Other Personality Disorders
Frequently Asked Questions # 15
Personality disorders are closely-related syndrome and this – together with the inherent flaws in the Diagnostic and Statistical Manual (DSM) – give rise to comorbidity.
By: Dr. Sam Vaknin
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Many of the symptoms and signs that you describe apply to other personality disorders as well (for instance, the histrionic, the antisocial and the borderline personality disorders). Are we to think that all personality disorders are interrelated?
The classification of Axis II personality disorders - deeply ingrained, maladaptive, lifelong behavior patterns - in the Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] - or the DSM-IV-TR for short - has come under sustained and serious criticism from its inception in 1952.
The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even the distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported.
The polythetic form of the DSM's Diagnostic Criteria - only a subset of the criteria is adequate grounds for a diagnosis - generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none.
The DSM fails to clarify the exact relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders.
The differential diagnoses are vague and the personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses).
The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) - from personality disorders.
The DSM does not incorporate personality disorders induced by circumstances (reactive personality disorders, such as Milman's proposed "Acquired Situational Narcissism"). Nor does it efficaciously cope with personality disorders that are the result of medical conditions (such as brain injuries, metabolic conditions, or protracted poisoning).
The DSM suffers from a dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities.
Numerous personality disorders are "not otherwise specified" - a catchall, basket "category".
Cultural bias is evident in certain disorders (such as the Antisocial and the Schizotypal).
The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:
“An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p.689)
The following issues - long neglected in the DSM - are likely to be tackled in future editions as well as in current research:
· The longitudinal course of the disorder(s) and their temporal stability from early childhood onwards;
· The genetic and biological underpinnings of personality disorder(s);
· The development of personality psychopathology during childhood and its emergence in adolescence;
· The interactions between physical health and disease and personality disorders;
· The effectiveness of various treatments - talk therapies as well as psychopharmacology.
All personality disorders are interrelated, at least phenomenologically - though we have no Grand Unifying Theory of Psychopathology. We do not know whether there are – and what are – the mechanisms underlying mental disorders. At best, mental health professionals record symptoms (as reported by the patient) and signs (as observed).
Then, they group them into syndromes and, more specifically, into disorders. This is descriptive, not explanatory science. Sure, there are a few etiological theories around (psychoanalysis, to mention the most famous) but they all failed to provide a coherent, consistent theoretical framework with predictive powers.
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Patients suffering from personality disorders have many things in common:
The Diagnostic and Statistical Manual [American Psychiatric Association. DSM-IV-TR, Washington, 2000] defines "personality" as:
"…enduring patterns of perceiving, relating to, and thinking about the environment and oneself … exhibited in a wide range of important social and personal contexts."
The international equivalent of the DSM is the ICD-10, Classification of Mental and Behavioural Disorders, published by the World Health Organization in Geneva (1992).
Each personality disorder has its own form of Narcissistic Supply:
Borderlines, for instance, can be described as narcissist with an overwhelming separation anxiety. They DO care deeply about not hurting others (though often they cannot help it) – but not out of empathy. Theirs is a selfish motivation to avoid rejection. Borderlines depend on other people for emotional sustenance. A drug addict is unlikely to pick up a fight with his pusher. But Borderlines also have deficient impulse control, as do Antisocials. Hence their emotional lability, erratic behaviour, and the abuse they do heap on their nearest and dearest.
More about Other Personality Disorders - in the Open Site Encyclopedia
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