BRITISH JOURNAL OF '2002),'2002),180,110^115 180, 110^115 REVIEW ARTICLE

The distinction between disorder cover personality disorders as well as mental illnesses $Department of Health & and mental illness Home Office, 2000).

R. E. KENDELL Implications of the term `personality disorder' The term `psychopathic' was coined by the German Koch in 1891, and he said firmly that `even in the bad cases the irregularities do not amount to mental dis- order' $Lewis, 1974). What Koch meant Background Proposals by the UK BACKGROUND by , however, was largely Government for preventive detention of restricted to and idiocy, and his The legislative background concept of `psychopathic inferiorities' people with`dangerous severe personality , and perhaps British psychi- embraced most non-psychotic mental ill- disorders' highlight the unresolved issue of atrists more than most, are ambivalent ness as well as what we now call personal- whether personalitydisorderspersonality disorders should be about whether to regard personality disorders ity disorder or . Even so, Kurt regarded as mentalillnesses. as mental illnesses. Until recently, there was Schneider subsequently argued that person- no compelling reason for attempting to ality disorders are simply `abnormal vari- Aims To clarify the issue by examining resolve the issue, but the situation was eties of sane psychic life' $Schneider, the concepts of psychopathy and transformed in 1999 when the UK Govern- 1950), and therefore of little concern to ment made it clear that it intended to intro- personality disorder, the attitudes of psychiatrists, a view that is still influential duce legislation in England and Wales for in Germany today. contemporary British psychiatrists to the compulsory and potentially indefinite Many ± perhaps most ± contemporary personalitypersonalitydisorders, disorders, and the meaning detention of people with what it called British psychiatrists seem not to regard ofthe terms`mentalillness'and`mental `dangerous severe personality disorder', personality disorders as illnesses. Certainly, disorder'.disorder'. whether or not they had been convicted of it is commonplace for a diagnosis of a serious criminal offence $Home Office personality disorder to be used to justify a MethodMethod The literature on personality & Department of Health, 1999). It is likely decision not to admit someone to a psychi- disorderisdisorder is assessedintheassessed in the contextofcontext of four that some of these people, almost all of atric ward, or even to accept them for treat- them men, will be detained in prisons and ment ± a practice that understandably contrasting concepts of illness or disease. others in high-security hospitals. However, puzzles and irritates the staff of accident the European Convention on Human ResultsResults Whichever ofthe four concepts and emergency departments, general practi- Rights, which was incorporated into UK tioners and probation officers, who find or definitions is chosen, it is impossible to legislation by the Human Rights Act themselves left to cope as best they can with conclude with confidence that personality 1998, prohibits the detention of anyone extremely difficult, frustrating people with- disorders are, or are not, mentalillnesses; who has not been convicted by a competent out any psychiatric assistance. The reasons there are ambiguitiesinthe definitions and court unless they are `of unsound mind, for this attitude were explored by Lewis alcoholics or drug addicts or vagrants' or & Appleby $1988). Using ratings of case basic information about personality their detention is `for the prevention of vignettes by 240 experienced psychiatrists, disorders is lacking. the spreading of infectious diseases'. This they showed that attempts and means that, to prevent a successful judicial other behaviours by patients previously Conclusions The historicalreasons for challenge, the Government will have to diagnosed as having personality disorders regarding personality disorders as argue that the potentially dangerous were commonly regarded as manipulative fundamentally differentfromdifferent from mental menmenitit wishes to incarcerate are `of un- and under voluntary control rather than illnesses are being undermined by both sound mind', and this means maintaining the result of illness, and that the patients that they have personality disorders, and clinical and genetic evidence.Effective themselves were generally regarded as that personality disorders are mental irritating, attention-seeking, difficult to treatments for personalitydisorderspersonality disorders disorders.disorders. manage and unlikely to comply with advice would probably have a decisive influence At present English legis- or treatment. on psychiatrists'attitudes. lation, which dates from 1983 but had its Personality disorders are described in origins in the recommendations of a Royal thethe International Classification of Mental Declaration of interest None. Commission in the 1950s, distinguishes and Behavioural Disorders $ICD±10) as betweenbetween mental illness andand psychopathic `deeply ingrained and enduring behaviour disorderdisorder, but the Government intends to patterns, manifesting themselves as inflex- abandon the concept of psychopathic dis- ible responses to a broad range of personal order and introduce a new `broad definition and social situations'; they represent of mental disorder covering any disability `either extreme or significant deviations or disorder of mind or brain' which will from the way the average individual in a

