeezed without causing pain. 1 Masters WH and Johnson VE (1966) Human sexual response. New York: Bantam Books. 2 Masters WH and Johnson VE (1980) Human sexual inadequacy. New York: Bantam Books. 1 Williams W (1985) It \200\231s up to you. Sydney: Maclennan and Petty. 2 Zilbergeld B (19 80) Men and sex. London: Fontana. 12_Semple_Chap12.indd 479 12/7/2012 3:42:32 PM CHAPTER 12 Reproductive psychiatry and sexuality 480 Disorders of sexual preference 1: general aspects1 Essence Disorders of sexual preference ( the term used in ICD-10) or paraphilias (the term used in DSM-IV) are disorders in which an individual is sexually aroused by inappropriate stimuli. Other terms used include sexual d evia- tion and perversion. There is some overlap between these disorders, sex offending, an d inappropriate sexual behavior, but the three are separate concepts. Homosexuality was pre viously included, but this is no longer the case. Disorders of sexual preference are one of three broad types of sexual disorders. The others are gender identity disorders and sexual dysfunc- tions (see Table 12.3). In some cases tw o or more of these are present. De \201 nition DSM-IV de \201 nes each paraphilia as at least 6mths of recurrent, intense , sexually arousing fantasies, sexual urges, or behaviors involving a par- ticular inapprop riate act or object. These fantasies, urges, or behaviors must cause clinically signi \201 cant distress or impairment in social functioning. ICD-10 has less strict and less detaile d criteria, referring to the particular object or act as being the most important source of sexual arousal or essential for satisfactory sexual response. Classi \201 cation There are many different objects and acts that may be the focus of dis- orders of sexual preference. Most of the de \201 ned categories are extreme forms of beha viors that are common parts of \200\230normal \200\231 sexual activity. The classi \201 c ation systems in DSM-IV and ICD-10 are very similar (see Table 12.3). A disorder of sexual preference may be present in addition to other mental disorders. Etiology Physiological factors These may include genetic factors, prenatal in \202 uence o f hormones in utero, hormonal abnormalities in adults, and perhaps brain abnormalities. Psychological theories These include absence of effective father with over- protective/clos e binding/intimate mother; failure of successful resolution of oedipal con \202 ict; model ing and conditioning; masculine insecurity. The various factors may lead to sexual deviation by (a) preventing nor- mal sexual developm ent and relationships, and/or (b) promoting deviant sexual interest. Epidemiology It is dif \201 cult to estimate the prevalence of these disorders as many ind i- viduals do not present for help and are unlikely to admit to sexually deviant arousal in surveys. Rates of sexual offending do not give a good approximation of rates of disorders of sexual preference, as these dis- orders represent one of many factors that may lead to s uch offending 12_Semple_Chap12.indd 480 12/7/2012 3:42:32 PM DISORDERS OF SEXUAL PREFERENCE 1: GENERAL ASPECTS 481 (see b p681). There is probably a wide range of sexual practices in the \200\230normal \200\231 population. Disorders of sexual preference are more common in males than females ( perhaps 30 times more common). From clinical samples, age of onset is usually between 16 an d 20, and many individuals have multiple paraphilias, in series and/or in parallel. Table 12.3 Classi \201 cation of disorders of sexual preference ICD-10 DSM-IV Sexually arousing object or act Fetishism Fetishism Non-living object (e.g. clothing, shoes, rubber). Fetishistic transvestism Transvestic fetishism Cross-dressing (not few articles but complete out \201 t, perhaps with wig and make-up). C lear association with sexual arousal distinguishes from transsexual tranvestism. However, m ay be an early phase in some transsexuals. Exhibitionism Exhibitionism Exposure of genitals to strangers. Voyeurism Voyeurism Watching others who are naked, disrobing, or engaging in sexual acts. Pedophilia Pedophilia Children (usually prebubertal or early pubertal). May be speci \201 ed as attracted to mal es, females, or both, or as limited to incest. Sadomasochism Sexual masochism Being humiliated, beaten, bound, or made to suffer. Sexual sadism Psychological or physical suffering of others. \200\224 Frotteurism Touching and rubbing against non- consenting person. Other disorders of sexual preference Paraphilia not otherwise speci \201 ed Includes telephone scatalogia (obscene phone calls), necrophilia (corpses), partialism (exc lusive focus on part of body), zoophilia (animals), coprophilia (feces), urophilia (urine), klismaphilia (enemas), autoerotic asphyxia (self-asphyxiation). Multiple disorders of sexual preference \200\224 Many individuals manifest multiple disorders. Term \200\230polymorphous perversity \200 \231 has been used. Most common combination is fetishism, transvestism, and sadomasochism. 1 Abel GG and Osborn CA (2000) The paraphilias. In: Gelder MG, Lopez-Ibor JJ, Andreasen NC (eds), New Oxford textbook of psychiatry, Vol, 1, pp. 897 \200\223913. Oxford: Oxford Unive rsity Press. 