Personality Disorders in a New Key

Personality and personality disorders are complex dimensional constructs, and it has been challenging to identify a single best classification system that could receive a strong consensus of support from the research and clinical communities. Furthermore, there is a growing drumbeat from the National Institute of Mental Health to move away from classification based on symptoms and, instead, to move toward research domain criteria (RDoC), referred to on the National Institutes of Health website as “new ways of classifying psychopathology based on dimensions of observable behavior and neurobiological measures.”

I applaud this crusade to populate a roadmap of reliable biomarkers and genetic risk factors for psychiatric disorders. However, as laudable as that goal is, I do not believe it is ready for prime time. So in the meantime, as a bridge to that goal, we need to harness the best and most up-to-date evidence to identify, treat, and prevent brain disorders. That’s how I think about DSM-5—the product of a lot of hard work by a lot of very smart and knowledgeable experts to update the shared language of our work.

A while ago I was asked, along with my co-editors Andy Skodol and Donna Bender, to put together a second edition of our Textbook of Personality Disorders and to include new material that would tie in to DSM-5. This new volume has just been published, with contributions from leading clinicians and researchers in the field, many of whom contributed to the first edition, plus some new contributors. All of them were asked to incorporate material referencing the Alternative Model (AM) for personality disorders (PDs) from Section III of DSM-5.

I thought it might be of interest to present a brief case from the new book to illustrate the useful new diagnostic term “personality disorder—trait specified.”

Sara, a single, 25-year-old receptionist, had attended college for one year but dropped out to “go into advertising.” Over the next five years, she held a series of receptionist, secretarial, and sales jobs, each of which she quit because she wasn’t “getting ahead in the world.” Sara lived alone in Chicago in an apartment that her parents had furnished for her. She ate all of her meals, however, at her mother’s house and claimed not even to have a box of crackers in her cupboard. Between her jobs, her parents paid her rent.

Sara’s “career” problems stemmed from the fact that although she felt ordinary and without talent for the most part, she had fantasies of a career as a movie star or high-fashion model. She took acting classes and singing lessons, but she never had even a small role in a play or show. What she desired was not so much the careers themselves as the glamour associated with them. Although she wanted to move in the circles of the “beautiful people,” she was certain that she had nothing to offer them. Sara sometimes referred to herself as nothing but a shell and scorned herself because of it. She was unable to picture herself working her way up along any realistic career line, feeling both that it would take too long and that she would probably fail.

Sara had had three close relationships with men that were characterized by an intense interdependency that initially was agreeable to both parties. She craved affection and attention and fell deeply in love with these men. However, she eventually became overtly self-centered, demanding, and manipulative, and the man would break off the relationship. After breaking up, she would almost immediately start claiming that the particular man was “going nowhere,” was not for her, and would not be missed. Between these relationships, Sara often had periods in which she engaged in a succession of one-night stands, having sex with as many as half a dozen partners in a month. Alternatively, she would frequent rock clubs and bars—“in-spots,” as she called them—merely on the chance of meeting someone who would introduce her to the glamorous world of which she dreamed.

Sara had no female friends other than her sister. She could see little use for such friendships. She preferred spending her time shopping for clothes or watching television alone at home. She liked to dress fashionably and seductively, but often felt that she was too fat or that her hair was the wrong color. She had trouble controlling her weight and would periodically go on eating binges for a few days that might result in a 10-pound weight gain. She read popular novels but had few other interests. She admitted she was bored much of the time but also asserted that cultural or athletic pursuits were a waste of time.

This patient demonstrated clear personality pathology, and she met the general criteria for a PD using the Alternative Model (the first two of which are key: [A] moderate or greater impairment in self [in terms of identity and self-direction] and interpersonal [in terms of empathy and intimacy] functioning, and [B] one or more pathological personality traits). However, her pathological personality traits did not align with the patterns typical of any of the six specific PDs. As a result, her diagnosis using the AM would be “personality disorder—trait specified” and could be summarized as follows:

A. Severe impairment in personality functioning manifested by difficulties in

1. Identity: lack of a sense of self-worth, chronic feelings of emptiness (feeling like an empty shell)

2. Self-direction: inability to plan and implement a realistic career path, disconnect between acknowledged lack of talent and fantasies of stardom

3. Empathy: little ability to mentalize and consider another’s viewpoint except in terms of meeting her needs, mostly self-referential

4. Intimacy: overintense and unrealistic involvement with romantic partners, inevitably not lasting due to lack of reciprocity and mature mutuality.

B. Pathological personality trait domains:

1. Negative affectivity: separation insecurity (overreliance on parents), submissiveness

2. Detachment: periods of anhedonia, depressivity, withdrawal, restricted affect

3. Antagonism: grandiosity, attention-seeking behavior, seductiveness, manipulativeness

4. Disinhibition: periods of impulsive overeating, sexual behavior, risky socializing.

Unlike the traditional diagnosis of PDNOS (referred to in DSM-5 Section II as “other specified PD”), PD—trait specified is both a “rule-out” and a “rule-in” diagnosis; that is, not just a diagnosis by exclusion, but also an opportunity to individualize a patient’s pathological trait profile, as demonstrated by the case above. In surveys and in the DSM-5 field trials, clinicians have reported that the Section III new model for PDs enhances communication with patients and families and facilitates treatment planning. It is also worth underscoring that the AM is not in the “Conditions for Further Study” part of Section III, but, rather, is truly an alternative model that can be selected for clinical use if preferred. I would encourage trying it on for size. It may take a little getting used to, but in my opinion, it provides a coherent template that defines and organizes all of the PDs in a way that is logical and easy to remember and apply. ■