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 ...

Please Tell Me It's Bipolar

 Following is an article I recently posted on mcmanweb ...

"Do all bipolar people lie or is it just my husband?"
"My boyfriend is bipolar and is coping with heroin."
"Is this an episode loving another man not my husband?"
"My husband is bipolar and every time we talk he always tells me I'm attacking him."

This is a sampling of queries that frequently arise on HealthCentral's BipolarConnect, where I contribute as an "expert patient." Are you beginning to spot a pattern?

First, let me say that these people and others are asking in good faith. They are going through hell. They are at the end of their rope. They are desperate for answers.

But I am also reading into their questions the type of answer they wish to hear, namely:

Yes, bipolar is the cause of [your husband's lying, your boyfriend's drug habit, your own infidelity, your husband's inability to discuss issues with you, and on and on]. Bipolar is a highly treatable illness, and with the right treatment these problems will all go away.

If only ...

These days, bipolar is copping a bad rap for no end of inappropriate behaviors. I think a lot of it has to do with the raised awareness of bipolar. Now, when people encounter behavior they don't like, the prime suspect is bipolar. Ironically, raising awareness may have raised stigma.

Inevitably, when responding to these questions, I point out that a mood disorder is very different from a personality issue or a personality disorder. Yes, there may be a connection. Yes, a mood episode obviously influences behavior. But first, it pays to make a separation.

To start, a mood disorder is morally neutral. Fluctuations in mood have nothing to do with one's personal character or values. Hitler may have had bipolar, but he was going to invade Poland, anyway.

On the other hand, there are complications. Hitler imprudently invaded Russia with winter coming on. Were it not for his unbalanced mental state, it is possible to imagine a far different outcome to World War II.

Psychiatry makes a very clear distinction between mood disorders and personality disorders. To vastly oversimplify, a mood episode is seen as "uncharacteristic" of an individual's baseline behavior. With a personality disorder, outrageous behavior is seen as embedded into an individual's make-up. With the former, the perception is that meds will quickly resolve the issue. With the latter, we see a far more problematic future.

Thus, you can see the logic in the desperate pleas of my readers. Please tell me it's bipolar, they seem to be saying. Then with a quick fix my abusive husband will become loving, my selfish wife will become considerate, my egotistical boyfriend will become understanding, my indifferent girlfriend will become caring.

Unfortunately, my correspondents almost always describe behavior far more indicative of a personality disorder than a mood disorder.

The bottom line is a loved one should not have to distinguish a bipolar episode from a personality disorder or just plain inappropriate behavior in the first place. Hurt is hurt, no matter what illness or condition or character defect you assign to it, and no one - for any reason - should have to put up with this type of abuse. But the people I hear from are willing to give their partners a second chance, to work with them, to help them. To give the relationship a chance.

If only, if only ...

Alas, I have to tell them probably not.

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More relationship articles on mcmanweb: Family and Relationship Fallout; Validating Family Pain; My Loved One Doesn't Understand - Really?; Emotional Safety - My Relationship Bottom Line; What Goes Up

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 ...   

Recent Personality Posts

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard? 

Personality Disorders: Decisions, Decisions ...

Judging Amy - Part II

In Part I, we investigated a single blow-up during a funeral service in the life of the fictional Amy. Her meltdown could have been the result of a bad hair day. It could have been from a mood disorder. Or Amy could be dealing with unresolved personality issues. We are leaning toward the latter, but we need a lot more to go on than one unfortunate incident ...

Okay, let’s play spot the pattern with Amy: Has told mom 15 years running that she is six months from submitting her novel manuscript - her friends call it the next Wuthering Heights - to a publisher; Has had fights with everyone who has tried helping her get her manuscript published; Says she will join an exercise program once she has submitted her novel…

Okay, we’re starting to pick up a pattern. But is it one that seriously impairs her life? She already has a secure and well-paying job. What about other aspects of her life, then, such as personal relationships? Her Wuthering Heights manuscript steams with hot sex, which she broadly hints to anyone who will listen is autobiographical, but her last fling was twenty years ago. She has never sustained a long-term intimate relationship, but then again she manages to attract a lot of friends.

Granted, these friends may have to cut her a bit of slack, such as the time she abused and stiffed a waitress because she couldn’t order from the children’s menu. And they roll their eyes when she says she’s going to have her own show on the Food Network, but she’s just crazy enough to pull it off. After all, she’s a good friend of Rachel Ray’s, and she wouldn’t be saying that if it weren’t true, right?

Yes, Amy may have issues, but her ability to manipulate and intimidate and draw attention to herself, not to mention the supreme self-confidence she exudes, are exactly the right stuff for personal success. If only she weren’t quite so normal she could be on the cover of People magazine.

