#dsm iii

[hauntedselves]

Other Personality Disorders

This post is about personality disorders that used to exist in the DSM or ICD but don’t anymore. You cannot be diagnosed with these disorders, as they’re not in any diagnostic manual; you would be diagnosed with Other Specified Personality Disorder (or the ICD-11 equivalent) instead.

Passive-Aggressive / Negativistic (PA/NegPD)

A pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance, beginning by early adulthood and present in a variety of contexts.

Masochistic / Self-Defeating (Ma/SDPD)

A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her.

Sadistic (SaPD)

A pervasive pattern of cruel, demeaning, and aggressive behavior, beginning by early adulthood and present in a variety of contexts.

Depressive / Melancholic (De/MePD)

A pervasive pattern of depressive cognitions and behaviors, beginning by early adulthood and present in a variety of contexts.

Other Personality Disorders

Turbulent

Turbulent PD has never existed in any DSM. It’s part of Millon’s theorised personality disorder taxonomy, but doesn’t appear in any other literature.

It seems to be an alternate way of categorising and defining hypomania & cyclothymic disorder, and is similar to ADHD, NPD & HPD.

Millon classes it on a spectrum from ebullient personality type -> exuberant personality style -> turbulent personality disorder.

Haltlose

Theorised in German, Russian, and French psychiatry.

Haltlose translates to “unstable” (literally, “without footing”) and refers to a “drifting, aimless and irresponsible lifestyle: a translation might be ‘lacking a hold' on life or onto the self)”.

“Those with haltlose personality disorder have features of frontal lobe syndrome, sociopathic and histrionic personality traits”.

Someone with haltlose PD “lacks concentration and persistence”, and “lives in the present only”. They are “easily persuaded, and [are] often led astray”.

Haltlose PD is similar to AsPD as there is “an inability to learn from experience, and no sincere sense of remorse”. They are often described as ‘lovable rouges’.

(Cullivan, R, ‘‘Haltlose’ type personality disorder (ICD-10 F60.8)’, Psychiatric Bulletin, 1998, pp. 58-59).

Immature

Immature PD was mentioned in the DSM-III as a specifier for Other Specified PD, but removed in later editions.

It seems to be a combination of borderline, histrionic, narcissistic, antisocial, dependent, schizoid and avoidant PDs.

Almeida et al. suggest the following criteria for Immature PD: irresponsibility; impulsivity; unreliability; easily swayed; mood swings; expect overindulgence from others; dependency on others; ability for remorse or regret but it’s “light and fleeting”; inability to manage assets; inability to follow plans; quick to lie; unable to delay gratification; quick to frustration; devaluation of others; risk-taking behaviour; unstable relationships and behaviour; feels both entitled and worthless; attention seeking; recklessness; shyness; ungrateful; over-familiar with others; unable to plan for the future; substance use.

They also suggest 3 subtypes of Immature PD: the dramatic and emotional subtype, the shy subtype, and the mixed subtype.

(Almeida et al., 'Immature Personality Disorder: Contribution to the Definition of this Personality', Clinical Neuroscience & Neurological Research, 2019, pp. 1-16).

Eccentric and Psychoneurotic

These two personality disorders existed only as ‘other specified’ PDs in the ICD-10, where no definition is given.

[hauntedselves]

Masochistic / Self-Defeating Personality Disorder (Ma/SDPD)

Note: You cannot be diagnosed with this disorder, as it's not in any diagnostic manual; you would be diagnosed with Other Specified Personality Disorder instead.

Criteria from the DSM-III-R (1987):

A. A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her, as indicated by at least five of the following:

chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available

rejects or renders ineffective the attempts of others to help him or her

following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)

incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)

rejects opportunities for pleasure, or is reluctant to acknowledge enjoying himself or herself (despite having adequate social skills and the capacity for pleasure)

fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so, e.g., helps fellow students write papers, but is unable to write his or her own

is uninterested in or rejects people who consistently treat him or her well, e.g., is unattracted to caring sexual partners

engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice

B. The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.

C. The behaviors in A do not occur only when the person is depressed.

Millon's subtypes:

(Millon, ed.).

