Bringing Order to Personality Disorder

Yesterday, we inspected the house-cleaning performed by the DSM-5 workgroup charged with bringing order to personality disorder. Unlike the rest of the DSM-5, this particular crew actually rolled up its sleeves and went to work. No mere light dusting for them. Five of ten of the personality disorders got tossed. The remaining five (now referred to as “types” rather than disorders) received a major refurbishing and a sense of congruency.

The grand piano, in effect, has been retuned and refinished and moved from the laundry room to the living room, though questions still remain as to what to do with the moose head now in the dumpster (think narcissism). These are the “categorical” reforms. There is a new element of “dimensionality” which we will get into later. Sticking with categories ...

The old (and still current system) was only useful in sorting out the obvious (such as green from blue) but of very little value where the colors blended (green, for instance, contains blue). An impulsive and angry individual with a skewed view of self and others, for instance, may be a candidate for both borderline and antisocial. Throw in a sense of me-me-me/I-I-I, and the narcissism diagnosis comes into play.

The new (and future) system acknowledges the overlap, but puts the reader on notice that we are not exactly dealing with the same phenomenon. The first thing that sticks out in comparing the new borderline to the new antisocial/psychopathy, for instance, is that the former comes loaded with six “negative emotionality” symptoms and only two “antagonism” ones while the latter is heavily laden with six antagonism symptoms and zero negative emotionality ones.

As for narcissism (may it rest in peace), a number of the old narcissist traits have been  folded into the new antisocial/psychopathy diagnosis. Not one appears in the new borderline diagnosis. Yes, it would be nice to have the narcissism diagnosis back in the picture (and I will be making that case in a future piece), but in this context its absence brings into sharper relief the inflated/lack of sense of self that separates borderline from antisocial.

The DSM-IV bunched the ten personality disorders into three clusters (A, B, and C), but with only five types left to choose from in the DSM-5, there is no sense in retaining these walls of separation. Again, we are dealing with overlap and loading. The new “avoidant,” for instance, contains nearly as many negative emotions as borderline (five in all, two of them the same as borderline) plus five “introverted” ones (such as “intimacy avoidance”) with nothing in the “antagonism” department.

Meanwhile, we know obsessive-compulsive (the personality disorder, not the Axis I diagnosis) and schizotypy are horses of a different color, but nevertheless they do share some of the primary colors across the personality spectrum.

So what are we looking at? According to the DSM-5:

Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.

This harkens back to the Freudian-influenced DSM-I of 1952 and the DSM-II of 1968 when even the likes of schizophrenia were seen as maladaptations to one’s environment. The DSM-5 revives the idea of maladaptation, but dials it back to personality disorders. In other words, personality type is a tip-off to our default protection mechanisms.

Do we, for instance, try to dominate those around us? (Antisocial.) Or do we freak out and lose it? (Borderline.) Or do we withdraw into a comforting cocoon? (Avoidant.) Maybe we look for order where none exists. (Obsessive-compulsive.) Perhaps we harbor unusual perceptions of reality. (Schizotypal.)

We may argue over what else should be there (such as Narcissism), and what more could have been done to clarify the different types, but when all is said and done, we are looking at a greatly improved navigational system.

Meanwhile, we all have personality in abundance and come preloaded with all manner of quirks and flaws. We may be successful adapters, but - trust me - we will all see a bit of ourselves in the DSM looking glass. In this sense, we are likely to get more out the DSM-5 than our clinicians. 

Much more to come ...   

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