Diagnosing Personality Disorders

Personality DisordersDuring previous years, it may have been that the differential diagnosis of specific personality disorders mattered only slightly, as clinicians did not find such a guide useful for diagnosing individual patients; however, research has proven the significance in clinical course and prognosis of the several different personality disorders.[1] It has been stated that the separate categories have also allowed for improved research on therapeutics. A controversial issue with the upcoming DSM-5, clinicians and researchers view personality disorders different from one another. While clinicians would like a system that is practical and suited for real-world situations, researchers would like a system that acquires the most information and separates it with specific categorical boundaries.1

Westen and colleagues have introduced a system they have developed which bridges both science and practice—a taxonomy, as they call it.[2] It is the most recent study in a 15-year program of research, one in which they argue personality disorders to be primarily clinical concepts.2 Westen and colleagues state that the individual disorders are syndromes that include meaningful characteristics recognized as “syndromic entities,” not “collections of independent phenomena.”2 Their system includes prototypic descriptions of eight personality disorders, with two being “neurotic styles” and one being “personality health.”2 In order to develop these prototypic descriptions, Westen and colleagues studied the way clinicians conceptualize their patients. They developed a sample of clinicians, including both psychiatrists and psychologists, asking each to describe a patient (with personality problems) using items selected from a set, developed by Westen and colleagues.2 From there, clusters of symptoms were identified and descriptions of characteristics were formed, modifying the set.

Westen and colleagues report that their system is empirically derived, one in which Cornell University, Department of Psychiatry, Robert Michels, M.D. believes to be true—as true as possible. Michels states that there are three parts to their data: the patients, the clinicians, and the descriptive items.1 The patients chosen all had personality problems, and generally were viewed as “sicker” than other trials, which was not a bad thing. Michels does state that while the clinicians, the real research subjects, would always be contaminated by their own concepts and theories, Westen and colleagues did a nice job neutralizing the pool by including a wide variety of clinicians ranging from theoretical to professional backgrounds.1 Finally, the items were refined by the responses of the clinicians, including 200 items. Michels states that as long as Westen and colleagues use verbal reports of observations of psychological functioning, he agrees the study is empirically derived.1

Outside criticism of Westen and colleagues’ study focuses on the fact that it is being conducted at all. One group of psychologists, who mainly focus upon personality traits of healthy subjects, state that personality is made up of multiple traits that are continuous and therefore best captured by a multidimensional system.1 They believe that categories are an unfortunate imposition, forcing biomedical concepts on a psychological area in which they do not belong.1 Westen and colleagues reply that trait psychology was developed for the study of normal personality and its results when applied to personality disorders are “clinically clumsy.”

Michels looks to assess how clinicians would respond to Westen and colleagues’ system by personally looking into its application and diagnostic prototypes.1 He states that while most seemed familiar to him, as well as user-friendly, he did find a couple of minor issues. First, Westen and colleagues included the schizoid-schizotypal category within the “internalizing spectrum.”1 Persons who fit this spectrum often “experience chronic, painful emotions, especially depression and anxiety.”1 However, interestingly enough, the schizoid-schizotypal individuals were described as having “a limited or constricted range of emotions”—it’s contradicting to have chronic emotions and constricted emotions at the same time.1 Second, the system describes hysteric-histrionic personality types to “tend to be suggestible or easily influenced by others.”1 Michels states that research explains the these patients are skillful when selecting who will make suggestions, in eliciting their own desired suggestions, and appearing to follow them.1 However, as clinicians’ understanding of these patients may come from misleading notions, the same notions will translate into the items included in the system.

While it is not surprising that clinicians and researchers differ in their stance for how personality disorders should be listed in the DSM-5, Westen and colleagues have provided an effective and clinician user-friendly strategy for consideration.1 However, it is up to the DSM-5 Work Group to make the final decision, resolving the tension that currently exists between clinicians and researchers, whose different goals call upon different ways to classify psychological diseases.1

[1] Michels, R. (2012, March 1). Diagnosing Personality Disorders. Am J Psychiatry 169(3): 241-243.

[2] Westen  D;  Shedler  J;  Bradley  B;  DeFife  JA:   An empirically derived taxonomy for personality diagnosis: bridging science and practice in conceptualizing personality. Am J Psychiatry 2012; 169:273–284.

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