MAUDSLEY DISCUSSION PAPER NO. 7
Should Psychiatrists Treat
Personality Disorders?
Paul Moran
Institute of Psychiatry, King’s College, London
ABSTRACT
Personality disorders are among the most controversial of all psychiatric conditions.
In the aftermath of some highly publicised tragedies involving people with a diagnosis
of personality disorder, the government seems determined to increase the powers of
psychiatrists to treat people with personality disorders. However, within the
profession there is a great deal of ambivalence about whether personality disorders
constitute medical conditions at all. In this discussion paper, evidence for and against
the proposition that psychiatrists should treat personality disorders is considered.
The case in favour is that recently there have been some promising findings from
clinical trials to suggest that, both psychotherapeutic and pharmacological treatments
are helpful in dealing with the behavioural disturbance associated with some
personality disorders. There is also evidence to show that some personality disordered
people gain benefit from a day care programme. Finally, the psychiatrist’s ability to
formulate and negotiate puts him or her in a good position to help manage this
difficult group of people, who are unlikely to be helped by another section of society.
The case against is that there are dangers in taking a psychiatric paradigm of deviant
behaviour too far. The term personality disorder, is a way of applying an
inappropriate medical model to personality variation and has created major difficulties
in defining the role of the psychiatrist. Moreover, the diagnosis is unreliable, lacks
validity and is often merely used as a way of describing people whom the doctor
dislikes. There are no specific medical treatments for underlying personality
disturbance and resources for the treatment of mental illness are already limited.
In conclusion, society is always likely to generate people who do not conform and
psychiatry is in a position to help some of these people. Psychotherapeutic
interventions have been shown to be the most effective intervention for modifying
some forms of difficult behaviour displayed by people with personality disorders.
These treatments require time and special expertise and should be delivered by
specialist treatment facilities. Personality disordered offenders do not fit neatly into
either the health or penal systems. A third service, within the penal system, but with
input from the health service, may go some way towards providing the necessary
containment and treatment for these people.
1
Background
‘As you know, I am very much interested in patients of this sort and feel that
they are the least understood of all psychiatric patients. I also feel that unlike
other psychiatric patients there is no specific provision made by society for
handling them adequately or dealing logically with the problems they create’
Hervey Cleckley, The Mask of Sanity (1941)1
Recent events
There is an expectation on the part of the public that psychiatrists should be able to
protect it from serious violence. However, if media reports are to be believed, it
seems that they are not particularly successful at doing this. The fact that it is very
difficult to predict a rare event, such as murder, does not seem to pacify anyone.
Crime is perceived to be on the increase and the perennial anxieties about violent and
sexual offences have been heightened by several highly publicised crimes committed
by people with abnormal personalities. In 1998, the conviction of Michael Stone
(who was diagnosed as having an ‘untreatable’ antisocial personality disorder) for the
brutal murders of Lin and Megan Russell provoked public outrage2. This led the
government to respond with a bitter attack on psychiatry for failing in its role to
protect the public. The press demanded ‘new laws’ to prevent other ‘monsters’ like
Stone from killing and the Home Secretary publicly argued that, by invoking the
treatability test in the English Mental Health Act, psychiatrists were absolving
themselves from the duty of providing health care.
2
By way of an unhappy coincidence, shortly after Stone’s conviction, the Fallon
Inquiry into Ashworth Hospital’s Personality Disorder Unit produced a damning
report3 detailing a catalogue of problems in the unit, including a regime which allowed
unimpeded drug misuse and the distribution of pornographic material to patients. Yet
again, psychiatrists were blamed for failing to manage properly personality disordered
patients.
In the light of these events, the government announced its own proposed ‘solution’ to
the problems presented by people who are ‘dangerously personality disordered’4.
These included the indeterminate reviewable detention of personality disordered
patients and the introduction of a ‘third service’ for offenders with severe personality
disorders.
