Personality Disorders

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Practical Management of Personality DisorderReview - Practical Management of Personality Disorder
by W. John Livesley
Guilford, 2003
Review by Matthew Broome
Feb 27th 2007 (Volume 11, Issue 9)

Personality disorder is one of the problems in mental health which, given its ubiquity in a specialist clinical setting, can almost be forgotten.  There is an old rule of thumb that one learns when starting clinical training in psychiatry as to the prevalence of personality disorders in various clinical settings: within a primary care practice, 10% of patients; in a psychiatric outpatient clinic, 20%; and within an inpatient psychiatric unit 40%.  Despite these startlingly high figures, recent research suggests that even these may be an underestimate.  For most psychiatrists, the personality disordered clients one encounters either have a comorbid Axis 1 disorder that is the explicit reason they present, or, may be at the very extreme end of disorder with severe and recurrent episodes of harm to themselves or others.  Thus, typically, psychiatrists tend to recognize dissocial and borderline personality disorders but fail to notice the others. What often is the case is that the other disorders become manifest only when the treatment for the presenting axis 1 condition fails and the physician needs to think again.  It is for this reason that specialist services have a great many clients with personality disorder: they present with a refractory mental illness that gets referred for specialist management.  Thus, to be a capable psychiatrist one not only needs to be able to manage Axis 1 and Axis 2 disorders in their own right, but perhaps more importantly, as complicating factors of one another that may jeopardize treatment.

Hence, the recognition and management of personality disorder is of great importance to all clinicians, regardless of their clinical or research focus.  However, coupled with the high prevalence of such disorders is a degree of theoretical and therapeutic nihilism in many clinicians regarding personality disorder.  Livesely's book serves as a very welcome addition to the books on this topic: many texts for the general psychiatrist have either focused on etiology/epidemiology or psychoanalysis and to have a book actually discuss treatment pragmatically is a great asset.  The book starts with more theoretical concerns ('A Framework for Understanding Normal and Disordered Personality') but even here links are drawn with clinical material and practical principles guiding intervention.  What is most refreshing is the eclecticism and pluralism of the author: treatment suggestions are guided by evidence, and based around symptom systems/dimensions rather than the categorical ICD-10 or DSM-IV diagnoses.  Further, pharmacological, as well as a wide variety of psychological interventions, are discussed. The book develops into specific chapters detailing the main phases of treatment: from 'Assessment' and 'Treatment Planning and Treatment Contract' to chapters on treating affective problems, trauma and dissociative symptoms, interpersonal difficulties, and core pathology.  As someone whose clinical work is in early psychosis, my personal wish would have been for more on quasi-psychotic symptoms in personality disorders and the relationship between personality disorders and the development of major mental illnesses, such as schizophrenia.  However, this book fills a very important niche in the literature: it addresses a neglected but important topic for any mental health professional and does so in a non-partisan and elegant manner.  I am sure in my clinical work I will turn to it again and again.


© 2007 Matthew Broome


Dr Matthew Broome, Associate Clinical Professor of Psychiatry and Honorary Consultant Psychiatrist, University of Warwick, UK; Honorary Lecturer, Section of Neuroimaging, Division of Psychological Medicine, Institute of Psychiatry, King's College London, UK.



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