110 PERSONALITY DISORDER AND AND MENTAL MENTAL ILLNESS

given culture perceives, thinks, feels, and disease in the ICD±10: it is coded E66 as in this wider context, however, there is no particularly relates to others' and are an endocrine, nutritional or metabolic agreement, and until recently surprisingly `developmental conditions, which appear disease $World Health Organization, little discussion. in childhood or adolescence and continue 19921992bb). Even so, most doctors, whether into adulthood' $World Health Organization, they be general practitioners, physicians or 19921992aa). They are distinguished from mental surgeons, are reluctant to attempt to treat DEFINITIONS OF ILLNESS illness by their enduring, potentially life- obesity, either because they regard the con- OR DISORDER long nature and by the assumption that dition as the result of self-indulgence rather they represent extremes of normal variation than metabolic abnormality, or simply The most contentious issue is whether rather than a morbid process of some kind. because they have no effective treatment disease, illness or disorder $like the World Whether or not these assumptions are to offer $Baxter, 2000). Health Organization, I regard these terms justified, there is broad agreement that Against the background of the UK as roughly synonymous) are scientific or personality disorders are important to psy- Government's legislative proposals it is biomedicalbiomedical terms, or whether they are chiatrists because they impinge on clinical clearly important for British psychiatrists, socio-political terms which necessarily practice in so many different ways. People legislators and jurists to decide whether involve a value judgement. Physicians have with personality disorders are at increased personality disorder, or any subset of it, is generally maintained, or simply assumed, risk of several different mental disorders, a mental illness or mental disorder. that they are biomedical terms, while including depressions and disor- Unfortunately, there is no agreed medical philosophers and social scientists have ders, suicide and parasuicide, and misuse definition of either term. The World Health generally argued that they are inherently of and dependence on alcohol and other Organization has always avoided defining socio-political, but this is not invariable. drugs. In addition, people with schizotypal `disease', `illness' or `disorder', and in its The American physician Lester King are at increased risk of schizo- current $ICD±10) classification of mental asserted long ago that `biological science phrenia and those with anancastic person- and behavioural disorders $which includes does not try to distinguish between health alities are at increased risk of obsessive± personality disorders) it simply states that and disease ...health or disease are value compulsive disorders. The presence of a `the term disorder is used throughout the judgements' $King, 1954). Conversely, the personality disorder also complicates the classification, so as to avoid even greater philosopher Bourse has argued that treatment of most other mental disorders, problems inherent in the use of terms such `disease, the theoretical concept ...appliesapplies most obviously because the individuals as disease and illness. Disorder is not an indifferently to organisms of all species. concerned do not easily form stable exact term, but it is used here to imply the That is because ...it is to be analysed in relationships with their therapists or take existence of a clinically recognisable set of biological rather than ethical terms' prescribed medication regularly. Indeed, in symptoms or behaviour associated in most $Bourse, 1975). I myself once argued that group settings they often disrupt the treat- cases with distress and with interference disease ought to be a biomedical concept ment of other patients as well. Finally, with with personal functions' $World Health $Kendell, 1975), but subsequently became or without treatment, the prognosis of most Organization, 1992aa). The current edition convinced that value judgements were mental disorders is worsened by coexistent of theofthe Diagnostic and Statistical Manual probably inescapable $Kendell, 1986). The personality disorder. Because of these $DSM±IV) of the American Psychiatric issue has attracted much attention in the important, complex relationships, it is Association, which likewise includes per- USA in the past decade, mainly in response taken for granted that psychiatrists need sonality disorders, does contain a detailed to the publication of a closely argued to be alert to the presence of personality definition of the term `mental disorder', analysis of the concept of mental disorder disorder, even if, as is often the case, the but although this runs to 146 words it is by Wakefield $1992). disorder does not correspond to any of the not cast in a way that allows it to be used distinct types described in textbooks and as a criterion for deciding what is and is listed in glossaries. The contentious issues not mental disorder $American Psychiatric STATUSOFSTATUS OF PERSONALITY are whether personality disorders are amen- Association, 1994). It is important to note, DISORDERS able to treatment, and whether people though, that DSM±IV does stipulate that displaying these habitual abnormalities of `neither deviant behavior nor conflicts that The question of whether personality dis- behaviour deserve to be accorded the privi- are primarily between the individual and orders are mental disorders cannot usefully leges of the `invalid role'. society are mental disorders unless the be discussed until agreement has been If personality disorders are not to be or conflict is a symptom of a reached on the implications of the term regarded as mental illnesses despite their dysfunction in the individual', and that `mental disorder', and at present there are undisputed relevance to psychiatric prac- there is a similar unambiguous statement at least four quite different, rival concepts tice, the obvious alternative is to regard in ICD±10.inICD±10. of disease or disorder, which are them as risk factors and complicating fac- There is no fundamental difference summarised below. tors for a wide range of mental disorders, between so-called mental illnesses or dis- in much the same way that obesity is a risk orders and physical illnesses or disorders; factor for diabetes, myocardial infarction, both are simply subsets of illness or dis- Socio-political breast cancer, gallstones and osteoarthritis, order in general $Kendell, 1993; American Although it has been suggested in the and complicates the of an Psychiatric Association, 1994). This implies past that disease is simply what doctors even wider range of conditions. Like per- that the basic issue is the meaning of the treat $e.g. KraKrauplÈupl Taylor, 1971), there sonality disorder, obesity is listed as a terms `illness' or `disorder' in general. Even are no contemporary advocates for such a

