Personality Disorder
Dr Ray Haddock
Consultant Psychiatrist in Psychotherapy
Sheffield Care Trust
What is personality that it gets
disordered?
How do we decide if it is disordered?
When is it disordered?
Where is it disordered?
When is a disordered personality not
disordered?
2
Objectives of Lecture
1. To briefly consider how personality is
defined.
2. To describe and compare main diagnostic
systems
3. How to diagnose personality disorder
4. What does NICE say
5. Treatment and Management evidence and
the lack of it.
6. The future - some speculation
3
What is personality?
http://dictionary.reference.com/browse/personality
The visible aspect of one's character as it impresses
others: He has a pleasing personality.
A person as an embodiment of a collection of qualities:
He is a curious personality.
Psychology .
a.
the sum total of the physical, mental, emotional, and
social characteristics of an individual.
b.
the organized pattern of behavioral characteristics of4
the individual.
The quality of being a person; existence as a
self-conscious human being; personal identity.
The essential character of a person.
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Personality from first principles
Adaptation
Context
Life Stage
Of
Personality
Genes
Development
Birth
Neurobiological
Physical
Nutritional
Educational
Emotional
Childhood
Adolescence
Early
adulthood
Adulthood
Personality
Adaptability
to context
Gene pool
Models
Attachment
Social learning
Psychoanalysis
Piaget
Maslow
Etc
Etc
Etc
Caregiver
Family,
school peers
Transition
Home to
community
Community
Work
Intimate
Reproduction
Personal
preference
and choice
6
Definitions of Personality Disorder

ICD 10

“….clinically significant conditions and behaviour which tend
to be persistent and are the expression of an individual’s
characteristic lifestyle and mode of relating to others…….as a
result of both constitutional factors and social experience…..”

DSM IV

“…. is 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.”
DSM-5
(No Longer Axis II)
The essential features of a personality disorder are impairments
in personality (self and interpersonal) functioning and the
presence of pathological personality traits. To diagnose
personality disorder, the following criteria must be met.
• Significant Impairments in self (identity or self-direction) and
interpersonal (empathy or intimacy) functioning
• One or more pathological personality trait domains or trait
facets
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General diagnostic criteria for a personality disorder (derived from ICD 10
and DSM IV
From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann
A. An enduring pattern of inner experience that deviates
markedly from the expectations of the individual’s culture.
This pattern is manifested in two (or more) of the following
areas:
1) Cognition, i.e. Ways of perceiving and interpreting self,
other people and events
2) Affectivity, i.e. The range, intensity, lability and
appropriateness of emotional response
3) Interpersonal functioning
4) Impulse control
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General diagnostic criteria for a personality disorder (derived from ICD 10
and DSM IV
From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann
A. An enduring pattern of inner experience that deviates
markedly from the expectations of the individual’s culture.
This pattern is manifested in two (or more) of the following
areas:
1) Cognition, i.e. Ways of perceiving and interpreting self,
other people and events
2) Affectivity, i.e. The range, intensity, lability and
appropriateness of emotional response
3) Interpersonal functioning
4) Impulse control
10
Comparison of DSM and ICD
DSM-IV-TR
DSM-IV-TR/DSM 5
ICD-10
Cluster A
Schizoid/Removed
Schizoid
Paranoid/Removed
Paranoid
Schizotypal
Cluster B
Borderline
Emotionally Unstable
-Impulsive
-Borderline
Antisocial
Dissocial
Narcissistic
Cluster C
Histrionic/Removed
Histrionic
Avoidant
Anxious (avoidant)
Dependent/Removed
Dependent
Obsessive-Compulsive
Anankastic
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Differences between mental state and personality
disorders
From Tyrer, 2000, Personality Disorders, Butterworth-Heinemann
Mental State Disorders
Personality Disorders
Temporary (Usually)
Permanent (or at least long
standing)
Reactive
Generative
Dominated more by
symptoms than behaviour
Dominated more by
behaviour and relationships
with others
Diagnosed mainly on mental
state
Diagnosed on basis of long
term function
May develop into other
mental states
Tends to remain stable13
DSM-5
The essential features of a personality disorder are impairments
in personality (self and interpersonal) functioning and the
presence of pathological personality traits. To diagnose
personality disorder, the following criteria must be met.
• Significant Impairments in self (identity or self-direction) and
interpersonal (empathy or intimacy) functioning
• One or more pathological personality trait domains or trait
facets
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General diagnostic criteria for a personality disorder - DSM 5
C.
D.
E.
The impairments in personality functioning and the
individual’s personality trait expression are relatively stable
across time and consistent across situations
The impairments in personality functioning and the
individual’s personality trait expressions are not better
understood as normative for the individual’s developmental
stage or socio-cultural environment.
The impairments in personality functioning and the
individual’s trait expression are not solely due to the direct
physiological effects of a substance (e.g., A drug of abuse,
medication) or a general medical condition (e.g., severe head
trauma
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DSM-5


IN
Antisocial
Avoidant
Narcissistic
Obsessive Compulsive
Schizotypal
PD Trait specific
Negative affectivity
Detachment
Antagonism
Disinhibition vs Cmpulsivity
Psychotisism
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DSM-5


Out
Paranoid
Schizoid
Histrionic
Dependant
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DSM 5 specific criteria for each PD
A.
Significant Impairments in personality
functioning
1. Impairments in self functioning (a or b)
a. Identity
b. Self-direction
2. Impairments in interpersonal functioning
(a or b)
B.
a. Empathy
b. Intimacy
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DSM 5 specific criteria for each PD
B.
Pathological Personality traits in the
following domains: (e.g. for Antisocial)
1 Antagonism etc
2 Disinhibition
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Prevalence

General Population - lifetime 2-18% !!
Primary Care 5-9% ?? great variation
Psychiatric population 30-40%
Inpatient populations 40-50%
Prison 70% +

Conclusion?




