Why we need to take personality disorder out of the doghouse

Commentary: Commentary on the Twitter comments evoked by the May 2022 debate on diagnosing personality disorders in adolescents

The debate about the value and utility of personality disorder (PD) diagnosis in adolescence published in the May 2022 issue of CAMH generated fervent Twitter discussion. This commentary addresses some points raised in the Twitter discussion that represent important social and/or cultural beliefs that are often presented in day-to-day practice but are rarely tested in the context of scientific evidence. This includes, in particular, the assertion that symptoms used to diagnose personality disorder are better described as sequelae of trauma, and the assertion that effective treatment for PD is possible without a diagnosis. The call for a fundamental transformation of mental health services that currently do not meet the needs of people with PD and for the involvement of people with lived experience as equal partner in this process is supported by evidence and might represent common ground among those clinician-scientist advocating for early intervention for PD and those expressing their concerns about this issue.

Five Failures and Five Challenges for Prevention and Early Intervention for Personality Disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services. Reprinted from Curr Opin Psychol 2021; 37:134-138, with permission from Elsevier. Copyright © 2021.

The prevalence of severe personality disorder in perpetrators of homicide

BACKGROUND

Current UK evidence on the prevalence of personality disorder in homicide is lacking. The aims were to estimate the prevalence of personality disorder in homicide perpetrators from court reports and carry out a dimensional assessment in keeping with the new ICD-11 classification of the prevalence of severe personality disorder. Associations between severe personality disorder and sociodemographic, historical and offence-related characteristics were then explored.

METHODS

Six hundred court reports from a national case series of homicide perpetrators in England and Wales were analysed using a document-derived version of the Personality Assessment Schedule (PAS-DOC), providing categorical and dimensional personality assessments. The prevalence of personality disorder and severe personality disorder was estimated. Factors associated with the diagnosis of severe personality disorder were examined.

RESULTS

The prevalence of personality disorder using the PAS-DOC was 56.3% (95% confidence interval 52.3%, 60.3%), compared with 16% as diagnosed in reports. Severe personality disorder was present in 62% (n = 338) of all those with a personality disorder and was significantly associated with homicides of strangers and previous violence.

CONCLUSIONS

Severe personality disorder is highly prevalent among perpetrators of homicide, and the finding that it is more prevalent when strangers are the victims stresses both the need for early identification of those at risk of developing severe personality disorder and the development of appropriate early preventive interventions. There is also a need for the development of effective treatment and interventions for those with established severe personality disorder and better identification of this level of disorder by psychiatrists. The forthcoming ICD-11 classification should help in this endeavour. © 2021 The Authors Personality and Mental Health Published by John Wiley & Sons Ltd.

Five failures and five challenges for prevention and early intervention for personality disorder

Despite global consensus regarding the early detection of personality disorder, current approaches to early intervention have failed to deliver for the majority of young people. This only serves to reinforce the enduring effects of personality disorder on functioning, mental and physical health, resulting in a reduction of quality of life and life expectancy. Here, we describe five significant challenges facing prevention and early intervention for personality disorder: identification, access to treatment, research translation, innovation and functional recovery. These challenges highlight the need for early intervention to shift from niche programmes in specialist services for a select few young people to become established in mainstream primary care and specialist youth mental health services.

Cross-cultural applicability of ICD-11 and DSM-5 personality disorder

PURPOSE OF REVIEW

This review explores recent literature on the applicability of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) and International Classification of Disease, 11th Revision (ICD-11) personality disorder classification systems across countries and cultural contexts.

RECENT FINDINGS

Several studies examining the cultural validity and utility of DSM-5 and ICD-11 personality disorder have been conducted in a number of language and cultural groups that are different from those in which the tools were originally developed. These studies, using quantitative methods, have largely supported the applicability of the new dimensional and trait approaches to classifying personal disorders. Studies qualitatively exploring the views of service users and clinicians on the development or operationalization of DSM-5 and ICD-11 personality disorder report that a lay summary of diagnostic constructs thatreflect concern about language of diagnostic criteria as well the lived experience of service users would be found useful. Clinicians found the dimensional system of ICD-11 slightly more useful than the categorical system of ICD-10 on several utility scales, but the studies on ICD-11 have been much less in view of its latter appearance.

SUMMARY

DSM-5 and ICD-11 personality disorder have shown a preliminary evidence of improved utility across cultures. More studies, including those reflecting the views of service users, are needed to confirm this early observation across many more cultural and linguistic groups.