Whether or not the proposals become law, there remains a growing
expectation that psychiatrists should be taking greater responsibility for people with
personality disorders and especially for those considered to be dangerous to others.
Professional Ambivalence
Psychiatry has a long tradition of ambivalence towards the personality disorders and
there is no shortage of quotations from psychiatrists on this topic, for example:
‘(Personality disorder) is a concept like body odour. . . indubitably affected
by
constitution and environment, a source of distress to both sufferer and
society,
yet imbued with ideas of degeneracy and inferiority so that its
possession is also a personal criticism.’
Tyrer & Ferguson (1988)5
3
The problems inherent in predicting dangerous behaviour, the current climate of
blame towards psychiatrists, and government plans to force psychiatrists to take
greater responsibility for difficult people, understandably have all led to anxieties and
questions within the medical profession about its role in the management of people
with personality disorders. It is therefore timely to consider whether psychiatrists
should be involved in the treatment of personality disorders. In doing so, it is not
disputed that doctors should treat mental illness in people with abnormal personalities.
Rather, the issue for discussion is whether doctors should adopt a treatment approach
to the underlying personality disturbance.
There is a good deal of confusion regarding the terminology surrounding the
personality disorders. The terms ‘personality disorder’, ‘psychopathy’ and ‘severe
personality disorder’ are often used interchangeably and incorrectly so. Therefore,
before embarking on the main debate, it is important to clarify some of these terms.
The current definition and classification of personality disorders
The term ‘personality’ has been described as one of the most abstract words in our
language. However, attempts have been made to define the term and there is now
some consensus as to what it means. DSM-IV6 defines personality traits as enduring
patterns of perceiving, relating to, and thinking about the environment and oneself that
are exhibited in a wide range of important social and personal contexts.
There are two current operational definitions of personality disorder. ICD-107 defines
a personality disorder as: ‘a severe disturbance in the characterological condition
and behavioural tendencies of the individual, usually involving several areas of the
4
personality, and nearly always associated with considerable personal and social
disruption’. The DSM-IV definition is very similar: ‘an enduring pattern of inner
experience and behaviour that deviates markedly from the expectations of the
individual’s culture’. ICD-10 recognises eight categories, whilst DSM-IV recognises
ten and these are all listed in Table 1.
The DSM-IV system also groups the
personality disorders into three clusters: Cluster A, characterised by odd or eccentric
behaviours; Cluster B, characterised by dramatic or flamboyant behaviours, and
Cluster C, characterised by anxiety or fear. The clustering system is largely derived
from empirical work, although there is some support for the system from factor
analytic studies of normal and personality disordered populations.
Some of the
categories, for example, paranoid personality disorder are very old and demonstrate
descriptive continuity over thousands of years.
Others, such as narcissistic and
schizotypal are more recent additions, and there is less agreement about their
nosological status.
The personality disorders are a heterogeneous group of conditions with some types
attracting more concern than others. General practitioners most frequently encounter
people with cluster C disorders (in particular, anxious and dependent) whose
management can be very time-consuming. In contrast, because of their association
with antisocial behaviour and deliberate self harm, the cluster B personality disorders
(the dramatic and flamboyant group) cause the most concern to psychiatrists. It is
people with these disorders, particularly if associated with persistent violent
behaviour, who are at the centre of the current debate about treatment or confinement.
These people are the focus of this discussion.
5
The concept of ‘severe personality disorder’
Recently there has been a tendency to refer to offenders with abnormal personalities as
having ‘severe personality disorders’. The notion of grading severity of personality
disturbance is not new - psychiatrists have long recognised that the amplification of
certain personality traits may make an individual more vulnerable to stress. However,
the term ‘severe personality disorder’ originates from a rating scale developed by
Tyrer & Johnson8. This grades severity from ‘no personality abnormality’ through to
‘diffuse personality disorder’ in terms of the numbers of personality disorder
diagnoses present within an individual. ‘Severe personality disorder’ has been added
to cover those individuals whose behaviour is characterised by ‘gross societal
disturbance’. The main problem with the term is that many have chosen to use it out
of context and as a synonym for psychopathy or even dangerousness. Thus, in a
recent statement to the House of Commons4, the Home Secretary conflated the issues
of ‘severely personality disordered’ with dangerousness to others. If the term is to be
used at all, its meaning should be explicitly defined.
