Giles Newton-Howes

The prevalence of personality disorder, its comorbidity with mental state disorders, and its clinical significance in community mental health teams

BackgroundPersonality status is seldom assessed in community mental health teams except at a rudimentary level. This study challenges the assumption that this policy is either prudent or wise.AimsTo measure the prevalence of personality disorder within community mental health teams and to investigate its relationship to mental state disorders and overall pathology.MethodA cross-sectional survey of 2,528 of 2,567 psychiatric patients (98.5%) managed by community mental health teams in four urban settings in the UK in which diagnoses of personality and mental state pathology were assessed separately. Of these, a sample of 400 was interviewed, with a 70.5% completion rate for more in depth information.ResultsIn total, 40% of all patients in secondary care suffered from at least one personality disorder. Regression modelling showed personality pathology accounted for a greater degree of global psychopathology than psychosis, alcohol or drug dependence, but was associated with anxiety disorders.ConclusionComorbid personality pathology contributes greatly to overall psychopathology in secondary psychiatric care. It should be both recognised and managed.

INFLUENCE OF PERSONALITY ON THE OUTCOME OF TREATMENT IN DEPRESSION: SYSTEMATIC REVIEW AND META-ANALYSIS

There continues to be debate about the influence of personality disorder on the outcome of depressive disorders and is relative interactions with treatment. To determine whether personality disorder, both generically and in terms of individual clusters, leads to a worse outcome in patients with depressive disorders and whether this is influenced by type of treatment, a systematic electronic search of MEDLINE, CINAHL, and PsycINFO from 1966, 1982, and 1882, respectively, until February 2007 was undertaken. The keyword terms depression, mental illness, and personality disorder were used. All references were reviewed and personal correspondence was undertaken. Only English language papers were considered. Any English language paper studying a depressed adult population was considered for inclusion. Studies needed to clearly define depression and personality disorder using peer-reviewed instruments or International Classification of Disease/Diagnostic Statistical Manual criteria. Outcome assessment at greater than 3 weeks was necessary. Final inclusion papers were agreed on by consensus by at least two reviewers. All data were extracted using predetermined criteria for depression by at least two reviewers in parallel. Disagreement was settled by consensus. Complex data extraction was confirmed within the study group. Data were synthesized using log odds ratios in the Cochrane RevMan 5 program. The finding of comorbid personality disorder and depression was associated with a more than double the odds of a poor outcome for depression compared with those with no personality disorder (OR 2.16, CI 1.83-2.56). This effect was not ameliorated by the treatment modality used for the depressive disorder. This finding led to the conclusion that personality disorder has a negative impact on the outcome of depression. This finding is important in considering prognosis in depressive disorders.

Attitudes of Staff Towards Patients With Personality Disorder in Community Mental Health Teams

Objective: The purpose of the present paper was to assess the attitudes of clinicians working with personality disordered patients. Methods: Secondary analysis of the Comorbidity of Substance Misuse and Mental Illness Collaborative (COSMIC) data set was undertaken using a priori hypothesis testing. The null hypothesis was that there would be no measurable difference between the attitudes of mental health professionals toward patients with a clinical diagnosis of personality disorder and those with an instrument-rated diagnosis of personality disorder. The potential confounders of global psychopathology, need, social functioning and documented aggression were assessed as possible reasons explaining a rejection of the null hypothesis. Results: Clinicians believed those with the clinical diagnostic label of personality disorder to be more difficult to manage than personality-disordered patients identified by a research tool who did not carry this label. These attitudes were not explained by the potential confounders of psychopathology, social morbidity or acts of aggression. Conclusions: An awareness of a personality disorder diagnosis is associated with a clinician belief that patients will be harder to manage. Objective measures of potential confounders do not explain why this group should be harder to manage. One explanation of this finding is that the label ‘personality disorder’ is stigmatizing. This may also explain the disparity between clinical and research assessments of personality disorder.

Personality disorder across the life course

The pervasive effect of personality disorder is often overlooked in clinical practice, both as an important moderator of mental state and physical disorders, and as a disorder that should be recognised and managed in its own right. Contemporary research has shown that maladaptive personality (when personality traits are extreme and associated with clinical distress or psychosocial impairment) is common, can be recognised early in life, evolves continuously across the lifespan, and is more plastic than previously believed. These new insights offer opportunities to intervene to support more adaptive development than before, and research shows that such intervention can be effective. Further research is needed to improve classification, assessment, and diagnosis of personality disorder across the lifespan; to understand the complex interplay between changes in personality traits and clinical presentation over time; and to promote more effective intervention at the earliest possible stage of the disorder than is done at present. Recognition of how personality disorder relates to age and developmental stage can improve care of all patients.

