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.)

 

The Weight Requirement, and Other Ways We Diagnose Anorexia

This is a post that’s been a long time in coming. Unfortunately, every time I start it, I get upset and then have to leave it alone. So here we have it: what’s wrong with how we diagnose anorexia. Now with less ragequitting!

Anorexia has a weight requirement.

Refusal to maintain body weight at or above a minimally normal weight for age and height, for example, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.

PROBLEMATIC.

Please, someone define what a normal weight is. Because I know this totally isn’t controversial. Using BMI? It doesn’t account for muscle mass, so you’re leaving out  anyone who’s particularly athletic. Using clothing sizes? Ahahahahahahaha. 

Even supposing we had some accurate scale of normal height-to-weight ratios, should a diagnosis rest on a weight? If I’m restricting caloric intake, and I drop under 85%… Bingo, I have anorexia. Ding ding ding and all that. The next day, I enter treatment, or I eat a particularly large meal, or retain a little water, and suddenly I’m at 86%. Have I suddenly developed a disorder that is markedly distinguishable from what I had on Monday? I think not.

The emphasis on being excessively thin is also in the second criteria:

Intense fear of gaining weight or becoming fat, even though underweight.

Anorexia does not just happen one day, when you stop eating and magically, everyone can tell! This, like lots of the criteria, seem to be waiting to diagnose after the disease has progressed significantly.* That’s dangerous.

This is particularly true for people who start at an above-average weight. We fetishize the idea of heavy people losing weight through whatever means possible, up to and including unhealthy ones. (Biggest Loser, anyone?) It’s going to take an especially long time for family and friends to notice such severe weight loss–and of course, they’ll probably praise and reinforce it along the way–and all the while, the disorder will become more entrenched, wreaking havoc on the body it inhabits.

Amenhorrea

In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive menstrual cycles. A woman having periods only while on hormone medication (e.g. estrogen) still qualifies as having amenorrhea.

Defined as non-menstruation for three cycles, this is competing with weight measurement for least helpful criteria. For one, it isn’t useful for anyone on hormonal birth control (withdrawal bleeding is not the same as getting your period). For two, it’s a fairly useless metric. Only cisgender women who can ovulate, are not pregnant, and who have reached puberty, but not menopause can use it. (Also, you qualify for this criteria automatically if you’re on birth control. Say what?) Further, there’s not a lot of research suggesting that amenhorrea occurs in a standardized way, or that it represents the severity of deprivation. Luckily, this is heading out with the publication of the DSM-5.

Waltzing between diagnoses.

In the span of six years, I met criteria for…

Anorexia nervosa (purging type)

Anorexia nervosa (non-purging type)

Binge Eating Disorder (BED)
Note: this is a proposed conditional diagnosis, given separate status from BN and AN. 

Bulimia Nervosa (non-purging type)

Eating Disorder Not Otherwise Specified (EDNOS)

…that would be all but two of the ways one can have an eating disorder. This suggests that we may just be quantifying eating disorders incorrectly. Those qualifying for anorexia diagnoses are automatically going to fall into EDNOS as they recover and gain weight (and consequently, no longer meet the first criteria for AN). Should we rename EDNOS as “Anorexia in Remission?” No, because then you leave out the others who were diagnosed as EDNOS for other reasons, such as not qualifying for a bulimia diagnosis. If EDNOS is made up of lots of people with very different manifestations of disordered eating, can we do any useful research about the diagnosis? Will we be able to draw any useful conclusions? Probably not.

And why does it all matter? After all, society recognizes that refusing to eat is bad, right? It matters because the research doesn’t look at “a population of women who have refused to eat at some point”. It looks at “300 female patients who had been diagnosed with anorexia in the last calendar year”. That means how we assess treatment, how we examine the genetic basis, how we study the disorder is a product of how we describe it.

And we’re doing it wrong.

*Also, the face of anorexia, besides being almost always a thin woman, is always white and upper class. Incorrect, and a scary myth to perpetuate.