12_Semple_Chap12.indd 481 12/7/2012 3:42:32 PM CHAPTER 12 Reproductive psychiatry and sexuality 482 Disorders of sexual preference 2: assessment and management1 Assessment Why is the person p resenting now? \200 May present directly or at request of spouse when behavior is discovered or starts to cause problems in relationships. Occasionally present as sexual dysfunction, with disorder of pr eference coming to light on further assessment. May present at own request, or more likely at request of court, prosecutor, or solicitor, after committing offense. Is there another mental disorder? Various psychiatric disorders may lead to release of sexu ally deviant behavior, perhaps in individuals who have experienced fantasies but not acted on them previously. Particularly important to exclude in someone presenting for \201 rst time in middle age or later. So full psychiatric history, MSE, and perhaps neurological exa mination/investigation important. Psychosexual assessment Full psychosexual assessment essential in anyone presenting with se xual problems. Interviewer should put person at ease and be able to facilitate by being ope n, sensitive, and able to discuss sexual matters. Involvement of sexual partner in assessme nt (either at the same time or through another interview) is usually helpful. Following are as should be covered: \200 \200 \200 Sexual knowledge Sexual attitudes Age of onset and development of sexual interest, masturba tion, dating, sexual intercourse Relationship history partners, duration, quality, problems , abuse Fantasy (content/use/development) Orientation Drive inquiry about arousal, impotenc e, premature ejaculation) Experience paraphilias) Current sexual practices conditions for a rousal during both intercourse and masturbation (many men with paraphilias report \200\230 normal \200\231 intercourse although at the time they are imagining deviant scenarios); whe re various forms of arousal are reported, estimate proportion of sexual practice devoted to each. and sources of information to self and others , including: age of self and partner, gender of \200 \200 (frequency of masturbation/intercourse) and dysfunction (speci \201 c (range of sexual behaviors with speci \201 c enquiry about : mood, thoughts, visual images, material used, and What does the person want from treatment? \200 Do they want help at all or have they just come as they have been forced to (by spouse, cou rts, etc.)? Do they want to change the focus of their sexual arousal and/or desist from the overt behavior? Do they want to adapt better to the behavior without changing it? Are they motivated to engage in treatment? \200 12_Semple_Chap12.indd 482 12/7/2012 3:42:32 PM DISORDERS OF SEXUAL PREFERENCE 2: ASSESSMENT AND MANAGEMENT 483 Further investigations Physical examination and investigations may be indicated, particular ly if sexual dysfunction coexists. Penile plethysmography, polygraphy, and visual reaction times may be useful in assessing paraphilias. Management General issues Treatment should not be imposed on people who do not want it. Pat ients should realize that treatment will take considerable effort on their part. The aims o f treatment should be clear from the beginning. Broadly, there are three possible aims: \200 \200 Better adjustment without changing the behavior. Desisting from overtly problematic behavio r but retaining \200\230deviant \200\231 arousal. Changing the focus of the arousal. Where treatment is aimed at change, the following may need to be addressed: \200 \200 Encouraging development of \200\230normal \200\231 relationships. Addressing sexual inadeq uacy (perhaps using approaches similar to those for sexual dysfunction). Develop interests, activities, and relationships that will \201 ll the time previously taken up by fantasiz ing about, preparing for, and taking part in the deviant activity. Decreasing masturbation to deviant fantasies and encouraging masturbation to more appropriate fantasies. Speci \201 c treatment approaches Physical treatments Neurosurgery and bilateral orchidect omy ( \200\230castra- tion \200\231) of historical interest only. Various medications have been used: antipsychotics, oestrogens, progestogens, luteinizing hormone-releasing analog, anti-androgens, and SSRIs. There is evidence for the ef \201 cacy of cyproterone acetate ( an anti-androgen) and medroxyprogesterone acetate (a progestogen) in the treatment of hyper sexuality and paraphilias. Recently, SSRIs have been used increasingly, and some use them \201 rst-line due to their relative lack of side-effects. Psychodynamic psychotherapy Individual and group approaches have been used, ranging from so phisticated psychoanalysis to primarily supportive therapy. Cognitive behavioral therapy Speci \201 c techniques may be used to decrease deviant (cove rt sensitization, aversive therapy, masturbatory satiation, bio- feedback) and increase \200\230normal \200\231 arousal (orgasmic reconditioning, shaping, fading, exposure to expl icit stimuli, biofeedback, systematic desensitiza- tion). Controversially used to treat hom osexuality until the 1970s. Social skills training, assertiveness training, sexual educatio n, and relapse preven- tion can also be helpful. Addressing cognitive distortions regarding sex, women, or children may also be important. 