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A 2.7 Minute Post About Personality Disorders

[I am being excessively pedantic. The average adult reads at 250 words per minute. This post is 670 words long.] 

I talked a little about my feelings on personality disorders and PDs as a whole at Chicago Skepticamp (So. FUN.) and in the last post.  Then I realized that few people get as into psych as I do, and as personality disorders are far too marginalized as it is, y’all might be missing some background. So here it is!

Personality disorders are on Axis II of the DSM

The DSM classifies using a five axis system. In a “full-workup” a client would be analyzed in terms of all axes. The idea is to include all factors of how behavior could be manifesting. For instance, if the patient is displaying disordered eating behavior, but hyperthyroidism hasn’t been ruled out…maybe they don’t have an ED? If they’re exhibiting erratic behavior that’s not responding to therapy or meeting criteria for something like schizophrenia, have you ruled out a brain tumor?

This doesn’t always happen in practice–which is incredibly frustrating. In a perfect world, psychiatrists and psychologists would have time to do these things, and clients would be able to afford it.

Wishful thinking aside, these are the axes.

Axis I: All the stuff you probably think of in terms of mental illness. Mood disorders, anxiety disorders, eating disorders, all of that. Also autism, a categorization location I have some quibbles about.
Axis II: Personality disorders and mental retardation. Autism diagnoses used to be located here.
Axis III: Stuff that is non-mental medical issues. Could be having migraines, cancer, etc.
Axis IV: Pyschosocial factors. For instance, the client could be in an unstable family environment, suffering abuse, in foster care, unable to get regular sleep due to work, imprisoned etc. All of those can contribute to manifesting a more severe version of a disorder, or major mood changes.
Axis V: Global Assessment of Functioning. This actually just a number from 0-100, based on the rater’s impression of how well the client can cope with day to day life tasks. Further elaboration here.

There are three categories of personality disorders. And there’s probably more PDs than you’ve heard of.

Cluster A (odd or eccentric disorders. I’m serious, that’s what they’re called)
-Paranoid Personality Disorder
-Schizotypal Personality Disorder (This isn’t schizophrenia.)
-Schizoid Personality Disorder (This isn’t schizophrenia either.)

Cluster B (dramatic/emotional)
-Antisocial Personality Disorder (ASPD)
-Borderline Personality Disorder (BPD. Here’s one experience of BPD.)
-Histrionic Personality Disorder
-Narcissistic Personality Disorder.

Cluster C (fearful/avoidant)
-Obsessive Compulsive Personality Disorder (OCPD. This isn’t OCD–we just like to make things confusing for you.)
-Avoidant Personality Disorder
-Dependent Personality Disorder

And Then These Conditional Diagnoses: (Which may or may not get added to DSM-5)
-Depressive Personality Disorder
-Negativistic/Passive-Aggressive Personality Disorder

There’s really very little research on personality disorders

This, as far as I can tell, isn’t actually because researchers don’t want to study PDs. But firstly, few people go in for treatment of their personality–because few people are distressed by their own personality. So there’s a small pool to begin with, often of people who have been jabbed into getting treatment by family or friends. (Borderline seems to be the only regularly studied one, but that just could be because DBT was developed for BPD and I read a lot about DBT.)

Secondly, research usually tries to use ‘clean’ patients, that is, people who have just one diagnosis. So, to avoid confounding data, research on OCPD is going to only want patients who have Obsessive Compulsive Personality Disorder and only Obsessive Compulsive Personality Disorder. Except…that doesn’t really happen all too often. PDs are, almost by definition, maladaptive to living in society, which results in increased stress, which can then up the risk of other disorders and suddenly….you don’t have lots of ‘clean’ patients wandering about. (Add in the complication of finding clean patients who live close enough to participate in your research and are interested and suddenly you have a very messy project on your hands. Probably better to make the psych undergraduates do Stroop tasks.)

 

Comments

  1. unbound says

    Also autism, a categorization location I have some quibbles about.

    I would be interested in hearing your quibbles. You can’t just dangle that out and walk away, can you? :-)

  2. erikabutler says

    One of mine said it like this:

    Axis V: 20/55

    What does it mean when they put it like that?

  3. Kate Donovan says

    well….I actually don’t think I know enough at all. It’s barely touched upon in school (I’ve never taken more than a single lecture on it) and I haven’t read much of the literature. I do, however, know it’s not caused by vaccines :P

    Mostly I’m not sure it should be called a mental disorder in the way mood and anxiety disorders and such are. And I’ve heard a lot of other things I think I agree with and arguments for moving it off Axis I to Axis II that I like. But I haven’t properly educated myself on them.

    And I lot of the arguments for removing it from the mental disorder category (so, not Axis II) entirely have been something like “well, people with personality disorders are scary and icky, so we shouldn’t be filed with them!!!!!1!!”. And well, that’s not going to win any points with me.

  4. Kate Donovan says

    So, *if* I remember properly and guess semi-educatedly I think it’s a two-score rating. I used to do these in structured interviews for schizophrenia research, and we did the number-slash-number thing. The first number was the score for that day we did the interview, and the second was the score based on what the client was telling us about their functioning for the past week or month (Depending on how often they were interviewed).

    BUT, huge caveat. That was years ago and
    1) I’m not sure I’m remembering correctly at all
    2) It could be something completely different.

  5. unbound says

    I had similar thoughts (I know it isn’t due to vaccines too :-) ).

    My youngest has Aspergers, so I’ve had to learn a few things about autism. Outside of the general public being insulted being in the same axis as mental retardation, I would think Axis II makes the most sense as I view (perhaps incorrectly since Aspergers is high functioning on the autism scale) autism as a personality issue predominantly.

    Mostly I was curious if there was something specific that was coming up.

    Thanx for the response.

  6. erinmcc says

    i think we will eventually see autism being separated out into different sections depending on cause, which of course hasnt been identified yet. my personal belief is that there are multiple causes, some being inheritable genetic causes (beyond fragile x and rett syndrome) and others being influenced by environmental factors or caused by random genetic mutation. there are way too many variations in the progression of autism for me to comfortably believe that it is caused by once source. there are valid regression cases where children lose previously held skills or verbal abilities, and there are also those where there is no regression but autistic behaviors have been present since birth (my partner and two of my kids are this way).

    i would agree that autism should not be considered a mental disorder, although it is definitely a developmental delay. autism does not have a treatment protocol like you find in other mental disorders. you cannot medicate an autistic and achieve neurotypicality.

    i would disagree however that autism necessarily belongs in the same category as personality disorders. autism is much more pervasive in the bodily systems than that. there are physical reactions and dysfunctions in autism that arent common in PDs and that are so frequent they seem to go beyond the scope of co-morbids. for example, the occurrence of sensory dysfunction in autistics is huge, and that has very physical issues that we dont generally see in PDs. and like with MDs, treatment protocols for PDs are totally inappropriate and ineffective for autism.

    and i can understand the problem with being able to find “clean” patients for research. to me, one big reason is that mental diagnoses are not as definitive as physical medical diagnoses. its not a simple case of having a blood or genetic test that tells you that you have OCPD or autism. a lot of times its reliant on observed or reported behavior or thought patterns, and those are just plain messy. we are relying on patients to accurately report and diagnosticians to accurately diagnose. in my personal experience, a lot goes wrong in that kind of system.

  7. unbound says

    Very interesting information. Really makes you wonder if autism (if not outright split), should really be on an Axis of its own.

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