Consult-Liaison Education Medicine

Personality Disorders (I).

I’ve been asked to give a talk about personality disorders.[1. Writing about personality disorders here, I hope, will help me organize my talk and post more frequently.]

It’s akin to being asked to give a talk about cookies. (Do I discuss the distinctions between bar, drop, and sandwich cookies? Do people want to hear about the varieties of butter, fruit, and nut cookies? Should I compare cookies with other confections? What about the term “biscuit”?)

I suspect that part of the reason why I find the breadth of the subject daunting is because I’ve never given a talk on personality disorders. (I also prefer teaching certain topics, such as schizophrenia and suicide risk assessment. My training in dialectical behavior therapy (DBT), though, has helped me craft talks about difficult interactions with clinical settings and borderline personality disorder. DBT has also significantly influenced my clinical practice; I am grateful for the opportunity to learn about this early in my training.)

DSM-4[2. Yes, DSM-5 is now out—I am already behind.] provides the following criteria to define a personality disorder:

A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture.

Personality disorders account for culture. This is why, in the United States, it is not considered aberrant when someone goes to church every Sunday because he believes that a crucified man was resurrected from the dead after three days in a tomb.

This pattern is manifested in two (or more) of the following areas:

Someone once commented that these diagnostic criteria are something like “ordering from a Chinese menu”. (No comment.)

(1) cognition (i.e., ways of perceiving and interpreting self, other people, and events)

“Cognition” can be summarized as “thoughts”.

(2) affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response)

“Affectivity” can be summarized as “emotions”.

(3) interpersonal functioning

This refers to relationships (both “deep” and “not so deep”).

(4) impulse control

… or, “What someone does when they feel an urge: can he sit with it? does she feel compelled to react immediately? if she does react, what is the reaction?”

To be clear, just because someone waits a while before demonstrating a reaction to an event does not necessarily mean that his impulse control is “good” (consider someone who reacts by planning and then executing a murder).

B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.

This is how one of my teachers impressed this criterion upon me: Most of us have all of the personality disorders, not just one of them. This means that we have a variety of ways (thoughts and behaviors) of coping with stress. This suggests healthy coping.

If, for example, I hear bad news, I might go for a walk, spend time with friends, or eat a sack of cookies.

If my sole coping skill consisted of eating sacks of cookies at home, at work, with friends, and by myself, that could suggest an inflexible and pervasive pattern.

C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The act of eating sacks of cookies probably won’t get me into too much trouble. If, however, I only talked about cookies, kept five sacks of cookies underneath my pillow “just in case”, insisted that my employer pay me in sacks of cookies, and refused to go out with my friends unless they took me to a bakery, that would probably lead to “significant impairment” in multiple areas of my life.

D. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.

This is why we generally avoid a diagnosis of a personality disorder until someone is at least 18 years old, though brain “maturity” may not actually occur until someone is closer to age 25.

Some psychiatrists insist that they can diagnose a personality disorder after meeting someone once. I disagree.

E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.

If someone’s thoughts and behaviors are most consistent with a diagnosis of schizophrenia, then diagnoses of schizoid, paranoid, and schizotypal personality disorders do not apply.

F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma).

A psychiatrist’s primary job is to rule out medical causes of a condition that appears psychiatric. (That is often easier said than done.)

If that is the general definition of a personality disorder, what about specific personality disorders? Should I discuss personality disorders discussed in ICD-10? What about the personality disorders described in previous editions of the DSM? (Only four have been present across all four editions of the DSM.) Where is the balance between theory (what the conditions are) and application (the function of the behaviors and how to work with people who have these conditions)?