The paper by Chartonas et al Reference Chartonas, Kyratsous, Dracass, Lee and Bhui1 gives understandable data but its title obscures a great deal of change since 1988. When Lewis & Appleby's paper Reference Lewis and Appleby2 was published the title alone was sufficient for many to give a nod of agreement without reading further. But there is a big difference between the patients seen by psychiatrists, often as emergencies, and the rest of the population who have personality disorder. Chartonas et al Reference Chartonas, Kyratsous, Dracass, Lee and Bhui1 also note that around 50% of people in secondary care services have personality disorder, yet I am sure it would be quite untrue to say that psychiatrists dislike half their patients.
The main trouble with our current diagnostic system for personality disorder is that it is hardly ever used. Only borderline and antisocial (dissocial) get a mention in official statistics, together with mixed personality disorder or ‘personality disorder – not otherwise specified’, an abject admission of diagnostic failure if ever there was one. In the proposed revised ICD-11 classification the key element that helps to define the patients psychiatrists dislike is severity of personality disturbance. Reference Tyrer, Reed and Crawford3 Only a tiny proportion of patients have severe personality disorder – probably less than 2% – but they create a great deal of trouble for services, having disproportionately greater contacts than others. Reference Yang, Coid and Tyrer4
At milder levels of personality disorder there is much greater acceptance of personality disturbance by all practitioners, and at some levels there may be a better response to treatment Reference Sanatinia, Wang, Tyrer, Tyrer, Crawford and Cooper5 than in patients with no personality disturbance, as there is good adherence to treatment yielding superior results. Reference Tyrer, Wang, Tyrer, Crawford and Cooper6 In the new classification, the level of severity is qualified by up to five trait domains: negative affective, disinhibited, dissocial, detached and anankastic. Reference Tyrer, Reed and Crawford3 It is when the first three of these are prominent at the level of severe personality disorder that antipathy may be created in the minds of psychiatrists. Until we can get away from the notion that personality disorder is just a synonym for havoc, the stigma of the diagnosis will persist. The new classification should show that only a relatively small number of us are free from personality disturbance at some level, and this is the best antidote to stigma I know.
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