#axis 2

Huddle up. Cluster B.

I really hadn’t planned on doing a DSM-IV style series but as I’m already headed in that direction let’s keep on it.

Personality Disorders are described as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts” and “are inflexible and maladaptive, and cause significant functional impairment or subjective distress”.

According to the DSM-IV there are 10 different personality disorders + 1 catch all ‘personality disorder not otherwise specified’. These disorders are broken down into 3 Clusters (A,B, & C). The purpose of these Clusters is to further organize these disorders into groups that are related to each other by their symptoms.

Characterization:-------------------------------------------------------------------------------------------------------------

Cluster A – Odd or Eccentric Behavior - includes Schizoid, Paranoid, and Schizotypal Personality Disorders.

Schizoid Personality Disorder - A pervasive pattern of detachment from social relationships and a restricted range of expressions of emotions in interpersonal settings. Those with SPD may be perceived by others as somber and aloof, and often are referred to as "loners."

Schizotypal Personality Disorder - A pervasive pattern of social and interpersonal deficits marked by acute discomfort with reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior. This disorder is characterized both by a need for isolation as well as odd, outlandish, or paranoid beliefs. In social situations, they may show inappropriate reaction or not react at all, or they may talk to themselves.

Paranoid Personality Disorder - A pervasive mistrust and suspiciousness of others such that their motives are interpreted as malevolent. Although they are prone to unjustified angry or aggressive outbursts when they perceive others as disloyal or deceitful, those with PPD more often come across as emotionally “cold” or excessively serious.

Cluster B – Dramatic, Emotional, or Erratic Behavior - includes Antisocial, Borderline, Narcissistic, and Histrionic Personality Disorders.

Antisocial Personality Disorder - A pervasive pattern of disregard for and violation of the rights of others. APD is characterized by lack of empathy or conscience, a difficulty controlling impulses and manipulative behaviors. This disorder is sometimes also referred to as psychopathy or sociopathy, however, Antisocial Personality Disorder is the clinical terminology used for diagnosis.

Borderline Personality Disorder - A pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses. This mental illness interferes with an individual’s ability to regulate emotion. Borderlines are highly sensitive to rejection, and fear of abandonment may result in frantic efforts to avoid being left alone, such a suicide threats and attempts.

Histrionic Personality Disorder - A pervasive pattern of excessive emotion and attention seeking often in unusual ways, such as bizarre appearance or speech. With rapidly shifting, shallow emotions, histrionics can be extremely theatrical, and constantly need to be the center of attention.

Narcissistic Personality Disorder - A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. Narcissism occurs in a spectrum of severity, but the pathologically narcissistic tend to be extremely self-absorbed, intolerant of others’ perspectives, insensitive to others’ needs and indifferent to the effect of their own egocentric behavior.

Cluster C – Anxious, Fearful Behavior -  Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders.

Avoidant Personality Disorder - A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation and are unwilling to take social risks. Avoidants display a high level of social discomfort, timidity, fear of criticism, avoidance of activities that involve interpersonal contact.

Dependent Personality Disorder - A pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of separation. Dependent personalities require excessive reassurance and advice, and are extremely sensitive to criticism or disapproval.

Obsessive-Compulsive Personality Disorder - Also called Anankastic Personality Disorder display a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. They can also be workaholics, preferring the control of working alone, as they are afraid that work completed by others will not be done correctly.

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My questions is: Are these clusters necessary?

Once you know which personality disorder someone has you’ve got it pegged. It would make more sense to use clusters to further narrow down behavior before diagnosis.

If the patient is obviously dramatic and emotional it is easier come to the Cluster B conclusions and therefore rule out disorders characterized by other clusters. However there can easily be overlap and therefore confusion. With Borderline (Cluster B) there’s an intense fear of abandonment, often paranoia that something will happen and people will leave, which is why we attach so hard to people regardless of there being any evidence to support this paranoia. To me this indicates anxious and fearful behavior which would be Cluster C, even though Paranoid PD is Cluster A. Confusing, no?

Being Borderline I’m grouped into Cluster B. I can tell you with absolute certainty that my personality characteristics fit almost all Cluster A criteria. In Cluster B I obviously hit Borderline but also Histrionic PD. As far as ASPD goes, I have at least the difficulty controlling impulses and manipulative behavior. For NPD a case could be made for being self-absorbed, intolerant of others’ perspectives (if they don’t satisfy what I need at the moment), and indifference to the effect of egocentric behavior. For ASPD and NPD my motivations are fundamentally different though. Maybe that’s the deciding factor. Motivation. Not consciously of course, but those underlying factors that set us apart from the other PDs that we’re not diagnosed with. To me this conclusion is obvious. It boils down to which behaviors are most predominant. This still doesn’t explain what the point of further breaking personality disorders into clusters is. In all of my research, so far, I have not found a single reason why these clusters are necessary.

