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Assessment of personality disorder

Published online by Cambridge University Press:  02 January 2018

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Summary

In 2003 the Department of Health, in conjunction with the National Institute for Mental Health in England, outlined the government's plan for the provision of mental health services for people with a diagnosis of personality disorder. This emphasised the need for practitioners to have skills in identifying, assessing and treating these disorders. It is important that personality disorders are properly assessed as they are common conditions that have a significant impact on an individual's functioning in all areas of life. Individuals with personality disorder are more vulnerable to other psychiatric disorders, and personality disorders can complicate recovery from severe mental illness. This article reviews the classification of personality disorder and some common assessment instruments. It also offers a structure for the assessment of personality disorder.

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Articles
Copyright
Copyright © Worcestershire County Council 

Historically, health professions have not always agreed on how best to conceptualise, categorise and define personality disorders. Although there are still many divergent views, there has been an increased consensus following the publication of definitions of personality disorder in ICD–10 (World Health Organization 1992) and DSM–IV (American Psychiatric Association 1994). In 2003 the Department of Health, in conjunction with the National Institute for Mental Health in England, produced Personality Disorder: No Longer a Diagnosis of Exclusion (National Institute for Mental Health in England 2003). This document outlined the government's plan for the provision of mental health services (both general and forensic) for people with a diagnosis of personality disorder, and emphasised the importance of practitioners having skills in identifying and assessing personality disorder in order to appropriately treat a person's difficulties.

Prevalence and comorbidity of personality disorders

Personality disorders are common conditions (Reference Coid, Yang and TyrerCoid 2006a) that, by definition, run a prolonged course and are often associated with poor outcome (Reference StoneStone 1993; Reference Skodol, Gunderson and SheaSkodol 2005) and increased mortality (Reference Harris and BarracloughHarris 1998). In a general population study of British households, Reference Coid, Yang and TyrerCoid et al (2006a) found a weighted prevalence of 4.4% for a diagnosis of any personality disorder. The weighted prevalence for each individual personality disorder varied between 0.06 and 1.9%, with obsessive–compulsive, avoidant, schizoid and borderline personality disorders being the most common. Dependent and schizotypal personality disorders were the least prevalent (the study failed to identify any cases of histrionic or narcissistic personality disorder, suggesting that these disorders are particularly rare in the general population). Comorbidity within personality disorders is common; thus, patients with personality disorder are likely to fulfil diagnostic criteria for more than one subtype of personality disorder. In Reference Coid, Yang and TyrerCoid et al's (2006a) sample, 54% had only one personality disorder, 22% had two personality disorders, 11% had three personality disorders and 14% had between four and eight personality disorders.

In a non-clinical sample, all personality disorders, except schizotypal, were more prevalent in men than women (Reference Coid, Yang and TyrerCoid 2006a); however, in clinical samples, women with borderline personality disorder may be more likely to seek treatment (Reference Tyrer, Seivewright and TyrerTyrer 2000). There is an increased prevalence of personality disorder in people who are unemployed, divorced or separated, living in urban areas and from lower socioeconomic groups (Reference Coid, Yang and TyrerCoid 2006a). Antisocial personality disorder is common in criminal justice settings. In the UK prison population, the prevalence of antisocial personality disorder has been estimated to be 63% in male remand prisoners, 49% in male sentenced prisoners and 31% in female prisoners (Reference Singleton, Meltzer and GatwardSingleton 1998).

Personality disorder is also frequently comorbid with other mental illness. There are strong associations between cluster B personality disorders (antisocial, borderline, histrionic and narcissistic) and psychotic, affective and anxiety disorders. There is also a strong association between cluster C personality disorders (dependent, obsessive–compulsive and avoidant) and affective and anxiety disorders (Reference Coid, Yang and TyrerCoid 2006a). Both psychiatric in- and out-patients have a high prevalence of personality disorder – estimated to be of the order of 50%. In-patients with substance misuse and eating disorders have a particularly high prevalence of personality disorder, thought to be in the region of 70% (Reference MoranMoran 2002).

