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Assessment of personality disorder

  • Penny J. M. Banerjee, Simon Gibbon and Nick Huband

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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Copyright

Corresponding author

Dr Penny J. M. Banerjee, East Midlands Centre for Forensic Mental Health, Arnold Lodge, Cordelia Close, Leicester LE5 0LE. Email: penny.banerjee@nottshc.nhs.uk

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Declaration of Interest

None.

Footnotes

References

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Assessment of personality disorder

  • Penny J. M. Banerjee, Simon Gibbon and Nick Huband
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eLetters

Problems in Diagnosis

Ravimal Galappaththi, MRCPsych, Registrar in Psychotherapy
28 October 2010

Personality disorders are at times a conundrum in psychiatry. Issues for management include diagnostic difficulties and the existence of significant co-morbidity (substance abuse, mood disorder psychosis etc.).

Fragmentation of ego/ personality may be evident at a time of Axis 1 disorder (major depression, psychosis, severe anxiety state etc.), which thus may mimic a personality disorder. To differentiate, careful investigation in to the person's coping styles, developmental trajectory, object & inter-relational style, use of defenses, level of 'self disorder' all need to be assessed. A good psychiatric history may illicit temperament, genetic vulnerability and precipitants of crisis; but assessment of modes of communication, affect regulation, attachment and mental state is necessary in addition. Issues can only be successfully dealt with after an adequate formulation following assessment of the above domains and level of self disorder based on affectivity, agency, continuity and cohesion.

Functionality in intrapersonal,interpersonal and social group domains may adequately be assessed only after a trusting relationship is developed between the client and the doctor. Some clients are alexithymic finding it difficult to comprehend the broad range of direct questions asked by doctors and struggling to find answers to them. Also a person from a different cultural background may have difficulty relating to some categorical questions, however may have an underlying personality disorder presenting with different ‘idioms’ of distress. During the process of diagnosis many doctors are unaware of transference, counter-transferance enactments which hamper the alliance and leads to early disengagement. Once disengaged the diagnosis will now be based on the objectification of the clients behavior rather than understanding of the client's internal world. This is particularly important as every assessment session will decide if the client is willing for treatment and therapy.

Validity of personality disorder is not based on externals but mostly on the understanding of subjective feelings of the client by an evaluator. Therefore an integral diagnostic system is needed which incorporates dimensional and dynamic evaluations yielding a successful formulation prior to treatment. Addressing the transference and countertransference issues is the most important issue. This article highlights the importance of such a process and the need for research evidence to back it up.

References: 1. McWilliams N, (1994), Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, Guilford Press

2. Gabbard G, Meares R, (2005) The Metaphor of Play: Origin and Breakdown of Personal Being, Routledge; 3 edition
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Conflict of interest: None Declared

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Other Personality Disorders

Devender Singh Yadav, Staff Grade Psychiatrist
16 September 2009

The authors fail to mention personality disorders that develop secondary to having a severe mental illness or experiencing a catastrophicexperience (F 62. Enduring personality changes not attributable to brain damage and disease. i.e. Enduring personality change after a catastrophic experience (F62.0) and a psychiatric illness (F62.1). Kendell RE [1] in his article (the distinction between personality disorder and mental illness) highlights similar problems that the authors report.

Moreover personality disorders can develop secondary to a general medical condition. Both the ICD-10 [2] (F 07 Personality and behavioural disorders due to brain disease, damage and dysfunction) & DSM IV [3] (310.1 Personality change due to a general medical condition) categorically mentions these. For example injuries to frontal lobes and right hemispheric strokes have often been shown to evoke personality changes. Personality changes also develop secondary to intractable epilepsy [4].

The authors do not mention personality disorders in old age either, which have been summarised in a previous edition of Advances in Psychiatric Treatment [5].

In a podcast by the Royal College of Psychiatrists Lord Owen discusses "Hubris Syndrome" with Professor Peter Tyrer. Could this syndrome which develops at a later stage in life after being in the hot seat of power be classified as a personality disorder? [6]

1. Kendell RE (2002). The distinction between personality disorder and mental illness. BJP; 180:110-115

2. World Health Organization (1992) Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines (10th edition)(ICD-10). WHO.

3. American Psychiatric Association (1994). Diagnostic and StatisticalManual of Mental Disorders 4th edition (DSM-IV). Washington, DC: APA.

4.Lopez-Rodriguez F, Altshuler L, Kay J, et al. Personality disordersamong medically refractory epileptic patients. Neuropsychiatry Clin Neurosci, Nov.1999; 11:464-469.

5. Mordekar A, Spence SA. Personality disorder in older age: how common is it and what can be done? Advances in Psychiatric Treatment (2008) 14: 71-77.

6. Lord Owen speaking to Prof Tyrer, Podcast broadcasted on 10/07/09,Royal College of Psychiatry.
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