Who’s to say what the difference between these traits are anyways? Who defines what is erratic (Cluster B) and not eccentric (Cluster A)?  Lack of interest in social relationships (Cluster A) and social inhibition (Cluster C)? There is no solid, scientific way of distinguishing between clusters. There is a lot of overlap between the Clusters so they don’t help narrow down the playing field. Any conclusions reached about a person will point directly to a personality disorder(s) regardless of which cluster they fall into, especially as symptoms may indicate multiple clusters. In fact, the cluster groupings may work to limit the consideration treatment options that other personality disorders could provide insight to.

My conclusion is that they’re basically erroneous.

Hah, Ok. I just found this abstract on Neuropsychological, Psychophysiological, and Personality Assessment of DSM-IV Clusters:

Testing the construct validity of the three DSM-IV cluster groupings of personality disorders, in terms of neuropsychological, psychophysiological, and personality traits measures, was the purpose of this study. The results hardly confirm significant differences between B and C cluster groups in their neuropsychological functioning, but, instead, suggest that Cluster A could have some empirical validity based on executive prefrontal deficits (concept formation and sustained attention tasks) and clinical features. Similarly, no consistent differences among groups emerge when psychophysiological measures are compared. With regard to the Big-Five personality dimensions, the results also indicate that clusters may be more heterogeneous than the DSM-IV suggests. It appears, therefore, that the categorical division of DSM personality disorders into three discrete clusters may not be empirically justified.

What’s going to happen to Borderline Personality Disorder in the DSM-V? For that matter, what’s going to happen to any Personality Disorder in the DSM-V?

There is going to be a major reclassification of Personality Disorders in the DSM-V.  Apparently Axis-II disorders aren’t clear enough in terms of diagnosis in the DSM-IV so they need to be updated. Can’t completely disagree with their reasoning. The whole point of the DSMs are to accurately diagnosis disorders in order to aid the clinician and patient. Without proper classification and standardized diagnostic criteria it’s very difficult if not impossible to receive the most helpful treatment. If help is what you want that is. I’m sure we can all think of a few PD types that don’t need to change a thing ;)

The current DSM-IV:  Diagnosing disorders in the current edition of the DSM-IV involves two aspects.

First: Define what a personality disorder is. Currently, a Personality Disorder is defined as a pervasive pattern of "inner experience and behavior" that is deviant from a person's cultural norms. These may be deviations in thoughts, emotionality, interpersonal relatedness, and impulse control. Deviations need to be pervasive, stable, present at least since adolescence, and not due to substances or another mental disorder. Importantly, these ways of thinking, feeling, or behaving need to be significantly distressful and problematic.

Deviant from cultural norms. This is inappropriate on so many levels. The most obvious being that since there are so many different cultures in the world what is considered a PD in one culture may be considered a different PD in another or more severely it may not be considered a PD at all.  Some cultures promote cannibalism. It’s a non-concern. I bet if I tried to apply that here and claim it was my standard proclivity to chow down on my neighbor I’d be tossed right into the ASPD category. People are food? Anti-social. Check.

Second: Define what type of personality disorder is present. DSM-IV currently lists ten Personality Disorders with a catch-all "not otherwise specified category". Each personality disorder has a certain number of criteria, to which you must meet a cut-off. For example, To be Borderline you need to have five out of nine symptoms such as: self-harming, unstable relationships, fear of real/imagined abandonment, impulsivity, identity disturbance, etc.

There are a lot of problems with this system though.

First, the different personality types were poorly defined. They weren't based on research-derived criteria, the individual symptoms were vague, and the idea of checking off abstract criteria such as "an exaggerated sense of self-importance" were difficult.

It does seem that the number of criteria required is arbitrary. Why are 5 qualifications better than 4? 4 symptoms may be significantly severe. For that matter, who decides what is significantly severe? Why are 7 met criteria more accurate than 5 if many of the 7 criteria are relatively subdued. Who’s to judge? 4 = “normal”, 7 = “abnormal”.  Regardless. Oh, I’m sorry. You only have 4 majorly severe symptoms present? You’re fine, go about your day. Next!

