Disorder in the Domain of the Personality Disorders

In contrast to medical conditions like cancer, pneumonia, and nephritis—all unequivocally diseases, application of the medical model to the domain of personality disorders is necessarily controversial. Everyone has a personality. The dividing lines between peculiarities and quirks, occasional outbursts under stress, persistent abnormalities of a mild sort, and chronic disorders with severe consequences for self and others—cannot readily be drawn, certainly not to universal agreement. Even where there is widespread acceptance about criteria for a particular disorder, one cannot speak prescriptively about its “ideal” treatment. The current diagnostic manual in psychiatry (DSM-IV) will soon be replaced by DSM-V. Some of the deficiencies and ambiguities of the last edition will be corrected; new ones will appear. There will always be some disagreement, in effect—some “disorder” in the domain of personality disorders. In this article some of the more pervasive problem areas are outlined. Among them: the continuum between personality oddity, outright personality disorder, and the more disease-like symptom-disorder pertinent to almost all the currently

recognized Axis II disorders. Also: the effects of culture on what is—or is not—recognized as a valid disorder of personality, the inherent complexities in the personality domain (which require attention to dimensional as well as category-based concepts), the overlap among the various categories, the tendency (especially in forensic work) toward diagnostic oversimplification (as though all narcissists or borderlines are alike), the interactions of genetic, prenatal, and environmental factors, and lastly, the importance of traits—including the often neglected positive traits modifying any given disorder. Awareness of these factors can help reduce, though not eliminate, the disorder in the personality disorder domain.