Perhaps better term than …
“ Personality Disorders ” would be
“
Personality-Related Disorders of Interpersonal Behavior
”
Why?
1.) Because disturbed or impoverished interpersonal relationships are the hallmark of most PDs.
2.) The characteristic that seems to define them is a pervasive and persistent abnormality in maintaining social relationships.
“ Attachment Theory ” appears to be one of the better predictors of and explanations for why individuals develop PDs.

Construction of diagnostic categories remains controversial and nowhere is this more clearly so than in the case of PDs, which are very dimensional. PDs are extreme variations of normally distributed personality characteristics.
For the most part, psychiatric patients suffer and attract medical attention. But patients with
PDs make others suffer and “evoke the anger and rejection, even of medical professionals.”
They’re almost untreatable.
-
They are, therefore, unique in being diagnosed more with respect to the clinician’s reaction to them than to their own reaction to the disorder.

PDs were the “ bread and butter
” of Freudian-psychodynamic orientation (which dominated from the 1920s-1970s)
1.) An onset in childhood or adolescence
2.) A long-standing persistence over time coupled to the pervasiveness of the abnormal behavior pattern across a broad range of personal and social situations
3.) The association with a substantial degree of personal distress and/or problems in occupational or social performance.
PDs are partly a hold-over from the previous DSMs and
Freudian-psychodynamic hegemony of American psychiatry and partly a reflection of the recognition that NOT all mental illness/disorders are solely or even primarily neurologicalbiological-organic in origin .

Silver Hill, CT biological/psychopharmacological orientation
Chestnut Lodge, MD dynamic/Freudian orientation

• Axis I ( depression, autism, schizophrenia, bi-polar, etc .)
states of illness, clinical syndromes [signs, symptoms and states that indicate disruption of the normal continuity of the person]
•
Axis II ( personality disorders )
traits of personality, not temporary states but fundamental aspects of selfhood nearly impervious to change. PDs are assumed to result from adverse psychosocial developmental experiences, characterized by traits and attitudes that sustain and emphasize the continuity of experience.
--------------------------------------------
The patient “ has ” depression or autism or ADHD, while the other patient
“ is ” a borderline or a histrionic or a dependent.
The distinction is essentially pragmatic, but it is less clear-cut than the DSM suggests.

1.) The temporal stability of personality traits does not support the conclusion that personality is immutable. In other words, personalities evolve over time, which often leads to substantial differences in a person’s behavioral expressions.
Moreover, many of the primary features of personality disorders diminish with age or under particular circumstances.

2.) Significant comorbidity appears to exist between Axis I disorders and Axis II PDs, which often makes distinction between them difficult to detect (the difference between states and traits is often blurry). For example . . .

3.) Both Axis I and PDs have complex etiologies (root causes/origins) that are a function of both psychosocial and biological factors, which makes their reliable distinction or diagnostic separation into different axes difficult to replicate with multiple clinicians.
Levels of stress and availability of social support significantly affect the clinical syndromes of Axis I disorders.
4.) Considerable overlap exists among the criteria for the personality disorders, which leads to substantial covariation among PD diagnoses.
The average patient diagnosed with a PD receives an average of 4 diagnoses.
Thus, Axis II disorders are not only not clearly demarcated from Axis I disorders, they’re not even clearly demarcated among themselves.
This problem becomes especially serious when the issue of gender is considered, because there is considerable conflation of “depression” and the “female” PDs: dependent, histrionic and borderline. Women are 8 times more likely to be diagnosed as histrionic than men.
Meanwhile, men are much more likely to be diagnosed with narcissistic, antisocial, and obsessive-compulsive disorders. Men are 5-10 times more likely to be diagnosed antisocial than women.

5.) Determination of appropriate threshold in relation to the number of criteria for diagnosis is arbitrary , particularly given the fact that the PDs are already a very heterogeneous group of disorders.
6.) The criteria used in DSM are at different LEVELS of generalization. Some are trait levels (e.g., identity disturbance or impulsivity), others are specific exemplars of traits (e.g., has no close friends), whereas still others are symptomatic acts (e.g., self-mutilating behavior).
7.) Some criteria occur in more than one PD syndrome and many patients fulfill criteria for 2 or more PD diagnoses, while many of the behaviors selected as exemplars occur independently of the presence of any PD at all.
(e.g., One study found the present of 1 or more PDs in 35% of a population of 274 healthy university students investigated by means of a diagnostic instrument, with an even higher proportion, 75%, found in a similar population in a related study.)

The PDs are not equal in SEVERITY :
Borderline is a disorder of extreme dependence , while
Paranoid is a disorder of extreme independence
Schizotypal can be seen as an intensification of the traits of detachment .

If the official criterial model represented by the DSM were sufficient, the casebooks would be unnecessary. Instead, psychiatrists refer more to the pocket edition of the DSM Case Books than to the pocket edition of the DSM itself.
The only time the situation is reversed is at the moment the psychiatrist must record the coded numerical diagnosis, usually for reimbursement purposes (which the case books don’t include).

“drama queens,” demand endless attention, jealous if anyone else gets attention, manipulative, seductive, overly emotional, superficial charm and adaptability
La Bohème
Tammy Faye Scarlett in Gone With the Wind

Used to be called “moral insanity,” “moral imbecility,” “moral defectiveness,” and “sociopathy”
(1) Failure to conform to social norms with respect to lawful behaviors (lots of arrests)
(2) Deceitfulness (lots of lying, manipulation, aliases, conning)
(3) Impulsivity or failure to plan ahead
(4) Irritability and aggressiveness (lots of fights, assaults)
(5) Reckless disregard for safety of self or others
(6) Consistent irresponsibility (failure to sustain work or honor financial obligations)
(7) Lack of remorse

Antisocial Personality: Only PD Diagnosis that Demonstrates
Adequate to Good Levels of Interrater Reliability
Duke Cancels Lacrosse Season and Initiates Critiques
Ryan McFadyen, Duke Lacrosse

Gregg Furth wants his leg amputated Robert Smith performed two operations
Identities can be built around desires (e.g., pornography, amputation), but what if the desire is really an obsessive-compulsive disorder that can be treated with, say, Prozac, Paxil or Wellbutrin?
e.g., link between smoking and depression