Take Two on Personality Disorders

Yesterday I reported on the DSM-5’s second go at revising the various diagnoses classified under Personality Disorders. The big issue is incorporating the concept of “dimensionality” into what to date has been a “categorical” system.

Category is all about either-or, all or nothing. Is it borderline, for instance, or is it normal? Is it borderline or is it antisocial? Lumping symptoms into categories is useful to a point, but simplistic labeling has its very obvious drawbacks.

Dimensionality acknowledges a lot more possibilities. Could it be a bit of Borderline, for instance, plus a bit of Antisocial? Maybe we should dispense with labels altogether and see what’s really going on. Impulsivity? Hostility? Lack of empathy? Dimensionality obviously best approximates reality, but at the expense of clarity and workability.

The DSM-5’s answer is a hybrid system, built on interchangeable parts. Assemble the parts one way to build a classic categorical diagnosis. Assemble the same parts another way to come up with a dimensional perspective. In this sense, it is more accurate to describe the new system as “modular” - think IKEA - rather than hybrid.

Okay, let’s see what we have second time around ...

The DSM-IV lists 10 personality disorders. The DSM-5 on its first go eliminated five, leaving us with Borderline, Antisocial, Schizotypal, Avoidant, and Obsessive-Compulsive (not to be confused with OCD). On its second go, the DSM-5 restored Narcissism.

This time around, the DSM-5 imposes strict order on its six categorical disorders. Thus, whether it’s Borderline or Antisocial or the other four we’re talking about, we see in common:

Significant impairments in personality functioning, broken down into impairments with self-function (involving issues with identity and/or self-direction) and impairments in interpersonal functioning (involving issues with empathy and/or intimacy).

This is Part A of the diagnosis. In Part B, we are looking at "pathological personality traits" organized into “domains.”

Let’s start with Part A. Below is a table of the Borderline and Antisocial Part A criteria side-by-side:

Criterion A	Borderline	Antisocial
1. Impairments in self functioning a.	Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.	Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
1. Impairments in self functioning b.	Self-direction: Instability in goals, aspirations, values, or career plans.	Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.
2. Impairments in interpersonal functioning a.	Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.	Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another. b.
2. Impairments in interpersonal functioning b.	Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.	Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

OK, clearly someone with borderline is living in a different interior world than someone with antisocial. Now let’s compare Part B criteria side-by-side (minus the lengthy descriptions):

Criterion B	Borderline	Antisocial
Negative Affectivity	Emotional lability Anxiousness Separation insecurity Depressivity
Disinhibition	Impulsivity Risk taking	Irresponsibility Impulsivity Risk taking
Antagonism	Hostility	Manipulativeness Deceitfulness Callousness Hostility

Note first the interchangeable parts. Borderline and Antisocial share two “domains” in common, Disinhibition and Antagonism. Thus a picture emerges of individuals prone to flying off the handle (often at you, their nearest victim), regardless of their diagnostic label. Criterion C makes it clear that these impairments “are relatively stable across time and consistent across situations.” In other words, we are talking about a clear and sustained pattern of bad behavior, not just a bad hair day.

But also notice the differences. Antagonism comes far more fully loaded in the Antisocial diagnosis. Meanwhile, those with Antisocial come up empty in the Negative Affectivity department. An abusive outburst may look the same, but over time we see different patterns. Moreover, the underlying dynamics are wholly different - one appearing to arise from an inflated ego, the other from an almost lack of ego.

In a sense, Antisocial shares a thing or two in common with Narcissism. Indeed, in the DSM-5’s first version, Narcissism was folded into the Antisocial diagnosis. The DSM-5 keeps its restored Narcissism diagnosis short and sweet, with only one domain (Antagonism) with two personality traits (Grandiosity and Attention-seeking).

Meanwhile, we see Borderline leaning in the direction of Avoidant, with both individuals in effect running scared, sharing the same personality trait of Anxiousness under Negative Affectivity, but with different ways of responding to their respective insecurities.

Thus, even in making categorical distinctions, we see dimensionality at work.

One important point: There are more domains than what you see listed under Borderline and Antisocial. Thus, in addition to Negative Affectivity, Disinhibition, and Antagonism, we also have Psychoticism (a major feature of Schizotypal) and Compulsivity (a major feature of Obsessive-Compulsive).

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Don’t worry if you’re confused. At this stage, it is simply enough to know that the DSM-5 is making an attempt to show dimensionality in its categories, namely that:

1. Regardless of diagnosis, individuals with personality disorders share in common major difficulties in self-function (relating to self) and in personal function (relating to others).
2. Individuals across the various diagnoses tend to share various traits common to other diagnoses, as well.

At the same time, the DSM-5 is also red-flagging key distinctions. These disorders are related, yet separate, kinda, sorta - if you get the drift.

Next: The DSM-5 takes on dimensions ...