Forensic Psychiatry and Forensic Psychology: Personality Disorder

R Nathan, Mersey Care NHS Trust, Merseyside, UK; University of Liverpool, Liverpool, UK; University of Chester, Chester, UK; and
Scott Clinic, Merseyside, UK
H Wood, Waterloo Manor Hospital, Leeds, UK and The Grange, Cleckheaton, UK
r 2016 Elsevier Ltd. All rights reserved.
This article is a revision of the previous edition article by J. Frazer, K.J.B. Rix, volume 2, pp 424–434, r 2005, Elsevier Ltd.

Abstract

Personality disorder is a broad concept that covers a wide range of enduring psychological dysfunctions
that tend to emerge in childhood and persist through the life-course. In this chapter, the prominent
conceptual models of personality disorder and etiolgical processes are described. Drawing on their
experience of assessing and treating patients with personality disorder in forensic and non-forensic settings,
the authors present common approaches to assessment and treatment.

Introduction lengthy standardized clinician-administered interviews

(Widiger, 2012). Many assessment approaches have
Personality disorder is a clinical concept that is used to emerged from the clinical tradition, whereas others have
describe extremes of personality functioning that has been developed from the extensive literature on ‘normal’
significant negative correlates such as intense distress or personality. These different approaches are not mutually
gross impairment in performance in work or social do- exclusive and in clinical practice they may be compli-
mains. Despite controversies, the concept of personality mentary. Most assessment techniques draw on internal
disorder has not become redundant, and it remains experiences and behaviors on which the patient and
useful to clinicians working with individuals identified as others are able to readily report. Experienced clinicians
having a personality disorder since they are able to relate are often able to additionally uncover potential psycho-
their clinical practice to an expanding scientific litera- logical mechanisms that account for the disturbed pattern
ture. The problem with the term arises when it is used in of experience and behavior, but standardized approaches
a way that the evidence base does not support. Whereas to this type of assessment are less well developed.
diagnostic practice in physical healthcare has developed
so that the diagnostic label has become more closely
linked with specific underlying pathology, a categorical
Models of Understanding Personality Disorder
diagnosis of personality disorder (in common with other
mental disorder diagnoses) has a more superficial func-
Personality disorders are at the extreme of continua with
tion as a description of associated symptoms or traits.
‘normal’ personality. The term personality is used to
In the recent past the personality disorder label was
describe the characteristic way in which an individual
often associated with therapeutic nihilism and an in-
thinks, feels, relates to others, and behaves. Although an
creased likelihood of rejection from mental health ser-
individual may think, feel, relate to others, and behave
vices. More recently, significant strides have been made
in different ways in different circumstances, there is a
in the study of interventions in this field which has
general consistency of experience and behavior over
generated convincing evidence for the effectiveness of
time and across situations. The consistent pattern is the
particular therapies for certain types of personality dis-
foundation both of our unique sense of self and of how
order. It should be recognized that there is less evidence
we are seen by others. Our pattern of personality func-
to support the benefits of interventions for some per-
tioning emerges in early life and becomes more generally
sonality disorder types, although this may be a reflection
well defined from adolescence.
of the more limited research in this area. Although there
In line with the paradigm of personality disorders
has been an increased level of clinical expertize in the
lying on continua with non-disordered personality, the
area of personality disorder, patients with this diagnosis
use of approaches developed from studies of nonclinical/
may still be disadvantaged in comparison to patients
non-forensic groups has been extended to the clinical
diagnosed with a mental illness. The reality, however, is
arena. Most notable, in terms of empirical support
that in many cases personality disorder and mental ill-
and widespread use, is the five-factor model (Costa and
ness coexist and there is some reason to question the
Widiger, 1994). This model posits five overarching
validity of the previously supposed distinction between
personality trait factors:
personality disorder and mental illness.
There are different methods of personality disorder 1. Neuroticism, contrasting with emotional stability
assessment ranging from brief self-report measures to 2. Extraversion, contrasting with introversion

