Many of the signs and symptoms you describe also apply to other personality disorders (such as histrionic, antisocial, and borderline personality disorders). Are we to think that all personality disorders are related?
Reply:
Classification of axis II personality disorders—deep-rooted, maladaptive, lifelong patterns of behavior—in the Diagnostic and Statistical Manual, Fourth Edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] – or DSM-IV-TR for short – has been subject to sustained and serious criticism since its inception in 1952.
DSM IV-TR takes a categorical approach that assumes that personality disorders are “qualitatively distinct clinical syndromes” (p. 689). This is widely doubted. Even the distinction between "normal" and "disordered" personalities is increasingly rejected. "Diagnostic thresholds" between normal and abnormal are either absent or poorly supported.
The polythetic form of the DSM's diagnostic criteria—only a subset of the criteria is an adequate basis for diagnosis—creates unacceptable diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one or none of the criteria.
The DSM fails to clarify the precise relationship between Axis II and Axis I disorders and the way chronic childhood and developmental problems interact with personality disorders.
Differential diagnoses are vague and personality disorders are poorly defined. The result is excessive comorbidity (more Axis II diagnoses).
The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) from personality disorders.
Lack of documented clinical experience regarding both the disorders themselves and the usefulness of different treatment modalities.
Numerous personality disorders are not "otherwise specified" - a catch-all, basket "category".
Cultural bias is evident in certain disorders (such as antisocial and schizotypal).
The emergence of dimensional alternatives to the categorical approach is confirmed in the DSM-IV-TR itself:
"An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that blend imperceptibly into normality and into one another" (p. 689).
The following issues—long neglected in the DSM—are likely to be addressed in future editions as well as in current research:
Longitudinal course of the disorder(s) and their temporal stability from early childhood;
Genetic and biological basis of the disorder (personality disorder);
Development of personality psychopathology in childhood and its emergence in adolescence;
Interactions between physical health and illness and personality disorders;
The effectiveness of various treatment procedures – talk therapy and psychopharmacology.
All personality disorders are related, at least phenomenologically—even if we have no grand unifying theory of psychopathology. We do not know if there are – and what are – the mechanisms that underlie mental disorders. At best, mental health professionals record symptoms (as reported by the patient) and symptoms (as observed).
Then they group them into syndromes and more precisely into disorders. This is descriptive, not explanatory, science. Sure, there are several etiological theories (psychoanalysis to mention the most famous), but all of them have failed to provide a coherent, consistent theoretical framework with predictive powers.
Patients suffering from personality disorders have many things in common:
Most of them persist (except those with schizoid or avoidant personality disorders). They demand preferential and privileged treatment. They complain of numerous symptoms. They never listen to the doctor or his recommendations and instructions for treatment.
They see themselves as unique, show traits of grandiosity, and have a reduced capacity for empathy (the ability to appreciate and respect the needs and wishes of other people). They regard the doctor as inferior to them, alienate him through many techniques, and bore him with their never-ending preoccupation with himself.
They are manipulative and exploitative because they don't trust anyone and usually cannot love or share. They are socially maladaptive and emotionally unstable.
Most personality disorders begin as problems in personal development that culminate during adolescence and then become personality disorders. They remain permanent characteristics of the individual. Personality disorders are stable and pervasive—not episodic. They affect most areas of the patient's functioning: his career, interpersonal relationships, and social functioning.
Typical patients are unhappy. He is depressed and suffers from mood swings and anxiety disorders. He does not like himself, his nature, his (insufficient) functioning, or his (crippling) influence on others. But his defenses are so strong that he is only aware of the distress - and not the reasons for it.
A patient with a personality disorder is vulnerable and prone to a number of other psychiatric problems. It is as if his psychological immunological system has been disrupted by his personality disorder and he has fallen victim to other variants of mental illness. The disorder and its consequences (for example obsession-compulsion or mood swings) consume so much energy that the patient becomes defenseless.
Patients with personality disorders are alloplastic in their defenses. They have an external locus of control. In other words: they tend to blame the outside world for their accidents. In stressful situations, they try to preempt a (real or imagined) threat, change the rules of the game, introduce new variables, or otherwise influence the world out there to suit their needs. This, in contrast to the autoplastic defense (internal locus of control), is typical, for example, of neurotics (who change their internal psychological processes in stressful situations).
The character problems, behavioral disturbances, and emotional deficits and labilities experienced by patients with personality disorders are mostly ego-syntonic. This means that the patient generally does not consider his personality traits or behavior objectionable, unacceptable, unpleasant, or foreign to him. In contrast, neurotics are ego-dystonic: they don't like who they are and how they behave all the time.
People with personality disorders are not psychotic. They have no hallucinations, delusions, or thought disorders (except those with borderline personality disorder who experience brief psychotic "micro-episodes", mostly during treatment). They are also fully oriented, with clear senses (sensorium), good memory and sati
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