No, the real test is when she returns home to her empty condo, alone with her thoughts and vulnerabilities.

It’s later in the day, and the funeral party has gathered for eats in the church rec hall. Now Amy is making nice with the family. She tells her mother how good she looks and fusses appropriately over her three nieces. Okay, reaching for that second piece of cake after she just informed people of her diabetes may have raised eyebrows, but even cynical cousin Paula is flattered to hear they must “do lunch” sometime soon.

“I’m flying out to see a client tomorrow,” she lets everyone know, as if to apologize for her early exit. She doesn’t tell them that the “client” is really a Ponzi scheme artist out to separate her from her personal fortune. But the joke is on the Ponzi schemer. Little does he know that the personal fortune he has heard Amy refer to involves the film rights to her next Wuthering Heights, the one that has been in a state of near-completion for 15 years, the one that Steven Spielberg will be shooting any day now.

And I say to myself, what a wonderful world …

For the full version of this article on mcmanweb, please check out: Poisonality

Judging Amy - Part I

Following is a chopped-down version of the article, Poisonality, from mcmanweb:

Rewind a bunch of years ago. Bill treats his mom to a cruise.

Fast forward to the present. An aunt is being laid to rest. Bill's mom happens to mention the cruise to her daughter. As the casket is carried out, the daughter pulls her other brother aside and says in a voice quivering with rage, one that carries into the distant pews, “She really knows how to push my buttons!”

Everyone would agree that the daughter’s behavior is highly inappropriate, but is it consistent with a personality disorder? Consider:

Let’s suppose the daughter – call her Amy – had been especially close to her aunt and not so close to her mother. Suppose for two days, in her state of distress, she has been enduring a steady stream of sugar-coated insults from a mother she can barely stand. Then mom makes a seemingly innocuous comment that sets her off …

Let’s change the context. This time, suppose Amy had to cross three time zones to attend her aunt’s funeral. She has missed a night’s sleep which has triggered an irritable hypomania. During the service, she is literally crawling out of her skin. The air is oppressive, the people are making her claustrophobic, she can’t sit still, she wants to scream. Her mother says something, and she turns to her brother …

Distinguishing a bad hair day from a mood episode from a personality disorder meltdown is notoriously difficult. Even Mother Teresa had her off-moments, and no doubt Gandhi had unresolved issues he needed to work through. We all have feet of clay. Labeling someone with a personality disorder, then, is perhaps the most insulting and stigmatizing act one can visit upon an individual, even in the name of therapy and treatment. Reflect for a second the names psychiatry has bestowed on the four main personality disorders, lumped together into what are called Axis II cluster B personality disorders: Borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder.

You are not supposed to like these people, is the strong message attached to these labels. These people are poison, the message goes on to say. They lack empathy, they are impulsive, and only they matter. The golden rule doesn’t apply to them and neither do most of the commandments and other people's personal boundaries. Cut them out of your life, run away, treat them like lepers

Then again, if a family member or an acquaintance or a colleague at work is currently making your life miserable, you probably don’t have much sympathy. Life is like that.

Let’s return to Amy. She could be having a bad hair day. She could be experiencing a mood episode. She could also be having a meltdown stemming from various personality issues.

Please make careful note of the term, various personality issues. We are not going to attribute Amy’s outburst to one full-blown personality disorder. She may have one, she may not. But in all likelihood, a number of things are going on, a bit of this, a bit of that. Amy may be a kind and loving person, but her funeral theatrics indicate that something is clearly wrong.

But does Amy know it? She looks at the people staring at her and wonders what THEIR problem is, then leaves the church as if nothing happened. Or, if she acknowledges something has happened, she has already justified it – clearly it was her mother’s fault, the one who knows how to push her buttons. If her mother is a saint, if cornered, Amy will find a way to demonize her.

Woe to the person who may challenge Amy, but even if all her defenses are unmasked, she can still play the pity card. Even when she admits she’s wrong, the attention is worth it. There is victory in defeat.

Therein lies the difference between a person experiencing a bad hair day or mood episode and one with personality issues. The former are typically mortified by their out-of-character behavior (once they have settled down). When personality comes into play, the issue is far more complex. There may be no settling down; the behavior in question may be part of one's default setting (though change is possible). Or, there may be only a small window for remorse before Amy's world once again closes in on her, overwhelms her.

We all know people like Amy, but before you congratulate yourself for not being like her, it pays to recall that we all have personality issues of some sort. Besides, we need a lot more to go on than a single incident, more like a pattern.

To be continued ...