The public health problem-solving paradigm is a comprehensive method not previously applied to preventive interventions for personality disorder.

To present an overview for clinical psychiatrists.

Review of epidemiological research into DSM–IV Axis II disorders and application to the paradigm.

Personality disorder affects a substantial proportion of the population. Burdens on health care, social and criminal justice agencies have yet to be accurately quantified. Debates continue over case definition, but there is increasing information on prevalence using ‘broad’ definitions and aetiology. A conceptual framework, based on development, suggests preventive interventions should be targeted in childhood. The public health approach also requires monitoring of risk factors operating at the population level.

Services in England and Wales for persons with personality disorder are currently inadequate. The problem-solving paradigm suggests new preventive interventions. Psychiatrists should renegotiate their relationship with policy-makers and reconsider their preventive role.

Antisocial personality disorder is usually preceded by serious and persistent conduct problems starting in early childhood, and so there is little difficulty in identifying an at-risk group.

To address six key areas concerning the relationship between early conduct problems and antisocial personality disorder.

Review of recent research into early identification of and intervention in child conduct problems, following up to possible adult antisocial behaviour.

Conduct problems are predictive of antisocial personality disorder independently of the associated adverse family and social factors. Prediction could be aided through identification of subtypes of conduct problems. There is limited evidence on which children have problems that are likely to persist and which will improve; children who desist from early conduct problems and those with onset in adolescence are also vulnerable as adults.

The predictive power of the childhood precursors of antisocial personality disorder provides ample justification for early intervention. Greater understanding of subgroups within the broad category of antisocial children and adults should assist with devising and targeting interventions.

Dual diagnosis of personality disorder and severe mental illness is an important clinical association that has been under-researched with regard to clinical management.

To compare the outcomes of differenttreatment models.

The outcome of patients with this combined diagnosis was compared in a systematic review of three randomised controlled trials in which different forms of community outreach treatment or intensive case management were compared with standard care.

The results from the three studies showed that the outcome of comorbid diagnoses was worse than that of single diagnoses. Although assertive approaches reduced in-patient care, they sometimes did so at the expense of increasing social dysfunction and behavioural disturbance.

For those with comorbid severe mental illness and personality disorder, the policy of assertive outreach and care in community settings may be inappropriate for both public and patients unless modified to take account of the special needs of this group.

A major short coming of current research into personality is its failure to explore the relationship between theories of general personality and mental disorder.

To provide preliminary data to address this deficit.

In the first of two studies, we examined the relationship between the Neuroticism, Extraversion and Other – Five-Factor Inventory (NEO–FFI) and DSM personality disorders in a consecutive series of mentally disordered offenders. In the second, we sought to separate the personality dimension neuroticism from symptoms of depressive disorder in a sample of subjects with current depression.

Factors from the NEO–FFI were associated with different personality disorders in a predictable manner (first study). It was possible to identify a component of neuroticism (i.e. ‘worry’) that could be separated from depressive symptoms (second study).

Theories of general personality theory can enlighten and refine descriptions of abnormal mental states by informing both their aetiology and their prognosis.

A number of studies have demonstrated reductions in the utilisation of psychiatric services, especially acute inpatient admissions, following therapeutic community treatment of personality disorder. These studies have, however, been of limited duration (1 year) and follow-up has not always been complete.

To identify hospital admissions before and after therapeutic community treatment of personality disorder.

A naturalistic clinical cohort of patients admitted between January 1993 and December 1995 was followed up for 3 years. All subjects were traced to their current consultant psychiatrist, general practitioner or death.

All patients were traced at 3-year follow-up. The significant reduction in in-patient admissions seen in the first year was maintained over 3 years. Those with the poorest outcomes, suicide, accidental death or prolonged admission were all in the quartile with the shortest admissions (under 42 days) to the therapeutic community.

Previously reported reductions in psychiatric admissions following therapeutic community treatment of personality disorder are maintained over 3 years.

Though contentious, the diagnosis of personality disorders in persons with learning disability is clinically relevant because it affects many aspects of management.

To examine published literature on the diagnosis of personality disorders in learning disability.

Selective review with computerised (Medline, Embase and PsychInfo) and manual literature searches.

The variation in the cooccurrence of personality disorder in learning disability, with prevalence ranging from less than 1% to 91% in a community setting and 22% to 92% in hospital settings, is very great and too large to be explained by real differences.

The diagnosis of personality disorders in learning disability is complex and difficult, particularly in those with severe disability Developing consensus diagnostic criteria, specific for various developmental levels, is one way forward. Such criteria may need to include objective proxy measures such as behavioural observations and informant accounts.

The Global Assessment of Function (GAF) scale is widely used in adult psychiatric practice and research but it has not often been used in learning disability, which is inherently more complex.

To evaluate the reliability of GAF in the assessment of learning disability.

GAF reliability was tested by simultaneous multiple rating of unselected case vignettes (n=19–25) from health professionals of different disciplines, under controlled conditions. Analysis of reliability was made with the intraclass correlation coefficient (R1) with separate assessments to determine rater bias and individual performance of raters.

The results of three data-sets showed generally poor overall levels of agreement, with R1 levels of 0.35 and 0.28 and somewhat better levels for current GAF scores (R1=0.49). However, a subset of raters was identified that achieved much higher levels (R1=0.54 to 0.74).

The GAF, in its current format, is not reliable enough to be used in the routine assessment of learning disability A subgroup of raters, however, have ratings that are, by current biostatistical criteria, sufficiently reliable.