Psychopathy and ‘psychopathic disorder’
‘Psychopathy’ is one of a number of terms used to describe abnormal personality.
However, the terms psychopathy and personality disorder are by no means
synonymous. The term originated in the late nineteenth century but was resurrected
6
Table 1. The Current Classification of
Personality Disorders
DSM-IV
ICD-10
Cluster A
Paranoid
Paranoid
Schizoid
Schizoid
Schizotypal
Cluster B
Antisocial
Dissocial
Emotionally unstable:
a) Impulsive type
Borderline
b) Borderline type
Histrionic
Histrionic
Narcissistic
Cluster C
Avoidant
Anxious
Dependent
Dependent
Obsessive-Compulsive
Anankastic
N.B. Shaded boxes indicate that there is no equivalent of the disorder in that particular
classification scheme.
7
by Cleckley1, who described the central features of ‘the psychopath’: superficial
charm, lack of anxiety, lack of guilt, undependability, dishonesty, egocentricity,
failure to form lasting intimate relationships, failure to learn from punishment, poverty
of emotions, lack of insight into the impact of one’s behaviour upon others, and
failure to plan ahead.
More recently, Hare9 has applied these characteristics to a series of prisoners and
developed the Psychopathy Checklist (PCL), which he believes can be used to
measure a syndrome of ‘psychopathy’. Individuals who score highly on the PCL have
usually met criteria for several personality disorder diagnoses (usually cluster B
personality disorders) and invariably qualify for a diagnosis of antisocial personality
disorder. Although the Hare definition of psychopathy has received enthusiastic
support in North America, it is not without its critics. It is too close to a moral
concept and appears to be no more than a disguised attempt to study evil scientifically.
Clinically, the term psychopathy is probably best avoided, as it can be a pejorative
label which may not refer to a single category of identifiable individuals.
‘Psychopathic disorder’ is one of four specific legal categories of ‘mental disorder’ on
the basis of which a patient may be compulsorily admitted to hospital. The 1983
Mental Health Act of England & Wales defines psychopathic disorder as:
“ A persistent disorder or disability of mind (whether or not including
significant impairment of intelligence) which results in abnormally
aggressive or seriously irresponsible conduct.”
8
A ‘treatability’ proviso has been added within the Act, so that a patient should not be
detained in hospital for treatment, unless it can be stated that medical treatment is
likely to alleviate or prevent a deterioration in the condition. The treatability criterion
has been at the heart of the present Home Secretary’s recent attack on psychiatrists’
management of people with personality disorders.
The majority of psychiatrists have long been unhappy with the term ‘psychopathic
disorder’ and it seems not unlikely that new English Mental Health legislation will
remove the category ‘psychopathic disorder’ from the Act. It is a medical/legal hybrid
term which has generated much confusion for both lawyers and doctors - it does not
correspond to a single group of patients and lacks legal clarity, leaving it open to
inconsistent interpretation. It is perhaps for these reasons that it has been used rarely
as a means of achieving the compulsory admission of people to hospital. Between
1990 and 1995 there were only 101 formal admissions to psychiatric hospital under
the legal category of Psychopathic Disorder. This contrasts with 10,099 for Mental
Illness10.
The Burden of Personality Disorders
Personality disorders exact a heavy burden on the individual and society.