111111 KENDELL

simplistic view. The simplest plausible at least encompass reduced fertility and life of mental disorder states that `it must socio-political definition is that a condition expectancy. currently be considered a manifestation of is regarded as a disease if it is agreed to be Little is known about the fertility of a behavioral, psychological or biological undesirable $an explicit value judgement) people with personality disorders, but there dysfunction'. The problem is that current and if it seems on balance that physicians is good evidence that their life expectancy is understanding of the cerebral mechanisms $or health professionals in general) and reduced. Martin et aletal $1985) studied the underlying basic psychological functions their technologies are more likely to be able mortality over 6±12 years of 500 former such as perception, abstract reasoning and to deal with it effectively than any of the psychiatric out-patients in St Louis and memory is too limited for it to be possible potential alternatives, such as the criminal found that antisocial personality disorder in most cases to do more than infer the justice system $treating it as ), the was associated with a greatly increased probable presence of a biological dysfunc- church $treating it as sin) or social work mortality $standardised mortality ratio tion; and rejecting both the evolutionary $treating it as a social problem). 8.57,8.57, PPˆ0.01), mainly from suicide, homi- $Wakefield) and biological disadvantage There is general agreement that the per- cide and accidents. Others have investi- $Scadding) criteria could open the way to sonality traits and behaviours characteristic gated the mortality associated with regarding a wide range of purely social dis- of personality disorders are undesirable, personality disorder as a whole and found abilities $such as aggressive, uncooperative certainly from society's viewpoint and it to be raised in both men and women behaviour or an inability to resist lighting probably from that of most of the indivi- $Harris & Barraclough, 1998). fires or stealing) as mental disorders. duals concerned as well. It is unclear, The evidence that personality disorders though, whether psychiatry or clinical psy- are harmful is quite strong and not chology yet possesses effective treatments Biomedical and socio-political restricted to clinic populations. Drake & for most types of personality disorder. Wakefield, who is a philosopher with a Vaillant $1985), for example, compared There is evidence that borderline personal- background in social work, argues that 86 middle-aged men who met DSM±III ities can be helped either by dialectical mental disorders are biological dysfunc- criteria for personality disorder with 283 behaviour therapy $Linehan et aletal, 1991),1991) tions that are also harmful. This implies men who did not. Both groups had origin- or by an analytically oriented day hospital that the concept of mental disorder in- ally been members of a cohort of mainly regimen $Bateman & Fonagy, 1999), but evitably involves both a scientific or bio- working-class, non-delinquent adolescent little evidence that this is so for any of the medical criterion $dysfunction) and anan)and boys previously studied as a control other types. Attempts to change the enduring explicit value judgement or socio-political population in Boston by the Gluecks, so attitudes and behaviours of personality dis- criterion ± what Wakefield $1992, 1999) extensive background information was orders are not often made; when they are, callscalls