Personality Disorders and Psychopathy

A personality disorder is defined in the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th Edition (DSM-IV), as an enduring pattern of inner experience and behaviour that differs 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. Personality disorders are a long-standing and maladaptive pattern of perceiving and responding to other people and to stressful circumstances.

The International Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organisation 1992), defines a personality disorder as: a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption.

The aetiology of personality disorders remains obscure. Traditional belief is that these behaviours result from a dysfunctional early environment that prevents the evolution of adaptive patterns of perception, response, and defence.¹ There is evidence of a genetic contribution but data is inconsistent.

People with personality disorders are at increased risk for many psychiatric disorders. Mood disorders are a particular risk across all personality diagnoses. Depression with personality disorder has a worse outcome than depression alone.² Some types of mental illnesses are more specific to particular personality disorders.

The ICD-10 gives 9 categories of personality disorder. In DSM-IV there are 10 personality disorders that are divided into 3 clusters, designated A, B, C. They will be used here.

Cluster A

Paranoid personality disorder may present as a prodrome to delusional disorder or frank schizophrenia. There is risk of agoraphobia, major depression, obsessive-compulsive personality disorder and substance abuse. Schizoid personality disorder may precede major depression. Patients with schizotypal personality disorder may develop a brief psychotic disorder, schizophreniform disorder, or delusional disorder. When diagnosed, between 30 and 50% already have major depression, and most have a history of at least one major depressive episode.
Schizoid personality disorder has a slight male preponderance.

Cluster B

Antisocial personality disorder increases the risk for anxiety disorders, substance abuse, somatisation disorder, and pathological gambling. Borderline personality disorder is associated with substance abuse, eating disorders (particularly bulimia), and post-traumatic stress disorder (PTSD). Suicide is a high risk in borderline patients. Histrionic personality disorder is often associated with somatoform disorders. Narcissistic personality disorder increases risk for anorexia nervosa and substance abuse as well as depression.
Antisocial personality disorder is 3 times more frequent in men than in women. Borderline personality disorder is 3 times as common in women as in men. Men account for 50% to 75% of people with narcissistic personality disorder.

Cluster C

Avoidant personality disorder is associated with anxiety disorders, especially social phobia. Dependent personality disorder increases risk for anxiety disorders and adjustment disorder. People with obsessive-compulsive personality disorder may be more liable to myocardial infarction because of their type A lifestyles. They may also be at risk for anxiety disorders.³
Obsessive-compulsive personality disorder occurs twice as often in men than in women.

It is said that personality disorder affects 10% to 13% of the general population with an equal sex ratio, although some forms are more prevalent in one gender or the other. This is so common as to be almost a variation of normal rather than pathological. Many of the features we can possibly recognise in ourselves or others, but often several features are required to make a diagnosis. It is much higher in certain groups and in the prison population there are probably comparatively few who do not have at least one of personality disorder, mental illness, learning difficulties and substance abuse.⁴ International figures must be viewed with caution as the diagnosis is highly dependent upon culture. Figures for prevalence in American society are as follows:

• Paranoid personality disorder - 0.5%-2.5%
• Schizotypal personality disorder - 3%
• Antisocial personality disorder - 3% of men, 1% of women
• Borderline personality disorder - 2%
• Histrionic personality disorder - 2%-3%
• Narcissistic personality disorder - Less than 1%
• Avoidant personality disorder - 0.5%-1%
• Obsessive-compulsive personality disorder - 1%

Personality disorders should not normally be diagnosed in children and adolescents because the development of personality is incomplete and symptomatic traits may not persist into adulthood.⁵ The general guideline is that the diagnosis is unsafe until the person is at least 18 years old. The criteria for diagnosis under DSM-IV are closely related to behaviours of young and middle adulthood. Hence they are unreliable in the elderly.

Personality disorders present with a wide-range of problems in social relationships and regulation of mood. They have usually been like it throughout their adult lives. The patterns of perception, thought and response are fixed and inflexible, although their behaviour is often unpredictable. These patterns do not adhere to their own culture's expectations. To meet the DSM-IV criteria for clinical diagnosis, the pattern must produce clinically significant distress or impairment in social, occupational or other important areas of functioning. The disorder occurs in all settings, social as well as work, and it is not limited to one sphere of activity.

Cluster A

They tend to be odd or eccentric.

Paranoid personality disorder

They display pervasive distrust and suspicion. Common beliefs include:

• Others are exploiting or deceiving them.
• Friends and associates are untrustworthy.
• Information confided to others will be used maliciously.
• There is hidden meaning in remarks or events others perceive as benign.
• The spouse or partner is unfaithful. Pathological jealousy is sometimes called the Othello syndrome.

Schizoid personality disorder

This type of personality disorder is less common in clinical settings.

• They are detached from others and have little desire for close relationships.
• There is little pleasure in activities.
• They appear indifferent to praise or criticism and often seem cold or aloof.

Schizotypal personality disorder

They show marked eccentricities of thought, perception, and behaviour. Typical examples include:

• Ideas of reference (believing that public messages are directed personally at them).
• Odd beliefs or magical thinking.
• Vague, circumstantial, or stereotyped speech.
• Excessive social anxiety that does not diminish with familiarity.
• Idiosyncratic perceptual experiences or bodily illusions.

