Personality disorder (PD): permanent personality traits that are inflexible and maladaptive, that cause significant social incapacitation, disrupt work efficiency or promote subjective discomfort or suffering. In principle, the definition and classification of personality disorders is presented as the “fruit” of an agreement, after a thorough review of the published literature and professional praxis, although, at an empirical level, it ends up being accepted as a “solution of commitment”, a certain nomenclature which does not correspond to the results obtained.
What is personality? Personality concept
In the concept of personality there are two alternatives:
- Personality is identified as the part of personal functioning that is resistant to change, is consolidated and has a generality and coherence of responses in different times and contexts, excluding the situational, reactive-differential in different situations. It refers to integrated psychological training, with levels of organization and hierarchy. Represented by Eysenck.
- Personality as that which identifies the individual human being throughout the life cycle, so it must be integrated into a personal model, from situational reactivity to lifestyle, motivations, beliefs and conceptions of the world. Represented by Royce.
The conceptual classifying system, in relation to personality disorders, is located in the first option, but it is not a dimensional but a categorical model.
Historical reflection on the concept of personality and personality disorders
Contributions from 3 theoretical traditions:
1. The medical characterology: They defend that there is a hereditary substrate that predisposes one to having one type of problem or another, and that external events would be producers-triggers of serious problems within the field of mental health:
- An advanced edition of Kraepelin’s work referred to the “autistic personality” as an antecedent of dementia praecox.
- Kretschmer proposed a rational continuum ranging from schizophrenia to manic-depressive psychosis, with intermediate intervals of more or less pathological “personalities.”
- Jaspers states that personality disorders do not become nosological entities like psychoses, but they could give rise to them. They were indicators of certain mental disorders.
2. The psychodynamics: The psychoanalytic tradition defended the existence of a theory of personality and psychopathology, in which the disturbance of personal evolution would be the explanatory source “responsible” for the alterations.
3. The social phenomenology: understands personality as a “response” to the reactions of others, as the set of roles that a human being plays throughout his or her life, and disturbance is conceived as those roles that are harmful to others. In this case, personality disorders are conceived as diseases or errors in the socialization process aimed at causing harm to others.
The 3 traditions conceive the DSM-III definition as an attempt to group and/or reach the greatest possible consensus.
Definition of personality
Definition of personality as a set of traits a person has. Personality traits are lasting patterns in the way each person perceives, thinks and relates to the environment and to oneself that are evident in a wide range of personal and social contexts. It is maintained throughout DSM-III-R and in the DSM-IV working manuscripts.
Personality types
Personality classification systems
There are 3 major classification systems considered for personality disorders:
- The ICD-10 (WHO).
- The classification called Statistical and diagnostic manual: DSM-IIIR and DSM-IV (just published).
- Millon’s proposal that includes a multiaxial system for personality disorders, used for the preparation of the DSM-III-R.
Types of personality disorders
Personality disorders are divided into 3 large clusters that encompass 11 disorders.
- Odd and eccentric individuals: Paranoid Personality Disorder, Schizoid Personality Disorder and Schizotypal Personality Disorder.
- Erratic, emotional and theatrical personalities: Histrionic Personality Disorder, Antisocial Personality Disorder, Narcissistic Personality Disorder and Borderline Personality Disorder.
- Fearful individuals with marked anxiety: Dependent Personality Disorder, Obsessive-Compulsive Personality Disorder, Passive-Aggressive Personality Disorder and Avoidant Personality Disorder.
There is a fourth nucleus called mixed and atypical for individuals whose traits do not fit well with any of the three. These disorders are atheoretical in terms of their etiology and theory.
Also in the DSM-IV version, the inclusion of depressive personality disorder and depression was proposed. personality negativist. The DSM-III-R proposes that polythetic diagnoses be made: The clinician can establish diagnoses using different combinations of the set of symptoms, as long as the number of those presented is half + 1 (except in antisocial personality). If there are not enough of them, the individual will not be diagnosed in axis II, although he or she may be diagnosed in axis I. This point is highly criticized, especially by supporters of dimensional classification systems. The DSM does not rank these disorders according to the severity of social impairment, occupational dysfunction, and subjective distress. DSM-IV Preparation:
- In the 1991 revision, 2 other categories are included: Depressive personality disorder and oppositional personality disorder. In the 1993 revision, both disorders disappear and are included in the category of “non-specific personality disorders.”
