As a psychiatry trainee early in my psychiatric training, I find the topic of personality disorders challenging in terms of their presentation, care planning and our role as trainees. It seems a necessary part of clinical practice to reflect on and understand the current role of the psychiatrist in diagnosing and managing personality disorders. An estimated 50% of patients attending UK outpatient psychiatric services have a personality disorder so therefore one would assume our training and resources would reflect that (Beckwith et al. 2014). Documentation of antisocial and borderline personality disorder diagnoses are routinely seen, but are all 10 current categories considered and incorporated into regular clinical practice? The only diagnoses often recorded are Diagnostic Statistical Manual (DSM-IV), International Classification of Disease (ICD-10), ‘Axis 1’ disorders, which do not always reflect the full complexity of our patient’s presentation, their therapeutic needs and potential barriers to their recovery. Reference may be made to a patient being ‘a PD’ (personality disorder) during unofficial discussions outside of formal multidisciplinary team (MDT) meetings. If this is not documented or a patient is not aware of this, the role or use of the diagnostic label must be considered. For example Endocrinologists in a Diabetic Clinic are implored to avoid calling a patient ‘a diabetic’, as this disease does not define the patient as a person. As physicians, we thrive on reproducible and structured diagnoses, however, this is not the case for all allied health professionals. Psychologists often distance themselves from our medical language and definitions weakening the integration of a common understanding and unified thinking in terms of proposed therapies.

So, where and when do we see personality disorders as young inexperienced trainees? These patients often present to emergency departments with self-harm thoughts or behaviours, or perhaps in addiction and forensic settings. In outpatient departments where we assess new and longstanding patients with a variety of difficulties there are sometimes unidentified or unnamed personality traits evident, for example, dependant, avoidant or obsessive compulsive. These patients can often be challenging, have had poor therapeutic response and ongoing significant risk issues. Complicating the matter further, there are often serious co-morbidities in this cohort. These co-morbidities may encompass other mental illnesses, physical illnesses, substance misuse or a variety of maladaptive coping strategies (Newtown-Howes et al. Reference Moran, Leese, Lee, Walters, Thornicroft and Mann2009). Naming the multiple diagnoses should give an idea of the clinical complexity and aid in more accurate expectations in terms of treatment length and outcome.

If we look at an example of psychiatry training in Ireland, The College of Psychiatrists of Ireland was founded in 2009 following its separation from the Royal College of Psychiatrists (United Kingdom). The college while still in its infancy has made great progress with regards to the structure of training. The training has been split into a Foundation Year (FY), Basic Training (BST) Scheme over 3 years and Higher Specialist Training Scheme over 3 subsequent years. In relation to our training as BST’s the goal is to satisfactorily meet the outcomes specified in our curriculum (College of Psychiatrists of Ireland, 2017b). Work place-based assessments are used to demonstrate competency in the learning outcomes on a training grid. In the FY Grid there are 2 of 75 specific personality disorder outcomes to be attained. With regard to the BST grid there is just 1 of 228 (Table 1). Attitudes towards patients with personality disorders are often reflective of abilities in approach and appropriate management of this cohort. Is it fair that they are stigmatised because of our lack of experience, as the most experienced clinicians have been found to be the most empathetic to this group of patients (Bodner et al. 2011). A greater emphasis on skills would improve our confidence when meeting these patients daily but also hopefully begin to decrease fundamental attribution error towards this vulnerable group. These patients are susceptible to multiple cognitive heuristics which can have a significant impact on diagnosis, clinical decision making and outcomes (Crumlish & Kelly, 2009). Sometimes it is easy to forget that we are treating people in great distress, often longstanding and because of this have a far higher morbidity and mortality compared to the general population (Fok et al. Reference Crumlish and Kelly2012).

Table 1 Learning outcome attainment grid (psychiatry trainees Ireland)

Early in my training one multidisciplinary team noted that some patients repeatedly presented with similar complaints about psychological distress, but these individuals had sometimes been managed mainly medically with only partial improvements. This varied from patients with recurrent depressive disorder, to Obsessive–Compulsive Disorder to eating disorders. We began to use the SCID-PD (Structured Clinical Interview DSM-5 Personality Diagnosis) as a diagnostic tool to ascertain whether we could confidently name personality disorders, beyond Borderline or Antisocial and discuss their clinical significance. The team found patients were receptive to the tool both with regards openness and acceptance of diagnosis with associated vulnerabilities. I feel the use of the tool enhanced my clinical experience and skills as a trainee, improving my confidence and knowledge of personality disorders. Although the tool was easy to use and increased personal insight into the patient from time spent administering the tool, fitting it into a busy job was challenging at times. Consideration could have been given to the use of a self rated screening tool, such as the Standardised Assessment of Personality-Abbreviated Scale which may fit more readily into clinical practise and may yield similar diagnostic impressions (Moran et al. Reference Krueger, Derringer, Markon, Watson and Skodol2003).

