Personality Disorders

Toward the DSM-V

William T. O'Donohue, Katherine A. Fowler, Scott O. Lilienfeld

• Publisher: SAGE Publications, Inc
• Year: 2007
• ISBN:
  9781506319100
• Edition: 1
• Topic: Psicologia
• Subtopic: Personalità in psicologia

Personality Disorders: Toward the DSM-V offers a scientifically balanced evaluation of competing theoretical perspectives and nosological systems for personality disorders. Editors William T. O'Donohue, Scott O. Lilienfeld, and Katherine A. Fowler have brought together recognized authorities in the field to offer a synthesis of competing perspectives that provide readers with the richest and most nuanced assessment possible for each disorder. The result is a comprehensive, current, and critical summary of research and practice guidelines related to the personality disorders.

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1	Introduction

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Personality Disorders in Perspective

Katherine A. Fowler

Emory University

William O’Donohue

University of Nevada, Reno

Scott O. Lilienfeld

Emory University

The personality disorders are a complex, controversial, and fascinating class of diagnoses. Decades of clinical observations of developmentally fixated “character types” (Freud, 1916/1991), “neurotic styles” (Shapiro, 1965), and “character disorders” (e.g., Horney, 1939) preceded the formal classification “personality disorders,” which first emerged in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association [APA], 1980). Most of the newly termed personality disorders were not new; indeed, some (e.g., schizoid personality, paranoid personality) had been included in prior editions of the DSM. In preparing the third edition, however, the DSM committee arrived at the consensus that personality disorders are a different “kind” of diagnostic category from the vast majority of disorders listed in the DSM. Thus, DSM-III was the first edition to adopt a multiaxial approach, assigning personality disorders to a separate axis (Axis II) from “clinical conditions” (Axis I). The most recent edition, DSM-IV-TR (APA, 2000), briefly states the rationale for this decision:

The listing of Personality Disorders and Mental Retardation on a separate axis ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders. (p. 28)

The above seems to imply that a diagnosis of personality disorder may provide the context for, or be overshadowed by, more “florid” Axis I diagnoses (such as depression or schizophrenia). It is interesting to speculate why personality disorders share this axis with mental retardation. Both are fairly pervasive across many situations, and both certainly bear implications for the diagnosis and treatment of Axis I disorders (e.g., cognitive therapy for depression might be contraindicated or implemented quite differently in either context); perhaps these similarities justify their placement on Axis II and explain in part why DSM-IV relegates personality disorders to a different diagnostic class from the other mental disorders. Moreover, it has been suggested that most personality disorders tend to be ego-syntonic (i.e., consistent with self-concept), whereas most Axis I disorders are ego-dystonic (i.e., inconsistent with self-concept; Grove & Tellegen, 1991).

DSM-IV-TR (APA, 2000) provides a broad definition of personality disorder:

A Personality Disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment. (p. 629)

This seemingly simple summary actually alludes to a complex set of properties, requiring exegesis of its key phrases. Without some clarification, we cannot make reliable and valid diagnoses and come to a shared understanding of personality disorders. For example, the following terms and phrases raise important questions:

1. Enduring: How long must an individual exhibit features of a personality disorder before a diagnosis is applicable?
2. Pattern: How consistently over time must an individual exhibit the characteristics in question? If there are periods of time when the individual does not exhibit these characteristics, how long can these time periods be?
3. Inner experience: Clearly, this term potentially comprises an extremely broad range of mental processes, including emotions, thoughts, impulses, fantasies, schemas, and memories. Which of these are considered most central to the conceptualization of personality disorders?
4. Deviates markedly: Whether a deviation is “marked” is clearly subjective. DSM-IV-TR encourages one to consider the individual’s context (e.g., family, culture) in making this determination. This is a step in the right direction, as it emphasizes that norms are not universal. However, it leads to the next point of inquiry:
5. Individual’s culture: Culture has many facets, including ethnicity, sexual orientation, socioeconomic status, geographic region, and gender. To which of these do we look to determine cultural norms, and what are the limits? How do we avoid confounding “cultural norms” with stereotypical perceptions?
6. Pervasive: How cross-situationally consistent must personality disorder features be for an individual to meet criteria? For example, can a person meet criteria for a personality disorder if he or she exhibits marked features in personal life but less marked features at work?
7. Inflexible: How much flexibility is allowed, and in which domains (e.g., work, school, relationships), and how pervasive must this inflexibility be?
8. Onset in adolescence or early adulthood: How does one discern “onset”? Must the person fully meet criteria by a certain age, or do some prodromal symptoms count? Particularly in the case of late adolescence and early adulthood, determining developmental norms is a difficult task. How do we find a balance between overpathologizing normal-range teenage behavior and overlooking true pathology? Furthermore, the age limits constituting adolescence and early adulthood are not specified.
9. Leads to distress and impairment: How does one establish the causal link between the symptoms and distress/impairment? What kinds of and how much distress/impairment are required?

Three levels of general questions surround personality disorders. First, there are semantic questions, such as those raised above. Second, there are operational questions: Once the semantics are clarified, what is the best way to gather the information we need? For example, say “enduring” is taken to mean “for at least 3 years.” Should we ask the client to self-report start dates and end dates of symptoms? Should we review records that cover this period, if available, to see if there are any corroborating or contradictory indicators? Should we use information provided by other informants who know the client well? The third problem is the measurement question: How does one begin to construct measures with adequate content- and criterion-related validity? This is no easy task, especially as many of these measures aim to assess complex constructs such as “impairment,” which requires historical or normative information often accessible only to the affected individual (“inner experience”). Part of the controversy regarding personality disorders can be tied to this complexity and to what some understandably perceive to be a lack of progress on these questions.

The DSM-IV Personality Disorders

DSM-IV-TR officially recognizes 10 personality disorders (PDs) and includes three others for further study (depressive personality disorder, passive-aggressive personality disorder, and sadistic personality disorder). A brief description of each of the 10 recognized PDs follows:

Paranoid Personality Disorder is a pattern of distrust and suspiciousness such that others’ motives are interpreted as malevolent;

Schizoid Personality Disorder is a pattern of detachment from social relationships and a restricted range of emotional expression;

Schizotypal Personality Disorder is a pattern of acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior;

Antisocial Personality Disorder is a pattern of disregard for, and violation of, the rights of others;

Borderline Personality Disorder is a pattern of instability in interpersonal relationships, self-image, and affects, and marked impulsivity;

Histrionic Personality Disorder is a pattern of excessive emotionality and attention seeking;

Narcissistic Personality Disorder is a pattern of grandiosity, need for admiration, and lack of empathy;

Avoidant Personality Disorder is a pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation;

Dependent Personality Disorder is a pattern of submissive and clinging behavior related to an excessive need to be taken care of;

Obsessive-Compulsive Personality Disorder is a pattern of preoccupation with orderliness, perfectionism, and control. (APA, 2000, p. 685)

The same three levels of questions noted in our discussion of PD conceptualization in general can be asked regarding individual diagnoses. Take paranoid PD, for example: there are semantic questions (e.g., what is meant by “suspiciousness”?), operational questions (how do we go about capturing this meaning?), and measurement questions (how do we develop a test that provides a valid measure of “suspiciousness”?). When these questions are multiplied across all the criteria for all of the diagnoses, we can again see both the potential for controversy and the large amount of work that lies ahead.

The individual diagnoses are organized into three broad clusters representing presumed superordinate features that characterize each group:

Cluster A (odd/eccentric disorders):

Paranoid personality disorder

Schizoid personality disorder

Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic disorders):

Antisocial personality disorder

Borderline personality disorder

Histrionic personality disorder

Narcissistic personality disorder

Cluster C (anxious/fearful disorders):

Avoidant personality disorder

Dependent personality disorder

Obsessive-compulsive personality disorder

These clusters presumably “carve nature at its joints” better than the individual diagnoses. There are consistent findings of high co-occurrence of diagnoses within each cluster but less co-occurrence of diagnoses in different clusters (Morey, 1988; see below).

