#dsm iii

This post is about personality disorders that used to exist in the DSM or ICD but don’t anymore. You cannot be diagnosed with these disorders, as they’re not in any diagnostic manual; you would be diagnosed with Other Specified Personality Disorder (or the ICD-11 equivalent) instead.

Passive-Aggressive / Negativistic (PA/NegPD)

A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood and present in a variety of contexts.

Masochistic / Self-Defeating (Ma/SDPD)

A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her.

Sadistic (SaPD)

A pervasive pattern of cruel, demeaning, and aggressive behavior, beginning by early adulthood and present in a variety of contexts.

Depressive / Melancholic (De/MePD)

A pervasive pattern of depressive cognitions and behaviors, beginning by early adulthood and present in a variety of contexts.

Other Personality Disorders

Turbulent

Turbulent PD has never existed in any DSM. It’s part of Millon’s theorised personality disorder taxonomy, but doesn’t appear in any other literature.

It seems to be an alternate way of categorising and defining hypomania & cyclothymic disorder, and is similar to ADHD, NPD & HPD.

Millon classes it on a spectrum from ebullient personality type -> exuberant personality style -> turbulent personality disorder.

Haltlose

Theorised in German, Russian, and French psychiatry.

Haltlose translates to “unstable” (literally, “without footing”) and refers to a “drifting, aimless and irresponsible lifestyle: a translation might be ‘lacking a hold' on life or onto the self)”.

“Those with haltlose personality disorder have features of frontal lobe syndrome, sociopathic and histrionic personality traits”.

Someone with haltlose PD “lacks concentration and persistence”, and “lives in the present only”. They are “easily persuaded, and [are] often led astray”.

Haltlose PD is similar to AsPD as there is “an inability to learn from experience, and no sincere sense of remorse”. They are often described as ‘lovable rouges’.

(Cullivan, R, ‘‘Haltlose’ type personality disorder (ICD-10 F60.8)’, Psychiatric Bulletin, 1998, pp. 58-59).

Immature

Immature PD was mentioned in the DSM-III as a specifier for Other Specified PD, but removed in later editions.

It seems to be a combination of borderline, histrionic, narcissistic, antisocial, dependent, schizoid and avoidant PDs.

Almeida et al. suggest the following criteria for Immature PD: irresponsibility; impulsivity; unreliability; easily swayed; mood swings; expect overindulgence from others; dependency on others; ability for remorse or regret but it’s “light and fleeting”; inability to manage assets; inability to follow plans; quick to lie; unable to delay gratification; quick to frustration; devaluation of others; risk-taking behaviour; unstable relationships and behaviour; feels both entitled and worthless; attention seeking; recklessness; shyness; ungrateful; over-familiar with others; unable to plan for the future; substance use.

They also suggest 3 subtypes of Immature PD: the dramatic and emotional subtype, the shy subtype, and the mixed subtype.

(Almeida et al., 'Immature Personality Disorder: Contribution to the Definition of this Personality', Clinical Neuroscience & Neurological Research, 2019, pp. 1-16).

Eccentric and Psychoneurotic

Note: You cannot be diagnosed with this disorder, as it's not in any diagnostic manual; you would be diagnosed with Other Specified Personality Disorder instead.

Criteria from the DSM-III-R (1987):

A. A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her, as indicated by at least five of the following:

chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available

rejects or renders ineffective the attempts of others to help him or her

following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)

incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)

rejects opportunities for pleasure, or is reluctant to acknowledge enjoying himself or herself (despite having adequate social skills and the capacity for pleasure)

fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so, e.g., helps fellow students write papers, but is unable to write his or her own

is uninterested in or rejects people who consistently treat him or her well, e.g., is unattracted to caring sexual partners

engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice

B. The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.

C. The behaviors in A do not occur only when the person is depressed.

Note: You cannot be diagnosed with this disorder, as it's not in any diagnostic manual; you would be diagnosed with Other Specified Personality Disorder instead.

