Assignment: Diagnosing Personality Disorders

Assignment: Diagnosing Personality Disorders

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A special caution is in order regarding the diagnosis of personality disorders because more misdiagnoses probably occur here than in any other category of disorder. There are a number of reasons for this. One problem is that diagnostic criteria for personality disorders are not as sharply defined as they are for most other diagnostic categories, so they are often not very precise or easy to follow in practice. For example, it may be difficult to diagnose reliably whether someone meets a given criterion for dependent personality disorder such as “goes to excessive lengths to obtain nurturance and support from others” or “has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.” Because the criteria for personality disorders are defined by inferred traits or consistent patterns of behavior rather than by more objective behavioral standards (such as having a panic attack or a prolonged and persistent depressed mood), the clinician must exercise more judgment in making the diagnosis than is the case for many other disorders.

With the development of semistructured interviews and self-report inventories for the diagnosis of personality disorders, certain aspects of diagnostic reliability increased substantially. However, because the agreement between the diagnoses made on the basis of different structured interviews or self-report inventories is often rather low, there are still substantial problems with the reliability and validity of these diagnoses (Clark & Harrison, 2001 ; Livesley, 2003 ; Trull & Durrett, 2005 ). This means, for example, that three different researchers using three different assessment instruments may identify groups of individuals with substantially different characteristics as having a particular diagnosis such as borderline or narcissistic personality disorder. Of course, this virtually ensures that few obtained research results will be replicated by other researchers even though the groups studied by the different researchers have the same diagnostic label (e.g., Clark & Harrison, 2001 ).

Given problems with the unreliability of diagnoses (e.g., Clark, 2007 ; Livesley, 2003 ; Trull & Durrett, 2005 ), a great deal of work over the past 20 years has been directed toward developing a more reliable and accurate way of assessing personality disorders. Several theorists have attempted to deal with the problems inherent in categorizing personality disorders by developing dimensional systems of assessment for the symptoms and traits involved in personality disorders (e.g., Clark, 2007 ; Krueger & Eaton, 2010 ; Trull & Durrett, 2005 ; Widiger et al., 2009 ). However, a unified dimensional classification of personality disorders has been slow to emerge, and a number of researchers have been trying to develop an approach that will integrate the many different existing approaches (e.g., Markon et al., 2005 ; Krueger, Eaton, Clark et al., 2011a ; Widiger et al., 2009 , 2012 ).

The model that has perhaps been most influential is the five-factor model. This builds on the five-factor model of normal personality mentioned earlier to help researchers understand the commonalities and distinctions among the different personality disorders by assessing how these individuals score on the five basic personality traits (e.g., Clark, 2007 ; Widiger & Trull, 2007 ; Widiger et al., 2009 , 2012 ). To fully account for the myriad ways in which people differ, each of these five basic personality traits also has subcomponents or facets. For example, the trait of neuroticism is comprised of the following six facets: anxiety, angry-hostility, depression, self-consciousness, impulsiveness, and vulnerability. Different individuals who all have high levels of neuroticism may vary widely in which facets are most prominent—for example, some might show more prominent anxious and depressive thoughts, others might show more self-consciousness and vulnerability, and yet others might show more angry-hostility and impulsivity. And the trait of extraversion is composed of the following six facets: warmth, gregariousness, assertiveness, activity, excitement seeking, and positive emotions. (All the facets of each of the five basic trait dimensions and how they differ across people with different personality disorders are explained in Table 10.2 on p. 335.) By assessing whether a person scores low, high, or somewhere in between on each of these 30 facets, it is easy to see how this system can account for an enormous range of different personality patterns—far more than the 10 personality disorders currently classified in the DSM.

Within a dimensional approach, normal personality trait dimensions can be recast into corresponding domains that represent more pathological extremes of these dimensions: negative affectivity (neuroticism); detachment (extreme introversion); antagonism (extremely low agreeableness); and disinhibition (extremely low conscientiousness). A fifth dimension, psychoticism, does not appear to be a pathological extreme of the final dimension of normal personality (openness)—rather, as we will discuss later in the chapter in the section on schizotypal personality disorder, it reflects traits similar to the symptoms of psychotic disorders (e.g., schizophrenia) (Watson et al., 2008 ).

With these cautions and caveats in mind, we will look at the elusive and often exasperating clinical features of the personality disorders. It is important to bear in mind, however, that what we are describing is merely the prototype for each personality disorder. In reality, as would be expected from the standpoint of the five-factor model of personality disorders, it is rare for any individual to fit these “ideal” descriptions. And, as the Thinking Critically About DSM-5 box below illustrates, this situation will not change in DSM-5.