The document discusses personality disorders as classified in the DSM-IV-TR. It notes that the categorical approach and diagnostic thresholds between normal and abnormal personalities are criticized. Personality disorders are seen as maladaptive patterns that emerge from problems in personal development. The document argues that all personality disorders are interrelated at least phenomenologically, though there is no single theory that fully explains them. It provides an overview of common traits in those suffering from personality disorders, such as ego-syntonic behaviors, blaming others, and vulnerability to other psychiatric issues.

1. Personality Disorders
Question:
Many of the symptomsandsignsthat youdescribe applytoother personality disordersas well (for
instance,the histrionic,the antisocialandthe borderlinepersonalitydisorders).Are we tothinkthatall
personalitydisordersare interrelated?
Answer:
The classificationof AxisII personality disorders –deeplyingrained,maladaptive,lifelongbehavior
patterns– in the DiagnosticandStatistical Manual,fourthedition,textrevision[AmericanPsychiatric
Association.DSM-IV-TR,Washington,2000] – or the DSM-IV-TRforshort – hascome undersustained
and seriouscriticismfromitsinceptionin1952.
The DSM IV-TRadoptsa categorical approach,postulatingthatpersonalitydisordersare “qualitatively
distinctclinical syndromes”(p.689).Thisis widelydoubted.Eventhe distinctionmade between
“normal”and “disordered”personalitiesisincreasinglybeingrejected.The “diagnosticthresholds”
betweennormal andabnormal are eitherabsentorweaklysupported.
The polytheticformof the DSM’s DiagnosticCriteria –onlya subsetof the criteriais adequate grounds
for a diagnosis –generatesunacceptablediagnosticheterogeneity.Inotherwords,people diagnosed
withthe same personality disordermayshare only one criterionornone.
The DSM failstoclarifythe exactrelationshipbetweenAxisIIandAxisIdisordersandthe waychronic
childhoodanddevelopmentalproblemsinteractwithpersonalitydisorders.
The differential diagnosesare vague andthe personality disordersare insufficientlydemarcated.The
resultisexcessiveco-morbidity(multipleAxisIIdiagnoses).
The DSM containslittle discussionof whatdistinguishesnormal character(personality),personality
traits,or personalitystyle(Millon) –frompersonalitydisorders.
A dearthof documentedclinical experience regardingboththe disordersthemselvesandthe utilityof
varioustreatmentmodalities.
Numerous personality disordersare “nototherwise specified” –a catchall,basket“category”.
Cultural biasisevidentincertaindisorders(suchasthe Antisocial andthe Schizotypal).
The emergence of dimensionalalternativestothe categorical approachisacknowledgedinthe DSM-IV-
TR itself:
“An alternative tothe categorical approachisthe dimensional perspectivethatPersonalityDisorders

2. representmaladaptive variantsof personalitytraitsthatmerge imperceptiblyintonormalityandinto
one another”(p.689)
The followingissues –longneglectedinthe DSM– are likelytobe tackledinfuture editionsaswell asin
currentresearch:
The longitudinal course of the disorder(s)andtheirtemporal stabilityfrom earlychildhoodonwards;
The geneticandbiological underpinningsof personalitydisorder(s);
The developmentof personalitypsychopathologyduringchildhoodanditsemergence inadolescence;
The interactionsbetweenphysical healthanddisease andpersonalitydisorders;
The effectivenessof varioustreatments –talktherapiesaswell aspsychopharmacology.
All personalitydisordersare interrelated,atleastphenomenologically –thoughwe have no Grand
UnifyingTheoryof Psychopathology.We donotknow whetherthere are – and whatare – the
mechanismsunderlyingmental disorders.Atbest,mental healthprofessionalsrecordsymptoms(as
reportedbythe patient) andsigns(asobserved).
Then,theygroupthemintosyndromesand,more specifically,intodisorders.Thisisdescriptive,not
explanatoryscience.Sure,there are afew etiological theoriesaround(psychoanalysis,tomentionthe
mostfamous) buttheyall failedtoprovide acoherent,consistenttheoretical frameworkwithpredictive
powers.
Patientssufferingfrompersonalitydisordershave manythingsincommon:
Most of themare insistent(exceptthose sufferingfromthe Schizoidorthe Avoidant Personality
Disorders).Theydemandtreatmentonapreferentialandprivilegedbasis.Theycomplainabout
numeroussymptoms.Theyneverobeythe physicianorhistreatmentrecommendationsand
instructions.
Theyregard themselvesasunique,displayastreakof grandiosityanda diminishedcapacityforempathy
(the abilitytoappreciate andrespectthe needsandwishesof otherpeople).Theyregardthe physician
as inferiortothem,alienate himusingumpteentechniquesandbore himwiththeirnever-endingself-
preoccupation.
Theyare manipulative andexploitativebecausetheytrustnoone and usuallycannotlove orshare.They
are sociallymaladaptive andemotionallyunstable.
Most personality disordersstartoutas problemsinpersonal developmentwhichpeakduring
adolescence andthenbecome personalitydisorders.Theystayonas enduringqualitiesof the individual.
Personality disordersare stable andall-pervasive –notepisodic.Theyaffectmostof the areasof