Psychiatry itself is a new and developing science and continues to evolve. It has moved from description to criterion based approaches to diagnosis. One factor in this change which began in the 1970s was the improvement in medications and the consequent need for consistency and reliability in diagnoses for research and prescribing purposes (Shorter, Reference Schneider2008). Although the momentum for change was heavily influenced by pharmaceutical industries it was also widely recognised between psychiatrists that a higher standard was needed, as was shown in the Rosenhan experiment which had a great influence on DSM-3 (Rosenhan, Reference Newton-Howes, Tyrer, Anagnostakis, Cooper, Bowden-Jones and Weaver1974). It is one of psychiatry’s strengths that it is continually re-evaluating diagnostic approaches (Table 2). With regards to personality disorders the classifications have been similar and transferable from Schneider’s first descriptions of emotionally unstable and explosive, through to the various ICD and DSM publications (Table 2) (Schneider, Reference Rosenhan1929).

Table 2 Personality disorder classification

DSM, Diagnostic Statistical Manual; ICD, International Classification of Diseases.

Over time they have become more refined, precise and rigid. To fit certain extremes of behaviour that interfere with daily functioning and interpersonal relationships into nine or 10 carefully defined and structured personality diagnoses is not always easy or reflective of complexity. DSM-IV further categorised psychiatric illness compared to poor mental health with the multiaxial system, which lead to an exclusion of patients with a diagnosis of a personality disorder from many psychiatric services (American Psychiatric Publishing, Reference Crawford, Koldobsky, Mulder and Tyrer1996). As was pointed out quite eloquently by Tom Burns psychiatry diagnosis now ‘dismisses experience and treats as important what can be measured rather than measuring what is important’( Reference Bodner, Cohen-Fridel and Iancu2013).

This shortcoming in the current criterion based diagnostic structure had been noticed by the writers of DSM-5 and they had proposed an alternative dimensional approach. During early training I found the SCID-PD helpful with the classification and familiarisation of personality disorder psychopathology, however, as my experience continued this newly evolving approach to diagnosis was intriguing. It suggested incorporating both subjective and objective reports in its diagnostic structure and placing emphasis on accumulative traits as opposed to single categories (Krueger et al. Reference Hopwood, Malone, Ansell, Sanislow, Grilo, McGlashan, Pinto, Markowitz, Shea, Skodol, Gunderson, Zanarini and Morey2011). The advantage to this structure is the enhanced significance of severity which we know is the best predictor of outcome (Hopwood et al. Reference Fok, Hayes, Chang, Stewart, Callard and Moran2011). At the time of writing the DSM-5 the American Board did not feel it held enough weight and evidence to put into clinical practice.

We are now expecting the awaited ICD-11 to shadow this new dimensional system, which leaves behind ‘traits’ as a subclinical category (Table 3). It breaks down into mild, moderate and severe, giving examples of the level of functioning disturbed and risk of harm that are generally required (Table 3). The third and final element is a description of domains, less rigid than current categories these domains are descriptions and rely on the clinicians knowledge of the patient and own judgement (Tyrer et al. Reference Tyrer, Crawford, Mulder, Blashfield, Farnam, Fossati, Kim, Koldobsky, Lecic-Tosevski, Ndetei, Swales, Clark and Reed2011). The advantages seem to be that the system takes into account the current presentation and recent past which are both extremely relevant and help contextualise the fluctuant nature and complexity of interplay of personality disorders (Crawford et al. Reference Burns2011). From a trainee perspective it is potentially more accessible, less stigmatising and clearer of the impact on functioning and treatment resistance. There are still a lot of questions and clarity needed, and experience with regards clinical judgement will be more important compared to the previously more structured categorical system.

Table 3 Summary of International Classification of Disease 11 reclassification of personality disorder (Tyrer et al. Reference Tyrer, Reed and Crawford2015)

There are many reasons why correct recognition of personality disorders is so important; they make life more stressful for the patient and their family while increasing the risk of mental illness and other co-morbidities, their presence affects treatment outcomes and there is significantly increased risk associated with this population. Again reflecting on our roles as psychiatrists, should we have more of an emphasis on diagnosis and skills to manage personality disorders as trainees? Psychiatry training bodies should consider incorporating a more skills based curriculum, with Dialectical Behavioural Therapy, formulation and risk management being at the forefront of this. Additional learning outcomes in our training grid could also be the use of diagnostic tools following benefits experienced from using the SCID-PD. All of this should improve overall psychological understanding of our patients, leaving us more than just prescribers. As we have moved so drastically from the Freudian based approached to the almost completely biological, a happy medium now needs to be found which is better for both doctor and patient. In time, this should lead to us feeling comfortable and confident in our skills to sufficiently evaluate and appropriately care plan for these patients. These encompass some of the daily challenges psychiatric trainees are faced with, but which are surmountable with enhanced training in this complex area.