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The DSM-5 Gets Personal



If we can't get a precise fix on personality, can we at least come up with a credible approximation?

by John McManamy


The DSM-5 and personality. The following is a highly condensed version of three articles that appear in the DSM-5 section of mcmanweb. These articles- beginning with Emphasis on Disorder - go into a lot more detail, but this will give you the gist of the issues the DSM-5 (due out in 2013) was dealing with in proposing sweeping changes to the various personality disorders diagnoses ...

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The Disorder in Personality Disorder

Basically, it seems we know a narcissist or someone with antisocial or borderline when we see one, sort of, until we start digging deeper. Then we find ourselves in a thicket of overlapping and interchangeable symptoms. Thus, for antisocial and borderline, respectively:

"Irritability and aggressiveness, as indicated by repeated physical fights or assaults."

"Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)."

Then there is the narcissist living in a world of self-delusion ("believes that he or she is 'special' and unique"), but so is someone living with borderline ("alternating between extremes of idealization and devaluation").

Then there there is the matter of runaway emotion:

"Impulsivity in at least two areas" (borderline), "impulsivity or failure to plan ahead" (antisocial), "often envious of others" (narcissistic).

Or it could be a deficit of emotion:

"Chronic feelings of emptiness" (borderline), "lack of remorse, as indicated by being indifferent ..." (antisocial), "lacks empathy" (narcissistic).

True, so-called "normal" people have their bad moments, as well. But in a reasonably operational brain, the thinking areas pick up that something is amiss, and we work at changing our behavior. With personality disorders, we're dealing with "a pervasive pattern" rather than a mere episode. Again and again, the individual fails to come to terms with his or her thoughts and actions. Thus:

"Preoccupied with fantasies ..." (narcissistic), "rationalizing having hurt ..." (antisocial), "paranoid ideation" (borderline).

Avoid these people like the plague, you think. Not so fast. If you happen to believe that the narcissist in your presence walks on water, then the two of you will get along just fine. Conversely, someone with borderline may think it is you who walks on water (and who are you to question his or her good judgment?).

Inevitably, though, reality intervenes, and there you are left to pick up the pieces, humiliated, mystified, violated, abused, jilted, duped, conned, and perhaps much worse. These people definitely need therapy, but - thanks to them - you may need it more. But where does the therapist start?

Diagnostic psychiatry can no more explain the reality of personality than theology can explain God. At best, psychiatry (and theology) can come up with an approximation of reality, based on what we know at the time. Clearly, a better approximation is needed. The people working on the DSM-5 recognized that, too.

In the one thing those charged with the DSM-5 did right, personality disorders will receive a major overhaul. Not coincidentally, this is the one realm of mental illness where big pharma is conspicuously absent.

In its background papers and rationale, the APA and the DSM-5 group note that separating out personality into discrete illnesses has generated no end of clinical confusion. Is someone who abruptly breaks off a friendship, for instance, an "antisocial" with no remorse, a "borderline" who can't cope, a "histrionic" overdoing it, or a "narcissist" who cares only about him or herself?

Personality - Categories

Four of the ten current personality disorders will be axed, leaving clinicians to decide between the disorders left standing: "antisocial", "avoidant", "borderline", "obsessive-compulsive", "schizotypal", and "narcissism", plus a catch-all "personality disorder trait-specified". But will they be happy making their choices?

The old (and still current system) of DSM personality disorders was only useful in sorting out the obvious (such as green from blue) but of very little value where the colors blended.

The new (and future) system acknowledges the overlap, but puts the reader on notice that the personality loading is quite different. Thus, the new borderline diagnosis is weighted with "negative emotionality" trait domain symptoms (such as "emotional lability") while the new antisocial comes heavily laden with "antagonism."

So what are we looking at? The first version of the DSM-5 offers an insight:

Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual's cultural norms and expectations.

This harkens back to the Freudian-influenced DSM-I of 1952 and the DSM-II of 1968 when even the likes of schizophrenia were seen as maladaptations to one's environment. The DSM-5 revives the idea of maladaptation, but dials it back to personality disorders. In other words, personality type is a tip-off to our default protection mechanisms.

Do we, for instance, try to dominate those around us? (Antisocial.) Or do we freak out and lose it? (Borderline.) Or do we withdraw into a comforting cocoon? (Avoidant.) Maybe we look for order where none exists. (Obsessive-compulsive.) Perhaps we harbor unusual perceptions of reality. (Schizotypal.) Or maybe we find it easier to navigate our personal universe by placing ourselves at the very center. (Narcissism.)

Meanwhile, we all have personality in abundance and come preloaded with all manner of quirks and flaws. We may be successful adapters, but - trust me - we will all see a bit of ourselves in the DSM looking glass. In this sense, we are likely to get more out the DSM-5 than our clinicians.

Personality - Dimensions

The dimensional view acknowledges the complexity and subtlety of personality. Instead of asking "which one?" at the expense of ignoring whatever else may be going on, a clinician would be asking "how much" and "how severe?" In a sense, psychiatry is bringing back neurosis, but with some important refinements.

Thus, in considering a personality disorder diagnosis, the DSM-5 would urge clinicians to measure for levels of impairment and functionality to distinguish a "good prognosis" patient from a someone with far more serious challenges. (The DSM-5 gives the example of a woman with an unstable self-image and difficulty maintaining relationships who is nonetheless holding down a very good job.)

Likewise, an individual may not technically meet the criteria for a full-blown diagnosis, but may require clinical attention, nonetheless. (The DSM-5 gives the example of a man who uses drugs and has run-ins with the law.)

Or the situation may call for wait-and-see (such as a teen-age girl acting out).

This may not be a perfect system, and already a predictably rotten tomato review has come in from Allen Frances, head of the criminally horrendous DSM-IV, who has characterized the DSM-5's second take on personality disorders as “an impossible mess to the rest of us.”

Dr Frances may well be right, but for all the wrong reasons. Dr Frances has indicated in all his DSM-5 writings to date that he sees himself as merely as the keeper of his precious DSM-IV, which is a very different proposition than lending his professional wisdom to improving the lives of those dealing with serious personality issues. In the final analysis, any attempt to pin down something as infinitely complex as personality is doomed to be flawed. Success, then, is modest, to be measured in terms of less flawed than the effort before.

Could the DSM-5 have done a better job? Of course it could have. Is the version it turned in way better than the sorry DSM-IV mess that Dr Frances is so in denial about? Don’t make me answer that.

Personality is fiendishly time-consuming and complex. Clinicians want it quick and simple. But what about our interests?

For more detail, check out the three articles on which this article was based, beginning with Emphasis on Disorder.

May 26, 2011, updated Oct 13, 2011

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