Feature

Diagnosing Personality
disorder in people with
learning disabilities
Having a dual diagnosis poses problems for clients.
Rebecca Chester discusses the implications for nurses
Summary
Service users are susceptible to developing personality disorders, but for them
the diagnosis can be particularly difficult. The author reviews the debates
about diagnosis, treatment and management of these conditions and describes
developments in the relevant services. She suggests that as treatment for these
clients is thought to be impossible, they are at risk of experiencing overly restrictive
practices unless learning disability and mental health staff have appropriate
training and agree to work together.
Keywords
Challenging behaviour, learning disability, personality disorder diagnosis, restrictive
practice
The diagnosis of personality disorder (PD) among
people with learning disabilities is controversial.
There are conceptual issues regarding the construct
of personality and limitations in the research
(Torr 2003, Lindsay et al 2006, 2007a, Pridding
and Procter 2008). There are also challenges to
assessment, diagnosis and the application of
classification systems (Levitas et al 2001, Oliver et al
2003). However, there is significant evidence that
people with learning disabilities are susceptible
to developing PD (Alexander et al 2007). This
article reviews the various debates, treatment
and management of people with PD and learning
disabilities, and developments in the services that
should support them.
Historical perspectives of personality were based
on the impact of intelligence levels on cognitive
functioning and suggested that, in dual diagnosis
where a person has a learning disability and a
14 October 2010 | Volume 13 | Number 8

personality disorder it was the learning disability

alone that caused abnormalities of personality.
However, the personality and motivation of people
with learning disabilities are influenced by the
same factors and life experiences as those of others
(Zigler et al 2002).

Definitions
The Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR) of the American Psychiatric
Association (APA) defines PD as an enduring pattern
of inner experience and behaviour that deviates
markedly from the expectations of the individuals
culture, is pervasive and inflexible, has an onset in
adolescence or early adulthood, is stable over time
and leads to distress or impairment (APA 2000).
This definition suggests disturbance in cognitive
processes as well as in interactions with others and
the environment.
Historically, definitions have focused on the
impact of PD on others and society (Tyrer et al
1991); current advice is that a diagnosis of PD
should be based on the clinical benefit of such a
diagnosis to the individual (Naik et al 2002).
Table 1 (page 16) provides a breakdown of the
International Statistical Classification of Diseases
and Health-related Problems (ICD-10) (World Health
Organization 1990) and DSM-IV personality disorder
sub-categories (Goldberg et al 1995). It shows
how the categories of personality disorder can be
arranged into clusters.
There have been a number of studies
investigating the prevalence of PD among people
LEARNING DISABILITY PRACTICE

Getty Images

Patients can experience disturbances

in cognitive processes and in their
interactions with others

Feature
Table 1

Categories of personality disorder

ICD-10

DSM-IV-TR

Paranoid

Paranoid
Schizoid

Cluster

Overshadowing
A

Schizotypal
Dissocial

Antisocial

Emotionally unstable:
Impulsive
Borderline

Borderline
B
Histrionic
Narcissistic

Anxious (avoidant)

Avoidant

Dependent

Dependent

Anankastic

Obsessive-compulsive

Other

Other

(Goldberg et al 1995)

with learning disabilities (Corbett 1979, Reid and

Ballinger 1987, Deb and Hunter 1991, Goldberg et al
1995, Khan et al 1997, Flynn et al 2002, Lindsay et al
2006, 2007b).
Prevalence figures range from 1 per cent to
92 per cent (Alexander and Cooray 2003), and this
variation has raised questions regarding the validity
and reliability of diagnosing PD in people with
learning disabilities.
Differences in prevalence may be due to
variations in methodology (including sample used,
population/setting, and inclusion/exclusion criteria)
and in classification, diagnostic instruments and
level of intellectual functioning examined (Khan et al
1997, Torr 2003).
The difficulties in the assessment of PD in people
with learning disabilities include the following
(Mavromatis 2000, Deb et al 2001, Naik et al 2002,
Alexander et al 2007):
Individual ability to self-report symptoms.
Communication skills.
Dependence on third-party informants.
Difficulties in applying classification systems.
Presentation of symptoms and potential overlap
with other psychopathology and behavioural
disorders.
These difficulties are increased when assessing
people with severe and profound learning
disabilities, so diagnosis is not recommended for
these (Royal College of Psychiatrists 2001, Naik et al
16 October 2010 | Volume 13 | Number 8

2002, Alexander and Cooray 2003, Alexander et al

2007, Lindsay et al 2007a).

