Personality disorders form a class of mental disorders that are characterized by long-lasting rigid patterns of thought and actions. Because of the inflexibility and pervasiveness of these patterns, they can cause serious problems and impairment of functioning for the persons who are afflicted with these disorders.
Personality disorders are seen by the American Psychiatric Association as an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it. These patterns are inflexible and pervasive across many situations. The onset of the pattern can be traced back at least to the beginning of adulthood. To be diagnosed as a personality disorder, a behavioral pattern must cause significant distress or impairment in personal, social, and/or occupational situations.
Personality disorders are noted on Axis II of the diagnostic manual of the American Psychiatric Association, the Diagnostic and Statistical Manual of Mental Disorders (DSM, or DSM-IV-TR as it is currently in its fourth edition with a text revision). (Note: Mental Retardation is also noted on Axis II).
General diagnostic criteria for a personality disorder
To make a diagnosis of a personality disorder, these criteria must be satisfied in addition to the specific criteria listed under the individually named personality disorders.
A. Experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:
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 or a general medical condition such as head injury.
People under 18 years old who fit the criteria of a personality disorder are usually not diagnosed with such a disorder, although they may be diagnosed with a related disorder. Antisocial personality disorder cannot be diagnosed at all in persons under 18.
List of personality disorders defined in the DSM
The DSM-IV lists ten personality disorders, which are grouped into three clusters:
Cluster A (odd or eccentric disorders)
Cluster B (dramatic, emotional, or erratic disorders)
Cluster C (anxious or fearful disorders)
The DSM-IV also contains a category for behavioural patterns that do not match these ten disorders, but nevertheless have the characteristics of a personality disorder; this category is labeled Personality Disorder NOS (Not Otherwise Specified). The previous version of the DSM also contained the Passive-Aggressive Personality Disorder and the Self-Defeating Personality Disorder. Passive-Aggressive Personality Disorder is a pattern of negative attitudes and passive resistance in interpersonal situations. Self-defeating personality disorder is characterised by behaviour that consequently undermines the person's pleasure and goals. These categories were removed in the current version of the DSM, because it is questionable whether these are separate disorders. Passive-Aggressive Personality Disorder and Depressive personality disorder were placed in an appendix of DSM-IV for research purposes.
A study of almost 600 male college students, averaging almost 30 years of age and who were not drawn from a clinical sample, examined the relationship between childhood experiences of sexual and physical abuse and presently reported personality disorder symptoms. Childhood abuse histories were found to be definitively associated with greater levels of symptomatology. Severity of abuse was found to be statistically significant, but clinically negligible, in symptomatology variance spread over Cluster A, B and C scales. Miller and Lisak. Journal of Interpersonal Violence. June 1999
Child abuse and neglect consistently demonstrate as risks for personality disorders in adulthood. In this study, efforts were taken to match retrospective reports of abuse with a clinical population that had demonstrated psychopathology from childhood to adulthood who were later found to have experienced abuse and neglect. The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong role in the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood. Cohen, Patricia, Brown, Jocelyn, Smailes, Elizabeth. "Child Abuse and Neglect and the Development of Mental Disorders in the General Population" Development and Psychopathology. 2001. Vol 13, No 4, pp981-999. ISSN 0954-5794
Current thinking and criticism
The DSM attempts to represent a consensus view of the members of the American Psychiatric Association. However, more so than in other parts of the DSM, the classification of Axis II personality disorders—deeply ingrained, maladaptive, lifelong behaviour patterns—has come under sustained and serious criticism from its inception in 1952. The DSM adopts a categorical approach, assuming that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is doubted by many. The polythetic form of the DSM's Diagnostic Criteria—only a subset of the criteria is adequate grounds for a diagnosis—generates diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none. Some people think that this is unacceptable.
The DSM has arbitrarily separated off Axes I and II so that it:
However, the DSM does not contain an explanation of the relationship between Axis II (personality) and Axis I (non-personality) disorders, or the way in which chronic childhood and developmental problems interact with personality disorders. It is possible that the arbitrary separation of Axes I and II, although well intended, has created the wide spread false impression that these are fundamentally and possibly even biologically different types of illnesses. This has contributed to the stigmatization of Axis II disorders in the mental health field.
One of the problems with diagnosis of personality disorder is that these such diagnosis typically has a lower reliability than most other disorders - indeed, Dahl (1986; cited in Marshall & Serin, 1997) found only modest test re-test reliability coefficients (between .5 and .6) for diagnoses of personality disorders over time, although as Marshall and Serin point out, evidence suggests that use of structured interviews can improve reliability of diagnosis. Improving breadth of information may also, as Marshall and Serin note, improve reliability of diagnosis.
Christine Warner, a neuroscientist, thinks that the differential diagnoses are vague and the personality disorders are insufficiently demarcated. This overlap is addressed in the DSM by grouping the personality disorders into three clusters, which contain similar disorders. The result of the overlap is excessive comorbidity: people often receive multiple Axis II diagnoses. This casts doubt on the assumption that the diagnostic categories correspond to independent disorders. The necessity of the "not otherwise specified" basket category can also be seen as an indication of poor construct validity; the current diagnostic categories are apparently insufficient to categorize all people with personality disorders.
The distinction made between "normal" and "disordered" personalities is also rejected by some. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported. The judgment whether a behavioural pattern is normal or disordered is also highly subjective. The DSM contains little discussion of what distinguishes personality styles (personality), from personality disorders and much is left to clinical judgment.
Cultural bias is evident in certain disorders such as Schizoid personality disorder, Antisocial personality disorder, and Schizotypal personality disorder. Also, diagnosis of some disorders may be vulnerable to bias because of gender role expectations.
The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:
Despite considering all of the above, the DSM continues for the present to prefer the use of a categorical approach over a dimensional approach which is seen as, "less useful than categorical systems in clinical practice and in stimulating research."
In the mental health field, the category of personality disorder has become a pejorative concept. Of all of the personality disorder categories, Borderline Personality Disorder, and Antisocial Personality Disorder, have become most negatively identified categories. Some clinicians refuse even to specify which Axis II category may be present, using instead the evasion, "Diagnosis Deferred". Personality disorder symptoms, as with all mental disorders, can vary markedly over time and become much more acute during times of stress in an individual's life.
The following issues, long neglected in the DSM, are likely to be addressed in future editions as well as in current research:
Finally, because the diagnostic categories are seen as less flexible than dimensional ones, a spin-off problem is created in managed care settings. Because personality disorders may be defined as enduring and inflexible behavioral patterns that are not as likely to change over time, insurance companies sometimes refuse to reimburse psychotherapy fees when the patient/client has received an Axis II diagnosis, i.e., a personality disorder diagnosis.
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