Epidemiological research conducted over the past twenty years11 has shown that
people with personality disorders (particularly those with an antisocial personality
disorder) have a wide range of psychosocial problems which include:
9
•
Early unnatural death through higher rates of suicide and accidents
•
High rates of associated mental illness - in particular, substance abuse,
eating disorders, depression, and anxiety
•
Worse outcome for the treatment of mental and physical illness leading to
high service utilisation and the ‘revolving door phenomenon’
•
High rates of family disharmony and violence
•
High rates of crime
•
High rates of unemployment and homelessness
The size of the problem
Research from North America and Germany shows that between 10% and 13% of
people in the community have a personality disorder according to a structured
interview12.
About 2-3% of the community are estimated to have an antisocial
personality disorder according to DSM-III criteria.
The majority of epidemiological research has been conducted in psychiatric settings.
Studies of consecutive psychiatric outpatients indicate rates as high as 40% and
among inpatients rates rise to 60%, with the most common subtype being borderline
personality disorder12.
The highest rates of personality disorders are found among prisoners; the recently
completed ONS survey of psychiatric morbidity among prisoners in England and
Wales found that the prevalence rate of personality disorders was almost 80% in the
remand population, with antisocial personality disorder having the highest prevalence
10
rate13. Is psychiatry in a position to meet the challenges posed by these figures in
terms of service delivery?
The Case In Favour Of Psychiatrists Treating Personality Disorders
The Prospect Of Change
There is a long-standing belief in psychiatry that personality disorders are impervious
to treatment. Unfortunately, this opinion becomes a self-fulfilling prophecy, when the
diagnosis is used to justify pessimism about outcome and to withhold treatment from
a difficult person. The reason personality disorders are traditionally considered to be
resistant to treatment, can be found in their definition as enduring and persistent
problems. However, recent research into personality disorders rather contradicts this
assertion.
Over the past fifteen years, a number of long term follow-up studies of cohorts of
personality disordered patients (largely borderline and antisocial personality disorder)
have been carried out in North America.
The more notable among these have
included the PI-500 study14, a large follow-up of general hospital patients15, and a
three year prospective study of borderline patients16. These studies show that the
social functioning, psychiatric symptoms and personality characteristics of some
people with borderline personality disorder, may improve with time. However, the
subjects in these studies have all had some form of concurrent treatment and it is,
therefore, not clear which aspect of treatment led to the improvement.
11
The Search For Specific Treatments
Personality disorder treatment research is not a new activity - there are reports in the
literature dating back to the late 1950s. However, many of the early treatment trials
used highly selected and heterogeneous samples of patients. The introduction of
operational criteria and specific instruments to screen for personality disorders has
improved research.
Yet, no treatment has been found which radically alters
personality structure. Also, as the concepts of relapse and remission have a somewhat
dubious meaning when applied to personality disorders, most studies have chosen to
focus on symptomatic behaviours and global levels of functioning as their main
outcome variables.
Pharmacological treatments
A number of placebo controlled trials have shown that, used judiciously, a variety of
psychotropic agents (particularly low dose neuroleptics and antidepressants) may help
relieve the distressing neurotic and affective symptoms associated with borderline and
schizotypal personality disorders17. In addition, a number of recent clinical trials have
found that use of an SSRI antidepressant may reduce aspects of impulsive aggressive
behaviour (specifically verbal aggression and aggression against objects) in subjects
with a variety of personality disorders18.
Psychotherapeutic Treatments
A variant of cognitive behavioural therapy, dialectical behaviour therapy (DBT), is
emerging as a potentially powerful intervention for reducing parasuicide in patients
with borderline personality disorder.
The treatment, which was developed by
12
Linehan, is eclectic and uses a combined motivation/capability deficit model of
personality disorders. A randomised, one year, controlled clinical trial of DBT found
that it was more effective than standard treatment in reducing the frequency and
severity of parasuicide episodes and the number of psychiatric inpatient days in a
group of 26 chronically suicidal women with borderline personality disorder19. In
addition, patients who had DBT did significantly better on measures of anger and
interviewer rated global social adjustment. However, strangely, the treatment seemed
to have little effect on measures of depression, hopelessness, suicidal ideation or
reasons for living. The gains were all maintained during the one year follow-up. In
view of the absence of lengthier follow-up data, it is unclear whether the benefits of
DBT are sustained.
