| Personality disorder | |
|---|---|
| Classification and external resources | |
| ICD-10 | F60 |
| ICD-9 | 301.9 |
| MeSH | D010554 |
Personality disorders, formerly referred to as character disorders, are a class of personality types and behaviors.[1][2] Personality disorders are noted on Axis II of the Diagnostic and Statistical Manual of Mental Disorders or DSM-IV-TR (fourth edition, text revision) of the American Psychiatric Association.
Personality disorders are also defined by the International Statistical Classification of Diseases and Related Health Problems (ICD-10), which is published by the World Health Organization. Personality disorders are categorized in ICD-10 Chapter V: Mental and behavioural disorders, specifically under Mental and behavioral disorders: 28F60-F69.29 Disorders of adult personality and behavior.[3] Personality, defined psychologically is the behavioral and mental traits that distinguish human beings. Hence, personality disorders are defined by experiences and behaviors that differ from societal norms and expectations. Those diagnosed with a personality disorder experience difficulties in cognition, emotiveness, interpersonal functioning and control of impulses. In general, personality disorders are diagnosed in 40-60 percent of psychiatric patients, which is the greatest of all psychiatric diagnoses. [4]
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 maladaptive coping skills, which may lead to personal problems that induce extreme anxiety, distress and depression.[5]
The onset of these patterns of behavior can typically be traced back to early adolescence and the beginning of adulthood and, in rarer instances, childhood.[1] General diagnostic guidelines applying to all personality disorders are presented below; supplementary descriptions are provided with each of the subtypes.
Because the theory and diagnosis of personality disorders stem from prevailing cultural expectations, their validity is contested by some experts on the basis of invariable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations.[6][7][8][9]
Contents |
ICD-10 groups for(F60) Specific personality disorders:
Cluster A
Cluster B
Cluster C
(F60.9) Other specific personality disorders
(F60.9) Personality disorder, unspecified
(F61) Mixed and other personality disorders
The DSM-IV lists ten personality disorders, grouped into three clusters in Axis II. The DSM also contains a category for behavioral patterns that do not match these ten disorders, but nevertheless exhibit characteristics of a personality disorder. This category is labeled Personality disorder not otherwise specified.
Appendix B contains the following disorders.[11] They are still widely considered amongst psychiatrists as being valid disorders, for example by Theodore Millon.[12]
The following disorders are still considered to be valid disorders by Millon.[12] They were in DSM-III-R but were deleted from DSM-IV. Both appeared in an appendix entitled “Proposed diagnostic categories needing further study”,[13] and so did not have any concrete diagnostic criteria.
A study of almost 600 male college students, averaging almost 30 years of age and who were not drawn from a clinical sample, examined the relationship between childhood experiences of sexual and physical abuse and currently reported personality disorder symptoms. Childhood abuse histories were found to be definitively associated with greater levels of symptomatology. Severity of abuse was found to be statistically significant, but clinically negligible, in symptomatology variance spread over Cluster A, B and C scales.[14]
Child abuse and neglect consistently evidence themselves as antecedent risks to the development of personality disorders in adulthood.[15] In the following study, efforts were taken to match retrospective reports of abuse with a clinical population that had demonstrated psychopathology from childhood to adulthood who were later found to have experienced abuse and neglect. In a study of 793 mothers and children, researchers asked mothers if they had screamed at their children, and told them that they didn’t love them or threatened to send them away. Children who had experienced such verbal abuse were three times as likely as other children (who didn't experience such verbal abuse) to have borderline, narcissistic, obsessive-compulsive or paranoid personality disorders in adulthood.[16] The sexually abused group demonstrated the most consistently elevated patterns of psychopathology. Officially verified physical abuse showed an extremely strong correlation with the development of antisocial and impulsive behavior. On the other hand, cases of abuse of the neglectful type that created childhood pathology were found to be subject to partial remission in adulthood.[15]
According to ICD-10, the diagnosis of a personality disorder must satisfy the following general criteria, in addition to the specific criteria listed under the specific personality disorder under consideration:
The issue of the relationship between normal personality and personality disorders is one of the important issues in personality and clinical psychology. The personality disorders classification (DSM IV TR and ICD-10) follow categorical approach whereas the trait personality approach follows the dimensional approach. Thomas Widiger[17] has contributed to this debate significantly. He discussed the constraints of the categorical approach and argued for the dimensional approach to the personality disorders. The Five Factor Model of personality has been proposed as an alternative to the classification of personality disorders. Many studies across cultures have explored the relationship between personality disorders and the Five Factor Model [18] This talks about Five-factor translations of DSM-III-R and DSM-IV personality disorders and expounds relevance of the FFM to a variety of patient populations, including patients with borderline personality disorder, narcissism, and bulimia nervosa as well as substance abusers, psychopaths, and sex offenders.
Early stages and preliminary forms of personality disorders need a multi-dimensional and early treatment approach. Personality development disorder is considered to be a childhood risk factor or early stage of a later personality disorder in adulthood.