Throughout the literature there have been questions

raised regarding diagnostic overshadowing in
relation to under- and over-reporting of PD among
people with learning disabilities.
Overshadowing occurs when the clients learning
disability is seen as the cause for symptoms,
rather than other potentially causative factors
that may require treatment (Priest and Gibbs
2004, Moreland et al 2008). The challenge in the
presence of low intellectual functioning is to
differentiate between a behaviour disorder, other
psychopathology and PD.
Alexander and Cooray (2003) and Torr (2003)
proposed that people with severe or profound
learning disabilities were more likely to be viewed
as having a behaviour disorder, whereas people
with mild to moderate learning disabilities were
more likely to receive a diagnosis of PD. Because of
these challenges, the Royal College of Psychiatrists
(2001) provided guidance on the classification and
diagnosis of PD. Recommendations include the
following:
Diagnosis should be made after the client has
reached the age of 21 years.
ICD-10 criteria for organic PD should not be met
on the basis of learning disability or epilepsy.
Diagnoses of schizoid, dependent, anxious or
avoidant PD are inappropriate.
One of the main factors influencing personality
development among people who have learning
disabilities is dependency on others (Zigler and
Burack 1989).
There needs to be recognition of realistic
dependency needs in this client group (Reid and
Ballinger 1987). Zigler et al (2002) showed that
people with learning disabilities were more likely to
be wary of strangers or others, to seek guidance and
to be dependent on others. This is compounded by
reduced expectations to succeed or derive pleasure
from success. These factors need to be considered
when formulating a diagnosis of PD among people
with learning disabilities (Moreland et al 2008).
Lindsay et al (2007a) warned of the twin trap of
diagnosing or not diagnosing due to the overlap of PD
and learning disabilities, and the diagnosis of schizoid
PD has been further challenged in view of the overlap
with autism spectrum disorders. For example, earlier
studies, such as Craft (1959), suggested there is a high
prevalence of people with learning disabilities and
schizoid-type personality. This was later challenged
by Deb and Hunter (1991) who suggested that this
LEARNING DISABILITY PRACTICE

Feature
apparently high prevalence may have been due to
autism among some participants.
Key features in diagnosing schizoid personality
type include detachment from social relationships
and difficulties in interpersonal situations (APA
2000), which overlap considerably with symptoms
of pervasive developmental disorders and autistic
spectrum disorders. Goldberg et al (1995) showed
that nearly half of those identified as having
anxious PD type also had a diagnosis of pervasive
development disorder, and Tsakanikos et al (2006)
found that people with autism were less likely to be
diagnosed with PD; conversely, the diagnosis of PD
can be a misdiagnosis of autism.
There has been discussion about whether there
is an increased incidence of PD among people with
epilepsy and possible organic personality changes
(Dana 1993), but research has not supported a
significant relationship between PD and epilepsy
(Reid and Ballinger 1987, Deb and Hunter 1991).
The Royal College of Psychiatrists (2001)
recommended that, because organic PD among
people with learning disabilities or epilepsy was over
diagnosed, it should be omitted.
Hurley and Sovner (1995) reported reluctance
among clinicians to recognise sociopathic behaviour
among people with learning disabilities and that
five out of six service users with sociopathic
behaviour did not receive a diagnosis before
specialist referral.
Goldberg et al (1995) also found a lack of
diagnoses of learning disability with antisocial PD,
after looking at the relationship between specific
clusters and predispositions to psychiatric disorder.
Reluctance to diagnose antisocial PD in people with a
learning disability may be related to the impact this
can have on the individuals quality of life.

Restrictive treatment
People with a dual diagnosis of personality
disorder and learning disabilities are more likely
to experience restrictive treatment and restrictive
placements than those who have a single diagnosis.
(Reis 1994).
The Mansell Report (Department of Health (DH)
2007) highlighted concern regarding the capacity
of services to understand and respond to the needs
of people with learning disabilities, challenging
behaviours and/or mental health needs.
It stated that commissioners need to prioritise
the improvement of local services for people who
challenge services, to reduce placement breakdown
and out-of-area placements.
Because of the challenges in assessing and
diagnosing PD among people with learning
LEARNING DISABILITY PRACTICE

disabilities, it is important that a comprehensive

assessment of the individual is undertaken. Where
clinically indicated, multidisciplinary assessment
may include the following.
Historical information, recognising potential
risk factors (such as childhood abuse) for
developing PD.
Physical health, considering organic causes for
changes in personality (such as epilepsy).
Presentation and current needs.
Assessment of functional skills, including
recognition of realistic dependency needs.
Functional analysis to understand behavioural
presentations.
Psychiatric assessment.

Interventions
Historically, PD has been referred to as untreatable,
and there are concerns about the impact this view
may still have on diagnosis and treatment (Pridding
and Procter 2008).
There has been surge in research into successful
interventions for PD (Roy and Tyrer 2001), but
little of this has related to the learning disability
population (Torr 2003) among whom the diagnosis
of PD, although contentious, can be important in
accessing the right support.
With a diagnosis, referral to specialist services,
and access to treatment and management are
possible (Hurley and Sovner 1995, Khan et al 1997,
Mavromatis 2000, Wilson 2001).
Multimodal approaches to treating PD are
advised (Esbensen and Benson 2003). These
include psychotherapy, behavioural strategies and,
when necessary, pharmacotherapy (Mavromatis
2000). Wilson (2001) adds to this the importance
of education and support of direct care staff,
emphasising the significance of their role in the
effectiveness of treatment.
It is common to experience splitting within
staff teams (Mavromatis 2000), and consideration
is necessary regarding transferring feelings from
client to carer/therapist and vice versa, known as
transference and counter-transference. There needs
to be good communication and consistency across
teams (Mavromatis 2000, Wilson 2001).
The National Institute for Health and Clinical
Excellence (NICE) guidelines on borderline and
antisocial PD (NICE 2009a, 2009b) highlight the