Cluster B

They tend to be dramatic and emotional.

Antisocial personality disorder

See Antisocial Personality Disorder and NICE guidance.⁶ People with antisocial personality disorder have a pervasive pattern of disregard for and violation of the rights of others and the rules of society. Onset must occur by age 15 years.

Borderline personality disorder

See Borderline Personality Disorder and NICE guidance.⁷ The important feature of borderline personality disorder is a pervasive pattern of unstable and intense interpersonal relationships, self-perception, and moods. Impulses are poorly controlled. At times they may appear psychotic because of the intensity of their distortions. It is a commonly overused diagnosis in DSM-IV.

Histrionic personality disorder

• They also display excessive emotion and attention-seeking behaviour.
• They are quite dramatic and often sexually provocative or seductive.
• Their emotions are labile.
• In clinical settings, their tendency to vague and impressionistic speech is often apparent.

Narcissistic personality disorder

Narcissistic patients are grandiose and require admiration from others.⁸ Features include:

• Exaggeration of their own abilities or achievements
• Sense of entitlement
• Exploitation of others
• Lack of empathy
• Envy of others
• An arrogant, haughty attitude

Cluster C

They tend to be anxious and fearful.

Avoidant personality disorder

• They are generally very shy.
• There is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to rejection.
• Unlike patients with schizoid personality disorder, they do desire relationships but are paralyzed by their fear and sensitivity into social isolation.

Dependent personality disorder

Many people exhibit dependent behaviours and traits but people with dependent personality disorder have an excessive need to be cared for and that results in submissive and clinging behaviour, regardless of consequences. Diagnosis requires at least 5 of the following features:

• Difficulty making decisions without guidance and reassurance
• Need for others to assume responsibility for most major areas of the one's life
• Difficulty expressing disagreement with others
• Difficulty initiating activities because of lack of confidence
• Excessive measures to obtain nurture and support
• Discomfort or helplessness when alone
• Urgent seeking for another relationship when one has ended
• Unrealistic preoccupation with fears of being left to fend for themselves

Obsessive-compulsive personality disorder

• People with obsessive-compulsive personality disorder are markedly preoccupied with orderliness, perfectionism and control.
• They lack flexibility or openness.
• Their preoccupations interfere with efficient function despite their focus on tasks.
• They are often scrupulous and inflexible about matters of morality, ethics and values, to a point beyond cultural norms.
• They are often 'stingy' as well as stubborn.

Physical findings

There are no physical abnormalities to help diagnose personality disorders but there may be findings related to the consequences of various personality disorders.

• Those especially with cluster B disorders, may show signs of intentional self harm or stigmata of substance abuse. There may be scars from self-inflicted wounds.
• Substance abuse is common and may present the physical stigmata of alcoholism or drug abuse.

Mental status

• Patients with histrionic personality disorder may display la belle indifférence, a seemingly indifferent detachment, while describing dramatic physical symptoms.
• A hostile attitude is typical of patients with antisocial personality disorder.
• Patients with cluster B personality disorders, particularly borderline personality disorder, frequently display affective lability.
• Patients with paranoid personality disorder voice persecutory ideation without the formal thought disorder observed in schizophrenia.
• Patients with schizotypal personality disorder speak with odd or idiosyncratic use of language.

Psychological testing may support or direct the clinical diagnosis.

• The Minnesota Multiphasic Personality Inventory (MMPI) is the best-known psychological test.
• The Eysenck Personality Inventory and the Personality Diagnostic Questionnaire are also used.
• The Structured Clinical Interview for DSM-IV for Axis II Disorders (SCID-II) can also be used to aid in diagnosis.

None of these has been reliably validated against DSM-IV diagnoses.

General approach

New guidance from NICE on the treatment, management and prevention of antisocial personality disorder and borderline personality disorder has recently been published.^6,7 It is clear from this guidance that improvements in the care of such patients are expected and that better collaboration, communication and training are required to achieve this improved care. Such an approach can be applied to management of all the personality disorders. A key element in this guidance is the call for better inter-agency communication and collaboration. The treatment of people with antisocial personality disorder must involve a wide range of services including particularly:

• Mental health services
• Substance misuse services
• Social care
• The criminal justice system

Psychotherapy

It used to be taught that psychopaths and personality disorders were untreatable. Psychotherapy is the basis of care for personality disorders. Personality disorders produce symptoms as a result of poor or limited coping skills. Therefore psychotherapy aims to improve perceptions of and responses to social and environmental triggers.⁹ A Cochrane review has called for more experimental studies in a "real world" situation.¹⁰

