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Personality Disorders
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Written by Sam
Vaknin
Question:
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?
Answer: 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, 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.
Patients suffering from personality disorders 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 typical patients is unhappy. 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 the reasons to it.
- The patient with a personality disorder is vulnerable to
and prone to suffer from a host of other psychiatric problems. It is as though
his psychological immunological system has been disabled by his personality
disorder and he falls prey to other variants of mental illness. So much energy
is consumed by the disorder and by its corollaries (example: by
obsessions-compulsions, or mood swings), that the patient is rendered
defenceless.
- Patients with personality disorders are alloplastic in
their defences. They have an external locus of control. In other words: they
tend to blame the outside 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 world out there to
conform to their needs. This is as opposed to autoplastic defences (internal
locus of control) typical, for instance, of neurotics (who change their
internal psychological processes in stressful situations).
- The character problems,
behavioural deficits and emotional deficiencies and lability encountered by
patients with personality disorders 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 the Borderline Personality Disorder and who experience brief psychotic
"microepisodes", mostly during treatment). They are also fully oriented, with
clear senses (sensorium), good memory and a satisfactory 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."
Click here to read
the DSM-IV-TR (2000) definition of personality
disorders.
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).
Click here
to read the ICD-10 diagnostic criteria for the personality
disorders.
Each personality disorder has its own form of Narcissistic
Supply:
- HPD (Histrionic PD) – Sex, seduction,
"conquests", flirtation, romance, body-building, demanding physical
regime;
- NPD (Narcissistic PD) – Adulation,
admiration, attention, being feared;
- BPD (Borderline PD) – The presence of their
mate or partner (they are terrified of abandonment);
- AsPD (Antisocial PD) – Money, power,
control, fun.
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.
Author Bio Sam Vaknin ( http://samvak.tripod.com ) is the
author of Malignant
Self Love - Narcissism Revisited and After the Rain - How the West Lost the
East. He served as a columnist for Central Europe Review, PopMatters, and
eBookWeb , and Bellaonline, and as a United Press International (UPI)
Senior Business Correspondent. He is the the editor of mental health and Central
East Europe categories in The Open Directory and Suite101. |