3. functioningof the patient:hiscareer,hisinterpersonal relationships,hissocial functioning.
The typical patientsisunhappy.He isdepressed,suffersfromauxiliarymoodandanxietydisorders.He
doesnotlike himself,hischaracter,his(deficient) functioning,orhis(crippling)influence onothers.But
hisdefencesare sostrong,that he isaware onlyof the distress – and notof the reasonsto it.
The patientwitha personality disorderisvulnerable toandprone to sufferfromahost of other
psychiatricproblems.Itis asthoughhispsychological immunological systemhasbeendisabledbyhis
personalitydisorderandhe fallspreytoothervariantsof mental illness.Somuchenergyisconsumedby
the disorderandby itscorollaries(example:byobsessions-compulsions,ormoodswings),thatthe
patientisrendereddefenceless.
Patientswith personality disordersare alloplasticintheirdefences.Theyhave anexternal locusof
control.In otherwords:theytendtoblame the outside worldfortheirmishaps.Instressfulsituations,
theytry to pre-empta(real or imaginary) threat,change the rulesof the game,introduce new variables,
or otherwise influence the worldoutthere toconformtotheirneeds.This isasopposedtoautoplastic
defences(internallocusof control) typical,forinstance,of neurotics(whochange theirinternal
psychological processesinstressful situations).
The character problems,behavioural deficitsandemotional deficienciesand labilityencounteredby
patientswithpersonalitydisordersare,mostly,ego-syntonic.Thismeansthatthe patientdoesnot,on
the whole,findhispersonalitytraitsorbehaviourobjectionable,unacceptable,disagreeable,oraliento
hisself.Asopposed tothat,neuroticsare ego-dystonic:theydonotlike whotheyare and how they
behave ona constantbasis.
The personality-disorderedare notpsychotic.Theyhave nohallucinations,delusionsorthought
disorders(exceptthose whosufferfromthe BorderlinePersonalityDisorderandwhoexperiencebrief
psychotic“microepisodes”,mostlyduringtreatment).Theyare alsofullyoriented,withclearsenses
(sensorium),goodmemoryandasatisfactorygeneral fundof knowledge.
The Diagnosticand Statistical Manual [AmericanPsychiatricAssociation.DSM-IV-TR,Washington,2000]
defines“personality”as:
“…enduringpatternsof perceiving,relatingto,andthinkingaboutthe environmentandoneself …
exhibitedinawide range of importantsocial andpersonal contexts.”
Clickhere toread the DSM-IV-TR(2000) definitionof personalitydisorders.
The international equivalentof the DSMisthe ICD-10,Classificationof Mental andBehavioural
Disorders,publishedbythe WorldHealthOrganizationinGeneva(1992).
Clickhere toread the ICD-10 diagnosticcriteriaforthe personalitydisorders.
Each personality disorderhasitsownformof NarcissisticSupply:

4. HPD (HistrionicPD) – Sex,seduction,“conquests”,flirtation,romance,body-building,demanding
physical regime;
NPD(NarcissisticPD) –Adulation,admiration,attention,beingfeared;
BPD (BorderlinePD) –The presence of theirmate orpartner(theyare terrifiedof abandonment);
AsPD(Antisocial PD) –Money,power,control,fun.
Borderlines,forinstance,canbe describedasnarcissistwithanoverwhelmingseparationanxiety.They
DO care deeplyaboutnothurtingothers(thoughoftentheycannothelpit) –butnot out of empathy.
Theirsisa selfishmotivationtoavoidrejection.Borderlinesdependonotherpeople foremotional
sustenance.A drugaddictis unlikelytopickupa fightwithhispusher.ButBorderlinesalsohave
deficientimpulse control,asdoAntisocials.Hence theiremotional lability,erraticbehaviour,andthe
abuse theydoheap ontheirnearestanddearest.
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