Personality Disorders

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;

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, in my view, at least phenomenologically. 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 register 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 theories around (psychoanalysis, to mention the most famous) but they all failed miserably at providing a coherent, consistent theoretical framework with predictive powers.

Patients suffering from PDs have many things in common:

Most of them are insistent (except those suffering from the Schizoid or the Avoidant Personality Disorders). They demand treatment on a preferential and privileged basis. They complain about numerous symptoms. They never obey the physician or his treatment recommendations and instructions.
They regard themselves as unique, display a streak of grandiosity and a diminished capacity for empathy (the ability to appreciate and respect the needs and wishes of other people). They regard the physician as inferior to them, alienate him using umpteen techniques and bore him with their never-ending self-preoccupation.
They are manipulative and exploitative because they trust no one and usually cannot love or share. They are socially maladaptive and emotionally unstable.
Most personality disorders start out as problems in personal development which peak during adolescence and then become personality disorders. They stay on as enduring qualities of the individual. Personality disorders are stable and all-pervasive – not episodic. They affect most of the areas of functioning of the patient: his career, his interpersonal relationships, his social functioning.
The patient is not happy, to use an understatement. He is depressed, suffers from auxiliary mood and anxiety disorders. He does not like himself, his character, his (deficient) functioning, or his (crippling) influence on others. But his defences are so strong, that he is aware only of the distress – and not of its reasons to it.
The patient with a personality disorder is vulnerable to and prone to suffer from a host of other psychiatric disturbances. It is as though his psychological immunological system has been disabled by the personality disorder and he falls prey to other variants of mental sickness. So much energy is consumed by the disorder and by its corollaries (example: by obsessions-compulsions), that the patient is rendered defenceless.
Patients with personality disorders are alloplastic in their defences. In other words: they tend to blame the external world for their mishaps. In stressful situations, they try to pre-empt a (real or imaginary) threat, change the rules of the game, introduce new variables, or otherwise influence the external world to conform to their needs. This is as opposed to autoplastic defences exhibited, for instance, by neurotics (who change their internal psychological processes in stressful situations).
The character problems, behavioural deficits and emotional deficiencies and instability encountered by the patient with personality disorder are, mostly, ego-syntonic. This means that the patient does not, on the whole, find his personality traits or behaviour objectionable, unacceptable, disagreeable, or alien to his self. As opposed to that, neurotics are ego-dystonic: they do not like who they are and how they behave on a constant basis.
The personality-disordered are not psychotic. They have no hallucinations, delusions or thought disorders (except those who suffer from a Borderline Personality Disorder and who experience brief psychotic "microepisodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and general fund of knowledge.
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."

It defines personality disorders as:

A. An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:

a. Cognition (i.e., ways of perceiving and interpreting self, other people, and events);
b. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response);
c. Interpersonal functioning;
d. Impulse control.

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.
F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma).

[American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR, Washington, 2000]

Each personality disorder has its own form of Narcissistic Supply:

a. HPD (Histrionic PD) – Sex, seduction, flirtation, romance, body;
b. NPD (Narcissistic PD) – Adulation, admiration;
c. BPD (Borderline PD) – Presence (they are terrified of abandonment);
d. AsPD (Antisocial PD) – Money, power, control, fun.

Borderlines, for instance, can be construed as NPDs with an overwhelming fear of abandonment. They are careful not to abuse people. They DO care deeply about not hurting others – but for the selfish motivation of avoiding 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.