• Psychodynamic psychotherapy examines the ways that events are perceived. It states that perceptions are shaped by experiences in early life and therapy aims to identify perceptual distortions and their origin and to facilitate the development of more adaptive modes of perception and response. Treatment is usually prolonged over a course of several years at intervals from several times a week to once a month. It uses transference.
• Cognitive and behavioural therapy (CBT) suggests that cognitive errors based on long-standing beliefs influence the meaning attached to interpersonal events. It explores how people think about their world and their perception of it. It is a very active form of therapy that identifies the distortions and engages the patient in efforts to reformulate perceptions and behaviours. This therapy is usually limited to episodes of 6 to 20 weeks at intervals of once a week. For personality disorders, therapy is repeated often over the course of years.
• Interpersonal therapy (IPT) assumes that difficulties result from a limited range of interpersonal problems including such issues as role definition and grief. Current problems are interpreted narrowly through the screen of these formulations, and solutions are framed in interpersonal terms. Therapy is usually weekly for a period of 6 to 20 sessions. It is used mostly for anxiety and depression and is not widely practised.
• Group psychotherapy allows interpersonal problems to be displayed among a peer group, whose feedback is used by the therapist to identify and correct maladaptive ideas, communication, and behaviour. Sessions are usually once weekly over a course that may range from several months to years. The technique enables several people to be treated simultaneously, reducing cost per patient.
• Dialectical behaviour therapy (DBT) is a skills-based therapy that can be used in both individual and group formats. It has been applied to borderline personality disorder. The emphasis is on the development of coping skills to improve affective stability and impulse control and on reducing self-harmful behaviour. This treatment is also being used with other cluster B personality disorders to reduce impulsive behaviour.

Pharmacotherapy

Drugs do not cure personality disorders but they may be useful as an adjunct so that the patient may productively engage in psychotherapy.
The focus is on treatment of symptom clusters such as cognitive-perceptual symptoms, affective dysregulation, and impulsive-behavioural dyscontrol. Such symptoms may complicate almost all personality disorders to some degree, but all of them have been noted in borderline personality disorder.

• The strongest evidence for drug treatment of personality disorders has been for borderline personality disorder, but even this has a small database of limited studies.¹¹
• As the depression of most patients with personality disorders stems from their limited range of ability to cope, antidepressants are usually less effective than in patients with uncomplicated major depression.
• Anticonvulsants help to stabilise the affective extremes in patients with bipolar disorder but are less effective for that purpose in patients with personality disorders. They have some benefit in suppressing impulsive and particularly aggressive behaviour in patients with personality disorder.
• Some personality disorders, especially borderline personality disorder, produce transient psychotic periods, while others such as schizotypal personality disorder show chronic idiosyncratic ideation bordering on psychosis. Response to antipsychotics is less dramatic than in true psychotic disorders, but symptoms such as anxiety, hostility and sensitivity to rejection may be reduced. Antipsychotics are normally used for a short period while the symptoms are active. The atypical antipsychotics have almost completely replaced the older neuroleptics because of their margin of safety, but neurological side effects including tardive dyskinesia and neuroleptic malignant syndrome do sometimes occur. Risperidone and olanzapine are often used and sometimes quetiapine and ziprasidone. There is no evidence of superior efficacy of any product and each one may have advantages and disadvantages of adverse effects.
• Benzodiazepines, opiates, and other drugs with potential for dependency should be used rarely and with great caution. Nearly all personality disorders show impaired impulse control and consequent risk of addiction.

Crisis management

The following may occur more often than expected:

• Suicide
• Substance abuse (including alcoholism)
• Accidents and injuries
• Depression
• Homicide

Frequent inquiries about suicidal ideation are warranted, regardless of whether the patient spontaneously raises the subject.¹² There is no risk of implanting the idea of suicide in a patient who is not already considering it. Inquiry about drugs and other available means of suicide may help prevention.

Patients with personality disorder who have children should be asked frequently and in detail about their parenting practices. Their low frustration tolerance, externalisation of blame for psychological distress and impaired impulse control put the children of these patients at risk of neglect or abuse.

New NICE guidance puts some emphasis on identification of individuals at risk of developing personality disorders.⁶ A variety of interventions are suggested to try to prevent some of the consequences of the personality disorders covered by this guidance. For example, NICE suggests that services should establish robust methods to identify children at risk of developing conduct problems and that vulnerable parents could be identified antenatally - for example, in antisocial personality, by identifying:

• Parents with other mental health problems, or with significant drug or alcohol problems.
• Mothers younger than 18 years, particularly those with a history of maltreatment in childhood.
• Parents with a history of residential care.
• Parents with significant previous or current contact with the criminal justice system.

A wide variety of different interventions is then suggested ranging from anger management to parenting classes.

It is unsurprising from the above that many people with personality disorders offend against the law. They are often held to be untreatable. Treatment is prolonged, difficult and far from universally successful. When society is pre-occupied with a punitive approach to offenders rather than the rehabilitation of offenders, the result is overcrowded prisons and recidivism amongst offenders. Jack Straw, when he was Home Secretary, wrote that one of the most important steps for the prevention of re-offending was that the person should secure a job. However, most employers enquire about criminal records and hold it against potential employees. The management of those with personality disorders, including those who have run foul of the law, is not easy and success is limited but the stakes are such that it is essential that society make the effort. New guidance from NICE poses challenges to the different agencies involved in the management and care of individuals with personality disorders.^6,7