16.6 PUTTING IT...together

Disorders of Personality—Rediscovered, Then Reconsidered

During the first half of the twentieth century, clinicians believed deeply in the unique, enduring patterns we call personality, and they tried to define important personality traits. They then discovered how readily people can be shaped by the situations in which they find themselves, and a backlash developed. The concept of personality seemed to lose legitimacy, and for a while it became almost an obscene word in some circles. The clinical category of personality disorders went through a similar rejection. When psychodynamic and humanistic theorists dominated the clinical field, neurotic character disorders—a set of diagnoses similar to today’s personality disorders—were considered useful clinical categories, but their popularity declined as other models grew in influence (Millon et al., 2011, 2000).

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In Their Words

“We continue to shape our personality all our life.”

Albert Camus

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During the past two decades, serious interest in personality and personality disorders has rebounded. In case after case, clinicians have concluded that rigid personality traits do seem to pose special problems, and they have developed new objective tests and interview guides to assess these disorders, setting in motion a wave of systematic research (Millon, 2011). So far, only the antisocial and borderline personality disorders have received much study. However, with DSM-5 now considering a new—dimensional—classification approach for possible use in the future, additional research is likely to follow. This may allow clinicians to better answer some pressing questions: How common are the various personality disorders? How useful are personality disorder categories? How effective is a dimensional approach to diagnosing these disorders? And which treatments are most effective?

Why do some observers suggest that personality disorders are little more than descriptions of undesirable personal styles?

One of the most important questions is, “Why do people develop troubled patterns of personality?” As you have read, psychological, as opposed to biological and sociocultural, theories have offered the most suggestions so far, but these explanations are not very precise and they do not have strong research support. Given the current enthusiasm for biological explanations, genetic and biological factors are beginning to receive considerable study, a shift in the waters that should soon enable researchers to determine possible interactions between biological and psychological causes. And one would hope that sociocultural factors will be studied as well. As you have seen, sociocultural theorists have only occasionally offered explanations for personality disorders, and multicultural factors have received little research. However, sociocultural factors may well play an important role in these disorders and certainly should be examined more carefully.

DSM-5’s proposal of a dimensional classification approach eventually may lead to major changes in the diagnosis of personality disorders. The future is also likely to bring significant changes to the explanations and treatments for these disorders. Now that clinicians have rediscovered personality disorders, they must determine the most appropriate ways to think about, explain, and treat them.

CLINICAL CHOICES

Now that you’ve read about personality disorders, try the interactive case study for this chapter. See if you are able to identify Alicia’s symptoms and suggest a diagnosis based on her symptoms. What kind of treatment would be most effective for Alicia? Go to LaunchPad to access Clinical Choices.

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Stolen Glances

22%

Percentage of people who regularly check their reflections in store windows and the like

69%

Those who steal glances at least occasionally

9%

Those who never look at themselves in public mirrors or windows

(Information from: Kanner, 2005, 1995)

SUMMING UP

  • PERSONALITY DISORDERS AND DSM-5 People with a personality disorder display an enduring, rigid pattern of inner experience and outward behavior. Their personality traits are much more extreme and dysfunctional than those of most other people in their culture, resulting in significant problems for them or those around them. It has been estimated that as many as 9 to 13 percent of adults have such a disorder. DSM-5 uses a categorical approach that lists 10 distinct personality disorders. In addition, the framers of DSM-5 have proposed a dimensional approach to the classification of personality disorders, an approach that they assigned for further study and possible inclusion in a future revision of the DSM. pp. 519–522

  • “ODD” PERSONALITY DISORDERS Three of the personality disorders in DSM-5 are marked by the kinds of odd or eccentric behavior often seen in schizophrenia. People with paranoid personality disorder display a broad pattern of distrust and suspiciousness. Those with schizoid personality disorder persistently avoid social relationships, have little or no social interest, and show little emotional expression. People with schizotypal personality disorder display a range of interpersonal problems marked by extreme discomfort in close relationships, very odd forms of thinking and behavior, and behavioral eccentricities. People with these three kinds of disorders usually are resistant to treatment, and treatment gains tend to be modest at best. pp. 522–529

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  • “DRAMATIC” PERSONALITY DISORDERS Four of the personality disorders in DSM-5 are marked by highly dramatic, emotional, or erratic symptoms. People with antisocial personality disorder display a pattern of disregard for and violation of the rights of others. No known treatment is notably effective. People with borderline personality disorder display a pattern of instability in interpersonal relationships, self-image, and mood, along with extreme impulsivity. Treatment apparently can be helpful and lead to some improvement. People with histrionic personality disorder (once called hysterical personality disorder) display a pattern of extreme emotionality and attention seeking. Clinical case reports suggest that treatment is helpful on occasion. Finally, people with narcissistic personality disorder display a pattern of grandiosity, need for admiration, and lack of empathy. It is one of the most difficult disorders to treat. pp. 529–547

  • “ANXIOUS” PERSONALITY DISORDER Three of the personality disorders in DSM-5 are marked by anxious and fearful behavior. People with avoidant personality disorder are consistently uncomfortable and inhibited in social situations, overwhelmed by feelings of inadequacy, and extremely sensitive to negative evaluation. People with dependent personality disorder have a persistent need to be taken care of, are submissive and clinging, and fear separation. People with obsessive-compulsive personality disorder are so preoccupied with order, perfection, and control that they lose their flexibility, openness, and efficiency. A variety of treatment strategies have been used for people with these disorders and apparently have been modestly to moderately helpful. pp. 547–554

  • MULTICULTURAL FACTORS Despite the field’s growing focus on personality disorders, relatively little research has been done on gender and other multicultural influences. Nevertheless, many clinicians believe that multicultural factors play key roles in the diagnosis and treatment of personality disorders, and researchers have recently begun to study this possibility. pp. 554–555

  • ARE THERE BETTER WAYS TO CLASSIFY PERSONALITY DISORDERS? The personality disorders listed in DSM-5 are commonly misdiagnosed, an indication of serious problems in the validity and reliability of the categories. Given the significant problems posed by the current categorical approach, a number of today’s theorists believe that personality disorders should instead be described and classified by a dimensional approach. One such approach, the “Big Five” model, may be included in the next edition of the World Health Organization’s International Classification of Diseases. Another dimensional approach, the “personality disorder—trait specified” model, is under study for possible inclusion in a future revision of DSM-5. pp. 555–560

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