Wednesday, April 8, 2015

Personality Disorders – The Common Bizarre Behaviors Part I: Diagnostic Considerations

Part I: Diagnostic Considerations

In order to understand many bizarre behaviors it is important to have some understanding of personality disorders. These are the most common of the serious mental illness and are seemingly related to many bizarre behaviors seen around the world. People suffering from these disorders tend to exhibit emotional patterns and behaviors that seem troubling to the majority of people and are not necessarily explicable by immediate environmental stimuli. Nevertheless many clinicians are unfamiliar with the most recent research on these disorders and the latest approaches to treatment. This article review the current diagnostic conceptualization of personality disorders, their clinical treatment, and their relationship to cultural characteristics and culture-specific disorders. Below I present an overview of the main diagnostic categories related to personality disorders. This is just a quick skim of the surface and I refer to the reader to the DSM-V (American Psychiatric Association, 2013) for greater detail.





Diagnosis of Personality Disorders

In the creation of the new DSM-V there was some debate about what to do with the diagnostic category for personality disorders. In the end the creators of the DSM-decided to holdover the different types of personality disorders from the DSM-IV but to remove these disorders from a separate axis. The DSM-V also keeps the same cluster structure as in the DSM-IV. The DSM-V: Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) defines the following criteria for the diagnosis of a personality disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas:
  • 1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events).
  • 2. Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response).
  • 3. Interpersonal functioning.
  • 4. Impulse control.
B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The pattern is stable and cf long duration, and Its onset can be traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.

F. The enduring pattern is not attributable to the physiological effects of a substance (e.g.,a drug of abuse, a medication) or another medical condition (e.g., head trauma).
(p. 646-647)


There are ten types of personality disorders recognized in the DSM V: Schizotypal, Paranoid, Schizoid, Antisocial, Borderline, Obsessive-Compulsive, Dependent, Avoidant, Narcissistic, and Histrionic.  Briefly, these can be understood to have the following characteristics:

Antisocial Personality Disorder:  People suffering from this disorder are characterized as having a disregard for moral or legal standards of their culture. They have trouble getting along with others and/or following the rules of society.  They used to be called psychopaths or sociopaths.

Avoidant Personality Disorder:  People suffering from this disorder have heightened social inhibitions combined with feelings of inadequacy. These people generally are extremely sensitive to criticism.

Borderline Personality Disorder:  People with this disorder lack a stable identity. They may be emotionally labile and have unusually intense, yet unstable relationships with others. Persons suffering from this disorder also have marked impulsivity, and often are dissociated from their emotions.

Dependent Personality Disorder:  People with this disorder have an extreme need of other people. They have trouble doing anything on their own and are often unable to make decisions or be independent in any aspects of their lives. They have an intense fear of separation, which may manifest itself in extremely submissive and conciliating behavior. People with this disorder lack self-confidence and self-esteem.

Histrionic Personality Disorder:  People with this disorder are overly dramatic with highly exaggerated and/or inappropriate emotional displays. They manifest sudden and rapidly shifting expression of emotions that often seem fake or shallow.

Narcissistic Personality Disorder:  People with this disorder see themselves as most important person in the universe, emanating grandiosity and omnipotence. They also lack empathy toward others while at the same time needing other people’s admiration and attention. This lack of empathy makes it difficult for them to understand other’s points of view making them intolerant and hypersensitive to criticism.

Obsessive-Compulsive Personality Disorder: People suffering from this disorder tend to be perfectionists and are inflexible. The disorder manifests as repetitive patterns of thought and/or behavior that the person feels are out of his or her control.

Paranoid Personality Disorder:  This disorder is characterized by an extreme distrust of others. This distrust can become extreme to the point where a person’s paranoid beliefs (i.e. that others are exploiting, harming, or trying to deceive) are thought disordered, containing their own set of internal logic unrelated to consensus reality. People suffering from this disorder often believe that they have been betrayed and that there is hidden significance in the behavior of others. People with this disorder are often unforgiving and hold grudges.

Schizoid Personality Disorder:  Those suffering from this disorder have a very limited range of emotional expression and experience. They present as being very ‘flat’, withdrawn and uninterested in social relationships.

Schizotypal Personality Disorder: This disorder is similar to schizophrenia except that it does not include frankly psychotic features such as hallucinations. Like schizophrenia however, it does include disordered thoughts, magical beliefs and thought patterns1. People with this disorder may appear or behave in an eccentric or disordered fashion as well as evincing belief in things that make no logical sense.

Also included in the DSM-V are two further categories, which are self-explanatory:

Personality change due to another medical condition is a persistent personality disturbance that is judged to be due to the direct physiological effects of a medical condition (e.g., frontal lobe lesion).

Other specified personality disorder and unspecified personality disorder is a category provided for two situations: 1) the individual's personality pattern meets the general criteria for a personality disorder, and traits of several different personality disorders are present, but the criteria for any specific personality disorder are not met; or 2) the individual's personality pattern meets the general criteria for a personality disorder, but the individual is considered to have a personality disorder that is not included in the DSM-5 classification (e.g., passive-aggressive personality disorder).
(American Psychiatric Association, 2013, p. 645)


The DSM-V (American Psychiatric Association , 2013), organizes personality disorders into three groups or clusters, with three or four disorders per group:

Cluster A - Eccentric Personality Disorders: Paranoid, Schizoid, Schizotypal:  People suffering from these disorders often appear odd or peculiar and begin to demonstrate these aspects of the disorder by early adulthood and in various contexts.

Cluster B - Dramatic Personality Disorders: Antisocial, Borderline, Histrionic, and Narcissistic: People suffering from these disorders have intense, unstable emotions, distorted self-perception, and are often behave in impulsive ways.

Cluster C - Anxious Personality Disorders: Avoidant, Dependent, Obsessive-Compulsive: People suffering from these disorders are often anxious and fearful. They begin to demonstrate these aspects of the disorder by early adulthood and in various contexts.

The DSM-V also notes that it is often difficult to separate the diagnoses of schizophrenia and personality disorder. The reported prevalence of personality disorders among people suffering from schizophrenia varies tremendously – from 4.5% to 100%. It has been suggested that type of care, country, study type, and diagnostic tools all bias prevalence rates. (Newton-Howes, et. al. 2008). Structural magnetic resonance imaging and computer tomography studies suggest that schizotypal personality disorder may in fact be a milder form of schizophrenia. Normal volume and perhaps functioning of the medial temporal lobes in those suffering from schizotypal personality disorder may explain why schizophrenics (who have abnormal medial temporal lobes) experience more severe psychotic symptoms Dickey, McCarley, &; Shenton, 2002). 

Next Part II: Co-morbidity & Prevalence

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Washington, DC: American Psychiatric Association.


Dickey, C. C., McCarley, R. W., & Shenton, M. E., (2002). The brain in schizotypal personality disorder” A review of structural MRI and CT findings. Harvard Review of Psychiatry, 10(1), pp. 1-15.


Newton-Howes G, Tyrer P, North B, Yang M. (2008). The prevalence of personality disorder in schizophrenia and psychotic disorders: systematic review of rates and explanatory modelling. Preview Psychological Medicine, 38(8), pp. 1075-1082.


Verheul, R., Bartak, A., & Widiger, T. (2007). Prevalence and construct validity of personality disorder not otherwise specified (pdnos). Journal of Personality Disorders, 21(4), pp. 359-370.

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