1 Brockman B and Bluglass R (1996) A general psychiatric approach to sexual deviation. In: Rosen I: (ed.), Sexual deviation, 3rd edn, pp. 1 \200\22342. Oxford: Oxford University Pres s. 12_Semple_Chap12.indd 483 12/7/2012 3:42:33 PM CHAPTER 12 Reproductive psychiatry and sexuality 484 Transsexualism 1: diagnosis Transsexualism is a disorder of gender identity characterized b y the desire to live and be accepted as a member of the opposite sex, usually accom- panied by a sense of discomfort with one \200\231s anatomical sex. Transsexuals usually come to p sychiatric attention, not because they wish to change these feelings, but in order to gain the psychiatrist \200\231s support for onward referral to specialist gender services with t he eventual aim of gender reas- signment +/- sex reassignment surgery (SRS). Gender disorder specialists are usually specially trained psychiatrists who work as part of an extended team of specialists which may include gender surgery, endocrinology, psycholog y, specialist counselors and speech therapy. There are few large specialist clinics within the UK and many areas are supported by smaller services which refer on to a larger regional service for surgical intervention. The aim of the gender disorder specialist is to make an accurate and appropriate diagnosis, to assess and treat comorbidities, and to provide ongo ing support through the period of assessment, transition, and beyond. Etiology Primary cause not understood. Most transsexuals report that their gender dysphoria was present from early childhood. A range of explanatory models has been suggested but the re is little evidence for one theory over another. Karyotype and phenotypic development is normal. Epidemiology Estimated incidences are based on those who seek help for gender reassignment or gender dysphoria. Reported \201 gures range widely between countries and cultures. In the UK male to female (MTF) 1 in 7500; female to male (FTM) 1 in 31 000. MTF to FTM ratio i s 3 \200\2234:1 in most samples. Diagnosis Transsexual identity should have been present for at least 2yrs, and must not be a symptom of another mental disorder, such as schizophrenia, or associated with any interse x, genetic, or chromosomal abnormality. Differential diagnosis Transvestism \200\224the wearing of clothing of the opposite sex wit hout the purpose of sexual arousal, often described as a stress alleviating activity, not a ssociated with the core belief of incorrect gender found in transsexuals; fetishistic trans vestism \200\224the wearing of clothes of the opposite sex for the purposes of sexual arous al but not associated with the ideal of living as the opposite sex; dual role transvestism \200\224individual spends time split between male and female role without the desire to tra nsition completely, they are clear regarding retaining biological sex persona and genitalia ; dysmorphobia \200\224focus of individual \200\231s dissatisfaction is with their primary or secondary sexual characteristics, the desire is for change or removal of genitalia rathe r than any wish to change gender; third sex \200\224individual identi \201 es self as a \200\230third \200\231 sex or \200\230neutral \200\231 sex, presents without identi \201 cation with either gender and may request medical surgical help to remove sexual characteri stics and function; intersexed condition \200\224ruled out by normal karyotyping and normal primary and sexual characteristics for 12_Semple_Chap12.indd 484 12/7/2012 3:42:33 PM TRANSSEXUALISM 1: DIAGNOSIS 485 the birth sex; schizophrenia \200\224occasionally associated with a delusion that the patie nt is the wrong sex or is changing sex. Comorbidity Self-harming and suicidal gestures are seen and may be directed at underscoring the need for surgery. Genital mutilation is rare. Some MTF transsexuals work in the sex in dustry and have consequent increased risk of STDs and HIV infection. There is an increased incidence of other mental disorders including depression, personality disorders, obsessive \200\223compulsive disorder, anorexia nervosa, conversion disorders, and coincidental psych osis. 12_Semple_Chap12.indd 485 12/7/2012 3:42:33 PM CHAPTER 12 Reproductive psychiatry and sexuality 486 Transsexualism 2: management Assessment Many patients will arrive with their diagnosis ( \200\230I am a trans- sexual \200\231) and preferred treatment option (hormones and sex rea ssignment surgery) already \201 xed in their minds. The aim of assessment is to establish the diagnosis with certainty and to identify signi \201 cant comorbidities and contraindi cations to treatment such as psychotic illness, major depression, substance misuse, and per sonality disorder. The majority of patients with con \201 rmed diagnosis of transsexualism on initial psychiatric assessment will be referred on to