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Personality disorder has been thrown into greater prominence in recent years as a consequence of the Government's Dangerous and Severe Personality Disorder Programme (www.dspdprogramme.gov.uk).
However, this document only applies to around 300-350 (male) individuals with personality disorder. According to epidemiological data, there are another 4,950,000 people with other personality disorders that do not receive this level of attention and yet deserve at least some of our concern.
What is personality disorder?
Personality abnormality is common in the population and almost follows a pattern of normal variation. Most people have adaptive personalities that allow them to adjust to their environments as needed, but those with abnormal personalities cannot adapt as well and create problems for both themselves and others.
Deciding when these problems constitute a 'disorder' or remain within normal variation is an arbitrary decision, and it is quite wrong to think that those with personality disorder are fundamentally different from the rest of the population.
Most studies suggest 25-30 per cent of GP attenders have a personality disorder1. This rises to 35-40 per cent for those attending psychiatric outpatient facilities and community teams, to over 50 per cent in psychiatric inpatients, and up to 90 per cent of those in prisons, special hospitals and specialist teams.
An interesting point to note is that the increasing prevalence of personality disorder in these populations is often not described in referral letters between agencies; much personality disorder remains covert in professional communications.
Effect of personality disorder on other mental illnesses
Most of the empirical evidence suggests the simultaneous presence of a personality disorder together with another mental illness impairs response to treatment. It is not known whether this is an indirect measure for instance, those with personality disorder being less likely to complete or adhere to treatment or a direct measure, in that those with personality disorder have more serious and resistant symptoms.
This distinction is important to recognise because often when people fail to respond to treatment it can be related to personality status. However, it would be a gross error to assume that all such people have personality problems
Treatment of personality disorder
Both psychological and drug treatments have been shown to be effective, including partial day hospital care associated with psychodynamic therapy, now formally describ-ed as mentalisation therapy, dialectical behaviour therapy, and cognitive analytical therapy (see www.acat.me.uk).
These treatments require considerable commitment on the part of the patient as well as specialist facilities, which can only be provided within secondary care. The strong-est effects on behaviour are on the recurrence of self-harm, which is often reduced significantly.
Drug treatments include low doses of antipsychotic drugs, both typical and atypical neuroleptics, and antidepressants, particularly the SSRIs such as fluoxetine and paroxetine. These have been shown to be effective in randomised trials, although the evidence is not particularly striking.
How should personality disorders be managed in primary care?
Many personality disorders are never recognised in primary care, but it would be an advantage if they were. The patient who attends diligently but always presents a new problem just at the point of being discharg-ed; the angry parent who threatens the receptionist; the patient with unexplained symptoms whose face falls when you reassure them that 'all the tests are normal'; and the litigious patient you are never quite sure how to manage as the covert threat of legal action dominates all exchanges....All these examples are likely to have some disturbance of personality.
Once recognised, anticipatory action is much more effective than irritable reaction to wasted time in the surgery. Those with personality disorders include some of the archetypal heartsink patients, but many others who take up a great deal of time and are excessively dependent or demanding can be understood and managed in a more detach-ed manner, once the personality problems have been identified and likely difficulties predicted.
Practice nurses may often be key figures in management; by constituting a reassuring presence without obvious threat they can settle patients with high levels of anxiety, reassure the obsessional, calm the impulsive and defuse the irritable.
In my personal practice I let my patients know if I judge them to have a personality disturbance. Although many of them find this a little uncomfortable, it can sometimes be appreciated and lead to useful dialogue (see box below). Certainly this form of reaction is much better than dismissing or ignoring the problem it rarely goes away.
What I say to patients
· When feeding back information, it is unwise to use the term 'personality disorder'. Use terms such as 'more sensitive to criticism than others', 'tendency to be over-anxious', 'have problems in controlling your temper' and similar descriptions. If directly asked about the diagnosis of personality disorder, emphasise that this is a shorthand term, and that everyone is on a spectrum of personality that includes both positive and negative aspects.
· Stress that every personality is unique and what can cause difficulties in one situation can be an asset in another for example, impulsiveness can be an asset on the sports field but less so in a blue-chip insurance company.
· Point out that it is always helpful to know your personality better, both for the GP and the patient, and that this knowledge can help in selecting treatments for other conditions. I often say it helps to make the person sitting in front of me a three-dimensional rather than a two-dimensional figure.
· Do not discuss personality features when the patient is in a highly charged emotional state of whatever type.