Therapeutic communities (TC) have a long tradition of helping personality disordered
patients dating back to World War II. Under the TC system, staff and patients share
responsibility for running the community and patients actively participate in their own
treatment. The treatment takes the form of psychotherapy, usually in a group setting.
Membership of the community and engagement in therapy is voluntary, although TCs
have been provided in prison settings, such as Grendon Underwood Prison. In a major
review of treatment studies of antisocial personality disorder, Dolan and Coid20 found
that therapeutic community treatment showed “the most promising results of any
treatment modality” for the disorder. Research from therapeutic communities, most
notably, the Henderson Hospital, has shown significant reductions in neurotic
symptomatology, service usage and costs following specialist treatment. However,
there have not been any adequate randomised controlled trials of TC.
13
The Setting For Treatment
There has been a general belief that personality disordered patients ‘do not do well in
hospital’. However, contrary to perceived clinical wisdom, recent research suggests
that brief time-limited admissions to hospital, may in fact be of benefit to the
personality disordered patient in crisis.
In a randomised controlled trial of one
hundred psychiatric emergency cases allocated to community or hospital-based
services, patients with personality disorders (50% of the patient group) showed greater
improvement in depressive symptoms and social functioning when referred to the
hospital-based service21.
The short-stay hospitalisation approach also has its
advocates in North America.
A recent randomised trial has shown that psychodynamically informed day hospital
treatment for borderline personality disordered patients is beneficial. It produced
greater improvement in depressive symptoms, a decrease in deliberate self harm and
better social functioning at 18 months, in the day hospitalised group, compared to the
group receiving standard psychiatric care22.
Treatment or Management?
In order to ensure the highest standard of care for patients, the practice of medicine
has become evidence based, and increasingly intolerant of treatments which lack
support from clinical trials. However, the current preoccupation with finding effective
treatments may have distanced doctors from their other traditional roles of relieving
suffering and providing comfort. The work of psychiatrists involves assessing and
managing difficult situations in a multidisciplinary context, using a combination of
drug and psychological treatments and social manipulation. Doctors may not have
14
found a way to radically alter personality structure, but they do have the ability to
build supportive relationships with a group of difficult, distressed and usually isolated
people who simply do not conform to society’s rules.
15
The Case Against Psychiatrists Treating Personality Disorders
Behavioural disturbance equals mental disorder: a logical fallacy
Mental disorder usually declares itself socially by behavioural disturbance.
For
example, episodes of violent behaviour may occur in the context of severe mental
illness. However, not all behavioural disturbance is caused by mental disorder. While
some forms of it are best explained by a psychiatric paradigm, the majority of such
disturbance, including much of criminal behaviour, has other explanations, for
example sociological and political. To conclude otherwise is to fall into the logical
fallacy that because all sheep have four legs, therefore all four-legged animals are
sheep.
Unfortunately, psychiatrists have added to the confusion by invoking
biopsychosocial explanations for many of society’s problems. This is particularly the
case with the personality disorders which have been used as a convenient medical
explanation for persistent violent behaviour.
The danger of this, in relation to
delinquent behaviour, is that the term ‘personality disorder’ is used to replace
concepts of moral or legal responsibility.
The risks of taking the psychiatric paradigm too far
Since the time of Schneider23 the definition of personality disorders has stressed that
these conditions should be judged by their effects on society. As Tyrer et al24 have
pointed out, this is particularly unsatisfactory when the society from which the
definition of normative behaviour is derived is itself abnormal:
‘Using Schneider’s definition literally, Heinrich Himmler and Hermann Goering had
normal personalities between 1933 and 1943, and Andre Sakharov and Nelson
16
Mandela are personality disordered, since they have caused suffering to themselves
and others through trying to reform the widest manifestations of society, the state’.
