Controversial Ideas in Medicine

Overview

Generally speaking, we can split psychiatric diagnoses in the following way:

1. Axis I: major psychiatric disorders such as schizophrenia, depression, anxiety, autism, substance abuse disorders, attention deficit disorder, delirium
2. Axis II: disorders of personality
3. Axis III: medical (read: biological) diagnoses which contribute psychologically, such as thyroid disorders, cancers, etc
4. Axis IV: psychosocial support network
5. Axis V: global assessment of function score (0-100, 0 = death, 100 = fully functional)

What is a disorder of personality? How can you have a disordered personality as such? Simply put, a personality disorder occurs when someone has:

• A stable, ongoing pattern of behaviour, thoughts, emotions and social function (since adolescence or early adulthood)
• That differs markedly from the cultural norm
• Causes significant social/occupational/functional impairment or distress
• And is not better accounted for by another mental, medical disorder or substance use

So, that asshole who antagonises every client without fail and gets constant complaints about him? The 30 year old drama queen (male or female) who is always full of gossip and never seems particularly sincere? The suspicious weird old lady down the street who everyone is convinced is a witch? That guy at work who always lets everyone walk all over him? That needy, intense woman who stalks her exes? These are examples of potential personality problems. It is their personality, the exaggerated nature of their behaviour, emotions, thoughts, interactions that is at fault. This is not to say that personality is not something which has a great deal of normal individual variation. All the above four features need to be fulfilled for this to be a personality disorder. Simple eccentricity, oddness, quirkiness or other differences are not a disorder- for something to be a personality disorder it needs to cause some sort of ongoing functional impairment or distress. Nor does it mean that someone with a personality disorder is incapable of future functionality because it is their intrinsic personality which is problematic- it is certainly quite possible for someone to moderate their behaviour, thoughts, emotions.

"Everyone has a personality with character traits such as stinginess, generosity, arrogance and independence. But when these traits are rigid and self-defeating, they may interfere with functioning and even lead to psychiatric symptoms. Personality traits are formed by early adulthood, persist throughout life and affect every aspect of day to day behavior. Individuals with personality disorders often blame others for their problems."

-BehaveNet.com In addition, they may find some difficulties with their attachment styles.

The Clusters

Cluster A

Cluster A can be considered the "aloof, suspicious" group. They have in common propensities to some of the "negative" symptoms of schizophrenia - ie social withdrawal, suspiciousness, flattened emotions etc.

Paranoid Personality Disorder

This personality disorder is exactly what it says on the packet; it is characterised by an excessively suspicious, paranoid nature. People who suffer from this tend to be constantly questioning others' motives and see others as a threat. They are preoccupied with ideas of lack of loyalty and others' trustworthiness. They also bear grudges strongly and tend to take offence easily as they believe others to be attacking them.

Schizotypal Personality Disorder

Schizotypal personality disorder is what can almost be considered to be part way on the spectrum of schizophrenia itself (though much milder). In fact, family members of people with schizophrenia and related disorders are much more likely to have this personality disorder. It is a disorder which is in fact characterised by the less paranoid and more, well, odd features of schizophrenia - albeit without being floridly psychotic. This includes- eccentric behaviour, speech and ideas, belief in magical and superstitious things, paranoia, social anxiety and a withdrawn nature, flattened emotions.

Schizoid Personality Disorder

These people tend to be socially uninterested and somewhat indifferent. They do not really miss the lack of social closeness with others, nor the variety of experiences. Praise and criticism does not really affect them. They seem somewhat aloof, but not because of nervousness, just because of a very solitary nature.

Cluster B

Cluster B personality traits are characterised by extroverted, emotionally unstable and often anxious and/or aggressive behaviour. In addition, there are often distortions of self-esteem, self-identity and impaired empathy.

