JRSM >
Volume 97, Number 8 >
Pp. 371-374
Department of Psychological Medicine, Imperial College, Claybrook Centre, London W8 8RP, UK
E-mail: p.tyrer{at}imperial.ac.uk
 | INTRODUCTION |
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 TOP INTRODUCTION EXISTING CLASSIFICATION AND...WHAT IS IMPORTANT FOR...CONCLUSIONREFERENCES |
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| EXISTING CLASSIFICATION AND REASONS FOR ITS FAILURE |
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TOPINTRODUCTIONEXISTING CLASSIFICATION AND...WHAT IS IMPORTANT FOR...CONCLUSIONREFERENCES |
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Although the general criteria for diagnosing personality disorder—pervasive pattern of maladaptive traits and behaviours beginning in early adult life and persisting at least to middle age, often improving in old age; conditions leading to significant personal distress and/or social dysfunction and disruption to others—were a reasonable synthesis in the light of knowledge at the time, the description of the individual disorders was awry. It used operational criteria to define ideal or prototypical manifestations that could be regarded as exemplars of each disorder. Two things were wrong with this approach. First, it assumed that personality disorders, conditions assumed to persist over long periods, could be clearly distinguished from normal variation and other mental disorders by this method; and, secondly, it made the mistake of assuming that the Schneiderian personality types were valid. It was an understandable mistake, since we all like to pigeon-hole people into entities that we can identify clearly so as to predict their behaviour. Unfortunately, unlike the characters from Charles Dickens' novels who behave in the same inimitable manner whenever they are encountered, real people are unpredictable and, when disordered, seldom show the 'pure' disturbance specified by the model.
| WHAT IS IMPORTANT FOR THE CLINICIAN TO KNOW ABOUT PERSONALITY AND PERSONALITY DISORDER? |
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TOPINTRODUCTIONEXISTING CLASSIFICATION AND...WHAT IS IMPORTANT FOR...CONCLUSIONREFERENCES |
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Reliable understandable homogeneous groupings
Since Schneider's time the search for reliable and understandable
groupings has continued but the simple categorical types introduced by him
have proved illusory. Most people with a personality disorder identified by
current diagnostic systems have more than one and, as the problems get more
severe, so do the number of personality
disorders.3 The
reliability of these categories is also poor, and very few ever reach the
agreement level of 
=0.75 or greater that is considered to be the
desirable
minimum.4,5
Two clear messages arise from the work to date: (i) dimensional ratings of
personality are much more reliable than categorical ones; and (ii) the fewer
the groupings the greater the
agreement.6,7
For this reason the notion of clusters of personality disorder has been
generated, in which the main groupings are: cluster A, odd, eccentric
personalities; cluster B, flamboyant, dramatic personalities; cluster C,
anxious, fearful personalities (Table
1). The true psychopathic personality, as described by
Cleckley8 and
refined by Hare,9 is
not included in this system except as an extreme variant of antisocial
personality disorders with an admixture of other
components.10
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Categorical and dimensional approaches operate by splitting the spectrum of personality disorder into four major groups—0=no personality disorder; 1=personality difficulty (or personality accentuation);11 2=simple personality disorder (personality disorder in one cluster only); and 3=complex or diffuse personality disorder (personality disorder in more than one cluster).12 A fourth category can be added for severe personality disorder in which risk and dangerousness are assessed13 (Table 2).
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Aiding clinical decisions
Clinical decisions in the management of people with personality disorders
remain uncertain since it is only recently that personality disorders have
been regarded as suitable for intervention. The most important decision is
when and when not to treat the personality disorder directly. Patients differ
strikingly in their response to the notion that a therapist might wish to
change their personality. Some take great exception to it, whereas others are
eager to embark on any treatment that might make them different from the
people they are. We have suggested that this is a sufficiently important
subject to introduce a new typology into the classification of personality
disorder—that of type R and type S
personalities.14
The main differentiating features of type R (treatment-resisting) and type S (treatment-seeking) personality disorders are shown in Table 3. Patients with type S regard their personalities as alien (i.e. they are egodystonic) and will go to great lengths to effect change. By contrast, those with type R personality disorders are fiercely protective of their personality features and feel it is others, rather than they themselves, who need to change. Our initial studies suggest that most cluster C patients fall into the type S group, schizoid and paranoid personality disordered patients into the type R one,14 but this is not exclusive. As clinical interventions become more widely used in personality disorder, the type R and S typology may assume greater importance. Complex interventions requiring considerable commitment by patients (e.g. dialectical behaviour therapy)15,16 are only likely to be taken on by type S personalities, whereas approaches such as nidotherapy (the systematic adjustment of the environment to fit the abnormal personality17) are much more popular with type R personalities.
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Of the treatments available, only four have clear evidence of efficacy, and all of these are for patients with borderline personality disorder, a heterogeneous group that allows little generalization but which often has a large proportion of type S personalities. The successful treatments (i.e. those with an acceptable evidence base) are (i) a special form of psychodynamic psychotherapy linked to day-hospital care;18,19 (ii) dialectical behaviour therapy, developed by Marsha Linehan in Seattle, for women with borderline personality disorder,15 whose treatment effects have been replicated recently;16 (iii) cognitive–behaviour therapy specially adapted for personality disorder which has been shown to be cost-effective in a large trial of 480 patients;20,21 (iv) antipsychotic and antidepressant drug treatment, in which there is considerable uncertainty about the mechanism of action and choice of disorder suitable for treatment.22 We have no preferred treatments for true psychopathy, and there is some evidence that psychological interventions may be counterproductive.23
To improve prediction and prognosis, and aid research
Until there were accepted treatments for personality disorder it was
reasonable to conclude that the outcome of each disorder was the same as the
natural history of the condition. Now we are beginning to see a pattern in the
natural history of personality disorders that has an important bearing on
treatment. Studies of the outcome of cluster B personality disorders suggest
that antisocial and histrionic personality disorders improve, to the extent
that they are virtually absent in old
age,24 and that
some characteristics of borderline personality disorder, such as
impulsiveness, likewise
improve25 but other
abnormalities such as affective disturbance persist. Obsessional, paranoid and
schizoid personality traits tend to become more pronounced as people approach
middle or old
age.26
| CONCLUSION |
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TOPINTRODUCTIONEXISTING CLASSIFICATION AND...WHAT IS IMPORTANT FOR...CONCLUSIONREFERENCES |
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| REFERENCES |
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TOPINTRODUCTIONEXISTING CLASSIFICATION AND...WHAT IS IMPORTANT FOR...CONCLUSIONREFERENCES |
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