The presence of more than one personality disorder in an individual is likely to result in a worse outcome for co-occurring mental illness (Reference Tyrer, Seivewright and TyrerTyrer 2000; Reference Newton-Howes, Tyrer and JohnstonNewton-Howes 2006) and may also increase the risk of violence in psychotic illness (Reference Moran, Walsh and TyrerMoran 2003). It is important that where personality disorder occurs in conjunction with mental illness this is recognised, as it may require adaptation of either the treatment, or the way in which this is delivered (Reference Tyrer and SimmondsTyrer 2003; Reference Dowsett and CraissatiDowsett 2007).

Classification of personality disorder

The ICD–10 definition of personality disorder is:

a severe disturbance in the characterological constitution and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption [World Health Organization 1992: p. 202].

In DSM–IV it is defined as:

an enduring pattern of inner experience and behavior that deviates 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 [American Psychiatric Association 1994: p. 629].

Despite minor differences, these two definitions are broadly similar and share several components: the disorder must be problematic for either the individual or others; it is pervasive across a number of situations; it is persistent across the lifespan; and it involves a disturbance of both behaviour and emotion. In DSM–IV the disorders can be grouped into three clusters: cluster A (the odd or eccentric disorders); cluster B (the dramatic disorders); and cluster C (the anxious or fearful disorders). There are nine categories of personality disorder in ICD–10 and ten in the DSM–IV (Table 1).

TABLE 1 ICD–10 and DSM–IV descriptions of personality disorders

Cluster DSM–IV ICD–10
A: Odd/eccentric Paranoid: Interpretation of other's actions as deliberately demeaning or threatening Paranoid: Excessive sensitivity, preoccupation with conspiratorial explanations of events, persistent tendency to self-reference
Schizoid: Indifference to social relationships and restricted range of emotional experiences and expression Schizoid: Emotional coldness, detachment, lack of interest in others, eccentricity and introspective fantasy
Schizotypal: Deficit in interpersonal relatedness with peculiarities of ideation, odd beliefs and thinking, unusual appearance and behaviour Categorised as a mental disorder (Schizotypal Disorder, F21) rather than a personality disorder
B: Dramatic Antisocial: Pervasive pattern of disregard for and violation of the rights of others Dissocial: Callous unconcern for others, irritability and aggression, and incapacity to make enduring relationships
Borderline: Pervasive instability of mood, interpersonal relationships and self-image associated with marked impulsivity, fear of abandonment, identity disturbance and recurrent suicidal behaviour Emotionally unstable borderline type: Impulsivity with uncertainty over self-image, liability to become involved in intense and unstable relationships, and recurrent threats of self-harm
No direct equivalent Emotionally unstable impulsive type: Inability to control anger, to plan ahead or think before acts, with unpredictable mood and quarrelsome behaviour
Histrionic: Excessive emotionality and attention-seeking, suggestibility and superficiality Histrionic: Self-dramatisation, shallow mood, egocentricity and craving for excitement with persistent manipulative behaviour
Narcissistic: Pervasive grandiosity, lack of empathy, arrogance and requirement for excessive admiration Not defined
C: Anxious/fearful Avoidant: Pervasive social discomfort, fear of negative evaluation and timidity, with feelings of inadequacy in social situations Anxious (avoidant): Persistent tension, self-consciousness, exaggeration of risks and dangers, hypersensitivity to rejection and restricted lifestyle because of insecurity
Dependent: Persistent dependent and submissive behaviour Dependent: Failure to take responsibility for actions, with subordination of personal needs to those of others, excessive dependence with need for constant reassurance and feelings of helplessness when a close relationship ends
Obsessive–compulsive: Preoccupation with orderliness, perfectionism and inflexibility which leads to inefficiency Anankastic: Indecisiveness, doubt, excessive caution, pedantry, rigidity and need to plan in immaculate detail

Dimensional and categorical approaches to personality disorder

Two broad approaches to the classification of personality disorder exist: the categorical and the dimensional.

Categorical classification is largely based on clinical psychiatry and uses clear operational criteria to define the behavioural elements of personality disorder, inferring that each personality disorder represents a qualitatively distinct clinical syndrome. This approach is used in both DSM–IV and ICD–10. Categorical classification has a number of fundamental problems. It focuses largely on the behavioural characteristics while ignoring the underlying psychopathology. As a number of different behavioural criteria can characterise a disorder, this system allows heterogeneity. Categorical systems have arbitrary cut-offs to classify the disorder. Also, some of the information obtained through a personality profile is lost in a categorical system.