The strong emphasis that the definition of personality disorders places on societal
effects makes it potentially vulnerable to misapplication. History is unfortunately
littered with examples of the misuse of psychiatric labels in order to achieve social
control, for example, the psychiatric incarceration of political dissidents in the former
Soviet Union.
Problems With The Categorical Model of Personality Disorders
Within medicine, there has been a long tradition of categorising abnormal personality,
and there continues to be a reliance on simplified and prototypical descriptions of
personality pathology. While such descriptions vividly convey patients’ flaws (with
words such as ‘shallow’ ‘aggressive’, ‘cold’, or ‘manipulative’), they fail to capture
the subtleties and contradictions inherent in human nature. Indeed a large amount of
research has shown that the categorical model of personality is inaccurate:
•
Population based studies of the distribution of personality traits have
failed to demonstrate bimodality or points of rarity25.
•
The diagnostic criteria for personality disorder subtypes considerably
overlap and there is substantial covariation among personality disorder
diagnoses26.
•
Studies examining the functional disability associated with a diagnosis of
personality disorder indicate that disability is a continuous variable27
17
A dimensional model of personality is in fact likely to be more accurate and indeed
research has shown that personalities vary across at least five dimensions: (i)
neuroticism (ii) extroversion (iii) openness to experience (iv) agreeableness and (v)
conscientiousness28.
Problems With The Classification of Personality Disorders
The current taxonomy for personality disorders has been criticised for its lack of a
coherent theoretical framework. An absence of knowledge about aetiological factors,
means that there is a total reliance on descriptive features - a situation rather akin to
the pre-Sydenham era in medicine, when fever and rashes were studied as separate
diseases. The problem is of course not unique to psychiatry. However, of all the
mental disorders, the classification of personality disorders is probably the least
satisfactory, borrowing elements from psychoanalysis (borderline and narcissistic),
phenomenology (schizoid and anankastic), genetics (schizotypal) and behavioural
psychology (anxious/avoidant).
It is therefore hardly surprising that descriptions
overlap and mixed categories of personality disorder are the rule rather than the
exception.
Problems With The Diagnosis Of Personality Disorder
In addition to having a weak conceptual foundation, personality disorders are difficult
to diagnose.
Firstly, they are usually diagnosed in an interpersonal context and
consequently unlike symptom states, one cannot reliably use an individual’s own
baseline to generate estimates of the degree of abnormality. Secondly, there is good
evidence to show that although personality disorders are by definition enduring, they
fluctuate considerably with the presence of mental illness. For example, hypomanic
18
patients may behave histrionically and depressed patients may behave in a dependent
fashion.
Finally, there are gender and sociocultural biases which threaten to
contaminate the assessment of personality.
When using a diagnosis, one should be confident that a similarly competent doctor
would come to the same conclusion about the patient (i.e. that the diagnosis can be
made reliably) and that the diagnosis allows one to make predictions about the
patient’s functioning (i.e. that the diagnosis has adequate predictive validity).
Unfortunately the diagnosis of personality disorder fails badly on both these counts.
Studies of the reliability of the clinical assessment of personality disorder have shown
that the agreement between clinicians’ diagnoses of personality disorder is often no
better than chance29, although the use of a standardised instrument does improve the
situation. There is, however, poor agreement between various instruments, even when
they are measuring the same diagnostic criteria. It is not even clear whether the
patient or an informant constitutes the best source of information for personality
assessment. Also, because there is a paucity of longitudinal data on the personality
disorders, the predictive validity of the diagnosis is uncertain.
