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What Are Personality Disorders? A Broad Introduction
Abnormal Psychology · Chapter 22: Personality Disorders: Rigid Patterns That Impair FunctioningSection 22.1 · lesson 84 of 9713 min · free with a free account
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In this lesson
Contested categories, enduring patterns, and better prognosis than once believed.
- Define personality and personality disorder, and separate traits from states
- Describe the general requirements, the clusters, and the dimensional model
- Explain the controversies: stigma, stability, and cultural and gender bias
- Describe assessment as formulation, and correct treatment pessimism
Transcript
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Personality Disorders: Rigid Patterns That Impair Functioning
What Are Personality Disorders?
Chapter twenty-two covers personality disorders. This first section is a broad introduction. We define personality and personality disorder, and separate traits from states. We look at the general requirements, the three clusters, and a dimensional alternative. And because these are among the most contested diagnoses in the classification, we take the controversies seriously, and finish with assessment and treatment.
Before You Begin
Clinical Descriptions, Not Labels
This material is educational and clinical. It is not a basis for self-diagnosis, or for diagnosing anyone else, including people you find difficult. The terms in this chapter are clinical descriptions, arrived at through careful assessment over time. They are not labels for a colleague, a relative, or a public figure. Some viewers may find this material personally affecting. If that is you, please speak with a qualified professional.
Beginning With the Controversy
Among the Most Contested Categories
Most chapters introduce conditions first, and address criticisms later. This one begins with the criticisms, because here they are not marginal. Personality disorder diagnoses are among the most contested categories in the classification. They have been used pejoratively, by clinicians as well as the public. People who receive them report worse treatment from services, and that is documented. It shows up in access to care, in staff attitudes, and in whether a person's distress is taken at face value. Three statements follow, and should be held throughout. A personality disorder diagnosis is not a statement about a person's worth. Describing someone as a difficult personality is not a clinical formulation, and using diagnostic terms as insults is inaccurate and harmful. And the historical pessimism, that these conditions were permanent and untreatable, is not supported by the evidence.
Personality
Traits, States, and Behavior
Personality is the enduring pattern of how a person perceives, thinks about, and relates to themselves and their world, expressed consistently across many situations. Three terms need separating. A trait is a stable disposition across situations and time. A state is a temporary condition, like a mood episode. And behavior is what a person does on one occasion, which may reflect a trait, a state, or just the circumstances. Confusing these is the central assessment problem in this area. Ordinary personality varies along five broad dimensions. Openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. They are continuous. Everyone sits somewhere on all five, and both ends of each are neutral descriptions. A high or low score on any dimension is not a disorder.
What Makes a Pattern Disordered
6 General Requirements
All personality disorder categories share six general requirements, described here by function. The pattern is inflexible, applied whether or not it fits, with few alternatives. It is pervasive, across many situations, not one relationship. It is stable over time, which is the requirement most in tension with the evidence. It deviates markedly from cultural expectation. It began by adolescence or early adulthood. And it causes clinically significant distress or impairment, which is what separates a difficulty from a disorder. The cultural requirement deserves a flag. It is the one most open to misuse, because it invites a clinician to record their own cultural expectations as a clinical finding. A pattern unremarkable in one context can look deviant to a clinician who does not share it. The requirement exists to prevent culture-blind diagnosis, and it is often used to do the opposite.
Trait Versus State
The Central Assessment Problem
Here is the central assessment problem. A person in an acute depressive episode may look withdrawn, dependent, pessimistic, and unable to decide. A person in an anxious period may look avoidant and inhibited. A person in a manic or psychotic episode, or during heavy substance use, may look like several personality disorders at once. None of these presentations tells you anything about the enduring pattern. Personality disorder cannot be validly assessed at that moment. So assessment needs longitudinal history, across years rather than weeks, and often collateral information. And it should wait until acute conditions are stabilized. Services without time for this often make the diagnosis anyway, which is one source of its unreliability.
Figure 22.1.2
A Persistent Pattern and an Episodic One
Here is the problem in one picture. Two people, followed over years. One has a persistent pattern, fairly constant over time. The other has an episodic condition, with periods of marked difficulty, and recovery between them. Now look at the single snapshot, the dashed line. At that moment, the episodic line is higher than the persistent one. At other moments, the two are indistinguishable. Only the shape across years separates them. That is why longitudinal information is a requirement, not a refinement.
