Definitions

Most fundamentally, there is continuing controversy about how to define personality disorder. The International Classification of Mental and Behavioural Disorders (ICD-10) (World Health Organisation, 1992) defines personality disorder as: 'a severe disturbance in the characterological condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption.'

ICD-10 lists eight specific personality disorders: paranoid, schizoid, dissocial, emotionally unstable (with two sub-types - impulsive and borderline), histrionic, anankastic, anxious (avoidant) and dependent.

The definition of personality disorder offered by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994) is similar: 'an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.'

DSM-IV identifies ten specific personality disorders, but organises them into three clusters based on descriptive similarities:

Cluster A (odd; eccentric):

Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that others' motives are interpreted as malevolent.

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

Schizoid Personality Disorder is a pattern of detachment from social relationships and a restricted range of emotional expression.

Schizotypal Personality Disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour.

Cluster B (dramatic; emotional; erratic):

Antisocial Personality Disorder is a pattern of disregard for, and violation of, the rights of others.

Borderline Personality Disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity.

Histrionic Personality Disorder is a pattern of excessive emotionality and attention seeking.

Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empathy.

Cluster C (anxious; fearful):

Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.

Dependent Personality Disorder is a pattern of submissive and clinging behaviour related to an excessive need to be taken care of.

Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism and control.

Both classificatory systems agree that personality disorder can be distinguished by its persistence (usually beginning in late adolescence and continuing throughout most of adult life), the impairment it produces in social and occupational functioning, and the degree of distress it causes. However, whereas the DSM system locates personality disorder within a separate diagnostic dimension, or axis (Axis II), from that containing clinical syndromes such as major depression, anxiety disorders and schizophrenia (Axis I), no such distinction is made in the ICD classification.

Although the ICD and DSM classificatory systems are categorical, many researchers and clinicians argue that personality disorder (and other manifestations of psychological distress) may be understood more accurately using a dimensional approach (for example, Cloninger, 1987; Widiger, 1992, 1993). This approach assumes that normal and abnormal personality types form a continuum and recognises the artificiality of divisions between categories - an observation that rings true with clinicians who routinely assess individuals meeting criteria for more than one ICD/DSM personality disorder. While a dimensional approach may have heuristic value, it does not solve the problems of case identification that bedevil the literature on personality disorder (see below).

Current classifications of personality disorder have not only been criticised on theoretical grounds but also appear to have limited value as a basis for treatment. A large study by Tyrer et al. (1990) assessed 210 patients with diagnoses of anxiety disorder, panic disorder and dysthymia using the Personality Assessment Schedule (PAS) (Tyrer & Alexander 1979) and found that 36 % of the cohort were comorbid for personality disorder and had more severe psychopathology than the rest of the sample. The PAS ratings were converted into 14 personality types corresponding to draft ICD-10 and DSM-III categories. The category of personality disorder had no predictive value regarding outcome of pharmacological/psychological treatments, suggesting that the classificatory systems were over-determined. Rutter (1987) proposed the pragmatic solution of abandoning trait-based categories and simply identifying those individuals who are unable to form and maintain satisfactory relationships. More recently, Tyrer and colleagues have proposed the clinically useful approach of distinguishing treatment-seeking and treatment-resistant personality disorders (Tyrer et al., 2003).

Letting Go, Moving On

Letting Go, Moving On

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