BRITISH JOURNAL OF PSYCHIATRY '2002),'2002),180,110^115 180, 110^115 REVIEW ARTICLE The distinction between personality 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 psychiatrist 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 mental disorder, however, was largely Government for preventive detention of restricted to insanity and idiocy, and his The legislative background concept of `psychopathic inferiorities' people with`dangerous severe personality Psychiatrists, 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 psychopathy. 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 suicide 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 mental health 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 anxiety 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 personalities 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