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Making the Diagnosis - 1









History, History History!
Recurring patterns of difficulty/symptoms
Wide range of previous diagnoses
Developmental history
Problems at school
Abuse/neglect (repeated and recurrent)
Family
patterns/relationships/breakdowns/violence
The internal world of the child
Changes in context
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Making the Diagnosis 2

“Childhood was normal and all
developmental milestones were normal” !

Most developmental, milestones are
genetically and biologically driven. Therefore
it takes very substantial environmental factors
to change them enough to notice as for most
the range is variable in any case.
There is however an experience of childhood
and development in the developmental
context

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Making the Diagnosis





Symptoms
All symptoms are possible
Interpersonal relationships – child and adult
Behaviour reflects perception of reality- go
beyond the explanation
Move from open to specific questioning
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NICE GUIDELINES -Borderline PD
Treatment and Management




CMHT management CPA
Consistent approach to treatment and
management
No stand alone short term psychological
treatments
Pharmacological treatments? - only for
treatment of co-morbidity
NICE GUIDELINES -Borderline PD
Psychological Treatment





No overwhelming evidence for any
treatment
Dialectical Behaviour Therapy (Linehan) certain groups - female -self harm,
impulsivity
Psychodynamic therapies - evidence but
not gold standard
Therapeutic community - for severe
No particular role for inpatient treatment
Treatment and management - Summary









Make the diagnosis
Discuss and put in context – “normalise”
Long term treatment and management plan
Psycho-education
Risk management
Impulse management and control
Specific interventions (short term to long
term)
Symptom targeted medication
At every step it is important to attend to
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NICE GUIDELINES - Antisocial
Personality Disorder





Mostly Tier 4 management
No specific treatments
Forensic - low/high secure
Mental Health services - management of
mental illnesses
Intervention focussed more on prevention intervention with children and families
Long term outcomes





Some evidence that severity of disorder
diminishes with age
Exacerbation and reduced recovery rates from
neurotic disorders
The more severe/co morbidity the smaller the
response to interventions
Impact of therapy?
Mortality?
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The Future?



Models of personality disorder that relate to
aetiology - increased understanding
Genetic
Developmental
Neurobiology of social functioning
Treatment and management approaches that
are based on sound evidence and theoretical
models
E.G.
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Personality from first principles
Adaptation
Context
Life Stage
Of
Personality
Genes
Development
Birth
Neurobiological
Physical
Nutritional
Educational
Emotional
Childhood
Adolescence
Early
adulthood
Adulthood
Personality
Adaptability
to context
Gene pool
Models
Attachment
Social learning
Psychoanalysis
Piaget
Maslow
Etc
Etc
Etc
Caregiver
Family,
school peers
Transition
Home to
community
Community
Work
Intimate
Reproduction
Personal
preference
and choice
30
Severe
PD
Moderately
Severe PD
Personality
Disorder
Personality
Difficulty not
qualifying as
PD
No Personality
Disturbance
Social/
Schizoid
Dissocial/
Externalising
Anxious
dependant/
Internalising
Obsessional/
Anankastic
Emotional
distress/
Instability
Proposed ICD 11 classification for Personality disorder
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







A Histrionic personality
B Anankastic personality
C Paranoid personality
D Dissocial personality
E Schizoid personality
F Borderline personality – unstable type
G Borderline personality – impulsive type
Which of the above corresponds best to the
following:
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


140. A man attends with his CPN. He
becomes very tearful when speaking about his
depression but then changes quickly to talking
rather loudly about his plans for the future
141. A man complains that his written
complaint to social work is being ignored. He
refuses to talk to the psychiatrist about it as
“she’ll not do anything about it either”.
142. A woman is kept waiting a couple of
minutes by the nurse having to take a
telephone call. She smashes a window in the
bathroom and is about to slash herself saying
“it’s your fault I’m doing this”.
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Answers



140. Probably A
141 C
142 G
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
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

Theme: personality
Eysenck Personality Questionnaire
Rorschach test
Repertory grid
Thematic appreciation test
Minnesota Multiphasic Personality Inventory
‘Big 5’ personality test
Q sort
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
Lead in: Which of the above methods used to assess
personality has the following features?

This projective tests of personality requires individuals to
make up a storey based on ambiguous pictures of people and
scenes
An idiographic test of personality developed by George
Kelly
This personality tests has scales which measure the tendency
to answer questions in a defensive and/or socially desirable
manner
This personality test posits that one of its dimensions reflects
the degree of cortical arousal
This test has dimensions measuring openness,
conscientiousness extraversion, agreeableness and
neuroticism




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
Theme: personality





D
C
E
A
F
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Useful sources of information



Mental Health Foundation –
http://www.mentalhealth.org.uk/information/
mental-health-a-z/personality-disorders/
Mind –
http://www.mind.org.uk/help/diagnoses_and_
conditions/personality_disorders
The Royal College of Psychiatrists –
http://www.rcpsych.ac.uk/mentalhealthinfofor
all/problems/personalitydisorders/pd.aspx
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