harmharm and the World Health Organiza- available for all 369. Compared with the the treatment is often given up prematurely; tiontion$1980)$1980) defines as handicaphandicap ± and isis±and 283 men without personality disorders, and few random allocation trials with attractive because it reconciles the socio- the 86 personality-disordered men $only adequate long-term follow-up of any form political and biomedical camps. It also six of whom had disorders of antisocial of treatment for any type of personality dis- seems to reflect the often intuitive ways in type) had poor mental health $79% vv.. order, other than the borderline type, have which physicians make disease attributions 14%), poor occupational performance and been conducted. Moreover, in the case of and does not obviously have unacceptable job satisfaction, and poor social compe- antisocial personality disorders, the most implications. tence $58% vv. 10%), and although alcohol contentious group, it is undoubtedly the Wakefield originally proposed that dependence or misuse was partly respon- case that, worldwide, the majority are dysfunction should imply the failure of a sible for their poor occupational per- `managed' most of the time by the criminal biological mechanism to perform a natural formance, it made little contribution to justice system rather than by health function for which it had been designed their poor mental health and social services.services. by evolution, but Lilienfeld & Marino competence. $1995) subsequently pointed out that this It is much harder to establish that per- evolutionary perspective raises many prob- sonality disorder involves dysfunction, in lems. Too little is known about the evolu- the sense of `failure of a mental mechanism Biomedical tion of most of the higher cerebral to perform a natural function for which it The most plausible purely biomedical functions whose malfunctioning presum- was designed by evolution' $Wakefield, criterion of disease is the biological dis- ably underlies most mental disorders; mood 1992). Indeed, it has been argued that advantageadvantage proposed by Scadding $1967). states such as anxiety and may several of the characteristic features of Scadding, a chest physician, defined a have evolved as biologically adaptive re- antisocial personality disorder, such as disease as `the sum of the abnormal pheno- sponses to danger or loss rather than being manipulation, and deception, mena displayed by a group of living failures of evolutionarily designed functions; were originally successful predatory strate- organisms in association with a specified and several important cognitive abilities, gies that evolved in a prehistoric social common characteristic or set of character- such as reading and calculating, have been environment $Lilienfeld & Marino, 1995). istics by which they differ from the norm acquired too recently to be plausibly re- Fundamentally, there are two sources of for the species in such a way as to place garded as natural functions designed by difficulty. The behaviours and attitudes them at a biological disadvantage'. He evolution. It is, of course, perfectly possible that define personality disorders are prob- never explained what he meant by bio- in principle to define dysfunction without ably graded traits present to a lesser degree logical disadvantage, but Kendell $1975) reference to either evolution or biological in many other people, and also quite and Bourse $1975) both argued that it must disadvantage, and the DSM±IV definition different in different types of personality

