By Andrea Ecklund
Personality disorders are difficult for me to wrap my head around. They are already rather strange, because if you think about it, someone’s personality – who they are as a person – is what is considered to be the disorder. I think it’s difficult for many of us to grasp this concept of a personality disorder because it’s basically pathologizing who a person is at their core. Personality disorders are generally difficult to diagnose because there is very little clinical research on what causes these disorders, and what treatments work best for people who are diagnosed.
The Diagnostic and Statistical Manual of Mental Disorder, or DSM 5, the American Psychiatric Association’s manual on standardized classifications of mental disorders, the defines personality disorder as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” The following personality disorders are included in the DSM 5:
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
- Antisocial personality disorder
- Borderline personality disorder
- Histrionic personality disorder
- Narcissistic personality disorder
- Avoidant personality disorder
- Dependent personality disorder
- Obsessive-compulsive personality disorder
- Personality change due to another medical condition
- Other specified personality disorder and unspecified personality disorder
The personality disorders are further grouped into three clusters based on their similarities:
- Cluster A: Paranoid, schizoid, and schizotypal personality disorders (per the DSM, people with these often appear “odd or eccentric”)
- Cluster B: Antisocial, borderline, histrionic, and narcissistic personality disorders (people often appear “dramatic, emotional, or erratic”)
- Cluster C: Avoidant, dependent, and obsessive-compulsive personality disorders (people often appear “anxious or fearful”)
After each cluster is described, the DSM states the following: “It should be noted that this clustering system, although useful in some research and educational situations, has serious limitations and has not been consistently validated.”
Serious limitations and has not been consistently validated. I wish I were kidding, but no, this statement actually appears in the DSM 5. And then let’s look at the wording of how people with these diagnoses “often appear,” because there is a whole lot of judgment going on in those very few descriptive words the authors of the DSM chose to use. All of these words are subjective, and my definition of odd, eccentric, dramatic, etc. are likely to be different from your definition. Does that mean one of us is right and the other is wrong? Does it only take into consideration our American society and what society views as normal? All of these aspects are up to interpretation to each individual. All of these factors are why I have an issue with labeling and diagnosing someone with a personality disorder.
It is imperative to remember how intersectionality plays a role in the diagnosis and interpretation not only with personality disorders but all mental disorders. The prevalence of certain mental illnesses within a particular population are rather disturbing. For example, there is generally a substantial amount of gender bias within personality disorders. Borderline personality disorder (BPD) is the most frequently diagnosed personality disorder, and of those diagnosed, 75% are female. Histrionic personality disorder is also more commonly diagnosed in women. And although we would like to point to biology and similar genetic makeup amongst women as the cause of such personality disorders and why it’s more prevalent in women, this has yet to be proven.
One possible explanation for why it is diagnosed more in women than men is because of the socialization of women and girls in our society and how society views women’s behaviors and personalities. Both BPD and histrionic personality disorder are in Cluster B, which often presents as “dramatic, emotional, or erratic.” Women in our society are often stereotyped as being more dramatic and emotional, and these stereotypes have been embedded into the American culture for centuries. Compared to the typical socialization of boys and men, who are usually taught to not show emotion, this concept of someone being “dramatic, emotional, or erratic” could be because the men who came up with these diagnoses were quite sexist and biased as to what kind of emotional expression was appropriate in society during that time.
Environmental factors also influence personality overall, including personality disorders. Traumatic experiences (usually in childhood or adolescence) have commonly occurred in people who are diagnosed with personality disorders. In fact, of the population diagnosed with BPD, 56% of those also meet criteria for PTSD. One hypothesis for this is that BPD is actually a “chronic form of PTSD” which has become integrated into a person’s personality framework. To reiterate, that is just one hypothesis for possibly explaining why these two disorders are commonly seen together. Mental health professionals need to remember to not immediately think that a person with PTSD will also be diagnosed with BPD. This is also true for BPD, as there is somewhat of a myth that all individuals who engage in self-harm behaviors are diagnosed with this disorder.
I want to be clear that I am not devaluing people who have been diagnosed with personality disorders, nor their life experiences that could be explained by one of these disorders. My issue lies with the notion of pathologizing someone’s personality in order to explain who they are and why they do what they do. We think of people who have been labeled as psychopaths or sociopaths (which are now just referred to as a person diagnosed with Antisocial Personality Disorder), but those two words conjure up a picture in our heads that has been greatly influenced by society, particularly by the media. They may be described as “crazy,” or they are portrayed as criminals or serial killers, or many times people will use those terms in a joking or exaggerated way. And then there’s multiple articles on the Internet that describe how to “spot a sociopath/psychopath,” such as this one on WikiHow, which is terribly offensive and downright ridiculous because it continues to further stigmatize those especially with Antisocial Personality Disorder.
To me, personality disorders are considered a mental health diagnosis because of society’s constant need to explain what causes or reasons there are for a person’s emotions, thoughts, and behaviors. But do these diagnoses help the individuals who are diagnosed with them, or is it only giving peace of mind to society?
Source: Castonguay, L.G., & Oltmanns, T.F. (2013). Psychopathology: From science to clinical practice. New York, NY: The Guilford Press.