Major Questions and Controversies in Personality Disorder Research

One consistent finding is that the prevalence of personality disorders in the general population is fairly high. For example, Mattia and Zimmerman (2001) averaged data across a number of epidemiological studies and found that in community samples, 13% of individuals had at least one personality disorder. Moreover, the prevalence of many of the individual diagnoses was relatively high; for example, obsessive-compulsive personality disorder was present in 4% of the population, while histrionic, schizotypal, and dependent personality disorders were each present in 2% of the population. This high prevalence is one reason that personality disorders remain an area of lively debate.

It is beyond the scope of this chapter to settle these contentions, as many of the issues remain unresolved in the literature. Furthermore, we do not mean to imply that these controversies are unique to personality disorders. Nevertheless, to provide a context for the remaining chapters, we give you their general flavor:

1. The predictive utility and perhaps even the existence of personality itself have been called into question. For several decades, psychologists actively debated whether personality is a valid construct rather than merely a convenient summary label that we invoke to describe behaviors that happen to covary (Mischel, 1968). Personality, particularly for radical behaviorists, was a controversial construct. Skinner (1957) argued that “personality is nothing but the locus of behavior” (p. 182). He thought of personality as an “explanatory fiction” (p. 182) that often seems to involve circular reasoning. For example, imagine that someone observes Jane acting in a consistently outgoing and friendly fashion and asks, “Why does Jane behave this way?” If the answer is that she has an “extraverted personality” and if one concludes that she has an extraverted personality by observing that she is generally outgoing and friendly, this is a tautological, pseudoexplanation. Radical behaviorists would be more comfortable using personality traits as descriptive rather than explanatory concepts.

Personality researchers responded to these criticisms. In particular, they demonstrated that many personality trait measures predict laboratory and biological indices that cannot merely be derived from the behaviors subsumed by the trait labels themselves (Kenrick & Funder, 1988). Nevertheless, some critics justifiably continue to argue that some personality disorders (e.g., dependent personality disorder) are little more than summary labels for behaviors that merit clinical attention.

Mischel re-ignited this controversy in the late 1960s in his book Personality and Assessment (1968), in which he pointed to the crosssituational inconsistency of personality traits and thereby called into question the traditional assumption of traits as pervasive behavioral dispositions. Once again, researchers responded to this criticism in a variety of ways. Some suggested that the sample of studies Mischel used to bolster his claim was unrepresentative and demonstrated how a review of different studies did not support his claim (e.g., Block, 1977), while others suggested that examination of moderator variables, such as tendency to “self-monitor” (Snyder, 1974) and prediction of aggregated behaviors (i.e., trends) rather than single behaviors, yield considerably higher estimates of cross-situational consistency (Bem & Allen, 1974; Epstein, 1979).

Although many consider these controversies resolved when it comes to personality in general, they bear repeating with respect to personality disorders. Personality disorder researchers should meet these challenges as personality researchers did by demonstrating that these conditions predict important external criteria (e.g., natural history, laboratory findings).

2. It is not clear whether personality disorders are underpinned by categories or by dimensions. The DSM-IV-TR adopts a categorical system for the diagnosis of personality disorders, as it does with all other disorders. Some have argued (e.g., Trull, 2005) that a dimensional system is better suited to the diagnosis of personality disorders. Categorical discriminations are made when constructs have or are thought to have clear boundaries in nature (tall or short, for example). Dimensional ratings, in contrast, simply provide a value on a continuum (such as 5' 10"). In general, categorical approaches presume that natural discontinuities exist, whereas dimensional approaches presume the existence of natural continua. Although dimensional systems seem to have the advantage of precision, they raise questions about which dimensions of personality and/or psychopathology ought to be used in c...