Leicester Frith Hospital, Leicester LE3 9QF, UK
Parkside NHS Trust, Kingsbury, UK
Correspondence: Dr Regi Alexander, Leicester Frith Hospital, Mansion House, Groby Road, Leicester LE3 9QF, UK
* Paper presented at the second conference of the British and Irish Group for
the Study of Personality Disorders (BIGSPD), University of Leicester, UK, 31
January to 3 February 2001.
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ABSTRACT |
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Aims To examine published literature on the diagnosis of personality disorders in learning disability.
Method Selective review with computerised (Medline, Embase and PsychInfo) and manual literature searches.
Results The variation in the co-occurrence of personality disorder in learning disability, with prevalence ranging from less than 1% to 91% in a community setting and 22% to 92% in hospital settings, is very great and too large to be explained by real differences.
Conclusions The diagnosis of personality disorders in learning disability is complex and difficult, particularly in those with severe disability. Developing consensus diagnostic criteria, specific for various developmental levels, is one way forward. Such criteria may need to include objective proxy measures such as behavioural observations and informant accounts.
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INTRODUCTION |
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METHOD |
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RESULTS |
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Schizoid/anancastic personality disorder
Earlier studies (Craft,
1959) suggested that schizoid personalities were very common in
people with learning disability. A significant proportion of these may
actually have had autism (Deb &
Hunter, 1991). Autistic traits also overlap significantly with
features of anancastic personality disorder.
Emotionally unstable (borderline) personality disorder
Features of borderline personality disorder, such as self-injurious
behaviour, impulsivity and affective lability, occur commonly in learning
disability (Mavromatis, 2000).
Consequently, additional features should be sought before making this
diagnosis (Wilson, 2001). Affective disorders commonly found in learning disability also mimic features
of emotionally unstable personalities (Deb
& Hunter, 1991).
Dependent and anxious/avoidant personality disorder
The presence of realistic dependency needs
(Reid & Ballinger, 1987) means that several criteria underpinning the diagnosis of dependent and
anxious/avoidant personality disorders may be difficult to apply in learning
disability.
The ability to diagnose personality disorders, inclusive of all sub-categories across the whole spectrum of learning disability, is hence debatable. Reviews of the published research literature fail to provide conclusive evidence.
Assessment/research instruments used
Instruments used in studies of personality disorders in learning disability
are described below.
Structured Assessment of Personality (SAP)
The SAP (Mann et al,
1981) relies on an informant account to establish a diagnosis of
personality disorder (Ballinger & Reid,
1987,
1988;
Reid & Ballinger, 1987).
The presence of three or more durable criteria establishes a personality
trait. If this causes significant personal distress, or occupational or social
impairment, the diagnosis of personality disorder is made.
Reiss screen and PIMRA
The Reiss screen is a screening tool for the detection of psychopathology
in mental retardation (Reiss,
1988). For those scoring above a threshold, the Psychopathology
Inventory for Mentally Retarded Adults (PIMRA;
Matson, 1988) is administered
(a checklist of psychopathological behaviour based on DSM-III).
Temporal-Lobe Personality Behaviour Inventory
This instrument is useful in identifying abnormal personalities
specifically associated with epilepsy (Bear
& Fedio, 1977).
Clinical diagnosis - ICD and DSM
Most studies have used clinical diagnoses based on either the
ICD or DSM systems to identify personality disorders. The standard categories
within these classificatory systems have sometimes been augmented with
additional items, e.g. Immature and Impulsive
(Corbett, 1979).
Diagnostic Criteria in Learning Disability (DC-LD)
Adopting a multi-axial, hierarchical approach to diagnosis, the DC-LD is a
new system providing operationalised criteria for psychiatric disorders in
adults with moderate to profound learning disabilities
(Royal College of Psychiatrists,
2001). The key points regarding personality disorders are
summarised below.
There are no published studies using the DC-LD criteria for personality disorders.
Studies with data on personality disorders in learning
disability
Many of these studies were designed to look not only at personality
disorders but also at any form of psychiatric morbidity in learning
disability. They vary widely in their methods and findings. The key studies
are summarised in Table 1.
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DISCUSSION |
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The introduction of the Standardized Assessment of Personality (SAP; Mann et al, 1981) was a crucial development in research in this area. Although initial studies using this instrument were limited to people with mild and moderate learning disabilities (Reid & Ballinger, 1987; Deb & Hunter, 1991), it has subsequently been used across the whole range of intellectual ability (Goldberg et al, 1995; Khan et al, 1997). Some of these studies revealed exceptionally high prevalence rates of up to 90% for different types of personality disorders in learning disability (Goldberg et al, 1995).
The ultimate validity of any diagnosis is in its clinical usefulness. Not surprisingly, therefore, unusually high prevalence rates would raise questions regarding the usefulness of such a diagnosis, particularly in those with severe or profound learning disabilities. Indeed, if diagnostic criteria are applied in such a way that an over-whelming majority of those with learning disability satisfy the criteria for personality disorders, it is not of much clinical use, either for the management of the individual patient or the planning of services.
