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A New Tool for Rating Complex Personality Disorders

Patients with DSM-Axis II personality disorders rarely present with a single diagnosis; the co-occurrence of Axis I conditions and comorbidities within and among DSM clusters is common. These overlapping diagnoses challenge our view of these conditions as distinct entities and our concept of how to assess and manage them. One recent report underscores the complex relations between personality disorders and other diagnoses, and another paper offers an alternative assessment tool.

The first study examined the relation between borderline personality disorder and Briquet's Syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders in 87 female patients (75 in St. Louis and 22 in Milan). All patients met criteria for borderline personality disorder according to the DSM-III-R and the Revised Diagnostic Interview for Borderlines. Each patient had at least one additional DSM diagnosis; the average was four or five. In the St. Louis group, 84% also met criteria for one of the following: somatization disorder (45% using DSM-IV criteria), Briquet's syndrome (43%), antisocial personality disorder (23%), alcoholism (49%), or other substance abuse disorders (27%). Other common comorbid conditions included major depression (87%), generalized anxiety disorder (55%), and panic disorder (51%).

The second study examined a new rating system for estimating the severity of personality disorder in 163 patients with personality disorders plus anxiety or depressive disorders. The new system classifies patients according to a four-point severity rating: no personality abnormality, personality difficulty (essentially subclinical criteria for one or more personality disorders), simple personality disorder (one or more personality disorders from within the same cluster), or diffuse personality disorder (two or more personality disorders from different clusters). When compared with an older system that predicted initial symptom levels and degree of improvement over a subsequent two-year period, the new method was better able to account for sources of patient variation (97% with the new system vs. 72% with the older one) and was more useful for predicting outcome.

Comment: Current schemes for the diagnosis of personality disorders leave much to be desired. Since multiple diagnostic burdens are more often the rule than the exception in patients with personality disorders, more sophisticated diagnostic concepts such as the one suggested by this severity index may be necessary for patients with personality disorders and extensive psychiatric comorbidities.

— J Yager

Published in Journal Watch Psychiatry February 1, 1997

Citation(s):

Hudziak JJ et al. Clinical study of the relation of borderline personality disorder to Briquet's syndrome (hysteria), somatization disorder, antisocial personality disorder, and substance abuse disorders. Am J Psychiatry 1996 Dec 153 1598-1606.

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Tyrer P; Johnson T. Establishing the severity of personality disorders. Am J Psychiatry 1996 Dec 153 1593-1597.

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