Personality disorder programme No longer a diagnosis of exclusion

Personality disorder

Personality disorders are classified using one of two internationally recognised systems: ICD-10 or DSM IV (see below). Diagnosis is based on information held in existing records, clinical interviews and self-report questionnaires. These are not usually applied to young people, as it is believed that personality continues to develop through late teens. Personality disorder is defined as:

“An enduring pattern of inner experience and behaviour that deviates markedly from the individual’s culture.

DSM-IV identifies three cluster classifications:
Cluster ‘A’ – ‘odd’ or ‘eccentric’

• Paranoid – interpretation of people’s actions as deliberately demeaning or threatening
• Schizoid – indifference to social relationships and restricted range of emotional experience and expression
• Schizotypal – deficit in interpersonal relatedness with peculiarities of ideation, odd beliefs and thinking, unusual appearance and behaviour

Cluster ‘B’ – ‘dramatic’

• Histrionic – excessive emotion and attention-seeking, suggestibility, and superficiality
• Narcissistic – pervasive grandiosity, lack of empathy, arrogance, and requirement for excessive admiration
• Anti-social – pervasive pattern of disregard for and violation of the rights of others
• Borderline – pervasive instability of mood, interpersonal relationships and self-image associated with marked impulsivity, fear of abandonment, identity disturbance and recurrent suicidal behaviour and/or other self-harm

Cluster ‘C’ – ‘anxious’ or ‘inhibited’

• Obsessive-compulsive – preoccupation with orderliness, perfectionism and inflexibility that leads to inefficiency
• Avoidant – pervasive social discomfort, fear of negative evaluation and timidity, with feelings of inadequacy in social situations
• Dependant – persistent dependent and submissive behaviour

For a personality disorder to be present, symptoms must be chronic or persistent (continuing for a long time or frequently recurring) and pervasive (affecting numerous areas of their life, for example, social, employment, personal life, etc). They must also cause the individual or those around him or her clinically significant distress or impairment.

The Royal College of Psychiatrists (1999) suggested that ‘severe’ should be defined as “gross societal disturbance” plus “gross severity of personality disorder within the flamboyant group and a personality disorder in at least one other cluster”.

Psychopathy is not, in itself, one of the DSM-IV or ICD-10 classifications. However, high scoring psychopaths present a particularly high risk of serious offending. Hare (1991) describes psychopaths as “grandiose, egocentric, manipulative, dominant, forceful and cold-hearted… they display shallow and labile emotions, are unable to form long-lasting bonds …and are lacking in empathy, anxiety, and genuine guilt and remorse. Behaviourally, psychopaths are impulsive and sensation seeking, and they readily violate social norms. The most obvious expressions of these predispositions involve criminality, substance misuse and a failure to fulfil social obligations and responsibilities.”

Prevalence

Estimates of the prevalence of personality disorder in community samples vary between 4% and 13%. Almost half of people with a personality disorder will have at least one other. However, it is significantly higher in the prison population – 73% of male remand, 64% of male sentenced and 50% of female prisoners. The most common is anti-social personality disorder, 63%, 49%; 31% respectively. For men paranoid is the second most prevalent and for women borderline. A small study which included high tariff offenders attending a probation centre found that, where personality disorder was diagnosable, the average was four.

Personality disorder is also more prevalent in substance-misusing populations. Estimates vary, however, in drug services approximately a third of clients have a personality disorder, the most common being cluster B. In alcohol services this increases to just over half of clients with cluster C more prevalent. Assessments need to be undertaken with particular care in these settings as the presentation may be masked or affected by the substance misuse.

DSM IV definition of Personality Disorder

Personality Disorders are mental illnesses that share several unique qualities.  They contain symptoms that are enduring and play a major role in most, if not all, aspects of the person’s life.  While many disorders vacillate in terms of symptom presence and intensity, personality disorders typically remain relatively constant.

To be diagnosed with a disorder in this category, a psychologist will look for the following criteria:

1. Symptoms have been present for an extended period of time, are inflexible and pervasive, and are not a result of alcohol or drugs or another psychiatric disorder.  The history of symptoms can be traced back to adolescence or at least early adulthood.
2. The symptoms have caused and continue to cause significant distress or negative consequences in different aspects of the person’s life.
3. Symptoms are seen in at least two of the following areas:

• Thoughts (ways of looking at the world, thinking about self or others, and interacting)
• Emotions (appropriateness, intensity, and range of emotional functioning)
• Interpersonal Functioning (relationships and interpersonal skills)
• Impulse Control

ICD-10 Definition of Personality Disorder