Descriptive Psychopathology: The Signs and Symptoms of ...

392 Section 4: Evidence-based classificationpower, order, idealism, independence, status, vengeance, romance, family, activity,saving, acceptance, eating, and tranquility. The details of the terms can form thediagnostic criteria for each personality deviation.Cluster considerationsCluster A should be eliminated. These entities reflect low-grade chronic illness.Schizoid personality is a variant of schizophrenia and should be included in thatcategory as a pre-psychosis trait. Paranoid personality is a variant of delusionaldisorder and should be included in that category as a mild form. Schizotypalpersonality is a heterogeneous class that includes patients with mood disorder,seizure disorder, and psychoses from traumatic brain injury and illicit drug use. 176It should be labeled as an independent schizotypal disorder in Axis I akin to delirium.Cluster B mixes disease and trait abnormalities. Antisocial, histrionic, andnarcissistic personality disorders overlap in presentation and in other variables,but are not well-defined categorically. 177 Their pattern of psychopathology alsosuggests that they are composed of sub-clusters that may indicate heterogeneity.178 They are better defined dimensionally as deviations on reliably identifiedand validated temperament traits, sharing high novelty seeking (high behavioralactivation), and low harm avoidance (low behavioral inhibition). They should begrouped in an independent class.Borderline personality is another heterogeneous category 179 and 50–80% of suchpatients have an Axis I diagnosis that accounts for all their symptoms. 180 About50% of patients with the borderline diagnosis exhibit features of the “soft bipolarspectrum” construct or manic-depressive illness with a childhood onset. The latteris less episodic, more chronic, and less severe than the classic form and is associatedwith drug abuse. Symptoms may be misconstrued as trait behaviors. 181 Suchpatients should be regarded as having a mood disorder and placed in that category.The remaining persons given the borderline diagnosis should be given independentstatus, recognizing their heterogeneity. 182 The term borderline should bereplaced. It borders nothing and has no scientific meaning. Persons with the labelwho do not have mood disorder are diagnosed by the consequences of behaviorsassociated with antisocial, histrionic, and narcissistic personality disorders.A stormy life with self-mutilating behavior is not a pathognomonic pattern andthe reliability of such criteria is poor. In addition to mood disorder, diagnosesassociated with these features are mild mental retardation and related syndromes(e.g. Asperger’s), obsessive–compulsive disorder, chronic drug abuse affectingbasal ganglia (stimulants), and epilepsy. 183Cluster C is poorly defined categorically. These patients are better delineateddimensionally as sharing low behavioral activation (low novelty seeking) andhigh behavioral inhibition (high harm-avoidance). 184