There is minimal empirical support for the perspective that disordered personalities can be captured by distinct categories, compared with the alternative perspective that there should be a quantitative distinction, with personality disorders on a continuum with one another, with mental disorders and with normal personality functioning. A dimensional approach reflects this perspective. It is based on personality traits and views personality along a continuum with normal variation at one end and personality disorder at the other.

Purpose of personality disorder assessment

Central to any discussion regarding the assessment of personality is the difficulty in describing, conceptualising and categorising any disturbance. Part of this difficulty arises from the disorder itself. For example, who is best placed to report on someone's personality: the person themselves, who may have no insight into how their personality interferes with their functioning, or an informant, who may experience the effects of an individual's adverse personality traits but has no insight into that person's inner subjective world? Another part of the difficulty arises from the definition of each of the personality disorders, in that some personality characteristics appear in the description of more than one personality disorder (e.g. avoidance of contact with others may be associated with both schizoid and avoidant personality disorders). Such overlap requires the assessor not only to describe the behaviour, but also to enquire about its meaning or purpose (e.g. a person with schizoid personality traits will avoid contact with others because they have no interest in engaging with them, whereas a person with avoidant personality traits will desire contact with others but avoid it because of feelings of inferiority and anxiety).

To add to the confusion, personality disorder is a highly comorbid condition, frequently occurring in combination with mental illnesses and substance use disorders (Reference Coid, Yang and TyrerCoid 2006a). There may be particular problems in assessing personality disorder in people with intellectual disability (Reference Alexander and CoorayAlexander 2003; Reference MasonMason 2007) or severe mental illness (Reference Tyrer, Strauss and CicchetiTyrer 1983; Reference Moran, Walsh and TyrerMoran 2003).

Personality may be briefly assessed as part of a standard psychiatric assessment. However, an increasing number of instruments are being designed specifically for personality assessment. Several factors have contributed to this development. In the USA in 1980, the American Psychiatric Association officially recognised personality disorder as a distinct and separate realm of psychopathology by giving it a separate axis within the DSM – Axis II. This resulted in increased clinical and research interest in personality disorder and the need for assessment instruments. In the field of psychology, the areas of personality and psychopathology developed along separate paths for decades, but in recent years their relationship has become the focus of much research. It began to be recognised that the knowledge accumulated about normal personality structure and personality measures could be used in the understanding of psychopathology. Assessment and classification of personality disorder are closely linked and therefore it is important to consider both areas before deciding how personality disorder may best be assessed.

In the UK in 1994, the Working Group on Psychopathic Disorder suggested that standardised assessments should be used (Reference ReedReed 1994), recommending ‘multi-method criteria’ for the assessment of severe personality disorder. A postal survey was carried out to evaluate how severe personality disorder was assessed in secure services and how the assessments compared with these recommendations (Reference MiltonMilton 2000). This survey revealed that only 40% of those who responded carried out a formal assessment. Assessments of personality structure and cognitive and emotional styles were more common than structured diagnostic instruments or ratings of interpersonal functioning. This suggests that, even in specialist centres, there is wide variation both in whether assessment of personality disorder occurs and in the assessment tools used.

A pragmatic approach to assessing personality disorder

Important factors in the assessment of personality disorder include the setting, purpose and time available for the assessment, as these will influence which of the several assessment methods are the most appropriate. Assessment to provide an accurate diagnosis requires a different emphasis from that used in assessing motivation to participate in treatment or of suitability for a particular treatment model. Assessment tools often allow more accurate diagnosis but give less information about other factors such as how an individual's interpersonal functioning actually affects them, the presence of comorbidity or response to previous treatments.

Assessment conducted in line with the principles of the National Health Service's care programme approach places an emphasis on the following areas (Reference Bennett, Sampson, McCubbin and TyrerBennett 2006: p. 284):

  1. risk of harm to self and others

  2. the presence of other mental health difficulties

  3. the complexity of a person's personality difficulties

  4. the level of burden and/or distress placed on other family members or agencies.

