For years they have lived as orphans and outliers, a colony of misfit characters on their own island: the bizarre one and the needy one, the untrusting and the crooked, the grandiose and the cowardly. Their customs and rituals are as captivating as any tribe’s, and at least as mystifying. Every mental anthropologist who has visited their world seems to walk away with a different story, a new model to explain those strange behaviors.
This weekend the Board of Trustees of the American Psychiatric Association will vote on whether to adopt a new diagnostic system for some of the most serious, and striking, syndromes in medicine: personality disorders. Personality disorders occupy a troublesome niche in psychiatry. The 10 recognized syndromes are fairly well represented on the self-help shelves of bookstores and include such well-known types as narcissistic personality disorder, avoidant personality disorder, as well as dependent and histrionic personalities. But when full-blown, the disorders are difficult to characterize and treat, and doctors seldom do careful evaluations, missing or downplaying behavior patterns that underlie problems like depression and anxiety in millions of people.
The new proposal — part of the psychiatric association’s effort of many years to update its influential diagnostic manual — is intended to clarify these diagnoses and better integrate them into clinical practice, to extend and improve treatment. But the effort has run into so much opposition that it will probably be relegated to the back of the manual, if it’s allowed in at all.
Dr. David J. Kupfer, a professor of psychiatry at the University of Pittsburgh and chairman of the task force updating the manual, would not speculate on which way the vote might go: “All I can say is that personality disorders were one of the first things we tackled, but that doesn’t make it the easiest.” The entire exercise has forced psychiatrists to confront one of the field’s most elementary, yet still unresolved, questions: What, exactly, is a personality problem?
Habits of Thought
It wasn’t supposed to be this difficult. Personality problems aren’t exactly new or hidden. They play out in Greek mythology, from Narcissus to the sadistic Ares. They percolate through biblical stories of madmen, compulsives and charismatics. They are writ large across the 20th century, with its rogues’ gallery of vainglorious, murderous dictators. Yet it turns out that producing precise, lasting definitions of extreme behavior patterns is exhausting work. It took more than a decade of observing patients before the German psychiatrist Emil Kraepelin could draw a clear line between psychotic disorders, like schizophrenia, and mood problems, like depression or bipolar disorder.
Likewise, Freud spent years formulating his theories on the origins of neurotic syndromes. And Freudian analysts were largely the ones who, in the early decades of the last century, described people with the sort of “confounded identities” that are now considered personality disorders. Their problems were not periodic symptoms, like moodiness or panic attacks, but issues rooted in longstanding habits of thought and feeling — in who they were. “These therapists saw people coming into treatment who looked well put-together on the surface but on the couch became very disorganized, very impaired,” said Mark F. Lenzenweger, a professor of psychology at the State University of New York at Binghamton. “They had problems that were neither psychotic nor neurotic. They represented something else altogether.”
Several prototypes soon began to emerge. “A pedantic sense of order is typical of the compulsive character,” wrote the Freudian analyst Wilhelm Reich in his 1933 book, “Character Analysis,” a groundbreaking text. “In both big and small things, he lives his life according to a preconceived, irrevocable pattern.” Others coalesced too, most recognizable as extreme forms of everyday types: the narcissist, with his fragile, grandiose self-approval; the dependent, with her smothering clinginess; the histrionic, always in the thick of some drama, desperate to be the center of attention.
In the late 1970s, Ted Millon, scientific director of the Institute for Advanced Studies in Personology and Psychopathology, pulled together the bulk of the work on personality disorders, most of it descriptive, and turned it into a set of 10 standardized types for the American Psychiatric Association’s third diagnostic manual. Published in 1980, it is a best seller among mental health workers worldwide.
These diagnostic criteria held up well for years and led to improved treatments for some people, like those with borderline personality disorder. Borderline is characterized by an extreme neediness and urges to harm oneself, often including thoughts of suicide. Many who seek help for depression also turn out to have borderline patterns, making their mood problems resistant to the usual therapies, like antidepressant drugs.
Today there are several approaches that can relieve borderline symptoms and one that, in numerous studies, has reduced hospitalizations and helped aid recovery: dialectical behavior therapy.
This progress notwithstanding, many in the field began to argue that the diagnostic catalog needed a rewrite. For one thing, some of the categories overlapped, and troubled people often got two or more personality diagnoses. “Personality Disorder-Not Otherwise Specified,” a catchall label meaning little more than “this person has problems” became the most common of the diagnoses.
It’s a murky area, and in recent years many therapists didn’t have the time or training to evaluate personality on top of everything else. The assessment interviews can last hours, and treatments for most of the disorders involve longer-term, specialized talk therapy. Psychiatry was failing the sort of patients that no other field could possibly help, many experts said. “The diagnoses simply weren’t being used very much, and there was a real need to make the whole system much more accessible,” Dr. Lenzenweger said.
It was easier said than done. The most central, memorable, and knowable element of any person — personality — still defies any consensus. A team of experts appointed by the psychiatric association has worked for more than five years to find some unifying system of diagnosis for personality problems. The panel proposed a system based in part on a failure to “develop a coherent sense of self or identity.” Not good enough, some psychiatric theorists said.
Later, the experts tied elements of the disorders to distortions in basic traits. For example, an interim proposal for narcissistic personality disorder involved rating a person on four traits, including “manipulativeness,” “histrionism,” and “callousness,” and the final proposal relied on just two, “grandiosity” and “attention-seeking.” The current definition includes nine possible elements.
The proposed diagnostic system would be simpler, as well as “responsive to the array of diverse and sometimes contradictory suggestions made by other” personality disorders experts, wrote Dr. Andrew Skodol, a psychiatrist at the University of Arizona and chairman of the group proposing the new system, in a paper published last spring.
But since then the outcry against the proposed changes has only grown louder. Some experts argued that throwing out existing definitions was premature and reckless. Others insisted that the diagnoses could not be simplified so much. And some complained that the effort to anchor the disorders in traits had not gone far enough. “You simply don’t have adequate coverage of personality disorders with just a few traits,” said Thomas Widiger, a professor of psychology at the University of Kentucky.
Dr. Widiger compares the process of reaching a consensus on personality to the parable of the six blind men from Hindustan, each touching different parts of the elephant. “Everyone’s working independently, and each has their perspective, their own theory,” he said. “It’s a mess.” “It’s embarrassing to see where we’re at. We’ve been caught up in digression after digression, and nobody can agree,” Dr. Millon said. “It’s time to go back to the beginning, to Darwin, and build a logical structure based on universal principles of evolution.” At least for now, then, the misfits will remain in their colony, part of mainstream psychiatry but still in the back country.
And if a unified theory can be devised to explain them, most agree that it will be some time in the making — perhaps requiring the efforts of an obsessive-compulsive narcissist with some political skills.
This article has been revised to reflect the following correction:
Correction: November 30, 2012
An article on Tuesday about efforts to adopt a new diagnostic system for personality disorders misstated the number of traits included in the proposed criteria for narcissistic personality disorder. The final proposal involves rating a person on two personality traits, not four.