Download Classifying and treating personality disorders: back to the future?

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Latest Advances in Psychiatry Symposium XI
z Keynote Lecture
Classifying and treating personality
disorders: back to the future?
Current diagnostic criteria proposals for personality disorder in what will become
the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5), due to be published in May 2013, are, to paraphrase Professor Peter
Tyrer, misguided. Steve Titmarsh reports on Professor Tyrer’s excellent Keynote
Lecture at the Latest Advances in Psychiatry Symposium in March on the
problems personality disorder presents to psychiatrists and how some of the issues
surrounding diagnosis might be resolved by taking a not-so-new approach to the problem.
I
n his Keynote Lecture, Professor
Tyrer detailed what he saw as the
shortcomings of the proposed criteria for DSM-5 and ways in which
he hoped the next version of the
International Classification of
Disease and Related Health
Problems (ICD-11) would provide a more practically useful set of
criteria for diagnosing personality
disorder.
The current description of personality disorder in ICD-10 is:
‘ingrained patterns of behaviour
indicated by inflexible and disabling responses that significantly
differ from how the average person in the culture perceives, thinks
and feels, particularly in relating
to others.’ 1 DSM-IV-TR is more
precise, describing personality disorder as: ‘An enduring pattern of
psychological experience and
behavior that differs prominently
from cultural expectations, as
shown in two or more of: cognition
(ie perceiving and interpreting the
self, other people or events); affect
(ie the range, intensity, lability, and
appropriateness of emotional
response); interpersonal functioning; or impulse control.2
Both classification systems
include additional criteria, which
in ICD-10 comment on the time
course of symptoms and detail the
types of behaviour and impact on
the individual and society typically
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Peter Tyrer is Professor of Community Psychiatry in the Centre for Mental
Health, Department of Medicine, at Imperial College, London. His main
interests are in models of delivering community psychiatric services, the
classification and treatment of common mental illnesses, particularly
anxiety and health anxiety, and the classification and management of
personality disorders. He also leads on research into the management of
patients with intellectual disability.
He is also experienced in the management of those with severe mental
illness, substance misuse and personality disorder and has developed a new
treatment, nidotherapy, to help these people by making environmental,
not personal, changes.
Professor Tyrer is Chair of the World Health Organization ICD-11
Working Group for the Revision of Classification of Personality Disorders.
seen in people with personality disorder. In DSM-IV-TR the additional criteria add context to
situations in which symptoms are
observed, detail time course again
and mention the importance of
identifying other possible causes
including other mental disorders
and substance abuse as well as
other medical conditions such as
head trauma.
Focus on symptom severity
Professor Tyrer explained that
these are, however, merely the
general criteria that need to be satisfied before a specific diagnosis
can be arrived at. However, in reality, Professor Tyrer argued, clinicians do not use the general
criteria, they tend to jump straight
to the specific diagnoses. In DSMIV-TR a person is determined to
have a specific diagnosis if they ful-
fil a specific number of criteria. In
other words, said Professor Tyrer,
there is in effect a cut-off point
between having the disorder and
not having it, which just does not
reflect the real world situation.
The symptoms of personality disorder, like so many psychiatric disorders, exist on a continuum. It is
the severity of symptoms that
changes from individual to individual, not whether they exist or
not: ever yone exhibits some
aspects of the symptoms of personality disorder.
Currently there are 11 different
personality disorders in the
DSM/ICD classification systems.
Professor Tyrer argued that the criteria for arriving at these 11 different diagnoses are not supported by
good empirical evidence. ‘They
are committee diagnoses,’ he contested. It appears that DSM-5 will
Progress in Neurology and Psychiatry May/June 2012
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Keynote Lecture z
Latest Advances in Psychiatry Symposium XI
Proposed for ICD-11
After Hippocrates and Galen
Externalising (sociopathic)
Internalising (neurotic)
Schizoid
Anankastic
Choleric; yellow bile humour
Black bile humour
Phlegmatic humour
Sanguine humour
Table 1. Personality disorder trait domains and their historical equivalents
continue in this vein with criteria
for six specific personality disorder
types. But these will be qualified by
37 personality traits. Some clinicians feel it will take at least a threehour inter view to diagnose
someone with personality disorder
properly using this system. It would
be preferable to have something
that is easy to understand and that
can be used fairly easily so it is clinically useful. Professor Tyrer hopes
ICD-11 might do something to
improve matters.