History-taking

A good psychiatric history provides the assessor with valuable information about the history of the problematic behaviour. Further understanding of problematic interpersonal functioning can be gained from education, employment and relationship histories. It is important to explore how long problems have been present, variations in the difficulties, any previous treatment and the efficacy of treatment. Other previous or current mental health problems and substance misuse should be explored.

Presentation

Part of the difficulty in assessing for personality disorder is that a person's presentation can vary greatly depending on their current affect or DSM Axis I (mental illness) symptomatology. It is therefore often helpful to carry out an assessment over several interviews. This allows the interviewer to be more confident that the patient's presentation reflects personality traits rather than their current mental state. It is also important to bear in mind that fluctuation in presentation may itself be a characteristic of personality disorder (e.g. emotional lability in borderline personality disorder).

Clinical interview

Clinical interview offers the opportunity to observe the patient's interaction with the interviewer. The interviewer has the opportunity to reflect not only on the content of the response but also on the emotional expression and any non-verbal communication. The patient's response to the assessor and the feelings evoked in the assessor also inform the assessor's understanding of the patient's interpersonal functioning and difficulties.

As well as developing an understanding of an individual's problems, it is important to allow them the opportunity to identify which part of their interpersonal functioning causes them most distress and what they wish to change or modify. A joint understanding of a patient's treatment goals helps to build a positive therapeutic alliance. It is important to enquire about high-risk behaviour directed against the self and others, as this affects treatment and management.

Clinical interview has some limitations in the assessment of personality disorder in comparison with assessment of other mental disorders. The interviewer is interested not just in the standardised recording of symptoms and clinical features; in particular, they should assess maladaptive behaviour, its effect on the individual and others, attitudes and relationships with others, and social functioning in all areas of the person's life over a prolonged period of time. The interviewer must assess both the individual's current functioning and their normal functioning throughout their life. Some individuals, particularly those with cluster B personality disorders, exaggerate their difficulties; others minimise them. In our experience it is beneficial to supplement a clinical interview with a more structured assessment to gain a fuller understanding of a person's problems.

Other sources of information

In addition to information from clinical interview and structured assessment it is also advantageous to use information from sources other than the patient. Often a patient has difficulty recognising which aspects of themselves are most problematic and sometimes family or friends are more able to identify these personality traits. Of course, information from an informant is may also not be totally reliable; the informant's descriptions may be influenced by their relationship with the patient or their own personality traits. Also, informants will usually be able to provide information on the patient's behaviour, but not on their emotions. Sources such as previous records can add to the assessment and be beneficial in either supporting or refuting the problems identified.

Assessment instruments

Personality disorder can be assessed in a number of ways, including self-report, checklists and structured clinical interview. Numerous instruments are available to aid the clinician in making a diagnosis. These differ in terms of both reliability and validity. The validity of an instrument is the degree to which it measures the true concept which it purports to. This usually requires comparison with a gold-standard measure. As there is currently no accepted gold-standard measure of assessment of personality disorder it is difficult to assess the validity of a particular instrument. Reliability is the extent of agreement between assessors (interrater reliability) or with subsequent testing (test–retest reliability). Generally, the structured clinical interview is regarded as more robust than self-report questionnaires as the latter tend to overreport personality pathology compared with a more detailed structured clinical evaluation (Reference Hunt and AndrewsHunt 1992; Reference Clark, Harrison and LivesleyClark 2001).

It is beyond the scope of this article to give a detailed description of all the available instruments, but Box 1 lists those most commonly used; a small number of these are described below in more depth. Readers seeking further information are also advised to consult Reference Tyrer, Seivewright and TyrerTyrer (2000) or Reference LivesleyLivesley (2001).