specialist gender services. \200 History taking history of gender development, sexual history, and discussion of gender diss atisfaction. Physical assessment This may have already have been performed by the referring service or by GP or may be recommended following assessment \200\224weight and BMI, cardio vascular status, evidence of abnormal clotting or thrombotic disease, additional number of blood tests may be required (including FSH, LH, sex hormone binding globulin, testosterone, dihydrotestosterone, oestradiol, prolactin, bone metabolic parameters, lipid pro \201 le) . In biological males PSA and testicular examination should be considered, in biological fe males routine smear tests should be up to date. Third party history/con \201 rmation Infor mation from patients \200\231 families, employers, friends, and any other supportive person s is not only extremely helpful in determining diagnosis but can also be vital in recruitin g support for the patient. Families of younger transsexual patients usually need support, g uidance, and education if they are to cope with a child \200\231s transition. Full psychiatric history with the addition of a detailed Treatment \200 Psychological treatment are ineffective in the majority of cases and are generally not welc omed by the patient. If the diagnosis of transsexualism is made then the psychiatrist \200 \231s role is supervision of the transition, with liaison with the primary care and surgica l teams and psychological support during the inevitable dif \201 culties. Real-life test l east one year prior to consideration for surgery. During this time the patient undertakes t o live full time and attempt to \201 nd employment in the new sex. Patients will change t heir name and \200\230come out \200\231 to friends and family. Hormones (male to female) a nd anti-androgen (e.g. \201 nasteride or cyproterone acetate) treatment produces feminiza tion effects including some breast and hip development, and skin softening, body fat redist ribution, diminished libido and erectile function. There is no effect on voice pitch and sp eech therapy may be required to produce an acceptable female vocal pattern. Negative effect s include increased risk of thromboembolic disease, abnormal liver function, increased risk of breast cancer, emotional dysregulation. Treatments aimed at altering the core beliefs Most centers require a successful \200\230real-life test \200\231 of at Synthetic estrogen (e.g. ethinylestradiol) 12_Semple_Chap12.indd 486 12/7/2012 3:42:33 PM TRANSSEXUALISM 2: MANAGEMENT 487 Testosterone treatment (via injection Hormones (female to male) or gel) produces muscle dev elopment, male pattern hair growth, suppression of menstruation, some lowering of vocal pit ch, growth of clitoris, increased aggression, increased libido. Negative effects: abnormal liver function, polycythaemia, artherogenic lipid pro \201 le increasing risk of cardiac d isease, osteoporosis. Surgery (male to female) orchidectomy and penectomy with vaginoplasty using penile skin. The cosmetic results can be good, although candidates vary in their abi lity to be orgasmic post-surgery. Some patients may undergo breast augmentation, facial fem inization procedures, and thyroid chondroplasty. Surgery (female to male) mastectomy, hyste rectomy, and bilateral salpingo-oophorectomy. Phalloplasty is undertaken in less than half of patients as current techniques are neither cosmetically acceptable or functional for pen etration. Sex reassignment surgery involves Sex reassignment surgery involves bilateral Legal In the UK the Gender Recognition Act 2004 allows transsexual individuals to change th eir legal gender and be issued with a new birth certi \201 cate re \202 ecting their curr ent, rather than birth, gender. Evidence of the change of gender (which does not have to in clude sex reassignment surgery) is presented to a Gender Recognition Panel at least two yea rs after transition to the new gender. Prognosis No RCTs are available comparing SRS with o ther treatment. Cohort follow-up studies report >90% of patients reporting improvement foll owing SRS on measures of psychological adjustment, absence of regret, and vocational adjust ment. Specialist services report signi \201 cant improve- ments in patients, general well- being and quality of life in those who have been appropriately assessed and supported. Reve rsion to former gender is very uncommon and is most likely in individuals where pre-assessm ent has been insuf \201 cient. 