Descriptive Psychopathology: The Signs and Symptoms of ...

352 Section 3: Examination domainsTable 15.1. Problems with “Axis II”ProblemDiagnostic unreliabilityExcessive co-occurrenceHeterogeneity within personalitiesUnstable and arbitraryboundariesMixing deviance from illnesswith deviance from traitConsequencesPersonality disorder diagnoses have poor reliability ingeneral clinical practice 6 leading to false positivediagnoses (e.g. patients with low-grade manic-depressionincorrectly identified as having borderline personalitydisorder). False negative conclusions occur whenmaladaptive traits go unrecognized.Many patients simultaneously meet criteria for severalpersonality disorders, eliciting diagnostic confusionand poor treatment. 7Patients who share the same personality disorderdiagnosis can be dissimilar in trait behavior. Tarred withthe same brush, they receive similar prescriptions andprognoses but require different treatment approaches(e.g. antisocial personality is based on socialconsequences not observable behavior; a cold-bloodedpsychopath and an illicit drug user receive the samelabel and societal response). 8Stability over time varies and the NOS designation is themost frequently used diagnosis in clinical practice. 9Patients with Cluster A diagnoses have low-grade illnesses,not deviant trait behavior. The prognostic and treatmentimplications are substantial and prevention strategiesand treatments are not considered.to personality disorders, but then explicitly ignore the dimensional construct inthe formulation and details of the personality disorder axes.The problems with present personality disorder classificationsThe problems with the present classification of personality disorders are fundamentaland cannot be fixed with cosmetic change. The structure is at variancewith the science. 10 Table 15.1 summarizes the problems in the DSM Axis II.False positive and negative diagnosisUsing the categorical structure to classify personality disorders rather than adimensional construct is a fundamental error generating many of the difficultiesassociated with the present system. 11 In categorical grouping, if the patient hasa certain number of problems he is identified as having that personality disorder.If he has one less problem he does not have the personality disorder. This “you