Criteria from the DSM-III-R (1987):

A. A pervasive pattern of cruel, demeaning, and aggressive behavior, beginning by early adulthood, as indicated by the repeated occurrence of at least four of the following:

has used physical cruelty or violence for the purpose of establishing dominance in a relationship (not merely to achieve some noninterpersonal goal, such as striking someone in order to rob them);

humiliates or demeans people in the presence of others;

has treated or disciplined someone under their control unusually harshly, e.g., a child, student, prisoner, or patient;

is amused by, or takes pleasure in, the psychological or physical suffering of others (including animals);

has lied for the purpose of harming or inflicting pain on others (not merely to achieve some other goal);

gets other people to do what they want by frightening them (through intimidation or even terror);

restricts the autonomy of people with whom they have a close relationship, e.g., will not let spouse leave the house unaccompanied or permit teen-age daughter to attend social functions;

is fascinated by violence, weapons, martial arts, injury, or torture

B. The behavior in A has not been directed toward only one person (e.g., spouse, one child) and has not been solely for the purpose of sexual arousal (as in Sexual Sadism).

I came of age as a psychiatrist just as the DSM III was being published. During medical school, I had found that my interests and my talents overlapped best in that area of doctoring that had to do with talking to people, and that the doctors who got to talk to people most were psychiatrists. That's why I entered a residency program in psychiatry. In those days, at least in my program, we still got a lot of training in psychotherapy, including a compulsory course in psychoanalysis. I happened that my most influential teachers were a psychologist and a social worker, both of whom were excited about family therapy. This was in the early 70's, and the air was full of ideas about systems theory, communication theory, and ecology, including "the ecology of ideas."  

I didn't realize at the time what a critical turn was happening in my chosen profession. Our embrace of the DSM project went hand in hand with a turn (well-intentioned for the most part) toward empiricism and biology. That turn has played out in ways that sadden me. Mickey, the semi-retired psychiatrist who writes the 1 boring old man blog, tells the story of our turn toward scientism and becoming lackeys of Big Pharma very well. Today's installment is especially good.

1 boring old man: 

In the DSM-II, the Mental Disorders without known physical cause were partitioned into two groups: The Psychoses [III. PSYCHOSES NOT ATTRIBUTED TO PHYSICAL CONDITIONS LISTED PREVIOUSLY] and the Neuroses [IV. NEUROSES]. The Psychoses were Disorders that would more likely be found to have a biological cause  at some future juncture and were treated with biological interventions. The Neuroses probably developed from the circumstances of life, were less likely biological, and were treated at the time with psychotherapy and symptomatic medications. In the drive to remove psychoanalysis ["hypothetical but unproven theories about etiology"] from psychiatry with the DSM-III, the categorical distinctions of the DSM-II [psychosis vs neurosis], [probably·biological vs probably·not·biological] were ablated. That move had many roots: the speculative nature of psychoanalytic theories; the untestable clinical outcome of psychoanalysis or its derivatives; the threat posed to third party medical coverage by long therapies of any kind; the inflexibility of the analysts/psychotherapists around these issues; and the political dominance of the psychoanalysts in American psychiatry in general [to mention a few]. And we’re all aware of the neo-Kraepelinian Tenets that fueled that revision:

Psychiatry is a branch of medicine.

Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.

Psychiatry treats people who are sick and who require treatment.


There is a boundary between the normal and the sick.


There are discrete mental illnesses.  They are not myths, and there are many of them.


The focus of psychiatric physicians should be on the biological aspects of illness.


There should be an explicit and intentional concern with diagnosis and classification.


Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.


Statistical techniques should be used to improve reliability and validity.

The combination of the DSM-III’s etiological neutrality, the neo-Kraepelinian injunction ["The focus of psychiatric physicians should be on the biological aspects of illness"], and the third party payers limiting payment to psychiatrists for medication management created a fertile soil for the flowering of the psychopharmacologic treatment of mental illnesses. The change in mental health treatment was dramatic. Psychiatrists drifted to medication management and the other mental health disciplines who were much more amenable to negotiation than psychiatrists took over psychotherapy and counseling. Access to treatment was tied to diagnosis and determined by the third party carriers through contracted panels of approved providers. Many patients had both a therapist and a psychiatrist. Those practicing traditional psychotherapy practiced off the grid.

The idea of biological causation was both on the forefront [at least in the research laboratories] and in the background [in the ubiquitous Clinical Trials focused on symptomatic improvement rather than cause] – nowhere more apparent than in the treatment of depression. The DSM-III destroyed diagnostic distinctions among the clinical depressions – essentially shutting down biological research on the probably·biological depressive syndromes by diluting them with the larger group of probably·not·biological symptomatic depressions. The primary focus of psychiatric research turned from etiology to treatment effect and moved from academic centers to private enterprise – the clinical research industry.