A key issue, particularly perhaps for British psychiatrists, is
whether personality disorder
should be regarded as a mental illness or not. Kendell noted in the
British Journal of Psychiatry in 2002:
‘If personality disorders are not to
be regarded as mental illnesses
despite their undisputed relevance to psychiatric practice, the
obvious alternative is to regard
them as risk factors and complicating factors for a wide range of
mental disorders, in much the
Traits characterised by social
indifference, aloofness,
introspection, reduced
expression of affect, suspicion
and lack of empathy
Schizoid domain
Traits characterised by
over-conscientious behaviour,
excessive orderliness,
perfectionism, inflexibility and
cautiousness
Anankastic domain
Traits characterised by
irresponsibility, antagonism and
lack of regard for the needs of
others, and by aggression and
anger, insensitivity or callousness,
deceit, and egocentricity
Externalising domain
Traits characterised by
anxiousness, lack of selfconfidence, poor self-esteem
and self-worth, shyness, timidity,
dependence on others and
reluctance to make decisions
Internalising domain
Figure 1. Summary of personality trait domain characteristics
26
Progress in Neurology and Psychiatry May/June 2012
same way that obesity is a risk factor for diabetes, myocardial infarction, breast cancer, gallstones and
osteoarthritis, and complicates the
management of an even wider
range of conditions.’3
Professor Tyrer argued, ‘We
have to make a clear distinction
between personality traits, which
are habitual long-lasting tendencies, and which are part of normal
functioning (ego-syntonic), and
symptoms, which are unpleasant
and regarded as alien and undesirable (ego-dystonic).’
Preliminary recommendations
for ICD-11 are to abolish all individual categories of personality disorder and replace them with four
severity levels. Severity should be
qualified by trait domains and
there should be no age limits. The
trait domains should remain secondary and not be regarded as primar y as they often seem to be
currently.
Professor Tyrer commented
that the proposed trait domains
were not exactly new. They correspond by and large to those
described by Hippocrates in
422BC and Galen in 192AD (see
Table 1). Under the proposed system for ICD-11, trait domains
would be defined by monothetic
rather than polythetic criteria such
that all criteria must be present for
each specific trait (see Figure 1).
Severity would be determined by
the number of domains involved
(the more domains involved the
greater the severity), by the degree
of social dysfunction and the risk
to the individual and to others (see
Table 2).
Borderline personality disorder
Professor Tyrer stressed he was
keen to avoid including the classification borderline personality disorder under the proposed new
diagnostic criteria. Under the current diagnostic criteria it is such an
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Latest Advances in Psychiatry Symposium XI
• No personality disturbance
• Personality difficulty
• Personality disorder
• Complex personality disorder
• Severe personality disorder
Table 2. Severity categories proposed for
ICD-11
amorphous, heterogeneous group
that almost anyone diagnosed with
personality disorder could be classified as borderline, he said. Under
the proposed criteria for ICD-11
people currently classified as having borderline personality disorder would fulfil criteria for
internalising and externalising
trait domains.
Professor Tyrer has previously
argued (although he admitted
that his was a minority view) that
borderline personality disorder
would be ‘better classified as a
condition of recurrent unstable
mood and behaviour, or fluxi thymia’.4 The problem is that borderline personality disorder is the
most common type of personality
disorder and those individuals so
classified are most likely to seek
treatment and are most likely to
be included in clinical trials.
Indeed, of the few good-quality
randomised trials of pharmacotherapy for personality disorder
that have been done in the past 20
years almost all have involved individuals with borderline personality disorder. In addition, most of
the trials have been judged by
NICE to be low quality. 5 The
other problem that besets
researchers tr ying to discover
whether treatment for personality
disorder works or not is that there
is a lack of consistency in outcomes used, which makes metaanalysis difficult, Professor Tyrer
commented.
The lack of a strong evidence
base may explain the current lack
of consensus about the use of pharmacotherapy for personality disorder. So although the current NICE
guideline does not recommend
drug treatment, some evidence is
z Keynote Lecture
emerging that mood stabilisers, for
example, may have some benefits.
However, that needs to be confirmed in trials with satisfactor y
long-term outcomes, Professor
Tyrer concluded.
References
1. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders
(4th edn. text rev). Washington, DC. 2000.
2. World Health Organization. International
Statistical Classification of Diseases and
Related Health problems, Tenth Revision.
Geneva, 2010.
3. Kendell RE. The distinction between personality disorder and mental illness. Br J
Psychiatry 2002;180:110-5. Available at
http://bjp.rcpsych.org/content/
180/2/110.full (accessed April 2012).
4. Tyrer P. Why borderline personality disorder
is neither borderline nor a personality disorder. Personality and Mental Health 2009;3:
86-95.
5. NICE (2009) Borderline Personality Disorder:
Treatment and Management. NICE clinical
guideline 78. Available at www.nice.org.uk/
CG78 (accessed April 2012).
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