In 2005, psychologists Belinda Board and Katarina Fritzon at the University of Surrey, UK, interviewed and gave personality tests to high-level British executives and compared their profiles with those of criminal psychiatric patients at Broadmoor Hospital in the UK. They found that one out of eleven personality disorders were actually more pronounced in executives than in the disturbed criminals:
Furthermore, they found no significant difference in the average scores of executives and the disturbed criminal offenders on two out of the eleven scales:
According to leading leadership academic Manfred F.R. Kets de Vries, it seems almost inevitable these days that there will be some personality disorders in a senior management team.[20]
Personality disorder is a term with a distinctly modern meaning, owing in part to its clinical usage and the institutional character of modern psychiatry. The currently accepted meaning must be understood in the context of historical changing classification systems such as DSM-IV and its predecessors. Although highly anachronistic, and ignoring radical differences in the character of subjectivity and social relations, some have suggested similarities to other concepts going back to at least the ancient Greeks.[3] For example, the Greek philosopher Theophrastus described 29 'character' types that he saw as deviations from the norm, and similar views have been found in Asian, Arabic and Celtic cultures. A long-standing influence in the Western world was Galen's concept of personality types which he linked to the four humours proposed by Hippocrates.
Such views lasted into the 18th century, when experiments began to question the supposed biologically-based humours and 'temperaments'. Psychological concepts of character and 'self' became widespread. In the 19th century, 'personality' referred to a person's conscious awareness of their behavior, a disorder of which could be linked to altered states such as dissociation. This sense of the term has been compared to the use of the term 'multiple personality disorder' in the first versions of the DSM.[21]
Physicians in the early 19th century started to diagnose forms of insanity that involved disturbed emotions and behaviors but seemingly without significant intellectual impairment or delusions or hallucinations. Philippe Pinel referred to this as 'manie sans délire' - insanity without delusion - and described a number of cases mainly involving excessive or inexplicable anger or rage. James Cowles Prichard advanced a similar concept he called moral insanity, which would be used to diagnose patients for some decades. 'Moral' in this sense referred to affect (emotion or mood) rather than necessarily ethics, but it was arguably based in part on religious, social and moral beliefs, with a pessimism about medical intervention so that social control should take precedence.[22] These categories were much different and broader than later definitions of personality disorder, while also being developed by some into a more specific meaning of moral degeneracy akin to later ideas about 'psychopaths'.
The German psychiatrist Koch sought to make the moral insanity concept more scientific, suggesting in 1891 the phrase 'psychopathic inferiority'. This referred to continual and rigid patterns of misconduct or dysfunction in the absence of apparent mental retardation or illness, supposedly without a moral judgement. Described as deeply rooted in his Christian faith, his work has been described as a fundamental text on personality disorders that is still of use today.[23] In the early 20th century, another German psychiatrist Emil Kraepelin included a chapter on it in his influential work on clinical psychiatry for students and physicians. He suggested six types - excitable, unstable, eccentric, liar, swindler and quarrelsome. Somewhat later, Scottish psychiatrist David Henderson published a theory of psychopathic states which was influential in linking that term to anti-social traits.
Towards the mid 20th century, psychoanalytic theories were coming to the fore based on the work of Sigmund Freud. This popularised the concept of 'character disorders', which were seen as enduring problems linked not to specific symptoms but to pervasive internal conflicts or derailments of normal childhood development. These were typically understood as weaknesses of character or willful deviance, and were distingished from neurosis or psychosis. The term 'borderline' stems from a belief that some individuals were functioning on the edge of those two categories, and a number of the other personality disorder categories were also heavily influenced by this approach.[24]
Meanwhile, German psychiatrist Kurt Schneider was popularising the use of the term 'personality' in a broad sense, in place of the then more usual terms 'character', 'temperament' or 'constitution'. Academic work in psychology was also addressing personality, developing theories of different types or dimensions.
American psychiatrists officially recognised concepts of personality disorders in the first Diagnostic and Statistical Manual of Mental Disorders in the 1950s, which relied heavily on psychoanalytic concepts. Somewhat more neutral language was employed in the DSM-II in 1968, though the terms and descriptions have only have a slight resemblance to current definitions. The DSM-III published in 1980 made some major changes, notably putting all personality disorders onto a second separate 'axis', intended to signify more enduring patterns, distinct from what were considered axis one mental disorders. In addition, the categories were given more specific 'operationalized' definitions, with standard criteria that psychiatrists could agree on in order to conduct research and diagnose patients.[25]
International differences have been noted in how attitudes have developed towards the diagnosis of personality disorder. Kurt Schneider had argued that they were simply 'abnormal varieties of psychic life' and therefore not necessarily the domain of psychiatry, a view said to still have influence in Germany today. British psychiatrists have also been reluctant to address such disorders or consider them on a par with other mental disorders, which has been attributed partly to resource pressures within the National Health Service, as well as to negative medical attitudes towards behaviors associated with personality disorders. In the US, the prevailing healthcare system and psychanalytic tradition has been said to provide a rationale for private therapists to diagnose some personality disorders more broadly and provide ongoing treatment for them.[26]
In the past, patients suffering from severe epileptic seizures would have their corpus callosum severed thus splitting the connection between their right and left cranial hemispheres. This in turn created a communication disrupt between the two hemispheres and so two or in some cases more personalities seemed to emerge. This was called "Split personality disorder". It involved the non-dominant hemisphere having a "mind" of its own. Some patients have reported cases of their left hand freely choking people while their right hand, by their will, tries to save them.[3]
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