By David Joel Miller, MS, Licensed Therapist & Licensed Counselor.
In the new DSM-5, the five-axis system was eliminated. Personality disorders are now included in the full list of mental, emotional, and behavioral disorders, just like any other mental health issue. I have left this post here, as originally posted because much of this information remains relevant. Not all of the changes we expected in the DSM-5 took place. For the current status take a look at some of the newer posts.
How many Personality Disorders are there?
Personality Disorders are a special class of mental illnesses that are considered different in kind and nature from other mental health problems. Mental illnesses in all their shades are recorded on Axis I. There are currently over 300 recognized Mental illnesses. Most mental illnesses have several standard treatments and if severe enough are likely to be covered by insurance or public funding. Not so with personality disorders.
Personality Disorders are kept separate. They are recorded on Axis II in a separate and small class of problems that just don’t seem to ever change or get better. They have long been considered like mental retardation, something we need to help with, but something that just won’t change. Personality Disorders are a short list, rarely over a dozen labels, though the list changes over time.
Personality Disorders are conditions in which the person to be diagnosed “deviates from expectations of their culture.” There are different. But that is not enough for the diagnosis to be imposed.
This pattern of “differentness” is “Pervasive and inflexible.” They stick to their irritating pattern no matter what. This pattern starts in adolescence or early adulthood and they just don’t change, “grow up” or “grow out of it.” So this pattern of differentness is “stable over time.” It is as if people with a personality disorder get stuck in one way of behaving and then can’t change their approach when they are in a different time or place.
This differentness needs to also cause them problems getting along with other people, holding a job or make them unhappy to get the diagnosis. They are not just a little different some of the time but a lot different all the time.
Some people could care less if they have a personality disorder or not. But most people who have a Personality Disorder are suffering, want, and need help, no matter how we label or understand their problem.
Currently, there are ten recognized Personality Disorders in three groups or “clusters.” The DSM-5 due out next year probably will reduce that list to six personality disorders and a new “Personality Disorder Trait Specified.” Not sure what will happen to the people who have a disorder now when their diagnosis is abolished. Will they be declared cured? Or maybe we just give them a new mental illness to compensate them for their loss.
When I was in Grad School I though these personality disorders were interesting, did extra research, and even wrote some papers on the topic. I considered specializing in treating these disorders. But what I discovered is that most people with a personality disorder come to the therapist for Depression, Anxiety, and relationship problems just like anyone else. Also since these are “inflexible” patterns, only two of these disorders end up in treatment with any regularity.
Here are the clusters as they stand now with the included diagnosis. The descriptors are mine with my apologies to the APA. Clusters A and C first as Cluster B is the biggie.
Cluster A: These are the “Weird” people.
Paranoid Personality Disorder – They are scared all the time. Most are NOT Schizophrenic. We don’t see many of these people unless family or police call us as they are so afraid they never leave home. This diagnosis disappears with the DSM-5. Lots of luck on that one.
Schizoid Personality Disorder
Loners. They do not like being around other people even family. They don’t have or want friends. They would make great hermits. When the DSM-5 arrives they are all cured and free to head for a cave in the hills. Just watch out for the zoning enforcement people as those dudes like to talk.
Schizotypal Personality Disorder.
Odd, superstitious, and believe in signs, spirits, and the supernatural. They may not have friends outside the family or only one close partner. If they think about something that needs to be done, say doing the laundry and then you go do it, they will believe that their thought caused you to do it. They often dress in odd ways. This description has been applied to people who look like “witches” etc. The DSM has an exemption here if they belong to a group that agrees with their beliefs. For the record Modern “Witches” who call themselves Wiccan do not wear funny clothes all the time and do not qualify for the diagnosis of Schizotypal. This is more common than the last two Personality Disorders and stays in the new DSM-5.
Group C Scared People
Avoidant Personality Disorder – they would like friends they are just sure no one will like them and so they avoid people. They are also sure people will criticize them or put them down so they don’t try. This one stays.
Dependent Personality Disorder.
Needy, clingy afraid they will be abandoned. They always need help and what to be told and what to do. This diagnosis goes. Find yourself a dominant partner before your diagnosis is repealed or get help and become less needy.
