Saturday, February 18, 2017

Portrait of a Personality Disorder, Part 1: What Is a Personality Disorder?

Can a personality be an illness?

Well, not exactly.  Everyone has a unique personality.  And, some are more likable than others, I suppose, but when and how is it appropriate to slap the "disorder" label on someone's personality?

In answering this question, it is important to understand that all mental disorders, including severe disorders such as schizophrenia, are defined by behaviors and/or inner states that cause distress or dysfunction for the individual or for people around them.  This concept is true of the larger medical field, as well.  Take for instance the individual with six digits on each hand.  It is an unusual condition, yes, but do we consider it an illness?  No, nor should we (unless of course, having six fingers is excessively distressing and dysfunctional or you simply want to say it is so the insurance will pay for surgical "correction," but that's a wholly different blog post, for another day).  On the other hand, being born with the inability to produce blood clotting components is considered a disease for the simple fact that it will lead to a quick demise unless treated.

Biologically, every individual is unique, and the human population presents a vast range of phenotypes.  Disease cannot be defined by deviation from the norm, alone, but must be defined by impact, dysfunction, pain and death.  This is even more true with mental disorders.  We cannot pathologize based on what looks different or anormative, alone.  We have to limit our determination of disorder to the impact of behaviors and inner states, i.e., distress and dysfunction.  And, this is even more important when discussing the pathology of personalities.  Why?  Because, it is far too tempting for us to label people we don't like or don't understand as disordered.

According to the American Psychiatric Association (APA) in the latest diagnostic manual (DSM 5), "A personality disorder is an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment" (emphasis mine).

This definition attempts to limit the idea of personality disorder within strict parameters, but let's face it, it's still wide open.  The DSM 5, like its predecessor, the DSM IV TR, then goes on to list 10 specific personality disorders grouped into three clusters, A, B, and C, and an eleventh, "unspecified" personality disorder for personalities that meet the general definition but do not meet criteria for any one of the 10 specific disorders.  Lastly, there is a disorder for personality change due to a medical condition.

Personality disorders carry some controversy in the field and some clinicians simply refuse to acknowledge them or diagnose them, but this is the minority of clinicians, I think.  I too was very skeptical as a new clinician, but over two decades of working with a wide variety of clients, I have come to recognize there really are some distinct patterns of personality dysfunction and pathology, and it does us no good to pretend it does not exist.

Personality disorders are categorically distinguished from major mental illness.  This idea goes back a ways, well before Freud, even.  The personality disorder idea is the intellectual descendant of the concept of moral insanity.  This was a diagnostic category proposed in 1835 by a certain Dr. Prichard.  He defined it as "madness consisting in a morbid perversion of the natural feelings, affections, inclinations, temper, habits, moral dispositions, and natural impulses, without any remarkable disorder or defect of the interest or knowing and reasoning faculties, and particularly without any insane illusion [delusions] or hallucinations."  It remains an important distinction that personality disorders are defined by cognitive distortions and aberrant behaviors and emotions as opposed to cognitive impairment or delusions or hallucinations as these are indicative of major mental illness.

Well, there's a nice little overview.  Not too boring I hope.  In the next installment, we will take a big bite into Cluster B types and figure out why they leave such a bad taste in your mouth.  Then, we'll examine what we mean by cognitive distortions and why it leaves you wondering if you're the crazy one.  Finally, we will narrow our focus on narcissists and what you can do when your family member, or your boss, or your president has this personality disorder.

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