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ProfessorTyrerLAPKeynote_Layout 1 30/05/2012 11:45 Page 1 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 www.progressnp.com 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 25 ProfessorTyrerLAPKeynote_Layout 1 30/05/2012 11:45 Page 2 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 www.progressnp.com ProfessorTyrerLAPKeynote_Layout 1 30/05/2012 11:45 Page 3 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). Visit us online Visit www.progressnp.com to view the slide set for Professor Tyrer’s Keynote Lecture. Visit us online Progress in Neurology and Psychiatry’s dedicated website www.progressnp.com has been redesigned and now features news, events diary, links to continuing professional development resources and journal supplements. More new features will be appearing over the coming months. www.progressnp.com