Abstract:
If personality disorder is no longer to be a diagnosis of exclusion it needs a conceptual framework that fits both the symptoms of the illness and the behavioural problems that constitute its current diagnostic criteria. In this article, we suggest that personality disorder is best understood as disorganisation of the capacity for affect regulation, mediated by early attachments. We present evidence for this argument based on both developmental and neurobiological research.
Conclusions:
"...Our heuristic model is based on an integrative synthesis of recent empirical evidence from the fields of attachment and neurobiology, relating it to current strategies for treating personality disorders. It proposes a biologically grounded system that is nevertheless sufficiently based on clinical findings to be clinically relevant.
Affect regulation is only one, but arguably the most critical, aspect of personality disorder. Given its developmental origins, it is a key foundation on which other aspects of personality – thoughts, perceptions and behaviour – are built.
Our model is purposely limited in scope and does not incorporate neuroendocrine regulation or the involvement and interaction of various neurotransmitters and neuromodulators. Neither does it deal with the problem of comorbid mental illness and the fact that personality disorders rarely occur singly. Finally, the model does not explain all types of personality disorder, especially psychopathy and schizotypy. We suggest that there are fundamental differences in the brain mechanisms underlying the latter disorders, which may be the result of altered patterns of neural connectivity and responses that are largely genetically based rather than a product of gene–environment interaction.
Our key conclusion is that a personality disorder is like many other complex medical conditions. It has degrees of severity and can manifest with varying levels of behavioural dysfunction and symptomatic distress. Mild degrees of personality disorder are probably compatible with reasonable mental health and functioning; more severe disorder or comorbid psychiatric conditions will cause more dysfunction and result in referral to mental health services. If there is to be a national strategy for personality disorder services, clinical teams will need explanatory models to help them understand their patients’ problems and plan treatment accordingly."
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