BOX 1 Structured personality disorder assessment instruments

Structured categorical (diagnostic) assessments

Observer-rated structured interview

  1. International Personality Disorder Examination (Reference Loranger, Sartorius and AndreoliLoranger 1994)

  2. Diagnostic Interview for DSM–IV Personality Disorders (Reference Zanarini, Frankenburg and SickelZanarini 1996)

  3. Structured Interview for DSM–IV Personality Disorders (Reference Pfohl, Blum and ZimmermanPfohl 1997)

  4. Structured Clinical Interview for DSM–IV Axis I Disorders (Reference First, Spitzer and WilliamsFirst 1997)

  5. Personality Disorder Interview–IV (Reference Widiger, Mangine and CorbittWidiger 1995)

Self-rated questionnaire

  1. Personality Diagnostic Questionnaire (Reference HylerHyler 1994)

Structured interview – other sources

  1. Standardised Assessment of Personality (Reference Mann, Jenkins and CuttingMann 1981)

  2. Personality Assessment Schedule (Reference Tyrer, Alexander and CicchettiTyrer 1979)

Structured dimensional assessments

Observer-rated structured interview

  1. Schedule for Normal and Abnormal Personality (Reference Clark, Butcher and SpielbergerClark 1990)

Self-rated questionnaire

  1. Personality Assessment Inventory (Reference MoreyMorey 1991)

  2. Minnesota Multiphasic Personality Inventory–II (Reference Butcher, Dahlstrom and GrahamButcher 1989)

  3. Millon Clinical Multiaxial Inventory–III (Reference Millon and DavisMillon 1997)

  4. Eysenck Inventory Questionnaire (Reference Eysenck and EysenckEysenck 1975)

  5. NEO Five-Factor Inventory (Reference McCrae and JohnMcCrae 1992)

Unstructured assessments

Interview based

  1. Clinical interview

  2. Psychodynamic formulation

Other

  1. Rorschach test (Reference RorschachRorschach 1964)

  2. Thematic Apperception Test (Reference Morgan and MurrayMorgan 1935)

Minnesota Multiphasic Personality Inventory–II

The Minnesota Multiphasic Personality Inventory–II (Reference Butcher, Dahlstrom and GrahamButcher 1989) is a self-report measure of global psychopathology consisting of 567 true/false items giving information about symptoms and interpersonal relationships. It does not strictly describe personality dimensions but describes different characteristics of personality, their coexistence and differing severity. This instrument takes about 60–90 min to complete.

Millon Clinical Multiaxial Inventory–III

This is a self-report instrument consisting of 175 items requiring a true/false response. It is designed to help practitioners assess the presence of DSM–IV Axis II disorders as well as a number of other clinical syndromes such as anxiety, alcohol dependence and post-traumatic stress disorder (Reference Millon and DavisMillon 1997). It takes approximately 25 min to complete.

International Personality Disorder Examination

The International Personality Disorder Examination (IPDE) (Reference Loranger, Sartorius and AndreoliLoranger 1994) is a semi-structured clinical interview developed by the WHO and US National Institute of Health joint programme on psychiatric diagnosis and classification (World Health Organization 1995). The IPDE is arranged in a format that attempts to provide an optimum balance between a spontaneous, natural clinical interview and the requirements of objectivity. The questions are arranged under six headings: work, self, interpersonal relationships, affects, reality testing and impulse control. Each question assesses either a criterion or a partial criterion in the DSM–IV or ICD–10 classification system. This assessment tool examines for the presence or absence of a personality disorder and also results in a dimensional score on each disorder. The IPDE takes about 2–4 h to administer.

There is also a self-administered screening questionnaire version of the IPDE (World Health Organization 1995). This requires less time and expertise but produces a higher level of false positives. The use of such an instrument allows an interviewer to focus on highlighted areas and screen out cases of no personality disorder.

NEO Five-Factor Inventory

This five-factor model of personality is the result of years of debate and research between scientists such as Cattell, Eysenck and Guildford, and psychometricians (Reference McCrae and JohnMcCrae 1992). The five factors are neuroticism, extraversion, openness to experience, agreeableness and conscientiousness. It is a dimensional model in which personality disorder can be interpreted as a maladaptive variant of personality. It has been argued that the dimensional approach to the assessment of personality disorder is theoretically superior. However, although this model offers a description of the various personality processes, it does not offer an explanation of the behaviour that a patient presents. The inventory is a self-report checklist, taking about 5–10 min to complete.

Personality Assessment Schedule

The Personality Assessment Schedule (Reference Tyrer, Alexander and CicchettiTyrer 1979) is another trait-based approach to the assessment of personality. It is a semi-structured assessment which also uses information from a collateral source and takes 30–40 min to complete. It assesses 24 traits, such as conscientiousness, aggression and impulsiveness, grouped together into five personality styles: normal, passive-dependent, sociopathic, anankastic (compulsive) and schizoid. Several studies have found good interrater reliability (Reference Tyrer, Cicchetti and CaseyTyrer 1984) and also validity when compared with other widely used instruments.