662 Encyclopedia of Forensic and Legal Medicine, Volume 2 doi:10.1016/B978-0-12-800034-2.00192-0

 Forensic Psychiatry and Forensic Psychology: Personality Disorder 663

3. Openness to experience, contrasting with discomfort another mental disorder, medical disorder, or the effects
with novel experiences of substances. These general criteria are important to
4. Agreeableness, contrasting with antagonism ensure that personality disorder is not used to describe
5. Conscientiousness, contrasting with undependability. more time-limited changes in psychological functioning
even if the manifestations of the psychological dys-
This structure, which is found to exist cross- function resemble personality disorder traits. Proper
culturally, appears to have a genetic basis, to be rela- application of the general diagnostic criteria also re-
tively stable over the life-course, and to predict health quires that the clinician explores for the possibility
outcomes. Each factor comprises six lower order facets that there may be another diagnostic explanation for
(e.g., neuroticism facets: anxiousness, anger hostility, the history. The experienced clinician is vigilant to this
depressiveness, self-consciousness, impulsivity, and vul- possibility and draws on their familiarity with the rec-
nerability). Five-factor personality functioning can be ognized potential overlaps between specific personality
assessed by means of self-report inventories or stand- disorder categories and other diagnoses. For example, it
ardized interview. is necessary to specifically examine for the possibility
Another established typology identified three in- that the patient with apparent paranoid personality
dependent temperamental dimensions that were pur- disorder traits is laboring under delusional ideas arising
ported to be strongly genetically influenced and to from a psychotic mental illness. Reports of apparent
have a neurobiological basis, i.e., novelty-seeking, harm schizotypal traits also require an assessment for symp-
avoidance, and reward dependence (Cloninger et al., toms of a psychotic mental illness. The identification of
1993). Although in comparison to the five-factor model schizoid personality disorder traits should stimulate the
this typology has received mixed support from the clinician to consider whether the history can be better
empirical evidence base, it has clinical utility since it en- accounted for by autism spectrum disorder. The absence
courages a focus on personality styles relevant to clinical of a similar criterion for mental illnesses requiring the
assessment and decision making particularly within a clinician to consider whether mental illness symptoms
forensic settings. Novelty-seeking describes a propensity are better explained by personality disorder establishes
to approach novel stimuli and an active avoidance of a hierarchy of diagnoses. However, it should not be
monotony. Harm avoidance involves strong behavioral forgotten that the categories in DSM-5 and ICD-10 are
inhibition in response to aversive stimuli. Reward de- not empirically derived and as such the validity of
pendence involves a particular tendency to respond to the diagnostic output should not be overstated. Thus,
rewarding responses. Different personality types may be the co-occurrence of apparent paranoid or schizotypal
described according to the profile of scores across these personality disorder traits and paranoid psychosis in
three dimensions, for example, offenders are more prone the same patient is more likely to be reflective of com-
to display a profile of high novelty-seeking, low harm mon underlying processes rather than the unfortunate
avoidance, and reward dependence. The original three- coincidental occurrence of two ‘paranoid conditions.’
factor model was subsequently extended to include A debate over whether a clinical history of preference for
another dimension of temperament (i.e., persistence) being alone, interpersonal detachment, and restricted
and three dimensions of character (i.e., self-directness, interests is a consequence of autism spectrum disorder or
cooperativeness, and self-transcendence). schizoid personality disorder is based on an assumption
The most widely used assessment approaches that that the diagnosis identifies the cause of the problems,
have been developed from work with clinical groups are whereas in fact it describes the problems. DSM and ICD
described in the International Classification of Diseases, are atheoretical pragmatic tools that are thought by
10th edition (ICD-10; World Health Organisation, many, but not all, clinicians to have sufficient utility to
1993) and the Diagnostic and Statistical Manual, 5th support their continued use. However, the burgeoning
edition (DSM-5; American Psychiatric Association, neuroscientific research into the core psychological
2014). Within these manuals a categorical approach is mechanism disturbances driving symptoms and traits is
adopted, in which different distinct personality disorder unlikely to support the carving of mental disorders at the
types are identified on the basis of the presence of a current DSM and ICD joints.
predefined number of traits from a longer list which is The second stage of the categorical diagnostic
mostly, but not exclusively, specific to each personality assessment process within DSM-5 and ICD-10 is the
disorder type. There are two stages to the diagnostic identification of a predefined number of personality
process. Firstly, the general diagnostic criteria for per- traits from a longer list of traits for each personality
sonality disorder need to be satisfied. In both ICD-10 disorder diagnosis. There are strong similarities between
and DSM-5, the general criteria require evidence of a the DSM-5 and ICD-10 personality disorder types, but
pattern of disordered thinking, feeling, relating, and also some notable differences. DSM personality disorder
behaving, that is present persistently over time (stretch- types have been grouped into three clusters.
ing back to adolescence or early adulthood) and across Cluster A, which has been described as the ‘odd
situations, and that is not better accounted for by or eccentric’ group includes paranoid, schizoid, and
664 Forensic Psychiatry and Forensic Psychology: Personality Disorder