People with a dual diagnosis of personality

disorder and learning disabilities are more
likely to experience restrictive treatment
October 2010 | Volume 13 | Number 8 17

Feature
Psychotherapeutic interventions for people
with learning disabilities have developed
significantly over the past decade
need for adult mental health teams to work with
learning disability services in the development
of care plans and strategies for all those with
challenging behaviour.
Wilson (2001) offers a model for supporting
people with borderline PD and learning disabilities.
The model involves behavioural and psychological
approaches in a proactive format and also the
development of direct care staff. The following
four stages are suggested:
Identification of antecedents and precursors.
Crisis resolution.
Development of treatment plans.
Staff training.
According to Wilson, behaviour, goals and
interventions should provide a framework for care
plans; but this advice is limited by the fact that only
one case is documented (Wilson 2001).
Psychotherapeutic interventions for people with
learning disabilities have developed significantly
over the past decade (Willner and Hatton 2006).
Before this, there was a belief that cognitive and
communication deficits made these treatments
inaccessible for people with learning disabilities

(Mirow 2008) who should not, however, be excluded

from the full range of psychotherapies available
(Brown and Marshall 2006).
Mavromatis (2000), Wilson (2001) and Esbensen
and Benson (2003) discuss the benefits of
psychotherapeutic intervention based on a system of
dialectical behaviour therapy (DBT) (Linehan 1993).
This approach includes cognitive behaviour training
and the promotion of emotional and behavioural
regulation.
Case studies of people with learning disabilities
and PD relate particularly to the role of the therapist
in validation, expression of emotion, setting limits
and developing coping strategies. There is no
accepted pharmacological treatment for PD and
therefore interventions should be based on clinical
presentation of symptoms of psychiatric illness
(Mavromatis 2000). Despite this, Naik et al (2002)
found that nearly all participants in their study were
receiving psychotropic medication, when only one
third had a co-existing mental health diagnosis.

Guidelines
The development of NICE guidelines for borderline
and antisocial PD (NICE 2009a, 2009b) has supported
closer integration between adult mental health
services and learning disability services.
The guidelines emphasise the importance
of joint access to adult mental health services
and of working together, recognising the skills

References
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18 October 2010 | Volume 13 | Number 8

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LEARNING DISABILITY PRACTICE

Feature
of learning disability services in managing
behaviour that challenges and in understanding
issues of assessment and diagnosis (NICE 2009a).
Implementation of the guidelines enables people
with learning disabilities to access mainstream
services and ensures that specific training is
provided regarding PD, learning disabilities and
challenges in assessment, diagnosis and treatment.
Other developments in practice that can support
services for people with PD and learning disabilities
include:
Joint working between learning disability and
mental health services.
Recovery approaches that shift the focus from
pathology, illness and symptoms to health,
strengths and wellness, hope and self-managment.
Development and growth of local forensic services
(inpatient and community).
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a pictorial framework (Ayres 2009).
Co-ordination of care through the Care
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Training on PD, including PD among people with
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Development of DBT groups for people with
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surprising that the diagnosis of PD in people with

learning disabilities is controversial.
The impact of such a diagnosis on the individual
and on access to appropriate services and treatment
may be negative because of perceptions that
treatment is not possible.
This could collude with restrictive practices,
as people with PD and learning disabilities are at
greater risk of living within restrictive placements
(Reis 1994).
Research into PD among people who have
learning disabilities should be extended; in
relation to treatment there is a lack of clinical
evidence, and more is required to validate current
practice. A multimodal approach to treatment
and joint working between adult mental health
and learning disability services is beneficial in
considering the individual as a whole, in line with
a biopsychosocial model.
The continued challenge for services jointly is to
ensure consistency in diagnosis and deliver the best
available treatment options for people with learning
disabilities and challenging behaviours.

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LEARNING DISABILITY PRACTICE

The article has been subject to

double-blind review and checked
using antiplagiarism software
Rebecca Chester is consultant
nurse trainee in learning
disabilities, Rufus Lodge,
Hampshire Partnership NHS
Foundation Trust

For related information visit our online archive

of more than 6,000 articles and search using
the keywords.

National Institute for Health and Clinical

Excellence (2009a) Antisocial Personality
Disorder: Treatment, Management and
Prevention. NICE, London.

For author guidelines visit

the Learning Disability
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www.learningdisabilitypractice.co.uk

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October 2010 | Volume 13 | Number 8 19

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