Even worse, there is evidence to suggest that not only does the diagnosis lack
adequate reliability and validity, but that it is a label applied to patients whom doctors
dislike. In a study in which 240 psychiatrists were asked to read case vignettes,
patients with an identical history, but given a previous diagnosis of personality
disorder in the vignette, were rated as more difficult, annoying, attention-seeking, and
less deserving of care compared with control subjects30. The diagnosis therefore
19
seemed to be no more than a negative value judgement which was used to justify
therapeutic nihilism.
Limited Resources
Epidemiological surveys indicate that personality disorders are very common
conditions with the highest prevalence rates of cluster B personality disorders being
found among prisoners. However, defining a large proportion of the population as
sick on the basis of social deviance creates major logistical problems for psychiatrists
who are then left to deal with the considerable responsibility of caring and treating
these ‘sick’ individuals.
Psychiatry is currently experiencing difficulties in recruiting and retaining doctors.
Clearly, there are many possible explanations for this. However, forcing doctors into
the essentially coercive role of modifying socially deviant behaviour and then blaming
them when things go wrong, is hardly an attractive prospect for the would-be
psychiatrist. Indeed, over twenty years ago, Schwartz & Schwartz31 warned of the
damaging effects of forcing psychiatrists ‘into a role which is completely out of
character with the traditional healing role of physician and has more in common
with that of gaoler.’
Staff working in general psychiatric settings commonly experience stress and burnout. Unacceptably high case loads, the ever-present threat of potential violence and
the current climate of scapegoating when things go wrong, conspire to make
professional life difficult for even the most seasoned of health professionals. People
with personality problems show their main difficulties in their interactions with others
20
and are therefore often the most difficult people to be encountered in clinical practice.
They do not readily reward health professionals and often intrude directly on their
feelings. Indeed, the emotional impact on staff which may occur when working with
these people is well documented and ranges from anxiety to sudden unexpected anger
and exhaustion. In this era of high stress and limited resources, why would anyone
choose to make difficult people into patients when there are no reliable symptoms and
no adequate treatments?
21
Conclusions
The need for greater diagnostic precision
Personality disturbance can be conceptualised categorically or dimensionally. The
debate about which of these models is superior has been well-rehearsed over several
decades and remains unresolved. There are, however, considerable problems with the
diagnostic label of personality disorder. In particular, evidence has been reviewed
which shows that it is an unreliable clinical diagnosis which is potentially harmful to
patients. Thus, it is not a diagnosis to be used carelessly. Psychiatric labels have their
limitations and the tendency to overuse them has had unfortunate consequences for
patients and the profession.
In a busy clinical environment, the diagnosis of personality disorder is usually arrived
at by a haphazard process of exclusion. Often the most powerful factor to influence
whether the diagnosis is made, is whether a patient is liked or not. This is simply not
good enough. There are operational criteria for the personality disorders and these
should be strictly applied before the diagnosis is made.
A number of reliable
standardised assessment procedures for personality disorders now exist and ideally,
one of these should be used as part of routine clinical assessment. Indeed a recently
published report on personality disorders by the Royal College of Psychiatrists32 went
further than this. It concluded that psychiatric trainees should receive routine training
in the assessment of personality disorders, including the teaching of standardised
interviewing techniques.
22
The treatment of personality disorders
Personality is an enduring phenomenon and is therefore, by definition, relatively
immutable to change. Personality disorders represent extreme variants of normal
personality and therefore the ‘core personality’ in these disorders is also likely to be
resistant to change. Thus, any change which occurs will be limited to behaviour
symptomatic of the underlying disorder. In addition, it is worth emphasising that the
personality disorders are a heterogeneous group of conditions, with differing
aetiologies and which therefore require different treatment approaches. Currently,
knowledge about these conditions is limited, as is the ability to treat them.
Evidence has been presented which shows that some of the behavioural manifestations
of certain personality disorders are amenable to treatment. The majority of research
has been directed at borderline personality disorder and there is evidence to suggest
that it may be possible to reduce repetition of deliberate self harm in some patients
with this disorder.