schizotypal personality disorders. ICD has paranoid and clinician has to explore beneath the behavior to identify
schizoid personality disorders, but schizotypal disorder disordered psychological functioning. The listed traits
is categorized within the schizophrenia, schizotypal, refer to interpersonal emotional impairments (in relation
and delusional disorder section. Patients with paranoid to concern for the feelings of others and the capacity
personality disorder display pervasive distrust and sus- to experience guilt), cognitive distortions (involving
piciousness as evidenced by unfounded suspicions that blaming others and other rationalizations for antisocial
others are harming or deceiving them and are likely to be behavior), problems managing frustration (with a
disloyal and untrustworthy. These patients tend to avoid readiness to aggressive responding), and attachment
disclosing personal information, misattribute threat or problems (difficulty maintaining but not establishing
criticism to the actions of others, display oversensitivity enduring relationships). Thus the terms antisocial and
to perceived slights, bear grudges, and maintain con- dissocial as applied to personality disorders are not
spiratorial explanations of events. Schizoid personality interchangeable. Although there may be some indi-
disorder is characterized by significant interpersonal viduals who meet the criteria for both, dissocial per-
detachment and limited capacity for the expression of sonality disorder is a narrower construct that has
emotions and for pleasure from activities. A patient with more in common with the even narrower notion of
these traits may appear cold and indifferent to others. psychopathy.
There has been relatively limited research into this per- Borderline personality disorder traits describe in-
sonality disorder category despite the significant associ- stability across a number of domains including inter-
ated impaired functioning. Schizotypal personality personal (avoidance of abandonment and unstable/
disorder, the third Cluster A personality disorder, is a intense relationships), identity (resulting in a lack of
multifactor construct comprising cognitive–perceptual clear sense of self), impulsivity (in areas such as spend-
traits (e.g., unusual beliefs, perceptual disturbances, ing, sex, and substance use), and emotional (manifest in
ideas of reference, and paranoia) disorganized/oddness unregulated and intense emotions on the one hand, and
traits (odd thinking, speech, and behavior) and inter- an emotional void experienced as emptiness on the
personal traits (lack of friends and social anxiety). other). Suicidal behavior, which is another trait of bor-
However, there is some overlap with other personality derline personality disorder, often occurs at crisis points
disorders in that the paranoia has been found to be more when the above instabilities are activated. Under
linked to paranoid personality disorder and the inter- particular stress there can be a transient reduction in
personal traits are correlated with several personality reality testing in the form of paranoia or dissociation.
disorders. This illustrates that blurred inter-diagnostic The term ‘borderline’ appears in ICD-10 to describe
boundaries not only exist between personality disorder a similar profile of personality traits, but it is one of the
and other mental disorder diagnoses, but also between two variants of the broader category of emotionally
different personality disorder diagnoses. unstable personality disorder. The other variant (im-
DSM Cluster B, the so-called ‘dramatic, emotional pulsive type) emphasizes lack of impulse control and
or eccentric’ group, includes antisocial personality dis- proneness to outbursts of threatening or aggressive
order, borderline personality disorder, histrionic per- behavior.
sonality disorder, and narcissistic personality disorder. At the core of the histrionic personality disorder
In ICD-10, the antisocial category is dissocial person- diagnosis, in both ICD-10 and DSM-5, is attention
ality disorder (which differs more than just in name), seeking (e.g., being uncomfortable if not the center of
the equivalent to borderline personality disorder is attention, use of physical appearance to draw attention,
emotionally unstable personality disorder and a distinct self-dramatization, and theatricality) and excessive
narcissistic construct does not appear. Within DSM-5, a emotionality (e.g., rapidly changing shallow expression
diagnosis of antisocial personality disorder is supported of emotions and exaggerated expression of emotions).
by a history of involvement in antisocial behavior, Additional diagnostic characteristics include suggest-
deceitfulness, impulsivity, aggression, irresponsibility, ibility, impressionistic style of speech, and a tendency to
recklessness, and lack of remorse. It is the only person- consider relationships more intimate than they are. The
ality disorder diagnosis that also requires the endorse- DSM narcissistic personality disorder diagnostic criteria
ment of specific childhood criteria (i.e., conduct include grandiosity in fantasy (about great success,
problems, such as stealing, fighting, truanting, and power, and being special) and behavior (haughtiness and
running away from home). This diagnosis has been expectations of being recognized as superior, of associ-
criticized as being so broad-brush that it is merely cap- ation with other special people, of excessive admiration,
turing those with a history of committing criminal and of entitlement). Patients with this disorder are con-
acts rather than describing a more coherent pattern of sidered to have difficulty recognizing the feelings of
psychological functioning associated with antisocial be- others and to exploit others. They often have strong
havior. This criticism is supported by the high preva- feelings of envy either in the form of envy of others or of
lence of this diagnosis within offender groups. To make beliefs that others are envious of him or her. Although
a diagnosis of ICD-10 dissocial personality disorder, the the DSM diagnosis is based largely on manifestations of
 Forensic Psychiatry and Forensic Psychology: Personality Disorder 665

