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Because personality disorders are seen as highly complex there is a natural tendency to describe them in convoluted and multifaceted language. Novelists and playwrights have done this for hundreds of years; it is not the task of nosologists to repeat it. Instead we need a simpler classification of a very common disorder, as even if we lose some of the subtlety of the condition this is more than compensated by greater use and understanding. We also need to pay more attention to science rather than to clinical intuition in our terminology. Both the DSM-5 alternative model and the new ICD-11 classification have moved towards a dimensional system of classification that should help in selecting treatment and diluting the pervasive and unhelpful spread of the grossly heterogeneous condition, horderline. This has hindered progress and made us forget the many parts of personality disorder that are not in any way connected to the borderline spectrum and yet which are highly relevant pathologies.
Personality disorder is likely to be common in late life, but our ignorance is such that, at present, we can only speculate about its frequency and importance. The only firm evidence we have is that antisocial personality features tend to be attenuated in older age and obsessional and detached features accentuated. Differentiating personality change following organic disease from personality disorder requires more attention as it is important for good clinical management.
The influence of severity of personality disorder on outcome of depression is unclear. Four hundred and ten patients with depression in 9 urban and rural communities in Finland, Ireland, Norway, Spain and the United Kingdom, were randomised to individual problem-solving treatment (n = 121), group sessions on depression prevention (n = 106) or treatment as usual (n = 183). Depressive symptoms were recorded at baseline, 6 and 12 months. Personality assessment was performed using the Personality Assessment Schedule and analysed by severity (no personality disorder, personality difficulty, simple personality disorder, complex personality disorder). Complete personality assessments were performed on 301 individuals of whom 49.8% had no personality disorder; 19.3% had personality difficulties; 13.0% had simple personality disorder; and 17.9% had complex personality disorder. Severity of personality disorder was correlated with Beck Depression Inventory (BDI) scores at baseline (Spearman's r = 0.21; p < 0.001), 6 months (r = 0.14; p = 0.02) and 12 months (r = 0.21; p = 0.001). On multi-variable analysis, BDI at baseline (p < 0.001) and type of treatment offered (individual therapy, group therapy, treatment as usual) (p = 0.01) were significant independent predictors of BDI at 6 months. BDI at baseline was the sole significant independent predictor of BDI at 12 months (p < 0.001). There was no interaction between personality disorder and treatment type for depression.
While multi-variable analyses indicate that depressive symptoms at baseline are the strongest predictor of depressive symptoms at 6 and 12 months, the strong correlations between severity of personality disorder and depressive symptoms make it difficult to establish the independent effect of personality disorder on outcome of depression.
The classification of mood and personality disorders has become unnecessarily complicated. It has become bogged down by well-meaning but unhelpful subcategories that puzzle the will of clinicians to make useful judgements. The answer is to think of bipolar, depressive and personality disorders as each constituting a spectrum of severity and not to be too preoccupied with individual labels. It would also be useful to avoid the diagnostic chimera of borderline personality disorder, a condition that defies proper classification.
Dissociative identity disorder (DID) is as real as any other psychiatric disorder but has been over-diagnosed by gullible clinicians, especially in forensic settings. Its classification has been poor, but the new ICD-11 classification, especially of partial DID, should help research and practice.
The diagnosis of personality disorder is sometimes tolerated but often reviled as a label to attach to people we do not like. This is hardly surprising when we consider that problems in interpersonal relationships constitute the main feature of the disorder. But we cannot escape the fact that personality problems are extremely common and rejection on grounds of perceived undesirability is doltish. Both the DSM-5 (2013) alternative model and new ICD-11 classification of personality may help understanding as they are more in tune with science. Most of the previous classifications have failed to help practitioners or patients.
Biomedical research from low- and middle-income countries (LMICs) is poorly represented in Western European and North American psychiatric journals.
To test the feasibility of trialling a capacity-building intervention to improve LMIC papers' representation in biomedical journals.
We designed an enhanced peer-review intervention delivered to LMIC corresponding/first authors of papers rejected by the British Journal of Psychiatry. We conducted a feasibility study, inviting consenting authors to be randomised to intervention versus none, measuring recruitment and retention rates, outcome completion and author/reviewer-rated acceptability.
Of the 26/121 consenting to participate, 12 were randomised to the intervention and 14 to the control arms. Outcome completion was 100% but qualitative feedback from authors/reviewers was mixed, with attrition from 5/12 (42%) of intervention reviewers.
Low interest among eligible authors and variable participation of expert reviewers suggested low feasibility of a full trial and a need for intervention redesign.
Declaration of interest
A.P., P.T. and M.Y. are British Journal of Psychiatry editorial board members. During this study P.T. was British Journal of Psychiatry Editor, A.P. was a trainee editor and A.H. was an editorial assistant.
We all think about the environment when treating mental illness, but we regard it as secondary to helping symptoms and behaviour. Nidotherapy is the collaborative and systematic process of changing the physical, social and personal environment for people who have failed to respond fully to conventional treatments. It can be given by therapists unqualified in other specific treatment interventions and is highly cost effective, and so offers great advantages in health services constrained by cost pressures. This new edition has been fully revised, and includes new chapters on the principles of nidotherapy, the evidence for its effectiveness, its use in intellectual disability and those of limited mental capacity, the skills needed for nidotherapy, the economic benefits and common misconceptions. This comprehensive guide shows how nidotherapy can be used across the range of mental disorders and gives evidence for its value.