The treatments which have proven to be most effective in
modifying deliberate self harm are psychotherapeutically informed and require special
expertise and time.
Psychotherapy units already undertake some of this work,
although the patients seen in these units tend to be highly selected. Patients with more
severe behavioural problems require assessment and treatment in a specialist facility
where the staff are sufficiently skilled and interested to deal with them. The reviewed
evidence suggests that treatment facilities adopting a day hospital model of care are
likely to be more successful in changing behaviour. Brief time-limited admissions to
hospital may also be occasionally helpful. However, the ability to treat complex
behavioural problems, is still at an experimental stage and specialist treatment
facilities should be actively researching their patient populations.
23
Who should take responsibility for personality disordered offenders?
Psychiatrists often deal with seriously mentally ill patients who temporarily show
violent behaviour. Therefore, the popular view is that they must be experts in dealing
with all violence. However, to conclude this is to ignore the fact that violence and
particularly violent crime, have as much to do with social factors as they do with
psychological ones.
The tragic events surrounding the Stone case2 highlight the
reality that doctors are no better than anyone else when dealing with this unpredictable
problem. The government has made a serious error if it assumes that with its limited
body of knowledge, psychiatry is able to deal with a societal problem, such as
persistent violence, under the guise of treating a personality disorder compulsorily.
It should not be forgotten that by definition, crime is a social construct and not a
medical one.
Therefore, people who break the law should be primarily the
responsibility of the criminal justice system and not doctors. It would be tempting to
end the discussion here. However, offenders with abnormal personalities do not adapt
to the penal system any better than they do to health care. Personality disordered
offenders pose great management problems to prison staff with repeated deliberate
self harm and additional offences. In addition, it has been shown that some people
with abnormal personalities can be helped with psychotherapy and drug treatments.
They are unlikely to receive this help in prison. Whilst Grendon Underwood Prison is
an example of the application of a therapeutic approach to personality disordered
offenders within the penal system, there are few special facilities like Grendon.
The Committee of Inquiry into the Personality Disorder Unit at Ashworth Hospital
suggested a possible solution to the management of personality disordered offenders3.
24
It proposed that the Department of Health and the Home Office develop a new third
service within prisons and High Security Hospitals. The service would consist of
small units for personality disordered offenders where prison rules would be in force
to maintain security, but be combined with an enhanced therapeutic input, provided by
the Health Service. If they were properly resourced, such units could provide the
right mixture of containment and treatment. However, the Committee also expressed
reservations about the proposed third service. These included, the creation of a new
bureaucracy, and the problem of attracting good staff. Although the notion of a third
service is in many respects appealing, it is likely that in whatever setting they find
themselves, personality disordered people are always likely to be difficult to manage.
A neat ‘solution’ to the problems posed by these difficult people is therefore likely to
remain elusive.
Society is always likely to generate people who do not conform and psychiatry is in a
position to help some of them. However, over thirty years ago, in contemplating the
“prospect of splendid new empires” for medicine, Barbara Wootton33 offered this
salutary reminder of the greater obligation that society has to these non-conformers:
“Let us not forget that all our misfits, failures, and deviants. . . . are in their several
ways attempting to register protests against the demands or the values of the world in
which they have to live. To treat those protests as symptomatic of mental disorder is
a subtle device for drawing their sting - and one which the merits of the society
against which those protests are directed cannot be said to justify.”
25
Acknowledgements
I am grateful to the following individuals for giving up time to share their thoughts
with me on the subject of personality disorders: Dr Mike Crawford, Dr Tom Fahy,
Professor Sir David Goldberg, Professor John Gunn, Professor Rachel Jenkins,
Professor Anthony Mann, Dr Emanuel Moran, Dr Steve Pearce, Professor Simon
Wessely.
In particular, I should like to thank Dr Crawford, Professor Goldberg, Professor Mann
and Dr Moran for their comments on an earlier draft of this paper.
26
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