Personality disorder

Personality disorder

Personality disorder can be defined as “an enduring pattern of inner experience and

behaviour that deviates markedly from the expectations of the individual’s culture”

(Diagnostic and Statistical Manual IV). It includes many different disorders ranging

from histrionic personality to antisocial personality disorder (often referred to as

psychopathic disorder). It is antisocial personality disorder that is most relevant to

this Review. This topic has been discussed in depth by one of the working groups of

the Reed Review.36

A diagnosis of personality disorder can lead to exclusion from care for a variety of

reasons. Personality disorder can be specified as not being part of the remit of the

service – that is, it is not considered a severe mental illness. It can be defined as

untreatable, and therefore used as a reason for refusing care. Particular problems

arise when a label of personality disorder is attached to a person because of difficult

behaviour such as criminality, violence or substance misuse – all of which are

associated with anti-social personality disorder – and as a consequence care is


On the other hand, other agencies are often equally reluctant to engage with people

with personality disorder because they consider them as mentally ill due to their long

association with mental health care. This increases the risk that people fall between

services. However, these are precisely the people who can create major difficulties

for themselves, relatives and society, and unless the responsibility for, and details of,

their care have been specified among the many organisations and individuals who can

contribute, problems will escalate. Inquiries have repeatedly highlighted this problem.

These difficulties need to be addressed openly, and it has to be recognised that some

service has to be responsible for this group. However, not all people and their

difficulties, whether social or behavioural, can be accepted by mental health services.

If people are to be excluded, the criteria and their reasons have to be made explicit

in operational policies, and other available services should be identified to meet the

needs of this group. If no such services exist, reasons should be given by the

responsible commissioners.


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