Descriptive Psychopathology: The Signs and Symptoms of ...

393 Chapter 16: An evidence-based classificationTable 16.3. Proposed Axis II changesEliminate the cluster systemPlace schizoid in the schizophrenia spectrumClassify paranoid personality as a mild delusional disorderClassify the schizotypal syndrome as an independent Axis I classReformulate the borderline condition into two groupings, one as a form of mood disorder andone as an independent Axis I classGroup antisocial, histrionic, and narcissistic personality conditions as an independent classdefined by dimensional criteriaGroup dependent and avoidant personality conditions as an independent class defined bydimensional criteriaClassify obsessive–compulsive personality in the OCD spectrumDependent and avoidant personality classes, however, differ from obsessive–compulsive personality in that patients with obsessive–compulsive personality arelow in reward dependence (i.e. they are less likely to be influenced by praise,affection, money and power), while patients with dependent and avoidant personalitiesexhibit high reward dependence and are greatly influenced by theresponses of others. Persons with dependent and avoidant personalities experienceanxiety associated with sensitivity to the actions of others. Persons withobsessive–compulsive personality exhibit anxiety when they are unable to actindependently and control their situation. 185There are, however, reports of avoidant and dependent personality disordersco-occurrence with some cluster A conditions. Such persons are said to exhibitlow reward dependence, and decreased sentimentality and the need for socialcontact. 186 In contrast, most persons with avoidant and dependent personalitydisorders have high reward dependence with increased sentimentality and theneed for social contact, 187 suggesting that the reported co-occurrence is superficialand an artifact of assessing personality categorically.Obsessive–compulsive personality should be classified as part of the OCDspectrum. Avoidant and dependent personality should be independently classified.Table 16.3 summarizes the proposed Axis II changes.ConclusionTraditions in psychopathology have served medicine well, delineating disordersthat permit the prescription of increasingly more specific treatments. Lithium inthe treatment of manic-depression is a classic model. Most recent efforts havereawakened the recognition of catatonia and melancholia and their treatments. 188