The Ghost of Personality Disorders Future

Our current diagnostic criteria for personality disorders have failed to demonstrate validity or reliability.  The DSM 5 encouraged psychiatrists to start considering a broad range of personality features adapted from the Five Factor Model. These are combined with global functioning measures to build a personality inventory for any patient who is having dysfunction related to their personality.  Proposed criteria include a Personality Disorder - Trait Specified diagnostic category that permits diagnosticians to accommodate the new formulation.  Criterion A considers the salient aspects of personality functioning while Criterion B catalogs which of the Big 5 Factors are notably deranged.  Dr. O'Leary reviews the basics of these criteria and explores why our current formulations are in such dire need of reform.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.

Transcript

Welcome to PsyDactic, I am Dr. O’Leary and today I have been enjoying watching the snow melt after a week of sledding and hot chocolate. In this podcast, I explore topics in psychiatry and neuroscience.  I am currently in the last 6 months of my 4 year psychiatry residency, after which, well people will still call me doctor, but I’ll have a few more letters after my name.  I typically imagine that medical students, psychiatry residents, and fully grown psychiatrists are my target audience, but all are welcome.  I produce this podcast by myself in my free time, so be aware that the content is generated from my brain and not moderated or fact checked or approved by anyone but me.  Everything here is my opinion, right or wrong, for better or for worse, until I change my mind.

Recently I realized that of the 49 full episodes I have produced, I have neglected to touch much on personality disorders.  Part of this has been unintentionally intentional.  These diagnoses can be controversial, and have a mottled history in psychiatry.  As little as thirty years ago, a diagnosis of a personality disorder in military members with post-traumatic stress disorder resulted in many being discharged from the military without compensation or evaluation for disability.  This has since been changed, but the damage done in the past is not limited to members of the military.  Anyone not conforming to society's expectations, if one found oneself in front of a psychiatrist and was not psychotic, was likely to get diagnosed with a personality disorder.  This included anyone with a visible tattoo prior to the 1990s.

There are over 600,000 permutations of DSM 5 criteria that can result in a diagnosis of PTSD, and many of the criteria may mimic those of personality disorders.  In addition, complex PTSD or Developmental Trauma Disorder, can result in maladaptive personality features as a child grows in an unpredictable or abusive environment. I am reminded of an episode of Dan Carlin’s immensely popular podcast, Hardcore History, where he explores the conjecture that for the majority of human history, most people had personalities that were molded by traumatic experiences.  Maybe during many or most periods in the past, everyone had complex PTSD.

Today, though, I am not going into too much detail about how PTSD can be confused with a personality disorder.  Instead, I want to discuss how the criteria that we have used in the past have failed us, and what the writers of the DSM are trying to do about that.

Zimmerman et al 2019 in Current Psychiatry Reports, “[T]he assumption that PDs are categories is incompatible with most available evidence, the thresholds for defining the presence of a PD are largely arbitrary, and the assignment of individual PD symptoms to specific disorders does not correspond to their empirical covariation.”  That is a fancy way of saying that what we do is not very reliable or even valid.

To address this issue, the DSM 5 proposed a personality model that was based on a personality construct called the Five Factor Model or Big 5.  It consists of neuroticism, extraversion (vs. introversion), openness (or unconventionality), agreeableness (vs. antagonism), and conscientiousness (or constraint vs. disinhibition).  Another way to look at this is to group the factors as opposing traits, for example neuroticism could be characterized as affective instability vs. stability, extraversion can be contrasted with introversion, openness vs closedness or protectiveness, agreeableness vs antagonism.  Conscientiousness could be seen as thoughtfulness or constraint vs disinhibition or impulsivity.  Each of the big 5 has many dimensions that I will give at least some lip service to in this episode.

The DSM has adapted these traits and named them according to what psychiatrists might find clinically useful.  The DSM Big 5 are Negative Affectivity vs Emotional Stability, Detachment vs Extraversion, Antagonism vs Agreeableness, Disinhibition vs Conscientiousness, and Psychoticism vs. Lucidity.  The last, psychoticism is an approximation of unconventionality, where the person seems strange, odd, abnormal in their thinking or behaviors, compared with their cultural peers.  Being unconventional doesn’t necessarily correlate well with psychoticism though.  An unconventional person may be odd due to the fact that they are so much more intelligent than their peers.  Psychoticism is more related to a failure of discriminatory intellect, looseness of associations, and magical thinking.  These things are unconventional in a more disorganized way.

