Descriptive Psychopathology: The Signs and Symptoms of ...

354 Section 3: Examination domainsmood non-reactive. Until 10 years before, his “personality problems” occurredepisodically and always in association with a disturbed mood. He had a strongfamily history of depressive illness and suicide. In early hospitalizations hewas treated with psychotherapy alone, while in later admissions haloperidoland fluphenazine were prescribed.In the index hospitalization, the patient’s difficulties during the previous10 years, including alcohol abuse, were considered expressions of a mooddisorder, rather than deviations in trait behavior. He received bilateral ECTand had a full remission.Diagnostic instabilityDSM and ICD personality disorder diagnoses are unstable. A person may meetcriteria one year, not the next, and meet criteria again a few years later. 14 Patients“fluctuate” in and out of the diagnostic categories over time. Deviant dimensionalpersonality traits are more stable. 15 A study of four different personality disordersfor fixed and changeable criteria found that certain behaviors are prevalent andfixed while others are not common and are changeable. Among patients withschizotypal and paranoid personality disorders, thought content and unusualexperiences were most prevalent and least changeable over time, while constrictedaffect was uncommon and varied in its presence over time, suggesting the criteriafor these categories are a combination of traits and illness behavior. 16Diagnoses within specific clusters are also indistinct, and about 40% of personswho receive one personality disorder diagnosis also meet criteria for a second,whereas studies of the patterns of dimensional traits find that a person has onlyone pattern that changes little over a lifetime. 17 A person who receives a diagnosisof narcissistic personality disorder, for example, may also meet the criteria forhistrionic personality disorder. 18 A patient who is diagnosed as borderline personalitydisorder when depressed may receive a diagnosis of histrionic personalitydisorder when no longer depressed. 19 Using a dimensional system to assess personalitytypically elicits stable diagnoses over repeated examinations. 20The categorical criteria are also poorly drafted, mixing characteristic behaviorswith the non-specific consequences of many behaviors. The borderline patient,for example, is said to be impulsive with affective instability and to have a historyof poor interpersonal relationships. While the association may be causal, poorinterpersonal relationships have many causes.Present classification of personality disordersThe defining construct for the personality disorders is “marked deviation” (notoperationally defined) that affects impulse control, interpersonal functioning,