Institute of Psychiatry, King's College, London
Personality disorders are among the most controversial of all psychiatric conditions. In the aftermath of some highly publicised tragedies involving people with a diagnosis of personality disorder, the government seems determined to increase the powers of psychiatrists to treat people with personality disorders. However, within the profession there is a great deal of ambivalence about whether personality disorders constitute medical conditions at all. In this discussion paper, evidence for and against the proposition that psychiatrists should treat personality disorders is considered.
The case in favour is that recently there have been some promising findings from clinical trials to suggest that, both psychotherapeutic and pharmacological treatments are helpful in dealing with the behavioural disturbance associated with some personality disorders. There is also evidence to show that some personality disordered people gain benefit from a day care programme. Finally, the psychiatrist's ability to formulate adn negotiate puts him or her in a good position to help manage this difficult group of people, who are unlikely to be helped by another section of society.
The case against is that there are dangers in taking a psychiatric paradigm of deviant behaviour too far. The term personality disorder is a way of applying an inappropriate medical model to personality variation and has created major difficulties in defining the role of the psychiatrist. Moreover, the diagnosis is unreliable, lacks validity and is often merely used as a way of describing people whom the doctor dislikes. There are no specific medical treatments for underlying personality disturbance and resources for the treatment of mental illness are already limited.
In conclusion, society is always likely to generate people who do not conform and psychiatry is in a position to help some of these people. Psychotherapeutic interventions have been shown to be the most effective intervention for modifying some forms of difficult behaviour displayed by people with personality disorders. These treatments require time and special expertise and should be delivered by specialist treatment facilities. Personality disordered offenders do not fit neatly into either the health or penal systems. A third service, within the penal system, but with input from the health service, may go some way towards providing the necessary containment and treatment for these people.