Psychopathy

Psychopathy is a disorder which was previously included in the DSM in place of the rather contentious and amorphous Antisocial Personality Disorder. There are said to be two major trait factors involved in psychopathy. Factor 1, "Aggressive Narcissism", connotes the selfish, remorseless, callous, charming, grandiose, shallow, flirtatious traits. Factor 2, "Socially Deviant Lifestyle" connotes the emotionally unstable, antisocial, violent, deviant, impulsive, parasitic, delinquent, stimulation-seeking traits. Thus, psychopaths lack empathy, are emotionally labile and generally superficially charming, very manipulative and guilt-free; they are impulsive, irresponsible, uncontrolled, hedonists. This category overlaps with both Narcissistic, histrionic personality disorders and Antisocial personality disorder.

Narcissistic Personality Disorder

Once again, the narcissist is what the label says. They are egocentric and believe they are self-important, unique, special and worthy of special treatment and rewards. They are obsessed with fantasies of power, success, beauty; they are manipulative, lack empathy, are arrogant and fluctuate between envy and the belief that everyone wants to be just like them.

Histrionic Personality Disorder

Histrionic means what most people think of as "hysterical"- these are what most would term the "drama queen". Attention-seeking, flirtatious, shallow, dramatic, with swinging moods and a bit, well, intense. Larger than life, and quite full-on.

Antisocial Personality Disorder, Conduct Disorder

Antisocial Personality disorder encompasses 2 main types of traits- the psychopathic traits as defined above as well as criminality. Needful to this diagnosis is also the diagnosis of Conduct Disorder, the juvenile equivalent of this disorder. Conduct Disorder has several categories of behaviour: aggression to people and animals; destruction of property; lying/theft; serious violations of parental rules.

Borderline Personality Disorder

Borderline personality disorder is a very overrepresented category of person who presents to hospitals, in particular to emergency departments. These people are strange cookies, and it is very likely you have met at least one- it is a fairly common disorder with an incidence of roughly 2%. BPD involves very unstable relationships, self-image, emotions and very impulsive behaviour. They are clingy and needy as they are constantly in fear of being abandoned. They alternately idolise and demonise people, often rapidly. They have little sense of who they are and think of themselves often as an empty void. They very often self-harm, threaten and attempt suicide - often as a response to their extreme anxiety. Their moods swing violently; they are often uncontrollably angry and sad. They do impulsive things, including self-destructive sexual relationships, gambling, spending. Under extreme circumstances they can become paranoid or even have anxiety related dissociation.

Cluster C

These are the anxious personality disorders. People who have always been a bit nervous. One can think of these disorders almost as the over-controlled, introverted counterparts to the Cluster B disorders.

Avoidant Personality Disorder

These people are inhibited, inadequate and over-sensitive to criticism and have poor self-esteem. In an attempt to avoid censure, rejection, embarrassment, they avoid social contact, relationships, any sort of risk. They believe themselves to be inferior, unappealling, inept, unloveable. They are shy.

Dependent Personality Disorder

Dependency in this case comes from a need to be taken care of, inability to make one's own decisions and fear of being left alone. There is difficulty making decisions without reassurance, advice; a need for others to take responsibility; inability to start things without others' support; neediness, passivity and submissive behaviour due to fear of rejection if they are assertive; fear of being alone and need for a constant relationship.

Obsessive-Compulsive Personality Disorder

OCPD is what the lay person may think of as an obsessive-compulsive person. Someone who is anally retentive, obsessed with organisation, perfection, lists, rules, work, productivity, morality. They are rigid, perfectionistic, can be miserly and sometimes even hoard things.

Passive-Aggressive Personality

This is sometimes included as part of Cluster C. Passive-aggressive people are unassertive and have difficulty expressing anger. As a result, they are resentful, sullen and express their anger through passive forms such as inviting criticism, performing poorly, being obstructive.

Not Otherwise Specified

Yes, they meet the criteria for a personality disorder but it does not fall neatly into a category, or is undefined by the above clusters. While people may fit easily into a personality disorder category, it is sometimes more useful to conceive of personalities as containing personality traits, cluster traits or similar.