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Complex personality disorders

Published online by Cambridge University Press:  26 November 2018

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Abstract

Type
From the Editor's Desk
Copyright
Copyright © The Royal College of Psychiatrists 2018 

Personality disorders: still neglected?

Personality disorders continue to challenge clinicians and researchers. These diagnoses are still stigmatised and often present as complex mental states that include comorbid alcohol or substance misuse, depression, dissociative experiences and other mental disorders; cultural factors also complicate the assessment and therapeutic process.Reference Van and Kool1Reference Trull, Freeman, Vebares, Choate, Helle and Wycoff5 In addition, people diagnosed with personality disorders may face social adversity, loss of social support, interpersonal distress and higher mortality.Reference Chartonas, Kyratsous, Dracass, Lee and Bhui6Reference McGilloway, Hall, Lee and Bhui8 Personality disorders are still underrecognised, especially among minorities, and in some socially excluded groups and service settings.Reference McGilloway, Hall, Lee and Bhui8Reference Hossain, Malkov, Lee and Bhui10 Volkert et al (pp. 709–715) provide an updated meta-analysis of the prevalence of categories of personality disorders, showing these to be common; they find that expert ratings produce a lower prevalence estimate than self-ratings.

New approaches to personality assessment

The ICD-11 and DSM5 propose a dimensional or trait model, alongside the assessment of severity and disrupted interpersonal function and relationships.Reference Bach, Sellbom, Kongerslev, Simonsen, Krueger and Mulder11, Reference Reed12 These new approaches may help to overcome some of the limitations of existing categories and the difficulties around recognition and overlapping diagnostic categories. Huprich et al (pp. 685–689) provide a compelling and thoughtful analysis of the implications of a dimensional model of personality functioning, arguing for a more dynamic assessment that considers defensive emotional states and behaviours. An idiographic assessment, they assert, may be more authentic and accurate, better capturing the person's experience and the complexities.

Traumatic events are thought to contribute to the likelihood of developing a personality disorder. Some argue that personality disorders are often confused with complex post-traumatic disorders.Reference Ford and Courtois13 These complex post-traumatic states may emerge from harsh early life influences that affect attachments.Reference Classen, Pain, Field and Woods7 Later traumatic events will then produce a different level of severity and symptoms compared with those with better earlier environments and attachment.

Post-traumatic stress

There is good evidence that childhood maltreatment is associated with later internalising and externalising behaviours (Kisley, pp. 698–703); the strongest associations are for anxiety and post-traumatic stress. By contrast, a study of natural disasters shows higher rates of post-traumatic stress disorder (PTSD) and depression (Beaglehole, pp. 716–722) but, surprisingly, not anxiety or alcohol misuse or dependence. Disaster-specific factors and variation in research methods explain some of the heterogeneity. The study by Stevelink et al study (pp. 690–697) of troops deployed to Iraq or Afghanistan shows that deployment and combat were associated with poorer mental health, for example, post-traumatic stress and common mental disorders, as well as alcohol misuse in ex-serving personnel but not in those actively deployed at the time of the study. These findings suggest that defensive functions and social supports are compromised on leaving the services.

Graham et al (pp. 704–708) report that early treatment responses for people with PTSD were as common with sertraline as prolonged exposure therapy. Early responders to sertraline have a better longer-term functional outcome. This may reflect expectations of treatments, or early response may be a marker of a subset of the sample that could be characterised to better target interventions in the future. The sample excluded those with comorbidities, and personality is not often assessed in studies of PTSD. We need trials that target complex post-traumatic states, including personality-related difficulties, dissociation, attachment problems and comorbidities.Reference Classen, Pain, Field and Woods7, Reference Ford and Courtois13

References

1Van, HL, Kool, M. What we do, do not, and need to know about comorbid depression and personality disorders. Lancet Psychiatry 2018; 5(10): 776–78.Google Scholar
2Kool, M, Van, HL, Bartak, A, de Maat, SCM, Arntz, A, van den Eshof, JW, et al. Optimizing psychotherapy dosage for comorbid depression and personality disorders (PsyDos): a pragmatic randomized factorial trial using schema therapy and short-term psychodynamic psychotherapy. BMC Psychiatry 2018; 18(1): 252.Google Scholar
3Fuchshuber, J, Hiebler-Ragger, M, Kresse, A, Kapfhammer, HP, Unterrainer, HF. Depressive symptoms and addictive behaviors in young adults after childhood trauma: the mediating role of personality organization and despair. Front Psychiatry 2018; 9: 318.Google Scholar
4Mezquita, L, Bravo, AJ, Ortet, G, Pilatti, A, Pearson, MR, Ibáñez, MI, et al. Cross-cultural examination of different personality pathways to alcohol use and misuse in emerging adulthood. Drug Alcohol Depend 2018; 192: 193200.Google Scholar
5Trull, TJ, Freeman, LK, Vebares, TJ, Choate, AM, Helle, AC, Wycoff, AM. Borderline personality disorder and substance use disorders: an updated review. Borderline Personal Disord Emot Dysregul 2018; 5: 15.Google Scholar
6Chartonas, D, Kyratsous, M, Dracass, S, Lee, T, Bhui, K. Personality disorder: still the patients psychiatrists dislike? BJPsych Bull 2017; 41(1): 12–7.Google Scholar
7Classen, CC, Pain, C, Field, NP, Woods, P. Posttraumatic personality disorder: a reformulation of complex posttraumatic stress disorder and borderline personality disorder. Psychiatr Clin North Am 2006; 29(1): 87112; viii–ix.Google Scholar
8McGilloway, A, Hall, RE, Lee, T, Bhui, KS. A systematic review of personality disorder, race and ethnicity: prevalence, aetiology and treatment. BMC Psychiatry 2010; 10: 33.Google Scholar
9Tyrer, P. Accurate recording of personality disorder in clinical practice. BJPsych Bull 2018; 42(4): 135–36.Google Scholar
10Hossain, A, Malkov, M, Lee, T, Bhui, K. Ethnic variation in personality disorder: evaluation of 6 years of hospital admissions. BJPsych Bull 2018; 42(4): 157–61.Google Scholar
11Bach, B, Sellbom, M, Kongerslev, M, Simonsen, E, Krueger, RF, Mulder, R. Deriving ICD-11 personality disorder domains from DSM-5 traits: initial attempt to harmonize two diagnostic systems. Acta Psychiatr Scand 2017; 136(1): 108–17.Google Scholar
12Reed, GM. Progress in developing a classification of personality disorders for ICD-11. World Psychiatry 2018; 17(2): 227–9.Google Scholar
13Ford, JD, Courtois, CA. Complex PTSD, affect dysregulation, and borderline personality disorder. Borderline Personal Disord Emot Dysregul 2014; 1: 9.Google Scholar
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