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Enduring Personality Change
Methodological flaws and confounders in study
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Akeem O. Sule, Consultant Psychiatrist Bedfordshire and Luton Mental health and Social Care Partnership NHS Trust, Farida Jan, Mehraj Shah
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mehraj.shah{at}blpt.nhs.uk Akeem O. Sule, et al.
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We read with keen interest Skodol et al (2007) article on personality disorder. However we disagree with the phrase ‘Adult-onset personality disorder’. The author implied that this group of personality disorder individuals’…had any personality disorder at mean age 33 years but not at prior assessment…’ However DSM-IV criteria described personality disorder individuals as having ‘an enduring pattern of inner experience and behaviour that deviates markedly from the individual’s culture’. The criteria also include a statement: ‘the pattern is stable and of long duration and its onset can be traced back at least to adolescent or early adulthood’. A possible explanation for ‘adult onset personality disorder’ is that this group of individuals might be classified under ICD-10, F62 category i.e. ‘enduring personality changes not attributable to brain change or disease’. The ICD-10 states that this group includes ‘disorders of adult personality and behaviour which develops following catastrophic or excessive prolonged stress or following severe psychiatric illness, in people with no previous personality disorder’. We notice that the investigators did not control for all these possible confounders in their study. American psychiatric Association (2005) Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV-TM) Skodol, A. E., Johnson, J. G., Cohen, p., et al (2007) Personality disorder and impaired functioning from adolescent to adulthood. British Journal of Psychiatry, 190, 415-420. World Health Organisation (1992) The ICD-10 Classification of Mental and behavioural Disorders: Clinical Description and Diagnostic guidelines. WHO Declaration of interest: None |
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Saddichha Sahoo, Resident in Psychiatry Central Institute of Psychiatry,Ranchi, India, Vibha Pandey
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saddichha{at}gmail.com Saddichha Sahoo, et al.
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The study by Andrew et al (2007) on impaired functioning in personality disorders, although interesting in its view, that remission of psychopathology is associated with better social functioning, is however limited by inherent methodological flaws. At the outset, we were unable to find the definition of “adult-onset personality disorders”. Is this a term coined by the authors, since both DSM-IV (APA, 2000) and ICD-10 (WHO, 1992) describe personality disorders to be an enduring pattern of behaviour that deviates markedly from the individual’s culture, with an onset usually in childhood or adolescence and continues into adulthood. In fact, the closest nosological diagnosis is personality change in ICD 10 (WHO, 1992), which is an entirely different concept and if present, a serious confounder. The calculation of psychosocial impairment also needs clarity, since a range of 0-24 could convey any value from mild to severe impairment. Further, we believe that the results do not mirror reality since results depict only 64 subjects with persistent PD compared to the 185 with PD, in remission. It is entirely plausible that the majority of patients with persistent PD would have simply dropped out of the study owing to the severity of their psychopathology, thereby skewing the results. Overall, we believe that the investigators have failed to control for all these possible confounders in their study. REFERENCES- 1.Skodol, A. E., Johnson, J.G., Cohen, P., et al (2007) Personality disorder and impaired functioning from adolescence to adulthood. British Journal of Psychiatry, 190, 415 – 420. 2.World Health Organisation (1992) The ICD-10 Classification of Mental and behavioural Disorders: Clinical Description and Diagnostic guidelines. WHO, Geneva. 3.American Psychiatric Association. (2000). Diagnostic and Statistical manual of Mental Disorders (4th ed.) Text Revision (DSM IV TR). Washington, DC: American Psychiatric Association |
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