the ‘grandiose’ dimension of pathological narcissism, the both by oneself adopting such a high degree of perfec-
‘vulnerable’ dimension is not reflected in the diagnostic tionism that task completion is disrupted, and by others
criteria. An understanding of Cluster B personality dis- insisting things are done their way, (3) possessions, re-
orders is particularly important in the forensic field. sulting in an inability to throw away objects of no value,
Antisocial personality disorder by definition is associ- (4) finances, resulting in miserliness, and (5) ethics and
ated with offending. However, identification of specific values to a degree that may lead to inflexible adherence
Cluster B personality disorder traits (such as impulsivity to rules. Consequently, the patient with obsessive–
and anger dyscontrol in borderline personality disorder; compulsive personality disorder often devotes them-
or empathy deficits and exploitative behaviour in nar- selves to work at the expense of their own leisure time
cissistic personality disorder) can inform the assessment and appears to others to be rigid and stubborn. The
and management of the risk of reoffending. equivalent ICD-10 category, anankastic personality
The third grouping, Cluster C (also known as the disorder, includes additional items that suggest a link
‘anxious and fearful’ group) is made up of avoidant with obsessive–compulsive disorder (i.e., feelings of ex-
personality disorder, dependent personality disorder and cessive doubt and the intrusion of unwelcome thoughts).
obsessive–compulsive personality disorder. Avoidant In recognition of the shortcomings of the categorical
personality disorder as defined within DSM-5 is char- approach to personality disorder assessment, the most
acterized by social inhibition as a consequence of feel- recent version of the DSM-5 has introduced an alter-
ings of inadequacy and sensitivity to negative evaluation native dimensional approach. However, to avoid major
(e.g., criticism, disapproval, or rejection). The diagnostic disruption to clinical practice, the categorical approach is
traits cover negative self-representations (inept, un- also retained within DSM-5. The dimensional model re-
appealing, or inferior), preoccupations about adverse lies on both an assessment of the level of personality
responses by others (being criticized or rejected) and dysfunction (Criterion A) and an assessment of the
certain types of interpersonal avoidance (of expression pathological personality traits (Criterion B). Dysfunction
of feelings and confiding within partner relationships, of is assessed on continua of self functioning (subdivided
unfamiliar social settings and activities, and of work into identity and self-direction) and of interpersonal
involving significant contact). The ICD-10 equivalent, functioning (subdivided into empathy and intimacy).
which is titled ‘anxious (avoidant),’ relies on similar According to this alternative dimensional model, the
evidence for a diagnosis, but additionally refers to per- pathological personality traits are grouped into five do-