Assessment of comorbidity, severity and ability to benefit from treatment

Comorbidity

Patients with one diagnosed personality disorder often have further personality disorders and other dysfunctional personality traits and mental health problems. The presence of comorbidity should be explored in the psychiatric history, and additional assessment instruments should be administered to check for further personality disorders. A structured clinical assessment tool such as the Structured Clinical Interview for DSM–IV Axis I Disorders (Reference First, Spitzer and WilliamsFirst 1997) may increase the identification of comorbid mental health problems.

Severity

The type of personality disorder diagnosed and an understanding of its impact on functioning gives an indication of the severity of the disorder. The notion of severe personality disorder is particularly pertinent in specialised personality disorder services and the field of forensic psychiatry. However, there is no standard way of recording this from DSM–IV or ICD–10. It has been noticed in many studies that patients with more severe personality disorder tend to have a greater number of personality disorder diagnoses than those with a less severe disorder (Reference Dolan, Evans and NortonDolan 1995). Disorder severity is also considered greater in those with disorders in more than one cluster. Some individuals have problematic personality traits but do not reach the threshold for a diagnosis of a particular disorder. Nevertheless, they can still experience marked interpersonal dysfunction and often show increased vulnerability under stress.

Reference Tyrer and JohnsonTyrer & Johnson (1996) proposed a system for classifying the severity of personality disorder into five levels, ranging from 0 (no personality disorder) to 4 (severe personality disorder) (Table 2). They define severe personality disorder as the presence of widespread personality abnormalities in more than one cluster and leading to gross societal disturbance.

TABLE 2 Classification of personality disorder severity

Level Diagnosis Characteristics
0 No personality abnormality No personality abnormality
1 Personality difficulty Meeting a probable diagnosis (DSM–IV) and three diagnostic criteria for paranoid, schizoid, histrionic, anankastic and/or anxious personality disorder and two criteria for dissocial, impulsive and/or borderline personality disorder (ICD–10)
2 Simple personality disorder Either a single personality disorder or if more than one, all personality disorders are within the same cluster
3 Complex personality disorder Two or more personality disorders from different clusters
4 Severe personality disorder Two or more personality disorders from different clusters, which causes gross societal disturbance

Treatability

Assessment of personality disorder often precedes decisions about treatability and whether an individual is suitable for a particular intervention. Interventions such as cognitive–behavioural programmes require a certain level of intellectual ability. If a programme or treatment intervention is too intellectually challenging for an individual, they may not be able to benefit from it. It is also likely to have a negative impact on their confidence and self-esteem and possibly exacerbate problem behaviours. Often the clinical interview will give some indication of level of intellectual functioning. It should be borne in mind that this can be influenced by many factors, including current mental state, education and cultural influences. A formal assessment is valuable for predicting whether an individual can potentially benefit from a particular treatment.

Many patients with a diagnosis of personality disorder disengage from treatment and services. This has a number of consequences. Studies looking at non-completion of treatment programmes in offender populations, both in the community and in institutions, revealed that non-completers were more likely to reoffend than those who had received no treatment (Reference McMurran and TheodosiMcMurran 2007). A number of explanations have been offered, including low motivation, resistance and low responsiveness. Reference Howells and DayHowells & Day (2007) proposed the term ‘readiness for treatment’, which they defined as:

the presence of characteristics (states or dispositions) within either the client or the therapeutic situation, which are likely to promote engagement in therapy and which, thereby, promote therapeutic change.

They suggested that readiness is a function of both internal (patient) and external (context) factors. Internal factors include cognition, affect, volition, behaviour and identity. External factors include circumstances, location, opportunity, resources, support and available treatment. Internal factors that suggest a greater level of readiness for treatment include: a positive appraisal of the treatment intervention offered; ability to trust others; a capacity to express emotions and reflect on emotional states; moderate (but not overwhelming) distress; experiencing guilt rather than shame; and a belief that change is possible.

