0.19 Personality disorders  (Page 6/6)

A New Alternative in the DSM-V

The purpose for adding a second approach to the diagnosis of personality disorders is twofold: first, the APA Board of Trustees wanted to provide continuity in the diagnoses being offered by clinicians, but second, they recognised that few individuals with a personality disorder clearly fit into the criteria for just one personality disorder. Thus, an alternative method has been proposed that considers assessing both "impairments in personality functioning and pathological personality traits " (pg. 761; APA, 2013).

After listing general criteria for personality disorder that are quite similar to the traditional general criteria, the alternative approach addresses personality functioning in terms of two dimensions: self and interpersonal. The healthy vs. unhealthy aspects of the self involve one's sense of identity and one's self-direction, whereas the interpersonal component addresses empathy and intimacy. The individual is then assessed (as appropriate to the presumed, primary personality disorder) on 25 specific trait facets as they apply within five broad trait domains . The trait domains and associated facets are as follows:

Negative Affectivity: emotional lability, anxiousness, separation insecurity, submissiveness,

hostility, perseveration, depressivity, suspiciousness, restricted affectivity (lack of)

Detachment: withdrawal, intimacy avoidance, anhedonia, depressivity, restricted affectivity,

suspiciousness

Antagonism: manipulativeness, deceitfulness, grandiosity, attention seeking, callousness, hostility

Disinhibition: irresponsibility, impulsivity, distractibility, risk taking, rigid perfectionism (lack of)

Psychoticism: unusual beliefs and experiences, eccentricity, cognitive and perceptual

dysregulation

The DSM-V then offers examples of diagnostic criteria according to this methodology for antisocial PD, avoidant PD, borderline PD, narcissistic PD, obsessive-compulsive PD, and schizotypal PD, as well as a new diagnosis of Personality Disorder - Trait Specified . Personality Disorder - Trait Specified is diagnosed based on two criteria. First there must be moderate or greater impairment in the functioning of personality, as manifested in two or more of the areas identified above as identity, self-direction, empathy, and intimacy. Second, there must be one or more pathological traits as defined by the 5 domains/25 facets.

So, with three different, utilitarian approach to the diagnosis of personality disorders, it is clear that disordered personality development is every bit as complex and fascinating as normal personality development. This should not be surprising, since individuals are unique and complex, and we all experience different lives. It will be quite interesting to see how the DSM-VI handles this issue.

A Final Note

This brief appendix on personality disorders merely scratches the surface of this complex set of psychological disorders. For example, it might appear as if Millon’s classification system for personality disorders is at odds with the DSM-IV/DSM-V classification system, and, therefore, Millon himself may be at odds with the DSM-IV/DSM-V system. Actually, Millon was a member of the DSM-IV Personality Disorders Work Group. In addition, the DSM-IV included among its “criteria sets and axes provided for further study” two of the personality disorders contained within Millon’s classification system: the depressive personality disorder and the passive-aggressive (negativistic) personality disorder. Accordingly, the classification systems continue to be the subject of ongoing research and potential modification, so much so that the DSM-V actually has two systems included. It will be years before we begin the hear about the DSM-VI, but it will be very interesting to see how personality disorders are handled then.

Likewise, although DBT has been very promising in the treatment of borderline personality disorder, there is less research on specific treatments for other personality disorders. Thus, continued research is necessary, perhaps including the development of new therapies specific to certain other personality disorders.

Review of key points

• Personality disorders are enduring patterns of deviant behavior that differ markedly from an individual’s culture.
• The DSM classification system identifies three clusters of personality disorder: odd/eccentric, dramatic/emotional/erratic, and anxious/fearful.
• The odd/eccentric personality disorders bear some resemblance to the symptoms of schizophrenia.
• The personality disorders within Cluster B appear to involve a significant gender factor.
• Millon has proposed an alternative classification scheme based on an evolutionary model of personality disorders. He suggests that these disorders represent individual efforts to exist, adapt, replicate, and abstract within an abnormal developmental environment.
• Millon’s model results in personality disorder clusters based on four factors: pleasure-deficiency, interpersonal-imbalance, intrapsychic-conflict, and structure-defectiveness.
• Personality disorders have traditionally been resistant to psychotherapeutic interventions.
• Linehan’s dialectical behavior therapy has been quite promising in the treatment of borderline personality disorder. This treatment incorporates Zen mindfulness as an approach to balancing the acceptance of the individual with the desire/need for change.