sistent feelings of tension and apprehension. A cursory mains (negative affectivity, detachment, antagonism,
behaviorally focused assessment of the interpersonal disinhibition, and psychoticism) each of which has a
functioning of a patient with avoidant personality dis- number of trait facets (25 in total, such as emotional
order may lead the clinician to conclude that there is lability, anxiousness, separation insecurity which are
schizoid detachment. However, an assessment of in- facets of the negative affectivity domain). Similarities can
ternal experiences reveals that the interpersonal avoid- be observed between this framework of pathological
ance in avoidant personality disorder is actively sought personality traits and the five-factor model of personality.
in response to the associated distress, whereas in schiz- The dimensional approach retains the requirements set
oid personality disorder there is a more passive detach- out in the general diagnostic criteria for the categorical
ment. At the core of the dependent personality disorder approaches for the disturbance: (1) to be present across
diagnosis is an intense need to be taken care of associ- situations and over time (pervasiveness and stability, re-
ated with submissiveness, clinging, and fear of separ- spectively) and (2) not to be better explained by another
ation. The DSM diagnostic traits describe the typical mental disorder, a medical condition, or a substance.
psychological experiences (feeling uncomfortable when Although it does not appear as a standalone diagnostic
alone and preoccupied by fears of being left to care entity within DSM-5 or ICD-10, psychopathy is an im-
for himself or herself) and interpersonal consequences portant concept in forensic clinical practice, not least be-
(needing excessive advice or reassurance to make de- cause it has been shown to be a predictor of the risk of
cisions, needing others to assume responsibility for his/ violence (Patrick, 2006). In his influential book, the Mask
her life, difficulty expressing disagreement due to an- of Sanity, Cleckley (1941) reported a series of case studies
ticipated loss of approval, difficulty starting projects to illustrate the characteristics of a ‘psychopath.’ Cleck-
alone, going to excessive lengths to obtain nurturance ley’s analysis informed the development of Hare’s Psych-
or support, and urgently seeking another relationship opathy Checklist which identifies two broad subsets of
following the end of a close relationship). There is sig- traits, i.e., ‘interpersonal-affective’ and ‘antisocial lifestyle.’
nificant overlap with the listed traits for an ICD-10
diagnosis. Obsessive–compulsive personality disorder,
which is distinct from obsessive–compulsive disorder, is Assessment/Measurement of Personality Disorders
characterized by excessive attempts to maintain control
of (1) events through an undue preoccupation with de- Personality disorder assessment can be supported by the
tails, lists and order, (2) the way tasks are carried out, use of standardized assessment tools, which mostly take
666 Forensic Psychiatry and Forensic Psychology: Personality Disorder