112 PERSONALITY DISORDER AND AND MENTAL MENTAL ILLNESS

disorder; and as yet little is known of the personality disorders ± indeed, the basic Assumptions about aetiology underlying mechanisms of which they are concept of personality disorder ± has few and time course a manifestation. It could be argued, forfor points of contact with the psychological example, that the impulsiveness and literature on personality structure and The first is the validity of the assumptions liability to become dependent on drugs or development, and little is known of the cer- about aetiology and time course which alcohol ± which are such prominent, and ebral mechanisms underlying personality originally underpinned the distinction frequently lethal, features of antisocial traits. There is also a glaring need for a between personality disorder and mental disorders ± are prima facie evidence of an better classification of personality disorders illness. The former was assumed to be part underlying dysfunction, but in the absence and for more long-term follow-up studies of the normal spectrum of personality of any understanding of the cerebral of representative samples, derived from variation and to be stable throughout mechanisms involved the argument remains community rather than clinical popula- adult life; the latter to be the result of a inconclusive. tions, to answer basic questions about the morbid process of some kind and to have extent, nature and time course of the handi- a recognisable onset and time course. caps associated with different types of These assumptions both appear increas- OstensiveOstensive personality disorder. ingly questionable, and as a result the dis- tinction between illness and personality Lilienfeld & Marino $1995) maintain that disorder is starting to break down. Some mental disorder is an ostensive or Roschian schizophrenic illnesses have the same time concept, implying that the term can only be Epistemologic arguments course as a personality disorder: they understood by considering the prototypes It could be argued that personality dis- develop during adolescence and persist of mental disorder. If this argument is orders are mental disorders on the grounds relatively unchanged throughout adult life. accepted ± and it is not easily dismissed ± that their high mortality clearly constitutes More significantly, it is becoming increas- it is impossible even in principle to deter- a biological disadvantage, the key criterion ingly clear that the genetic bases of affec- mine whether personality disorders are of Scadding's concept of disease. However, tive personality disorders and mood mental disorders, because mental disorder there is little support for this definition, and disorders, and of schizotypal personality is inherently indefinable. The only criterion $apart from antisocial personalities) the disorder and , have much in is whether personality disorders are suffi- reduction in life expectancy is fairly common. As a result, the affective person- ciently similar to the prototypes of mental modest. If Wakefield's definition, giving a ality disorder of ICD±9 has been replaced disorder $schizophrenia and major depres- central role to dysfunction, comes to be in ICD±10 by two new mood disorders, sion, perhaps), and similarity is obviously adopted as a general definition of mental and , `because of open to a range of interpretations. It is disorder the issue may remain unresolved evidence from family studies that they important to note, though, that both the for some time, because it may not be poss- are genetically related to the mood dis- World Health Organization and the ible to decide whether there is a dysfunction orders, and because they are sometimes American Psychiatric Association include of some natural mechanism until much amenable to the same treatments'. For personality disorders in their classifications more is known of the cerebral mechanisms similar reasons, schizotypal disorder ± of mental disorders, without explanation or underlying key personality characteristics which is listed as a personality disorder apology, and have always done so, which such as , impulse control and in DSM±IV ± is classified with schizo- implies that both bodies do regard them emotional stability. $There is, though, phrenia and delusional disorders $F20±29) as sufficiently similar to warrant inclusion. already evidence that low central sero- in ICD±10 despite the fact that `its evo- The fact that some forensic psychiatrists tonergic activity may underlie impulsive, lution and course are usually those of a see close similarities between personality aggressive behaviour in a wide range of personality disorder' $World Health disorders and schizophrenia, both in the settings: see Coccaro & Kavoussi, 1997.) Organization, 1992aa). Most disconcert- extent of the disturbance of personality in- Although it is difficult to provide irrefu- ingly of all, avoidant personality disorder volved and in their need for treatment table arguments that personality disorders has so much in common with the mental $Blackburn$Blackburn et aletal, 1993), is also relevant. are mental disorders, it is equally difficult illness known as generalised social to argue with conviction that they are not. that it is suspected that `they may be alter- The fact that they have been included in native conceptualisations of the same or DISCUSSION the two most influential and widely used similar conditions' $American Psychiatric classifications of mental disorders $the Association, 1994). Unsurprisingly, such It seems clear from this analysis that it is ICD and the DSM) for the past half-century problems are leading many American psy- impossible at present to decide whether is difficult to disregard, whether or not one chiatrists to question the value of the dis- personality disorders are mental disorders accepts the view that mental disorder is an tinction between Axis I and Axis II or not, and that this will remain so until ostensive concept. It could be argued, disorders in DSM±IV, despite the state- there is an agreed definition of mental dis- though, that the crucial issue is not whether ment in its manual that `the coding of order. It is also apparent that personality personality disorder is embraced by any personality disorders on axis II should disorders are conceptually heterogeneous, particular definition or concept of mental not be taken to imply that their pathogen- that information about them is limited, illness, but what kinds of considerations esis or range of appropriate treatment is and that existing knowledge is largely lead doctors to change their minds about fundamentally different from that for the derived from unrepresentative clinical assignations of illness, and in this context disorders coded on axis I' $American Psy- populations. The clinical literature on two issues loom large. chiatric Association, 1994).

