A Complex Problem
When I first wrote this appendix I approached the complexity of personality disorders by including two sections: the DSM criteria for diagnosing personality disorders and an alternative way of categorizing these disorders proposed by Theodore Millon. With the advent of the DSM-V (American Psychiatric Association, 2013) things have gotten even more complex. The DSM-V continues with the same categories as were used in the DSM-IV (American Psychiatric Association, 2000), but then it offers a completely different set of criteria for diagnosing personality disorders. No other DSM edition has done this, suggesting that personality disorders are proving to be the most complex group of psychological disorders.
So, I have now kept the same two first sections, since the official diagnostic criteria are essentially the same (only some changes in the wording of the text) and Theodore Millon's alternative theory is particularly interesting. Then, I briefly describe the new alterntive being offered in the DSM-V (leaving it up to you to explore them in more detail).
DSM-V Categories of Personality Disorder
The Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. (DSM-V; American Psychiatric Association, 2013) defines personality disorders as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” The consideration of cultural context is perhaps the most significant change in this definition from the earlier DSM-III. The DSM-V suggests that the personality disorders can be grouped into three clusters, plus a “not otherwise specified” category, for a total of 11 specific diagnoses, the authors caution that the identified clusters have not been consistently validated and that individuals may present combinations of personality disorders from different clusters. Nonetheless, the DSM-V still presents the three clusters of personality disorders (plus the “not otherwise specified” classification). Cluster A, the odd or eccentric types, are paranoid, schizoid, and schizotypal personality disorders. Cluster B, the dramatic, emotional, or erratic types, are antisocial, borderline, histrionic, and narcissistic personality disorders. And finally, Cluster C, the anxious or fearful types, are the avoidant, dependent, and obsessive-compulsive personality disorders.
The odd or eccentric personality disorders represent several of the typical symptoms of schizophrenia (paranoia, emotional detachment, and social withdrawal), leading some to suggest that they represent mild forms of the most widely recognized form of psychosis. However, distinct differences suggest that these personality disorders are not part of a continuum between normal personality and schizophrenia. For example, in individuals with an odd or eccentric personality disorder who also exhibit psychotic symptoms, the personality disorder can be recognized prior to the onset of psychotic symptoms and persists when the psychotic symptoms are in remission. Also, these disorders are not characterized by a pronounced thought disorder, which appears to be the defining characteristic of schizophrenia.
The dramatic, emotional, or erratic personality disorders include the most well-known, due in no small part to their dramatization in movies and television. Most serial killers suffer from antisocial personality disorder (they are often referred to as psychopaths), as do many people in prison. People with antisocial personality disorder demonstrate a complete lack of regard for the rights of others, and will routinely violate those rights. The other personality disorders in this cluster involve various forms of unstable interpersonal relationships, excessive emotions, and a distorted self-image. Interestingly, this cluster appears to involve a significant gender factor, in that antisocial personality disorder is diagnosed more frequently in men, whereas the borderline and histrionic personality disorders are diagnosed more frequently in women.
Probably the least recognized group of personality disorders, among students and the general public are the anxious or fearful personality disorders. The first two, avoidant personality disorder and dependent personality disorder, both involve pervasive patterns of anxiety relating to interpersonal relationships. Finally, obsessive-compulsive personality disorder involves a pervasive preoccupation with neatness, perfectionism, and interpersonal control.
Although the DSM-IV-TR made a point of adding cultural context to the definition of personality disorders, it wasn't until the publication of the DSM-V that much was said in the manual about culture. Not only is there limited research regarding the influence of culture on personality disorders, there is likewise only limited research on cultural influences on normal personality. The notable exception to this may be the well-known research on fundamental differences between individualistic vs. collectivist cultures, which are generally associated with Western vs. Eastern approaches to life. There are also fundamental religious associations that match these basic distinctions, since Western cultures are typically associated with the Abrahamic religions (Judaism, Christianity, and Islam), whereas Eastern cultures are typically associated with Yoga, Buddhism, Taoism, etc.
Discussion Question: What sort of impression do you have of people with personality disorders (it’s OK to consider things you have seen on television and in movies)? Is this what you think of when you typically think of mental illness or psychological disorders?