INTRODUCTION TO GENERAL PERSONALITY DISORDER

INTRODUCTION TO GENERAL PERSONALITY DISORDER

INTRODUCTION TO GENERAL PERSONALITY DISORDER

All humans (and numerous other species as well) have personality traits. These are well-ingrained ways in which individuals experience, interact with, and think about everything that goes on around them. PDs are collections of traits that have become rigid and work to individuals’ disadvantage, to the point that they impair functioning or cause distress. These patterns of behavior and thinking have been present since early adult life and have been recognizable in the patient for a long time.

Personality, and therefore PDs, should probably be thought of as dimensional rather than categorical; this means that their components (traits) are present in normal people, but are accentuated in those with the disorders in question. But for good reasons and bad, DSM-5 has retained the traditional categorical structure that has been used for more than 30 years. There are promises that this will change in the coming years; indeed, DSM-5 devotes a long portion of its Section III (material not officially approved for use) to exploring alternative diagnostic structures. However, the experts will first have to agree as to which dimensions to use, then how best to measure and categorize them, and then how to interpret the results. In the meantime, we will continue to muddle along pretty much as before.

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As currently defined in DSM-5, all PDs have in common the following characteristics.

Essential Features of a General Personality Disorder

There is a lasting pattern of behavior and internal experience (thoughts, feelings, sensations) that is clearly different from the patient’s culture. This pattern includes problems with affect (type, intensity, lability, appropriateness); cognition (how the patient sees and interprets self and the environment); control of impulses; and interpersonal relationships. This pattern is fixed and applies broadly across the patient’s social and personal life.

The Fine Print

The D’s: • Duration (lifelong, with roots in adolescence or childhood) • Diffuse contexts • Distress and disability (work/educational, social, and personal) • Differential diagnosis (substance use, physical illness, other mental disorders, other PDs, personality change due to another medical condition)

The information PDs convey gives the clinician a better understanding of the behavior of patients; it can also augment our understanding of the management of many patients.

As you read these descriptions and the accompanying vignettes, keep in mind the twin hallmarks of the PDs: early onset (usually by late teens) and pervasive nature, such that a disorder’s features affect multiple aspects of work, personal, and social life.

Diagnosing Personality Disorders

The diagnosis of PDs presents a variety of problems. On the one hand, they are often overlooked; on the other, however, they are sometimes overdiagnosed (borderline PD is, in my opinion, a notorious example). One (antisocial PD) carries a terrible prognosis; most, if not all, are hard to treat. Their relatively weak validity suggests that no PD should be the sole diagnosis when another mental disorder can explain the signs and symptoms that make up the clinical picture. For all of these reasons, it is a good idea to have in mind an outline for making the diagnosis of a PD.

1.  Verify the duration of the symptoms. Make sure that your patient’s symptoms have been present at least since early adulthood (before age 15 for antisocial PD). Interviewing informants (family, friends, coworkers) will probably give you the most valid material.

2.  Verify that the symptoms affect several areas of the patient’s life. Specifically, are work (or school), home life, personal life, and social life affected? This step can present real problems, in that patients themselves often don’t see their behavior as causing problems. (“It’s the world that’s out of step.”)

3.  Check that the patient fully qualifies for the particular diagnosis in question. This means checking all the characteristics and consulting all 10 sets of diagnostic criteria. Sometimes you have to make a judgment call. Try to be as objective as possible. As with other mental disorders, with enough motivation you can usually force a patient into a variety of diagnoses.

4.  If the patient is under age 18, make sure that the symptoms have been present for at least the past 12 months. (And be really, really sure that they aren’t due instead to some other mental or physical disorder.) I personally prefer not making such a diagnosis at such a tender age.

5.  Rule out other mental pathology that may be more acute and have greater potential for doing harm. The flip side is that other mental disorders are also often more responsive to treatment than are PDs.

6.  This is also a good time to review the generic features for any other requirements you may have missed. Note that each patient must have two or more types of lasting problems with behavior, thoughts, or emotions from a list of four: cognitive, affective, interpersonal, and impulsive. (This helps ensure that the patient’s problems truly do affect more than one life area.)

7.  Search for other PDs. Evaluate the entire history to learn whether any additional PD is present. Many patients appear to have more than one PD; in such cases, diagnose them all. Perhaps more often, you will find too few symptoms to make any diagnosis. Then you can add to your summary note something to the effect: schizoid and paranoid personality traits.

8.  Record all personality and nonpersonality mental diagnoses. Some examples of how this is done are shown in the vignettes that follow.

Although you can learn the rudiments of each PD from the material I present here, it is important to note that these abbreviated descriptions only begin to tap their rich psychopathology. If you want to make a study of these disorders, I strongly recommend that you consult standard texts.