Obsessive-Compulsive Personality Disorder.
This goes beyond everyday OCD. They want everyone else to do things just so. They are often stingy with money, needs to control everything and they have the rule book to do it. Often they cannot get anything done because their rules are so complex they can’t follow them. This one stays.
Cluster B personality disorders.
The people who cause others problems. Cluster B diagnoses are the most common diagnosis in prisons.
Antisocial Personality Disorder.
They disregard the rights of others and violate those rights. This is the number one diagnosis of men in prison. This one needs a whole post all by itself.
Borderline Personality Disorder – The main ingredient here is lots of pain. Unstable interpersonal relationships, poor self-image, unstable mood, often impulsive with a chaotic life. Most people who are diagnosed with Borderline Personality Disorder are women. This traditionally is the number one diagnosis of women in prison. Many women with this diagnosis have been victims of one kind or another at an early age. They did what they had to do to cope in a bad situation but now the way they cope is not working. There are some really good treatments for this, especially DBT, but it takes a time to heal.
Histrionic Personality Disorder.
Excessive emotionality and attention-seeking sometimes referred to uncomplimentary as “Drama Queens.” Not common in practices and we are doing away with this diagnosis when the DSM-5 comes out. Most of these folks have their own T. V. shows by now so they can pay for therapy even without a diagnosis.
Narcissistic Personality Disorder.
We’re keeping this one. Not sure why. First, we treat you for low self-esteem and then we tell you that you are Narcissistic. Most people who come for marriage counseling tell me their partner is Narcissistic.
This should be on a continuum. Is this a political season? How can we tell the Narcissists from the candidates? Don’t you need to be a lot Narcissistic to think you should be running the show? Does the top Narcissist get to run a Bank or Wall Street?
Running out of time and this post is going long. More on Personality Disorders to come. Do any of you have any thoughts on the topic?
Staying connected with David Joel Miller
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Is it possible to have layers or multiple personality disorders? Both someone I care about and myself have worked as much as possible with therapy & behavior modification within the limitations of lack of consistent funds & access to care. Some things have changed or improved by glacial increments, but the overall charateristics and issues remain for this person. Based on the descriptions here it seems to be a combination of Borderline Personality Disorde combined with characteristics of Dependent Personality Disorder.
Yes it is possible to have more than one diagnosis on any or all Axis. Someone could have diabetes, high blood pressure, Bipolar Disorder, abuse drugs and be anxious. In practice we “stack up” diagnosis” to get a full picture. Some diagnosis “trump” others so if you have Bipolar Disorder most recent episode depressed, you stop getting the depression diagnosis. You can also have some mild symptoms of one thing that do not meet the threshold for one diagnosis at the same time you have the full symptoms for another. Since most people with Borderline Personality Disorder crave and need good relationships they may also be too dependent. Most clinicians would not give you both personality disorder diagnoses even if you had the symptoms as the Borderline Diagnosis includes most of the symptoms and is the more significant. Thanks for reading the blog and for the question.
Thank you, are there any books you can recommend for people in relationship/living with someone with personality disorders?
Books would depend on the personality disorder. Most treatment for Personality disorders involves both treating the thinking problem and learning new life skills. For Borderline and related disorders anything by Marsha Linehan would be good. Her First book is heavy reading but her later ones are more user friendly. Skills Training Manual for Treating Borderline Personality Disorder by Marsha M Linehan, Ph.D., PhD is a good one for someone with BPD. She also wrote the forward to another book “Loving Someone with Borderline Personality Disorder: How to Keep Out-Of-Control Emotions from Destroying Your Relationship by Shari Y Manning, PhD, Marsha M Linehan, Ph.D., PhD (Foreword by)”, I have not read that one but it sounds good.
Anything by Aaron Beck or Albert Ellis on changing your thinking might be helpful. If substance abuse is involved there is not much that beats Alcoholics Anonymous (the book) or the Al-Anon books. As with support groups most of the resources are for the person with the disorder rather than the family member.
Thank you for the information. I really appreciate it.
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