Personality disorder: a new global perspective

Personality disorder is now being accepted as an important condition in mainstream psychiatry across the world. Although it often remains unrecognized in ordinary practice, research studies have shown it is common, creates considerable morbidity, is associated with high costs to services and to society, and interferes, usually negatively, with progress in the treatment of other mental disorders. We now have evidence that personality disorder, as currently classified, affects around 6% of the world population, and the differences between countries show no consistent variation. We are also getting increasing evidence that some treatments, mainly psychological, are of value in this group of disorders. What is now needed is a new classification that is of greater value to clinicians, and the WPA Section on Personality Disorders is currently undertaking this task.

The central domains of personality pathology in psychiatric patients.

There is general agreement that the classification of personality disorders in DSM-IV is unsatisfactory. We systematically reviewed all studies that have analyzed patterns of personality disorder symptoms and signs in psychiatric patients; twenty-two papers were included in the final synthesis. There is reasonable consistency over the number and type of personality pathology traits reported despite differing samples, varying assessment methods, and different statistical manipulations. There are three or four high order traits; an externalizing factor incorporating borderline, narcissistic, histrionic, and antisocial traits (the latter is sometimes recorded as a separate trait); an internalizing factor incorporating avoidant and dependent traits; a schizoid factor; and often a compulsive factor. Using these domains of personality pathology would simplify classification, have higher clinical utility, and allow relatively easy translation of current research.

Community Mental Health Teams for People With Severe Mental Illnesses and Disordered Personality

BACKGROUND Closure of asylums and institutions for the mentally ill, coupled with government policies focusing on reducing the number of hospital beds for people with severe mental illness in favor of providing care in a variety of nonhospital settings, underpins the rationale behind care in the community. A major thrust toward community care has been the development of community mental health teams.

The challenge of transforming the diagnostic system of personality disorders

While the DSM-5 alternative model of personality disorder (PD) diagnosis allows the field to systematically compare categorical and dimensional classifications, the ICD-11 proposal suggests a radical change by restricting the classification of PDs to one category, deleting all specific types, basing clinical service provision exclusively upon a severity dimension, and restricting trait domains to secondary qualifiers without defining cutoff points. This article reflects broad international agreement about the state of PD diagnosis. It is argued that diagnosis according to the ICD-11 proposal is based on broad, potentially stigmatizing descriptions of impaired functioning and ignores much of the impressive body of research and treatment guidelines that have advanced the care of adults and adolescents with borderline and other PDs. Before radically changing classification, which highly impacts the provision of health care, head-to-head field trials coupled with the views of patients as well as thorough debate among scientists are urgently needed.

Pharmacotherapy for personality disorders

Although there are many methodological uncertainties in the treatment of personality disorders, which make it difficult to be confident about efficacy, there is growing evidence that at least in some personality disorders, drug treatment may be of value. Borderline personality disorder is a condition in which treatment evidence is the most promising, but it is also one of the most difficult disorders to disentangle the mental state from personality components. In summary, there is reasonable evidence that antidepressants, particularly serotonin re-uptake inhibitors and monoamine oxidase inhibitors, have beneficial effects independent of their antidepressive ones and albeit, less favourable, evidence that antipsychotic drugs and mood stabilisers may also be of value. None of this evidence is yet sufficient to point to any specific drug treatment indications.

Personality characteristics in childhood and outcomes in adulthood: findings from a 30 year longitudinal study.

Objective: Personality has been associated with a variety of outcomes in adulthood. Most of the literature related to mental state disorder and personality is cross sectional. Methods: Data from more than 900 participants of the Christchurch Health and Development Study (CHDS) were examined. Extroversion and neuroticism were measured at 14 years old and social outcomes at age 30. The presence of mental state disorder between 18-30 years old was identified. Multiple potential confounders in childhood were included in the analysis. Results: Neuroticism at fourteen was significantly correlated with multiple environmental exposures whereas extroversion had relatively few associations. Regression analysis found that neuroticism at 14 predicted depression, anxiety, suicidality and overall mental health problems at 30 as well as poor self-esteem but not relationship quality or wellbeing. Extroversion at 14 predicted alcohol and drug dependence and overall mental health problems, but also predicted improved social wellbeing, self-esteem and relationship quality at 30. Conclusions: In this analysis extroversion interacts with significantly fewer environmental factors than neuroticism in predicting adult outcomes. Neuroticism at 14 years predicts poorer mental health outcomes in adulthood. Extroversion in childhood may be a protective factor in the development of mental disorder other than alcohol use disorders. Extroverted adolescents have more positive social outcomes at 30 years.