the form of clinician-administered interviews and psychopathology later in life, including personality dis-
self-report questionnaires. Some measures involve the order traits. A range of different adversities (such as
simultaneous assessment of the full range of personality physical, sexual, and emotional abuse and neglect) have
disorders. One of the most commonly used is the Inter- been demonstrated to increase the risk of personality
national Personality Disorder Examination (IPDE), which disorder pathology. It has been proposed that some
is a semi-structured clinician-administered interview. types of adversity make a specific contribution to the
For each personality disorder type, the IPDE produces a vulnerability for specific types of personality disorder.
categorical output (definite, probable, and absent) and a For example, invalidating responses to the child’s emo-
dimensional output (sum of the rating for each item) for tions and emotional abuse/neglect have been presented
each personality disorder category. Other structured as key adversities associated with borderline personality
interviews include the Structured Clinical Interview for disorder. Harsh and inconsistent discipline has been
DSM-IV Axis II personality disorders (SCID II) and the linked with antisocial outcomes.
Diagnostic Interview for DSM-IV Personality Disorders
(DIPD-IV). Self-report questionnaires with comprehen-
Developmental Pathways
sive coverage include the Millon Clinical Multiaxial
Inventory-III (MCMI-III) and Minnesota Multiphasic An individual’s personality, whether it is considered
Personality Inventory-2 (MMPI-2). Self-report measures disordered or non-disordered, starts to take shape in
have the advantages that they require less clinician time to the context of a two-way interaction between genetic
administer, they are not subject to inter-administrator and environmental factors. This is two-way in that on
variation and scales may be included to index the pa- the one hand temperamental characteristics may have
tient’s response style. However, these measures are more an influence on the nature of the environment. For ex-
dependent on the patient being able to recognize their ample, infants vary in the degree to which they are liable
styles of psychological functioning and over-endorsement to express emotions and there is a genetic contribution
can be a problem. There are also tools designed to assess to this variability. Parents vary in their responses to their
specific personality disorder types, using self-report child’s expressions of emotions. In some cases, poor
and clinician interview methodology (e.g., Narcissistic parenting may be a response to an infant who displays
Personality Inventory and Revised Diagnostic Interview extremes of emotional expressivity (i.e., over- or under-
for Borderlines, respectively). expression of emotions). On the other hand, parenting
or care-giving influences the infant’s developing capacity
to reflect on emotions and contain negative emotions.
Etiology of Personality Disorders Thus the experience of poor parenting may be associated
with the impaired understanding of one’s emotions and
Familial/Genetic Factors
a propensity to emotional crises. Interactive influences
Personality disorders are moderately heritable. The apply to a range of psychological processes, in addition
etiology of some personality disorders has received to emotional expression, such emotional empathy,
more attention than others. The familial aggregation of attributional style, sociability, impulse control, and
paranoid, schizotypal, and (to a lesser extent) schizoid risk taking. There is a continued interaction over time
personality disorders with schizophrenia supports the between the developing profile of psychological func-
positioning of these personality disorders on the tioning and the changing environment. The psycho-
schizophrenia-spectrum. There is also some evidence of logical profile at any one time can be understood as the
a specific link between paranoid personality disorder combination, on the one hand of the effects of inter-
and delusional disorder. There is strong evidence for the actions between the environmental and psychological
role of genetic factors in the development of antisocial processes up to that point and on the other the en-
and borderline personality disorder. Genes appear to vironmental and psychological demands of the particu-
have a more pronounced influence in the early-onset lar developmental stage. These demands are both
life-course persistent variant of antisocial personality biologically and socially influenced.
disorder. Current research into the etiology of borderline
personality disorder suggests that genetic processes
Psychological Processes
influence the development of underlying processes (such
as emotional sensitivity and impulsivity) that confer an Studies of psychological mechanisms have generated
increased risk of specific personality disorder traits in the clinically useful insights into the etiology of patterns of
context of particular environmental experiences. behavior that are described by personality disorder
traits. For example, empathy deficits are thought to ac-
count in part for the interpersonal style of patients with
Environmental Factors
narcissistic personality disorder. Exploring the empathy
Adverse environmental experiences are associated with construct reveals that there are varied underlying pro-
an increased vulnerability to the development of cesses that may be differentially affected in different
 Forensic Psychiatry and Forensic Psychology: Personality Disorder 667