Another problem is that the criteria overlapped heavily. A person meeting criteria for one personality disorder usually met criteria for 3 or 4 others, as well.

No disagreements here. I for one am sure I qualify for Histrionic PD in many ways. From a cultural stand point I cross over into Schizotypal (if not for my ‘spiritual’ beliefs alone), and so on. Hey! Check out the PD test, that’ll give an “accurate” crossover chart.

The proposed DSM-V:

The proposed revision for the DSM-V is relatively complicated and has 3 essential criteria for PDs.

(1)  A rating of mild impairment or greater on the Levels of Personality Functioning (criterion A),

(2)  A rating of 

        (a)  a “good match” or “very good match” to a Personality Disorder Type or

       (b)  “quite a bit” or “extremely” descriptive on one or more of six Personality Trait Domains (criterion B).

(3)  Diagnosis also requires relative stability of (1) and (2) across time and situations, and excludes culturally normative personality features and those due to the direct physiological effects of a substance or a general medical condition.

Quite complicated indeed. However when you think about it, it fits. Normal personalities are complicated. Personality Disorders are complicated to the order of {insert large magnitude}.

Let’s look at each of these 3 new criteria:

1.) First, the general definition of what a personality disorder is has changed. It will now suggest that instead of a pervasive pattern of thinking/emotionality/behaving, a personality disorder reflects "adaptive failure" involving: "Impaired sense of self-identity" or "Failure to develop effective interpersonal functioning".

See, now I disagree that it should be defined as {solely} an “adaptive failure”. This implies that Personality Disorders are strictly a product of your developmental environment. I’ve done a lot of research into biogenetic temperament, pathology, differences in brain affectations/structuring (all of which I’ll be posting on eventually) and there is a biological aspect to personality disorders. This definition seems to ignore those factors completely. Maybe they’re just focusing on the manifestations though. They can always do brain scans later. I for one want my brain scan.

The breakdown of “impaired sense of self-identity” and “failure to develop effective interpersonal functioning” is good though. They even have a little severity scoring system. I like all these scoring levels actually. It’s like a game of personality disorders. Step right up folks. Place your bets, put your credibility on the line. Spin the wheel of characteristic crazy and I’ll guess your personal pathology. Takers? Loser are the norm. Winners get a shiny new Personality Type. Woot!

Five personality types

2.a.) DSM-V has simplified the system by cutting down Personality Disorders from10 to 5:

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

Antisocial Personality Disorder (ASPD)

Borderline Personality Disorder (BPD)

Histrionic Personality Disorder (HPD)

Narcissistic Personality Disorder (NPD)

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

They plan to collapse these 10 into the following 5 buckets:

Antisocial/Psychopathic Type

Avoidant Type

Borderline Type

Obsessive-Compulsive Type

Schizotypal Type

Avoidant, O-C, and Schizotypal haven’t changed much. A/P Type and Borderline are apparently still pretty complex but hey! We made the cut! Take that Paranoid PD. Who’s watching you now? No one? Now you’ll never know. I’m actually not sure that this will make it easier to identify potential Personality Disorders. I don’t see why they couldn’t keep the established Personality Disorders and simply apply the new diagnostic techniques to them. This is supposed to be most helpful to clinicians who I suppose the DSM is specifically designed for, but it will make the information less accessible to the population at. Or, maybe the APA is trying to boost therapy sales by making it so confusing that patients need to seek professional help to figure out what’s wrong with them.

2.b.) Personality trait domains and facets

Finally there are a series of six personality "trait domains". The six domains include: Negative Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity and Schizotypy. Clinicians would be asked to rate each of the six domains on a 0-3 scale depending on how descriptive each is of the patient. The rating game continues.

Each of the six trait domains also comes with a subset of trait facets.  These are more descriptive indicators to help you decide which domains you fall under. I’m not sure these are enough. I fit all of these in some way, but then again, I have a Borderline Personality Disorder so Good Job! I think I just disproved my own concern. I guess when you pull the whole system together it will be able to distinguish maladaptive personalities versus, say, non-PD abuse victims, true A/P types versus your everyday douchebag.  Only time will tell I suppose.

3.)  And time is what it’s all about. One thing that has been kept from the DSM-IV is the fact that these characteristics need to be “stable”. I love that they use the term stable. Especially since the nature of half of these disorders is how generally unstable people with PDs can be. I know what they mean of course; these problems are persistent and unchanging over time and not situation dependent.