Ego-Syntonicity
People Present for a Consequence
These patterns are often ego-syntonic, experienced as an ordinary part of who one is, rather than as symptoms of something. So people do not usually arrive saying, that their way of relating to others has been consistent and costly since adolescence. They arrive because of a consequence. A relationship has ended, a job has been lost, or a co-occurring condition has become intolerable. The personality pattern is found during assessment of something else, or not at all. But this is a generalization, and should be handled as one. Many people with these diagnoses are acutely aware of their patterns, and acutely distressed by them. Assuming a person is untroubled by something they have not named is itself a clinical error.
Table 22.1.3
3 Clusters - and a Categorical Model Under Strain
The categories are grouped into three clusters, on descriptive grounds. Cluster A is odd or eccentric, with paranoid, schizoid, and schizotypal personality disorders. Cluster B is dramatic, emotional, or erratic, with borderline, antisocial, narcissistic, and histrionic. Cluster C is anxious or fearful, with avoidant, dependent, and obsessive-compulsive. The grouping is convenient, but it has limited empirical support. The clusters do not hold together well statistically. They are kept largely because they organize a long list. And people who meet criteria for one personality disorder commonly meet criteria for several. That is a finding about the categories, not the people. The categorical model has five problems. Thresholds are arbitrary. Two people with the same diagnosis may share few features. Categories overlap heavily. Coverage is poor, with heavy use of unspecified categories. And stability is limited, which is the most serious problem of the five.
Table 22.1.4
The Dimensional Alternative
A dimensional alternative was developed in response. Instead of sorting a person into categories, it rates the level of impairment in self and interpersonal functioning. Then it describes a profile across pathological trait domains, which map onto the five dimensions. It was placed in the manual's section for conditions needing further study, rather than adopted. In its favor, it fixes the threshold, heterogeneity, overlap, and coverage problems at a stroke, and connects clinical description to personality research. Against it, it is more complex to apply, and decades of literature and service structures are organized around the categories. Notice that most of the categorical model's advantages are practical, and most of the dimensional model's are conceptual. And the international classification has now moved to a dimensional approach, making this a live experiment.
Stability and Its Consequences
More Change Than the Definition Assumed
The definition requires stability over time. Longitudinal research has found substantially more change than that assumed. Many people who meet criteria at one point no longer do some years later, across categories. So prognosis is better than historical pessimism suggested, and people receiving these diagnoses should be told that. They are often told the opposite. And a category defined by stability, that turns out not to be stable, has a problem in its definition. The diagnosis also changes the care people receive, in specific ways. Distress is more often attributed to personality, rather than assessed. Pejorative terms appear in notes. People are excluded from services on the basis of the diagnosis, and less often treated for co-occurring conditions. What reduces this is not exhortation but structure. Staff training, explicit policies against exclusion, and supervision that treats language as a supervisable matter.
Development, Age, Culture
Multi-Determined - and Not About Blame
The origins are multi-determined. Temperament, with a heritable contribution, is present early. Early relationships shape how a person expects others to behave. And adversity raises risk. Several routes lead to similar patterns, and similar starts lead to several outcomes. One thing must be stated without hedging. A diagnosis is not an account of blame, and families are not the cause of these conditions. Older clinical writing implied otherwise, and did lasting damage. Diagnosis in adolescence is genuinely disputed. For it, the patterns are identifiable earlier, and withholding a diagnosis can withhold effective treatment. Against it, personality is still developing, the stability evidence is weakest at this age, and a stigmatized label may outlast the pattern it describes. These diagnoses are also applied differentially across gender, culture, and class. Explanations include differences in adversity, expression, and presentation, and clinician judgment. And several criteria encode culturally particular expectations, about independence, emotional expression, and ambition. Distance from the clinician's norm can be recorded as pathology.
In the Clinic
Formulate a Pattern, Don't Label a Person
Here is the difference between labeling and formulating. Two notes can describe the same person. The first reads, difficult, non-engaging, likely personality disorder. The second describes someone who learned early that expressed need was not met. So they expect services to withdraw, they test that expectation, and they withdraw first when it seems confirmed. The first note tells the next clinician how to feel about the person. The second tells them what to do. Be predictable, name the pattern openly, and do not withdraw. The difference is not tone. It is whether the note contains any clinical information at all.
Assessment and Treatment
Formulation, and Real Treatments
Good assessment here has four components. Longitudinal history, covering years rather than the current episode. Collateral information, where the person consents. Assessment once acute conditions are stabilized. And structured approaches, which improve reliability over unstructured judgment. The goal is a formulation, an account of how the pattern developed, what maintains it, and what it costs the person. A label answers what to call something. A formulation answers what to do. And these conditions were long considered untreatable. That view is no longer supported. Specific evidence-based treatments exist, especially for borderline presentations. The evidence is thinner for other categories, and thinnest for Cluster A. Correcting the assumption matters, because a clinician who believes treatment is futile will not offer it.
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