I mentioned that personality features tend to be stable over time, but I should point out that some of them are stably unstable, or their pathological variant only presents itself under certain conditions.  Think about someone whose mood is highly reactive to stress or who is detached when around strangers, but highly extroverted around trusted persons.

Before I go on, I don’t want the listener to get the impression that the opposing states any personality feature can take are meant to be some kind of good trait vs bad trait dichotomy.  Instead, any trait can be pathological.  Too much openness can result in a person being frequently taken advantage of or easily manipulated.  An impervious affect will hamper a person’s ability to relate to other humans.  Being too conscientious or thoughtful may result in difficulty making decisions.

The DSM 5 encourages psychiatrists to start considering these factors along with global functioning measures and build an inventory for any patient who is having dysfunction that is likely related to their personality.  They propose a Personality Disorder - Trait Specified diagnostic criteria in order to accommodate the new formulation.  Criterion A considers personality functioning while Criterion B catalogs which of the Big 5 Factors are notably deranged.

There is a table on page 775 of the DSM 5 that proposed a kind of rubric for identifying and rating Criterion A, the Level of Personality Functioning.  Without any notable dysfunction, gaining a full catalog of Criterion B would be an exercise in curiosity more than a clinically important task.

Personality function is divided into how someone operates internally and how someone deals with others in interpersonal interactions.  Self functions are divided into identity and self-direction.  Interpersonal functions are divided into empathy and intimacy.

Identity is described as whether someone is aware of a unique identity and has a realistic view of themselves.  Also assessed are their level of self-esteem and control over emotional states.  On the extreme end of a pathological self concept, a patient is almost entirely externally focused, feels no ability to direct their own actions, relies on others for assessments of oneself or has delusional self-appraisals.  Patients with severe identity disturbance tend to lack the ability to control their own emotions, which are entirely attributed to their current circumstances.  Without a sense of self, their only other option is to blame someone or something else.

Self-direction describes the ability of a patient to make and meet goals, adapt behaviors to a range of new contexts by applying socially appropriate standards, and have a meaningful internal dialogue regarding one's cognitive abilities and emotional control.  On the extreme pathological end, a person may have absent, incoherent, or unrealistic goals, act on thoughts with little ability to restrain oneself, and be unable to consistently apply reasonable, situationally appropriate standards to one's actions.  Someone without the ability for adaptive self-direction is motivated almost entirely by reactions to their external environment or current emotional state.

A patient’s capacity for empathy and intimacy are assessed in the interpersonal criteria.  Empathy versus sympathy is hard for me to define as I have encountered dozens of permutations of the difference between the two, so I have decided not to care which word is used and just figure out what someone is trying to get at.

Empathy on the personality functioning scale refers to someone’s ability to relate to others and consider them as autonomous beings with their own unique feelings and perspectives either similar or different from one’s own.  Someone with high functioning empathy will, for example, be able to consider that they should not necessarily do unto others as they would have done to themselves, but instead, do unto others as others would want someone to do.  An extreme lack of empathy will entail an inability to consider the internal states of others and may result in the patient being confused or oblivious to others’ motivations or emotions.

Intimacy requires some level of empathy just as self-direction requires some level of identity.  Someone with normally functioning intimacy both desires and is able to maintain close relationships with others that are mutually beneficial.  The relationship is able to grow and develop as individuals change.  Extremely dysfunctional intimacy is characterized by relationships being almost entirely transactional.  One may view others as either means to gain pleasure or pain.  One may have no desire for interpersonal interaction at all.