conditions. Narcissistic personality disorder is thought • Collaboration: working with the individual in a
to be associated with impaired emotional empathy (i.e., transparent and including them in every aspect of
the emotional response to the emotional display of their treatment,
others), but with relative preservation of cognitive em- • Consistency: maintaining a consistent approach that
pathy (e.g., understanding the beliefs of others) (Baskin- is understood and shared by all members of the in-
Sommers et al., 2014). On the other hand, theory of dividual’s team, and
mind, which is an example of cognitive empathy, is • Motivation: addressing issues relating to changes in
found to be impaired in autism spectrum disorder. The the individual’s motivation for recovery and instilling
degree of impairment may fluctuate in the same indi- a sense of hope for the future.
vidual at different times. Notably, the picture in bor-
These key principles are reflected in the guidelines on
derline personality disorder is of marked impaired
antisocial personality disorder and borderline person-
emotional empathy (with hyperreactivity to certain cues)
ality disorder published by National Institute for Health
when emotionally aroused.
and Care Excellence (2009a,b) which both highlight the
Socio-emotional capacities develop in the inter-
importance of equality in access to services, promoting
personal space between the child and his/her care giver
autonomy and choice, instilling hope and optimism,
(i.e., the attachment relationship). Attachment theory
and building trusting therapeutic relationships. The
provides a useful framework to understand both the
NIHCE guidelines also stress the importance of clin-
transactional context in which personality facets develop
icians working in skilled teams in which professionals
and how disturbances in early key relationships can in-
are provided with appropriate training and regular
fluence the development of vulnerabilities to later psy-
supervision in support of the work that they do.
chopathology including personality disorder. A number
A number of specialist services developed in recent
of the psychotherapeutic approaches that have been
years and services have used Livesley’s model of the
developed in the treatment of personality disorder, e.g.,
stages of change in personality to develop interventions
Mentalization Based Therapy, have their theoretical
that ensure safety while allowing the individual to pro-
origin in attachment theory.
gress. The authors of this chapter work on two different
examples of this kind of service. One of the authors
works in a hospital setting which is based on the
Treatment and Management of Personality Disorders Waterloo Integrated Safe and Eclectic (WISE) pathway.
This is a care pathway approach to treatment that rec-
The treatment of personality disorder has received a ognizes that individuals’ have different needs as they
great deal of academic and clinical attention in recent proceed in their recovery and that the components of
years. Having at one time been an area that was re- their care and treatment need to change accordingly.
garded with a certain amount of therapeutic disdain, an The other author works in a prison setting in which the
increasing number of researchers have invested their approach to relational security is informed by a psy-
resources in exploring and evaluating intervention chosocial understanding of personality disorder and of
strategies and a number of specialist personality disorder the specific needs of the inmates.
services have developed within the past 10 years. Central A number of psychotherapies have either an existing
to the ‘treatment’ of personality disorder is the under- evidence base or a developing evidence base for the
standing that, although medication might have a role in effective treatment of personality disorder. These are
managing the symptoms that are associated with some introduced in the following section.
personality disorder, neuroleptic medication does not
offer a resolution to the underlying disorder. In the UK
no medications are currently licensed by the National Psychosocial Treatments: Treatments that Combine
Institute for Health and Care Excellence (NIHCE) for Group Work with Individual Therapy
the treatment of personality disorder. It is generally
accepted that a psychotherapeutic approach is required Dialectical Behaviour Therapy
to identify and ‘treat’ the underlying issues that drive
Dialectical Behaviour Therapy (DBT) is a cognitive be-
personality disorder.
havioral approach to therapy developed by Marsha
Personality disorder services stress the need for a
Linehan in the late 1980s to provide an effective means
holistic approach to treatment that accommodates all
of treating individuals with borderline personality
of the individual’s needs from a biopsychosocial per-
disorder (Linehan, 1993). In its full form it combines
spective. It has been suggested that there are a handful of
individual therapy sessions with attendance at weekly
key ingredients that must be features of services if they
skills training groups in which the participants are sup-
are to succeed. These are as follows (Livesley, 2003):
ported to learn new skills increasing their ability to
• Validation: acknowledging how the individual is feel- tolerate of distress and to manage their emotions. DBT
ing and accepting this in a non-judgemental manner, includes explicit instruction in the use of mindfulness, a
668 Forensic Psychiatry and Forensic Psychology: Personality Disorder