Two recent studies have examined this issue further. In the first (Naik et al, 2002), those with a clinical diagnosis of personality disorder were identified and ICD-10 (World Health Organization, 1992) criteria applied thereafter. The prevalence rate of 7% in this study may well be an underestimate of the true prevalence, but nevertheless succeeds in identifying a group of patients with specific care needs and resource implications. The second study (Flynn et al, 2002), apart from estimating the prevalence rate, examined the diagnostic validity in terms of an association with abusive experiences in early life. The authors also introduce the concept of severe personality disorders and suggest criteria for making this diagnosis. This is a novel approach in this field and carries particular significance for the practising clinician.
The diagnosis of personality disorders across the whole spectrum of learning disability is complex and difficult, particularly in those with severe disability. In this context, the need for a personality typology based on the developmental perspective has been highlighted (Gostasson, 1987). Developing consensus diagnostic criteria for each personality disorder, specific for various developmental levels and including objective proxy measures such as behavioural observations and informant accounts is one way forward.
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Clinical Implications and Limitations |
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LIMITATIONS
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REFERENCES |
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American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, (4th edn) (DSM-IV). Washington, DC: APA.
Ballinger, B. R. & Reid, A. H. (1987) A standardised assessment of personality disorder in mental handicap. British Journal of Psychiatry, 150, 108-109.[Abstract]
Ballinger, B. R. & Reid, A. H. (1988) A standardised assessment of personality disorder in mental handicap. British Journal of Psychiatry, 152, 577a.
Bear, D. M. & Fedio, P. (1977) Quantitative analysis of interictal behaviour in temporal lobe epilepsy. Archives of Neurology, 34, 454-467.[Abstract]
Bouras, N. & Drummond, C. (1992) Behaviour and psychiatric disorders of people with mental handicaps living in the community. Journal of Intellectual Disability Research, 36, 349-357.[Medline]
Corbett, J. A. (1979) Psychiatric morbidity and mental retardation. In Psychiatric Illness and Mental Handicap (eds F. E. James & P. Snaith), pp. 11-25. London: Gaskell.
Craft, M. (1959) Mental disorder in the defective. American Journal of Mental Deficiency, 63, 829-834.
Day, K. (1985) Psychiatric disorder in the middle-aged and elderly mentally handicapped. British Journal of Psychiatry, 147, 660-667.[Abstract]
Deb, S. & Hunter, D. (1991) Psychopathology of people with mental handicap and epilepsy. III: Personality disorder. British Journal of Psychiatry, 159, 830-834.[Abstract]
Eaton, L. F. & Menolascino, F. J. (1982) Psychiatric diagnosis in the mentally retarded: types, problems and challenges. American Journal of Psychiatry, 139, 1297-1303.[Abstract]
Flynn, A., Matthews, H. & Hollins, S.
(2002) Validity of the diagnosis of personality disorder in
adults with learning disability and severe behavioural problems: Preliminary
study. British Journal of Psychiatry,
180,
543-546.
Goldberg, B., Gitta, M. Z. & Puddephatt, A. (1995) Personality and trait disturbances in an adult mental retardation population: significance for psychiatric management. Journal of Intellectual Disability Research, 39, 284-294.[Medline]
Gostasson, R. (1987) Psychiatric illness among the mildly mentally retarded. Upsala Journal of Medical Science, 44 (suppl.), 115-124.
Hurley, D. A. & Sovner, R. (1995) Six cases of patients with mental retardation who have anti-social personality disorder. Psychiatric Services, 46, 828-831.[Abstract]
Jacobson, J. W. (1990) Do some mental disorders occur less frequently among persons with mental retardation? American Journal of Mental Retardation, 94, 596-602.[Medline]
Khan, A., Cowan, C. & Roy, A. (1997) Personality disorders in people with learning disabilities, a community survey. Journal of Intellectual Disability Research, 41, 324-330.[Medline]
Matson, J. L. (1988) Psychopathology Inventory for Mentally Retarded Adults. Orland Park, IL: International Diagnostic Systems.
Mann, A. H., Jenkins, R., Cutting, J. C., et al (1981) The development and use of a standardized assessment of abnormal personality. Psychological Medicine, 11, 839-847.[Medline]
Mavromatis, M. (2000) The diagnosis and treatment of borderline personality disorder in persons with developmental disability - 3 case reports. Mental Health Aspects of Developmental Disabilities, 3, 89-97.
Naik, B. I., Gangadharan, S. K. & Alexander, R. T. (2002) Personality disorders in learning disability - the clinical experience. British Journal of Developmental Disabilities, 48, 95-100.
Reid, A. H. & Ballinger, B. R. (1987) Personality disorder in mental handicap. Psychological Medicine, 17, 983-987.[Medline]
Reiss, S. (1988) Reiss Screen Test Manual. Orland Park, IL: International Diagnostic Systems.
Reiss, S. (1990) Prevalence of dual diagnosis in community based day programmes in the Chicago metropolitan area. American Journal of Mental Retardation, 94, 578-585.[Medline]
Royal College of Psychiatrists (2001) Diagnostic Criteria in Learning Disability (DC-LD). London: Gaskell.
Tyrer, P., Casey, P. & Ferguson, B. (1993) Personality disorder in perspective. In Personality Disorder Reviewed, pp. 1-16. London: Gaskell.
Wilson, S. R. (2001) A four stage model for management of borderline personality disorder in people with mental retardation. Mental Health Aspects of Developmental Disabilities, 4, 68-76.
World Health Organization (1992) Tenth Revision of the International Classification of Diseases and Related Health Problems (ICD-10). Geneva: WHO.