113 KENDELL

The influence of effective therapies

CLINICAL IMPLICATIONS The second issue is the influence on medical attitudes of the acquisition of an apparently && Because the term mental illness has no agreed meaning it is impossible to decide effective therapy. For nearly 150 years, with confidence whether or not personality disorders are mental illnesses. claims that alcoholism was a disease, from Thomas Trotter in 1804 to Alcoholics && The historical reasons for regarding personality disorders as fundamentally Anonymous in the 1930s and 1940s, cut different from illnesses are being undermined by both clinical and genetic evidence. little ice with the medical profession. It was only in the late 1940s and 1950s, when && The introduction of effective treatments would probably have a decisive influence disulfiram became available, that doctors on psychiatrists'attitudes. changed their minds. Now, of course, it is LIMITATIONS evident that disulfiram is not generally an effective therapy, but in its early years && No comprehensive literature review was carried out. enthusiastic reports of cures were published in many different countries,and it was && The literature on personality disorders is not extensive and consists mainly of against this background that the World clinical rather than population-based studies. Health Organization decided to include alcoholism itself, as distinct from alcoholic && Psychiatrists'attitudes are influenced by the setting in which health care is psychoses and acute alcohol poisoning, provided. in the ICD, and medical organisations throughout the world issued formal state- ments to the effect that alcoholism waswas aa disease after all. Thereasoning involved suggests an acceptance of the socio-political R. E.KENDELL,E. KENDELL, FRSE,FRSE,University University of Edinburgh, 3 West Castle Road, Edinburgh EH10 5AT,UK definition described above, although this 1First received 23 November 2000, final revisionrevision11June 11June 2001, acceptedaccepted12 12 June 2001) has rarely commended itself to the medical profession. It does seem, none the less, that possession of an apparently effective treat- ment can produce a decisive change in away, and the same will be true for British psychiatrists to accept personality medical opinion, and Campbell et aletal other types of personality disorder. disorders as mental disorders. $1979) showed that an established medical role in diagnosis or treatment has more in- REFERENCES fluence on doctors' concepts of disease than Economic and cultural influences on those of the public. At present, neither Finally, it is necessary to acknowledge the American Psychiatric Association '1994) Diagnostic personality disorder nor obesity is accepted influence of the setting in which psychiatric and Statistical Manual of Mental Disorders 14th edn) as a genuine illness by most British doctors; care is delivered. For the past 50 years the 1DSM^IV).Washington, DC: APA. but as effective drugs for treating obesity constraints of the National Health Service Baxter,Baxter,J. J. '2000) Obesity surgery ^ another unmet come into widespread use over the next have ensured that the time and energy of need.need. British Medical Journal,, 321321,523^524., 523^524. decade it is likely that obesity will come most British psychiatrists have been fully Bateman, A. & Fonagy, P.'19 '1999) 9 9) Effectiveness of to be accepted as a genuine metabolic dis- occupied treating patients with severe partial hospitalisation in the treatment of borderline order, and the same may happen to person- mental illnesses. As a result, National Health personality disorder: a randomised controlled trial. ality disorders. Indeed, it is already Service psychiatrists have generally been American Journal of Psychiatry,, 156,1563^1569.,1563^1569. happening to the `borderline' disorders as reluctant to add to their workload by also Blackburn, R., Gunn, J., Hill, J., et aletal '19 93) evidence accumulates that the disruptive accepting responsibility for people with Personality disorders. In : Clinical, Legal and Ethical Issues 1eds J.GunnJ. Gunn & P. J.Taylor),J. Taylor), and self-destructive behaviours that charac- deeply ingrained maladaptive behaviours pp. 373^406.373^406.Oxford: Oxford: Butterworth-Heinemann. terise the disorder are amenable to forms of for which there were no proven therapies. $Linehan et aletal, 1991; Bate- In North America the situation has been Bourse, C. '1975) On the distinction between disease and illness.illness.and Philosophy and Public Affairs,, 55, 49^68.,49^68. man & Fonagy, 1999). There is also some different. The prevailing systems of health evidence that fluoxetine reduces irritability care have facilitated the development of Campbell, E. J. M., Scadding, J. G. & Roberts, R. S. and aggression in people with a variety of '19 79) The concept of disease. British Medical Journal,, ii,, both private office practice and various 757^762.757^762. personality disorders $Coccaro & Kavoussi, forms of psychotherapy, and the psycho- 1997). If, therefore, the psychiatrists and analytic concept of `borderline personality Coccaro, E. F. & Kavoussi, R. J. '1997) Fluoxetine and impulsive aggressive behavior in personality-disordered politicians who maintain that `antisocial disorder' has provided a rationale for subjects.subjects. Archives of General Psychiatry,, 5454,1081^1088. personality disorder' has as good a claim treating, as personality disorders, large to being accepted as a mental disorder as numbers of patients who in Britain would Department of Health & Home Office '2000) Reforming the Mental Health Act. Cm 5016. London: schizophrenia can demonstrate that it mostly be regarded as suffering from Stationery Office. responds to some form of treatment that recurrent depression. These economic and Drake, R. E. & Vaillant, G. E. '1985) AAvaliditystudyof validity study of is notisnotsimply a disciplined environment, cultural differences have probably con- Axis II of DSM^III.DSM ^ III. American Journal of Psychiatry,, 142142,, it is likely that the opposition will melt tributed to the comparative reluctance of 553^558.553^558.