strategy that has increasingly demonstrated its value in Dynamic Deconstructive Psychotherapy
the treatment of a range of different mental health
Dynamic Deconstructive Psychotherapy (DDP) was
problems. Individuals who are engaged in DBT are
developed by Professor John Gregory to offer an
supported directly through their involvement in therapy
approach to the treatment of individuals with borderline
and in group sessions and receive support outside
personality disorder who had found it difficult to
of sessions in the form of their access to a 24-hour
engage in alternative approaches to treatment (Gregory
telephone, ‘hotline,’ that they are invited to make use
and Remen, 2008). The theory that underpins DDP
of at times of crisis and in support of their decision
combines translational neuroscience, object relations
making. A number of randomized controlled trials
theory and deconstruction philosophy. Therapy involves
have demonstrated that DBT provides an effective
weekly individual sessions which are designed to help
approach to the treatment of borderline personality
patients to activate the areas of the brain that are
disorder. DBT is now often offered as part of the
responsible for adaptive and integrative processing. A
treatment approach in a number of specialist personality
12-month randomized controlled trial indicated that this
disorder services and the evidence in support of this in
approach was effective in helping individuals to improve
a number of different types of services, including out-
in a number of areas of functioning. Although the evi-
patients, in-patients and in patients detained in hospital,
dence in support of DDP is not yet great in terms of the
is growing.
number and range of studies, it is recognized that the
evidence that supports this is of the highest caliber and
Mentalization Based Therapy
involves an empirical approach that is robust and valid.
The early indications are that this approach offers an
Mentalization Based Therapy (MBT) was developed by effective treatment, not least for individuals who have
two psychoanalytic psychotherapists, Peter Fonagy and failed to respond to other approaches.
Anthony Bateman, to treat people with borderline per-
sonality disorder (Bateman and Fonagy, 2006). MBT is
based on a significant amount of research looking at the Integrative Approaches to Psychotherapy
attachment experiences of adults who have developed
personality disorder. The focus is on, ‘mentalization,’ or Schema Focused Therapy
the individual’s ability to think about thinking and to
acknowledge and to consider differences between their Schema Focused Therapy (SFT) was developed by Jeff
own mental world and that of others. Treatment in- Young to provide a form of cognitive therapy that
volves a combination of individual therapy sessions and focuses upon identifying and exploring the underlying
involvement in group treatment with others with similar beliefs that influence the individual’s thinking style and
presentations. There is a growing research base for MBT behavior (Young et al., 2003). SFT is informed by cog-
which indicates that it provides an effective treatment nitive therapy, behavior therapy, object relations psy-
for personality disorder and that the benefits of this are chotherapy, and gestalt therapy. It was developed with
maintained over time. the treatment of personality disorder in mind. Treatment
usually takes place in the form of individual therapy
sessions in which the individual is helped to identify the
maladaptive beliefs that are present and cognitive and
Psychodynamic Psychotherapies behavioral strategies are introduced to challenge their
validity and relevance. Randomized controlled trials
Transference Focused Psychotherapy have demonstrated the efficacy of SFT in the treatment
Transference Focused Psychotherapy (TFP) was de- of personality disorder and the positive effects of this
veloped to provide a highly structured psychodynamic have been maintained over a period of time.
approach to the treatment of personality disorder based
on Otto Kernberg’s object relations model of borderline
Cognitive Analytic Therapy
personality disorder (Kernberg et al., 2008). The inter-
vention involves individual therapy sessions that follow Cognitive Analytic Therapy (CAT) was developed by
a prescribed pathway including the use of an explicit Tony Ryle to provide a time-limited relational psycho-
contract in which both therapist and patient make a therapy that could be offered to individuals with a wide
commitment to the therapy, and detailed exploration range of presentations on the NHS (Ryle, 1995). It was
of the individual’s sense of self and understanding of based on an integration of object relations psycho-
others. The therapy involves a focus upon the process therapy and cognitive therapy, and is informed by social
of sessions and interpretation of transference. The aim is constructionism. Therapy takes the form of an agreed
to help the patient to develop a more integrated sense of number of sessions; often 16- or 24-sessions, which take
self and others. The efficacy of TFP has been demon- place on a weekly basis. There are then between one
strated in randomized controlled trials. and five follow-up sessions. Active collaboration is an
 Forensic Psychiatry and Forensic Psychology: Personality Disorder 669

essential part of therapy, which uses therapeutic letters References

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See also: Forensic Psychiatry and Forensic Psychology: Autism
Spectrum Disorder. Forensic Psychiatry and Forensic Psychology:
Forensic Psychiatric Assessment. Forensic Psychiatry and Forensic
Psychology: Multiple Personality Disorder. Forensic Psychiatry and
Forensic Psychology: Stalking. Mental Health: Crime and Mental
Health. Suicide: Self-Harm