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Personality Disorders

Axis 2 of DSM-IV is used by clinicians to note "prominent maladaptive personality features and defense mechanisms" as well as to rate the degree of disability in mentally retarded individuals. The rationale for making Axis 2 separate from Axis 1 is to encourage clinicians to look for "the possible presence of Personality Disorders and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid [obvious] Axis 1 disorders." (DSM-IV, 1994). The Axis 2 disorders do not always require clinical treatment, and a person may have more than one of them at the same time.

What is the rationale for including "Axis 2" in DSM-IV? What are personality disorders?

Personality disorders are, by definition, exaggerations of normal personality traits that are both inflexible and maladaptive (Widiger and Trull, 1985). Let us examine those two words.

1. Inflexible. People with personality disorders find they cannot change, even if they want to. In some cases they do not consider themselves abnormal and are brought into treatment (if ever) by people around them, such as parents or marriage partners, rather than volunteering for treatment.

2. Maladaptive. By definition, an abnormality prevents some normal, expected talent or ability from being expressed, or it has an adverse impact on the individual's ability to live harmoniously with others. To say personality disorders are maladaptive is to say they harm people or make it harder for people to live normal and productive lives.

What is an older term for people with personality disorders?

Many people now diagnosed with personality disorders would once have been called neurotics. The term "neurosis" was dropped from the previous major revision of the Diagnostic and Statistical Manual of Mental Disorders, DSM-III, because to include it seemed like an implicit endorsement of Freudian theory. But a theory-neutral definition of neurosis—persistent, maladaptive behavior—is identical to what is now called the personality disorders.

In what sense are these diagnostic categories unreliable?

Turkat and Alpher (1983) looked through textbooks on abnormal psychology to find descriptions of personality disorders and found that not one text discussed all of them. That was hard to justify, they said, because personality disorders are among the most common diagnoses in psychology clinics. However, they are also among the least reliable diagnoses. In other words, different specialists often disagree in their diagnosis of personality disorders. There is much overlap between the different categories, and sometimes it is not clear where a patient fits.

How (again) does the paranoid personality disorder differ from paranoid schizophrenia?

The paranoid personality is suspicious of others, irritable, often jealous, and tends to overvalue a private perspective on the world. Unlike paranoid schizophrenics, people with paranoid personality disorders are not delusional. They do not hear voices or believe in wildly unrealistic conspiracy theories; they are just suspicious and hostile all the time. They also tend to be litigious, bringing many lawsuits against their imagined enemies.

What is the schizotypal personality?

A schizotypal personality is an "odd individual" who has trouble coping with social relationships and tends to interpret events in the outside world as having a special personal meaning that other people cannot understand. Such a person may seem halfway to the delusions of schizophrenia, but the schizotypal personality is still coping. The schizotypal person may deteriorate under stress and may occasionally express delusional ideas. A schizotypal personality may use unusual words and catch phrases that have a special private meaning. The person's speech rambles but is not incoherent like the speech of a disordered schizophrenic.

What is the schizoid personality?

The schizoid personality disorder is characterized primarily by one symptom: voluntary social aloneness. The schizoid person is unlikely to have friends. He or she does not care about the advice or praise of others. He or she usually lives alone and seems self-absorbed or absent-minded. Unlike the schizotypal personality, the schizoid does not make exotic interpretations of events or have rambling speech. People with a schizoid personality may do well in a skilled job if they can work independently and avoid interacting much with other people.

What is the histrionic type?

A fourth personality type listed in DSM-IV is the histrionic personality. This type of person is prone to emotional displays.

How does a histrionic person seem to himself or herself? To others?

Histrionic personalities will "faint" at the sight of blood, will dominate an entire dinner party with the tale of their recent faith healing, will be so "overcome" with emotion during a sad movie that they have to be taken home immediately (thus spoiling their companion's evening), will threaten suicide if a lover's interest cools, and so forth. To themselves, they seem very sensitive; to others, they often seem shallow and insincere. (Bootzin & Acocella, 1984)

What is the narcissistic type?

The narcissistic personality disorder is characterized by a grandiose self-image and sense of self-worth, combined with a lack of interest in the interests and feelings of others. Narcissistic types care mostly about themselves. Most of their behavior is designed to impress others or boost their image. Usually they come to a clinic not because they think they have a disorder, but because they are distraught over a ruined social relationship, having alienated friends or a marriage partner.

The obsessive-compulsive personality is a "workaholic without warmth" (Meyer and Salmon, 1984). They tend to be preoccupied with details until it hampers their productivity. Such people are overly controlled emotionally and unable to express caring. They make lists, sort things into neat piles, and may be fanatically detailed in their planning. People with an obsessive-compulsive personality disorder have trouble loosening up or having fun in social situations. They tend to have a poor sense of humor and are not usually very creative.

How can the obsessive-compulsive personality disorder be distinguished from OCD?

According to the DSM-IV manual, the obsessive-compulsive personality is easily distinguished from a person with obsessive-compulsive disorder (OCD), because people with the obsessive-compulsive personality disorder do not show "true obsessions and compulsions." They do not engage in repeated checking or suffer from intrusive, obsessive thoughts. However, if behavior becomes too extreme (for example, if a person stacks up old newspapers until they create a fire hazard and prevent people from walking through the room) then "a diagnosis of obsessive-compulsive disorder should be considered." (DSM-IV, p. 671)

How does the dependent personality react to relationships?

Dependent personalities, as the name suggests, show extreme dependence on other people. They may panic if left alone but function well if not left on their own. They tend to cling to, or imitate, somebody else. This is their source of strength but also their weakness. If "dropped" they are devastated. Often their imitative tendency is so great that they adopt the mannerisms and speech habits of the person to whom they look for support.

What is the "borderline" type?

A borderline personality tends to have intense, erratic relationships. The murderous woman in the movie Fatal Attraction is an example of this type. The borderline type is hostile and demanding but may also be intelligent and challenging. Borderline patients (simply called "borderlines" by clinicians) are often unique, complicated, and hard-to-please. They are also unpredictable and inconsistent, being calm and controlled one week, running up huge bills or binging on drugs another week. Some borderlines make dramatic improvements in therapy, but suicide is also more common among this group than among other patients (Sleek, 1997).

DSM-IV focuses on instability in all facets of behavior as diagnostic of the borderline personality, making it rather hard to diagnose. Some experts question whether it should be included as a psychiatric syndrome, because inter-judge reliability is low for this syndrome. In other words, independent clinicians often disagree on the diagnosis.

What are characteristics of the avoidant personality disorder?

Avoidant personalities are anxious to avoid the risks of social contact. Millon (1981) describes the avoidant personality as hypersensitive to rejection, humiliation, or shame. This type of person wants to be loved but expects not to be and therefore seeks reassurance constantly, over-reacting to any hint of disapproval. They have low self-esteem and are typically angry with themselves over their own social failures. As Bootzin and Acocella (1984) point out, "...These feelings further erode their self-esteem-a vicious cycle." The schizoid personality enjoys aloneness; the avoidant personality does not.

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