114 PERSONALITY DISORDER AND AND MENTAL MENTAL ILLNESS

Harris, E. C. & Barraclough, B. '1998) Excess KraKraupl« upl Taylor, F. '1971) A logical analysis of the medico- Scadding, J. G. '1967) Diagnosis: the clinician and the mortality of mental disorder. British Journal of Psychiatry,, physiological concept of disease. Psychological Medicine,, 11,, computer. LancetLancet,, iiii, 877^882.,877^882. 173, 11^53.,11^53. 356^364.356^364. Schneider, K. '1950) Die psychopatischen Home Office & Department of Health '1999) Lewis, A. '1974) Psychopathic personality: a most Personlichkeiten 19th edn).Vienna: Deuticke. Managing Dangerous People with Severe Personality elusive category. Psychological Medicine,, 44,133^140.,133^140. Disorder: Proposals for Policy Development . London: Home Wakefield, J. C. '19'1992) 92) The concept of mental disorder: Office/Department of Health. Lewis, G. & Appleby, L. '1988) Personality disorder: on the boundary between biological facts and social the patients psychiatrists dislike. British Journal of values.values. American Psychologist,, 47, 373^388. The concept of disease and its Kendell, R. E. '1975) PsychiatryPsychiatry,, 153, 44^49.,44^49. implications for psychiatry. British Journal of Psychiatry,, __ '1999)'19 9 9) Evolutionary versus prototype analyses of 127127, 305^315.,305^315. Lilienfeld, S. O. & Marino, L. '1995) Mental disorder the concept of disorder. Journal of Abnormal Psychology,, as a Roschian concept: a critique of Wakefield's`harmfulWakefield's `harmful 108108, 374^379.,374^379. __ '19 8 6) What are mental disorders? In Issues ininIssues dysfunction'analysis. Journal of Abnormal Psychology,, 104104,, Psychiatric Classification 1eds A. M. Freedman, R. WorldHealthOrganization'1980)International 411^420. Brotman, I. Silverman, et aletal), pp.23^45. New York: Classification of Impairments, Disabilities and Handicaps.. Geneva: WHO. Human Sciences Press. Linehan, M. M., Armstrong, H. E., Suarez, A., et aletal

__ '19 93) The nature of psychiatric disorders. In '19 91) Cognitive-behavioral treatment of chronically __ '19 992'19 2 aa)) The ICD^10 Classification of Mental and Companion to Psychiatric Disorders 15th edn) 1eds R. E. parasuicidal borderline patients. Archives of General Behavioural Disorders: Clinical Descriptions and Diagnostic Kendell & A.K. Zealley), pp.1^7. Edinburgh: Churchill PsychiatryPsychiatry,, 48,1060^1064. Guidelines..Geneva:WHO. Geneva: WHO. Livingstone. Martin, R. L., Cloninger, R., Guze, S B., et aletal '19 8 5)5)'19 __ '19 992'19 2 bb)) International Classification of Diseases and King, L. S. '1954) What is disease? Philosophy of Science,, Mortality in a follow up of 500 psychiatric outpatients. Related Health Problems ,10th revision) ,ICD ^10).Geneva: 2121,193^203. Archives of General Psychiatry,, 4242, 47^54; 58^66. WHO.WHO.

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