12_Semple_Chap12.indd 487 12/7/2012 3:42:33 PM This page intentionally left blank 489 Chapter 13 Personality disorders The concept of personality disorder 490 \200\230Normal \200\231 personality 492 Classi \201 cation of personality disorder 494 Psychopathy and \200\230severe \200\231 personalit y disorder 496 Etiology of personality disorder 498 Epidemiology of personality disorder 50 0 Relationship between personality disorder and other mental disorders 502 Assessment of personality disorder 504 Management of personality disorder 1: general aspect s 506 Management of personality disorder 2: speci \201 c treatments 508 Outcome of persona lity disorder 510 13_Semple_Chap13.indd 489 12/7/2012 3:43:10 PM CHAPTER 13 Personality disorders 490 The concept of personality disorder Essence Personality describes the innate and enduring characteristics of an indi- vidual wh ich shape their attitudes, thoughts, and behaviors in response to situations. We all recogn ize, amongst people we know well, some who manifest certain characteristics more than other s: shyness, con \201 dence, anger, generosity, tendency to display emotions, sensitivity, and being per- nickety to name but a few. When these enduring characteristics of an individ ual are such as to cause distress or dif \201 culties for themselves or in their relations hips with others then they can be said to be suffering from personality disorder (PD). PD i s separate from mental illness, although the two interact. De \201 nition The following de \201 nition is based on ICD-10 and DSM-IV (both are very similar). PDs are enduring (starting in childhood or adolescence and con- tinuing into adul thood), persistent, and pervasive disorders of inner expe- rience and behavior that cause d istress or signi \201 cant impairment in social functioning. PD manifests as problems in c ognition (ways of perceiving and thinking about self and others), affect (range, intensity, and appropri- ateness of emotional response), and behavior (interpersonal functioning, occ upational and social functioning, and impulse control). To diagnose PD, the manifest abnorm alities should not be due to other conditions (such as psychosis, affective disorder, subst ance misuse, or organic disorder) and should be out of keeping with social and cultural nor ms. Development of the concept The development of clinical concepts of conditions which would t oday be recognized as PD started in the early nineteenth century, at a time when the main t wo groups of mental conditions acknowledged by psychiatrists were insanity and idiocy. It b ecame clear that there were individuals who were neither insane (i.e. suffering from delusi ons or hallucinations) nor clearly idiots, imbeciles, or morons (to use the then contempora ry termi- nology for learning disability), but who nevertheless had abnormalities in their behavior. In 1801 Pinel described non-psychotic patients with disturbed behav- iour and thinking as \200\230manie sans d lire \200\231, while the term \200\230moral insanity \200\231 was in troduced by Prichard in 1835. \200\230Moral \200\231 then meant \200\230psychological \200\231 (rather than the modern meaning concerning ethics), and amongst the patients descr ibed were people who had affective disorders as well as people who were personality disorde red. Koch in 1873 described \200\230psy- chopathic inferiority \200\231, making the social ly maladaptive nature of the disor- der the key to diagnosis. Kraeplin is reported as \201 nding \200\230the classi \201 cation of PD defeating \200 \231. Nonetheless, he attempted to \201 nd a place for the description of its sub- types within his evolving classi \201 cation system. In 1921 he postulated that the PDs as they were then described were biologically related to the major psychotic and affective illnesse s. 13_Semple_Chap13.indd 490 12/7/2012 3:43:10 PM THE CONCEPT OF PERSONALITY DISORDER 491 In 1927 Schneider introduced a classi \201 cation system which can be seen as a forerunner of the current categorical approaches in DSM-IV and ICD- 10. He did not use a spectrum con cept, but saw PD as representing a pronounced and maladaptive variation of normal personali ty traits and used social deviance as a diagnostic marker for his ten subtypes. The individual PD subtypes in use today derive from a number of differ- ent academic and th eoretical backgrounds: antisocial (dissocial) PD from child psychiatric follow-up studies; borderline, histrionic, and narcissistic PDs from dynamic theory and psychotherapeutic prac tice; schizoid and anankastic PDs from European phenomenology; and avoidant PD from academi c psychology. Notably absent from the list of academic sources is the psychological study o f normal personality which has developed a trait model of normal personality along a varyin g number of axes (b p. 493). Controversy There is ongoing debate about the clinical usefulness, diagnosis, categor- izat ion and description of PD. A frequently repeated criticism of the present clinical concept has been the problem of tautology. That is, the same features displayed by a patient which suggest a diagnosis of PD are then \200\230explained \200\231 by the presence of that diag nosis. For example a patient may, among other features, display \200\230an incapacity to e xperience guilt \200\231 and \200\230a low threshold for discharge of frustration, includi ng violence \200\231. This may lead to an ICD-10 diagnosis of dissocial PD. It is then illo gical to use that same diagnosis to \200\230explain \200\231 a subsequent episode of viole nce without remorse in that individual. Some psychiatrists believe that psychiatry has no role in the treatment 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