The diagnosis of personality disorder is often seen as pejorative, so an important part of assessment should be the identification of the individual's strengths and protective factors. These can be revealed in the clinical history and by some of the assessment instruments, and they need to be emphasised by both patient and clinician: successful treatment requires the management of problematic functioning, and the building and enhancing of the individual's positive qualities.

Assessment of risk to self and others

Patients with personality disorder are at increased risk of harming themselves and others (Reference StoneStone 1993; National Institute for Mental Health in England 2003). Although the magnitude and causes of this increased risk are unclear, it should be acknowledged that only a minority represent a risk to others. Patients with cluster B personality disorders are at greater risk of criminal offending than the general population, but this increased risk is not found in those with cluster A and C personality disorders (Reference Coid, Yang and TyrerCoid 2006a). There is a particularly strong association between antisocial (dissocial) personality disorder and violent offending (Reference Coid, Yang and RobertsCoid 2006b), but given that features of this disorder include anger outbursts, failure to conform to social norms and lack of concern for others, perhaps this is not surprising. Despite the association between cluster B personality disorders and violence, most people with personality disorders, including half of those with antisocial personality disorder, have no history of violent behaviour (Reference Coid, Yang and RobertsCoid 2006b).

Risk assessmentFootnote is an important part of any psychiatric assessment and should include an assessment of risk to both self and others. The depth and breadth of the risk assessment when assessing a person with possible personality disorder will depend on the particular clinical circumstances, but the factors in Box 2 should be considered. Many different risk assessment tools are available to help the process of assessing risk to others, although there is increasing evidence that structured clinical judgement, using, for example, the Historical, Clinical and Risk Management scale (HCR–20; Reference Webster, Douglas and EavesWebster 1997) may have particular clinical utility (Reference Doyle and DolanDoyle 2006; Reference MadenMaden 2007).

BOX 2 Factors to be considered during assessment

  1. Demographic factors

  2. Current social situation

  3. Current presentation

  4. Psychosocial stressors

  5. Previous history of violence and self-harm

  6. Previous response to treatment/supervision

  7. Level of social support

  8. Anger

  9. Impulsivity

  10. Substance misuse

  11. Presence or absence of mental illness

(Reference Doyle and DolanDoyle 2006)

Psychopathy

Of particular relevance to the assessment of risk of harm to others in people with personality disorder is the Psychopathy Checklist – Revised (PCL–R; Reference HareHare 2003). This rating instrument aims to operationalise a clinical concept of psychopathy based on Hare's modification of Reference CleckleyCleckley's (1976) description of psychopathy. Compared with offenders without psychopathy, those with psychopathy (as assessed by the PCL–R) begin offending at an earlier age, commit more criminal offences, commit more types of offence and are more likely to reoffend (Reference Harris, Rice and CormierHarris 1991; Reference Hart, Cooke, Forth and HareHart 1998).

Psychopathy is a clinical concept that, although not included as a category of personality disorder in ICD–10 or DSM–IV, meets the general DSM–IV criteria for personality disorder. It may be thought of as a more severe form of antisocial/dissocial personality disorder in which antisocial behaviour is accompanied by emotional deficits such as callousness and lack of empathy (Reference HareHare 1996). There is increasing evidence that psychopathy may have a particular neurobiological basis (Reference BlairBlair 2003).

The PCL–R assesses traits of psychopathic personality on the basis of patient interview and review of previous records. Although clinical judgement is required, trained raters yield reliable scores and the test–retest reliability is also high (Reference HareHare 2003). The result of a PCL–R assessment may have negative implications for the individual, such as exclusion from treatment programmes or harsher disposal by the criminal justice system. It is therefore important that assessment is carried out for a specific purpose and that the full implications of an assessment are shared with the individual before it is undertaken. One of the benefits of the identification of high-risk behaviour is that it helps in setting treatment goals.

Dangerous and severe personality disorder

The criminal justice system in England and Wales has shown increased interest in personality disorder as a result of the government's Dangerous and Severe Personality Disorder (DSPD) programmeFootnote (www.dspdprogramme.gov.uk). The DSPD programme was set up after a number of high-profile cases in England focused public opinion on the potential risk that individuals with personality disorder present to the public (Reference FeeneyFeeney 2003). ‘Dangerous and severe personality disorder’ is not a clinical diagnosis. Rather, it is a descriptive term, embodying both psychiatric and social references, that is applied to a small number of individuals who are thought to be potentially suitable for this treatment programme. The Department of Health has defined this group as ‘[people over 18] who have an identifiable personality disorder to a severe degree, who pose a high risk to other people because of serious antisocial behaviour resulting from their disorder’ (Department of Health 2004).

