The rationale for the reclassification of personality disorder in the 11th revision of the International Classification of Diseases (ICD‐11)

Šalkovskis

et al. 2017

Health Technol Assess

Self Cite

BackgroundHealth anxiety is an under-recognised but frequent cause of distress that is potentially treatable, but there are few studies in secondary care.ObjectiveTo determine the clinical effectiveness and cost-effectiveness of a modified form of cognitive–behaviour therapy (CBT) for health anxiety (CBT-HA) compared with standard care in medical outpatients.DesignRandomised controlled trial.SettingFive general hospitals in London, Middlesex and Nottinghamshire.ParticipantsA total of 444 patients aged 16–75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics who scored ≥ 20 points on the Health Anxiety Inventory (HAI) and satisfied diagnostic requirements for hypochondriasis. Those with current psychiatric disorders were excluded, but those with concurrent medical illnesses were not.InterventionsCognitive–behaviour therapy for health anxiety – between 4 and 10 1-hour sessions of CBT-HA from a health professional or psychologist trained in the treatment. Standard care was normal practice in primary and secondary care.Main outcome measuresPrimary – researchers masked to allocation assessed patients at baseline, 3, 6, 12, 24 months and 5 years. The primary outcome was change in the HAI score between baseline and 12 months. Main secondary outcomes – costs of care in the two groups after 24 and 60 months, change in health anxiety (HAI), generalised anxiety and depression [Hospital Anxiety and Depression Scale (HADS)] scores, social functioning using the Social Functioning Questionnaire and quality of life using the EuroQol-5 Dimensions (EQ-5D), at 6, 12, 24 and 60 months, and deaths over 5 years.ResultsOf the 28,991 patients screened over 21 months, 5769 had HAI scores of ≥ 20 points. Improvement in HAI scores at 3 months was significantly greater in the CBT-HA group (mean number of sessions = 6) than in the standard care, and this was maintained over the 5-year period (overallp < 0.0001), with no loss of efficacy between 2 and 5 years. Differences in the generalised anxiety (p = 0.0018) and depression scores (p = 0.0065) on the HADS were similar in both groups over the 5-year period. Gastroenterology and cardiology patients showed the greatest CBT gains. The outcomes for nurses were superior to those of other therapists. Deaths (n = 24) were similar in both groups; those in standard care died earlier than those in CBT-HA. Patients with mild personality disturbance and higher dependence levels had the best outcome with CBT-HA. Total costs were similar in both groups over the 5-year period (£12,590.58 for CBT-HA; £13,334.94 for standard care). CBT-HA was not cost-effective in terms of quality-adjusted life-years, as measured using the EQ-5D, but was cost-effective in terms of HAI outcomes, and offset the cost of treatment.LimitationsMany eligible patients were not randomised and the population treated may not be representative.ConclusionsCBT-HA is a highly effective treatment for pathological health anxiety with lasting benefit over 5 years. It also improves generalised anxiety and depressive symptoms more than standard care. The presence of personality abnormality is not a bar to successful outcome. CBT-HA may also be cost-effective, but the high costs of concurrent medical illnesses obscure potential savings. This treatment deserves further research in medical settings.Trial registrationCurrent Controlled Trials ISRCTN14565822.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 21, No. 50. See the NIHR Journals Library website for further project information.

Section: Research Objectivesmentioning

confidence: 99%

Section: Assessmentsmentioning

confidence: 99%

Section: Influence Of Personality Status On Outcomementioning

confidence: 99%

See 1 more Smart Citation

Cognitive–behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years

Šalkovskis

et al. 2017

Health Technol Assess

Self Cite

“…These concepts of the self have only been defined to a limited extent, with many writers resorting to more ‘common parlance' or ‘folk psychological' definitions. This includes the authors of internationally used classification systems, such as the DSM-5 [6] and the proposed ICD-11 [7]. While these refer to the self and its functions, neither incorporates a formal concept of the self.…”

Section: Introductionmentioning

confidence: 99%

The ‘Self' and Borderline Personality Disorder: Conceptual and Clinical Considerations

Kerr

Finlayson-Short²,

McCutcheon³

et al. 2015

Psychopathology

Some concept of self has been used by many, although not all, researchers and clinicians as an ‘organising construct' for borderline personality disorder (BPD). There is considerable variation in this usage and how clearly researchers have defined the self. Given this diversity, and that ‘self' is often used interchangeably with parallel concepts (e.g. psyche, brain-mind, ‘person') or with features of self (e.g. self-awareness, identity), unqualified use of the term is problematic. This is further complicated by the heterogeneity and ‘comorbidity' of BPD and the limitations of syndromally based psychiatric nosology. Still, BPD remains in current classification systems and can be reliably diagnosed. A considerable body of research on self and BPD has accrued, including a recent profusion and confluence of neuroscientific and sociopsychological findings. These have generated supporting evidence for a supra-ordinate, functionally constituted entity of the self ranging over multiple, interacting levels from an unconscious, ‘core' self, through to a reflective, phenotypic, ‘idiographic' and relational self constituted by interpersonal and sociocultural experience. Important insights have been generated regarding emotional and social-cognitive dysregulation, disorder of self-awareness, relationality, identity, and coherence and continuity of the self. Many of these are shared by various trauma-related, dissociative disorders. A construct of the self could be useful as an explanatory principle in BPD, which could be construed as a ‘self-state' (and relational) disorder, as opposed to a less severe disorder of aspects of the self (e.g. mood or memory). We offer a tentative description of ‘Self' in this context, noting that any such construct will require a clear definition and to be evaluable.

“…It would be helpful if the Work Group shared its thinking on why a generally accepted structure was rejected in favour of the results of its own single analysis. An explanation is needed because ICD-11, presumably after considering the same evidence, proposes to adopt the four-factor structure to diagnose individual differences in personality disorder [35]. …”

Section: Evidence-based Classificationmentioning

confidence: 99%

The DSM-5 Personality Disorder Proposal and Future Directions in the Diagnostic Classification of Personality Disorder

Livesley¹

2013

Psychopathology

Background: The compilation of DSM-5 presented a substantial opportunity to develop a coherent, evidence-based classification of personality disorder. The irremediable problems with DSM-IV are widely recognized, the field seemed ready for change, and the data and methods for constructing a scientific classification are readily available. Rather than seize this opportunity, DSM-5 advanced an incoherent proposal lacking in evidential support and too poorly organized for clinical use. Methods: This article examines the problems with the proposal based on a consideration of the basic requirements of a satisfactory classification. It is suggested that an adequate system should have an explicit and coherent conceptual structure, be based on the best available scientific evidence, possess clinical utility, and be as parsimonious as possible. Results: The DSM-5 proposal fails to meet these criteria. Problems with the product and process suggest the need for a radical reconsideration of how personality disorders are classified and how classifications are compiled. Conclusions: The article proposes that greater emphasis be placed on developing a classification that provides the diagnostic information clinicians need to treat personality disorder and that future classifications should be constructed through an explicit process that is open to public scrutiny.