For each of these categories, identity, self-direction, empathy, and intimacy, the DSM proposes a scale from 0 to 4 where 0 is little to no impairment and 4 is extreme impairment.  Because there are 5 levels, this scale acts like a Likert scale where higher scores indicate more impairment.  As I mentioned earlier, these dimensions do not on the surface appear to be independent of each other, so the scores on identity for example will likely correlate with self-direction.  I think the most important part of using a dimensional scale is not the final score, but the particular observations or assessments.  It also provides a numerical way to assess whether someone meets Criterion A instead of just a hunch.  However, it is unclear whether someone should apply the 0-4 scale for each level of impairment separately or just assign a single value for all 4.  If you base it on all the traits, do you calculate an average or do you just pick the most severe rating in any level and use that?

Another glaring hole in the proposed diagnostic process is the failure to incorporate Bayesian statistical methods, but this is true for everything in the DSM.  The rates of false positives and negatives could be attenuated if we focused more research on estimating likelihood ratios from our instruments and reliable prior probabilities that particular patients have a disease.  You’ll hear me complain about this a lot, but I don’t want to get off track here.

There are so many different possible combinations of traits that the normal interview psychiatrists conduct is likely insufficient to do more than identify the need to identify these factors.  Once dysfunction is suspected, in order to get reliable and valid information from the patient about the domains of dysfunction, psychological testing is probably our best option.  Psychiatrists may be able to conduct some of these instruments, but to do a good job, we would need more training than we typically get currently.  Indeed, various measures of interrater reliability for Criterion A or B show only moderate levels of agreement at best, but this is considered “acceptable.”    There are numerous proposed scales or inventories that can be used.  I will not discuss most of them here.  If you want the nitty gritty on that see Zimmerman 2019.  References are either in the description or transcript available at PsyDactic. Buzzsprout.Com.  I will mention the Personality Inventory for DSM-5 (PID-5), which has various versions based on who is doing the assessment, because it was specifically designed to assess the DSM criteria.

I have so far discussed Criterion A which gives us a determination of whether someone is dysfunctional or not, but Criterion B (which is an inventory of the “Big 5” domains I mentioned earlier) tells us in what way someone is particularly dysfunctional.  As a reminder, these are labeled Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism.  Each of these has varying numbers of subdimensions (called facets) that can describe it.

The facets in each domain may be shared among different domains.  For example, depressivity and restricted affectivity are present in the negative affectivity and detachment domains.  Hostility is present in the negative affectivity and antagonism domains.  There seems to be quite a diversity of facets for some domains. Negative Affectivity, for example, could be described in terms of how depressive someone is prone to be, but also how anxious and worried someone appears, how easy it is to disturb their emotions, how submissive they are, how suspicious they are of others, how hostile they are; and inexplicably it also encompasses the catatonic sign of perseveration, not to be confused with rumination, but instead referring to temporally correlated, repeated behaviors, that either have no goal, are attempting to accomplish an inappropriate or unattainable goal, or are repeated despite the fact that they could not possibly accomplish an attainable goal.  This variability has me scratching my head.

I would put the listener to sleep, if you are not asleep already by discussing the details of each domain.  You can read the DSM 5 or Google them if you want.  I think it is important to note that these domains were chosen as a way to assess psychopathology, and are likely giving a limited picture of the fullness of any particular person’s personality or cognitive, emotional and behavioral tendencies.

Also, even though these dimensions have been shown to be mostly valid across different cultures, that doesn’t mean that the assessment of these dimensions will be reliable cross-culturally, so psychiatrists and psychologists should take great care when they make judgments about what is dysfunctional versus what is within the normal limits for a particular culture.

I am considering exploring these domains in more depth and relating them to the already existing personality disorders that the powers that be have determined to exist to a great enough degree that they deserve their own name and place in the DSM.  Borderline personality disorder itself is a bane of the diagnostic process due to its high comorbidity with trauma related disorders, affective disorders, and disturbances of perception.  It is the most diagnosed personality disorder, due in part to the fact that schizoid, schizotypal, paranoid, avoidant, antisocial, and obsessive compulsive personalities are unlikely to voluntarily present to a psychiatrist.  Borderline traits almost guarantee that someone will find themselves in a psychiatrist's office at some point and be placed on numerous medications.

Cross your fingers that I don’t get too distracted by some other topic before putting these episodes together.  If I do get distracted, hopefully it will be with the neurological correlates of personality.

Thank you for listening.  Until next time (and even after), I am Dr. O and this has been an episode of PsyDactic.




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