Being classified as having a personality disorder and being at high risk of harming others may have significant consequences, such as long-term incarceration (Reference Morris, Gibbon and DugganMorris 2007).

Although the aim of formal risk assessment is to provide a means of identifying and predicting any potential risk that an individual poses to both themselves and others, it should be used in tandem with risk management. This involves the interpretation of assessment tools in monitoring both dynamic and static risk factors and identifying appropriate treatment and/or supervision for the individual.

Conclusions

Personality disorders are common conditions that have an impact on all areas of an individual's functioning and on other mental health problems. It is important to make a detailed diagnosis specifying both the personality disorder(s) diagnosed and the maladaptive traits displayed, together with the evidence on which this is based. An accurate description of the disorder is an essential prerequisite to providing appropriate treatment.

Personality disorder is a highly comorbid condition and it is important that a systematic attempt is made to evaluate the patient for other personality disorders, mental illnesses and substance use disorders.

The eventual aim of assessment is to arrive at a shared understanding with the patient about their difficulties so that patient and professional can work collaboratively on shared treatment goals. Part of this assessment should focus on the patient's strengths and protective factors.

MCQs

  1. 1 Patients with a diagnosis of personality disorder:

    1. a often have more than one personality disorder

    2. b rarely have evidence of mental illness

    3. c recover more quickly from major mental illnesses such as schizophrenia

    4. d are less likely to misuse drugs and alcohol than the general population

    5. e have decreased all-cause mortality.

  2. 2 Regarding the use of assessment instruments:

    1. a self-report instruments tend to produce a higher rate of false negatives than structured clinical interviews

    2. b reliability refers to the extent to which an instrument actually measures the characteristic it purports to measure

    3. c validity refers to whether an instrument uses questions that can be easily understood by the patient

    4. d a good assessment instrument should have both good reliability and validity

    5. e structured clinical interview can only be used if an informant is also present.

  3. 3 Regarding the diagnosis of personality disorder:

    1. a ICD–10 and DSM–IV use a dimensional approach

    2. b narcissistic personality disorder appears in ICD–10 but not DSM–IV

    3. c since personality cannot be reliably diagnosed and personality disorder is a pejorative label, it is an unhelpful diagnosis to make

    4. d dangerous and severe personality disorder is an ICD–10 diagnosis

    5. e in terms of validity and reliability, structured clinical interview is the most robust way of assessing personality disorder.

  4. 4 Examples of structured categorical personality assessment instruments are the:

    1. a International Personality Disorder Examination

    2. b NEO Five-Factor Inventory

    3. c Thematic Apperception Test

    4. d Global Assessment of Functioning scale

    5. e Adult Attachment Interview.

  5. 5 Factors indicating a more favourable engagement in treatment include:

    1. a feelings of shame

    2. b negative view of the treatment available

    3. c severe distress

    4. d feelings of guilt

    5. e difficulty trusting others.

MCQ answers

1 2 3 4 5
a t a f a f a t a f
b f b f b f b f b f
c f c f c f c f c f
d f d t d f d f d t
e f e f e t e f e f

Footnotes

Declaration of Interest

None.

This topic is discussed in Advances by: Carroll A (2009) How to make good-enough risk decisions. 15: 192–8; Undrill G (2007) The risks of risk assessment. 13: 291–7. Ed.

For a discussion in Advances of treatment within the DSPD programme and of the concept of DSPD see: Howells K, Krishnan G, Daffern M (2007) Challenges in the treatment of dangerous and severe personality disorder. 13: 325–32; Kingdon D (2007) DSPD or ‘Don't Stigmatise People in Distress’. 13: 333–5. Ed.

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Figure 0

TABLE 1 ICD–10 and DSM–IV descriptions of personality disorders

Figure 1

TABLE 2 Classification of personality disorder severity

Figure 2

MCQ answers

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