So there you have it. The new DSM-V.

Where does Borderline Personality Disorder belong?

I’m referring to the DSM criteria for Axis I and Axis II designation. Let’s start off with, what’s the difference between Axis I and Axis II.

* Axis I: major mental disorders, developmental disorders and learning disabilities. Axis I disorders are predominantly mood disorders.

 * Axis II: underlying pervasive or personality conditions, as well as mental retardation. Axis II disorders are personality disorders.

For or Against?

[For Axis 2] Personality disorders are classified as Axis II disorders.

Personality disorders in general have their own list of general criteria that must be satisfied. They’re a class of personality types and behaviors that the American Psychiatric Association (APA) defines as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it”.

“These behavioral patterns in personality disorders are typically associated with severe disturbances in the behavioral tendencies of an individual, usually involving several areas of the personality, and are nearly always associated with considerable personal and social disruption. Additionally, personality disorders are inflexible and pervasive across many situations, due in large part to the fact that such behavior is ego-syntonic (i.e. the patterns are consistent with the ego integrity of the individual) and are, therefore, perceived to be appropriate by that individual. This behavior can result in the client adopting maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress and depression in clients.”

The behaviors cause serious interpersonal and social difficulties as well as general functional impairment. I don’t think anyone can argue that BPD fits this criteria, which is a large part of why it is considered Axis II. It also has a sub-designation as Axis II, Cluster B which is characterized by dramatic, emotional or erratic behavior. No argument there either.

Debate:

[For Axis 1] Both Axis I and Axis II are psychiatric disorders. Only personality disorders and mental retardation are segregated onto Axis II. All other psychiatric disorders are Axis I. Does it really make sense to segregate these if they are essentially the same type of thing?

[For Axis 2] However Axis I disorders are generally treatable with medication. While some presenting symptoms of Axis II disorders may be treatable with medication, it’s not shown that medication can ‘cure’ a personality disorder and correct all presenting symptoms.

 [For Axis 1] Moving BPD to Axis I would have economic benefits. Many insurance companies don’t recognize BPD as a treatable condition and use it as an excuse to withhold payments. I know for a fact that my therapist classifies me as Major Depressive when billing my insurance company. I am pretty certain my psychiatrist does as well. This is certainly true, but not completely accurate.  I’m not going to complain though.

I think the major debate lies here:

[For Axis 2] Axis II BPD is pervasive to a person identity, characterlogical in nature.

[For Axis 1]: But…There’s some debate about whether BPD should be considered a ‘personality disorder’ at all because it has such a high rate of co-morbid symptoms that fall into the Axis I designation.

Axis I disorders are primarily for mood disorders that are reactions to atypical situations which are not part of a person’s character. “Mood disorder is the term designating a group of diagnoses in the DSM IV TR classification system where a disturbance in the person's mood {not their character} is hypothesized to be the main underlying feature. The classification is known as mood (affective) disorders in ICD 10.”

[For Axis 1] There are many disorders that are just as pervasive as BPD such as bipolar, anxiety, and depression that are not caused by atypical situations, and are classified as Axis I disorders.

“Two groups of mood disorders are broadly recognized (though not limited to these two); the division is based on whether the person has ever had a manic or hypomanic episode. Thus, there are depressive disorders, of which the best known and most researched is major depressive disorder (MDD) commonly called clinical depression or major depression, and bipolar disorder (BD), formerly known as manic depression and characterized by intermittent episodes of mania or hypomania, usually interlaced with depressive episodes.”

People with Borderline Personality Disorder almost always have a history of long term, pervasive depression.  I’ve never heard of anyone that didn’t, but I’m not a clinician. Hypomania is not always present. If you have manic phases though, that is the definition of Bipolar and while you can have bipolar disorder and BPD, I think you would then have both Axis I and Axis II designations, not just one or the other. From here it could be argued that the mood regulation disorders are the underlying cause for all the other disorder manifestations. 

[For Axis 1] There’s also the stigma that a personality disorder just means that a person has a flawed personality that can’t be changed.  Except there has been plenty of research to support the idea that this is an emotional regulation disorder.  Which means it would technically be a mood disorder and qualify it for Axis I.

I can see how the mood disorder aspects can affect a lot of the behaviors and symptoms of BPD. I'm not sure it can explain all of them though. Things like a tendency towards impulsive behavior, identity disturbance, fear of abandonment, etc... these are not necessarily dependent on mood alone.