- In the version there would be 10 personality disorders + one category of unspecified. This version tries to achieve greater agreement with the ICD-10. Differences: 1. Between specific and mixed: The specific ones include serious disorders of the constitutive character and behavioral tendencies, which affect various aspects of the personality and which, almost always, are accompanied by considerable social and personal alterations.
- The mixed ones: when characteristics are presented that do not allow it to be integrated into a complete category. 2. Between specific and persistent transformations: The specific: They tend to occur in childhood and adolescence, persisting throughout adult life. Transformations occur during adult life as a consequence of catastrophes, traumas, stressful situations, and must be maintained as well-defined and lasting changes. The 3 groups are configured: Specific disorders: Paranoid, schizoid, dissocial, emotional instability of the personality, histrionic, narcissistic, anxious, dependent, anacastic and “unspecified”. Mixed disorders: Mixed personality disorders and problematic personality variations. Persistent personality transformations: Subsequent to traumatic experiences, psychiatric illnesses, other transformations and unspecified transformations.
They all refer to long-lasting and deep-rooted forms of behavior, which manifest themselves as stable modalities of response to a wide spectrum of individual and social situations. Only the first category coincides with the general consideration of personality disorders. For the diagnosis, at least 3 of the symptoms specified by the ICD-10 (half, in most cases). The ICD-10 does not provide a gradation of the severity of the disorders.
Millon: Personality is made up of learned categories or patterns of coping with the environment (biosocial learning theory). They are complex and stable ways of managing one’s environment; they involve instrumental behaviors that produce reinforcement and avoid punishment.
So, Million organizes personality disorders according to 4 variable criteria: Severity: mild/light, intermediate, high Nature of reinforcement: positive and negative Source of reinforcement: self and others Instrumental behaviors to obtain reinforcement: passive coping strategies and active strategies
From these criteria, he obtains 8 fundamental types of anomalous personalities of mild-light severity (maladaptive intrapsychic conflicts that make social adaptation difficult to find personal satisfaction and find reinforcement in themselves or in others) and 3 variants of high severity ( deficits in social skills and periodic and reversible psychotic breaks)
- Mild-light severity. Histrionic Dependent Antisocial Narcissistic
- Intermediate gravity. Passive-aggressive Obsessive-compulsive Avoidant Schizoid
- High gravity. Schizotypal (variant of avoidant and schizoid) Borderline (variant of histrionic, dependent, passive-aggressive and obsessive-compulsive)
Paranoid (variant of antisocial and narcissistic, and in some cases of passive-aggressive and obsessive-compulsive) Characteristics shared by the 11 disorders:
- Great inflexibility, limits the possibilities of learning new behaviors
- Frequent existence of actions that promote vicious circles
- Great emotional fragility in stressful situations.
Later Million It will base its new classification on 6 points where the scheme is always the same:
- Apparent behavior: how others perceive the behavior of the S to be treated
- Interpersonal behavior: how they interact with others.
- Cognitive style: what thought process the subject carries out
- Affective expression: how to show emotions.
- Self-perception
- Self defense mechanisms
Currently, the existence of 10-11 personality disorders is accepted in categorical classification systems.
Etiological and epidemiological issues
A generic analysis, from the biological-medical point of view, personality disorders would have a strong biological component, which would explain its appearance. But, from a more social approach, interpersonal interactions and learning would be responsible for its appearance. Rather, it would be the continued interaction between the two, which, throughout childhood and adolescence, would shape a pattern of behavior that would lead to the establishment (around the third decade) of a personality diagnosis.
Only Millon (and Everly) dares to give concrete data (the wording of the DSMIII-R and DSM-IV is presented as atheoretical with respect to etiology). Millon proposes that there are biogenic and psychogenic determinants, which covary to form personality. over time. The weight of each of them varies depending on time and circumstances.
The biological structure of the brain, could be considered the first cause, but environmental influences immediately begin. The genetic bases must be sought in polygenic and non-monogenic explanations, which further complicates the study of the biological bases…