About Ma/SDPD

Ma/SDPD is similar to avoidant, dependent, obsessive-compulsive, depressive / melancholic, negativistic / passive-aggressive and borderline PDs. It's part of what Millon & Bloom term the "Compliant Personality Patterns", along with OCPD, DPD & HPD.

Differential diagnoses include ongoing abuse, anxiety disorders, somatic disorders, and mood disorders.

The most common PD comorbidities with Ma/SDPD are AsPD (22.17%), Depressive / Melancholic PD (16.74%), & SzPD (12.22%). The least common was HPD (4.07%). Less than 8 percent (7.24%) had only ("pure") Ma/SDPD [much higher than those who had pure Negativistic / Passive-Aggressive, Depressive / Melancholic and Sadistic PDs] (Millon & Bloom).

Millon defines it on a spectrum from aggrieved -> masochistic (self-defeating) (Millon Personality Group); or alternatively from abused [personality type] -> aggrieved [style] -> self-defeating [disorder] (Millon). It also exists on a spectrum from self-sacrificing -> yielding -> masochistic (Millon, ed.).

Originally called masochistic PD, the name was changed to self-defeating PD in the DSM-III-R "to avoid the historic association of the term masochistic with older psychoanalytic views of female sexuality and the implication that a person with the disorder derives unconscious pleasure from suffering" (DSM-III-R). However, Millon & Bloom write that the specific name chosen is pointless, because "all personality disorders are “self-defeating.”"

Childhood trauma is a predisposing factor (DSM-III-R).

Herman argues that Ma/SDPD is a misdiagnosis of Complex PTSD, due to victim blaming and sexism (she also argues the same for Dependent and Histrionic PDs).

In the DSM-III-R it was described as being characterised by “ubiquitous self-defeating behavior such as repeatedly entering into unsatisfying and hurtful relationships, avoiding opportunities for pleasure, rejecting relationships with seemingly caring people, and repeatedly rendering ineffective reasonable efforts by others to help the person" (Coolidge & Segal).

Ma/SDPD "is a mixing or confusion of the usual pleasure-seeking drive with the pain avoidance. As a result, these individuals appear to create personal and social discomfort in their lives. Although it is often reported that they seem to feel comfortable only with guilt and shame, they are also believed to use their self-deprecation as a social strategy to gain support from others" (Millon & Bloom).

In Ma/SDPD, "the individual experiences what is emotionally painful as a means of fulfilling his or her survival aims" (Millon, ed.).

Ma/SDPD only ever appeared in the appendix of the DSM-III-R, and it was dropped because it was associated with 'feminine sexual submissiveness' (Millon, ed.).

References

Coolidge, Frederick L., & Segal, Daniel L., ‘Evolution of Personality Disorder Diagnoses in the Diagnostic and Statistical Manual of Mental Disorders’, Clinical Psychology Review, 1998, vol. 18, no. 5, pp. 585-599.

Herman, Judith Lewis, Trauma and Recovery, 2015.

Millon, Theodore, & Bloom, Caryl, The Millon Inventories, 2008.

Millon, Theodore, Disorders of Personality, 2011.

Millon, Theodore, ed., Personality Disorders in Modern Life, 2004.

'Aggrieved / Masochistic Personality', Millon Personality Group, 2015, https://www.millonpersonality.com/theory/diagnostic-taxonomy/masochistic.htm.

[hauntedselves]

Sadistic Personality Disorder (SaPD)

Note: You cannot be diagnosed with this disorder, as it's not in any diagnostic manual; you would be diagnosed with Other Specified Personality Disorder instead.

Criteria from the DSM-III-R (1987):

A. A pervasive pattern of cruel, demeaning, and aggressive behavior, beginning by early adulthood, as indicated by the repeated occurrence of at least four of the following:

has used physical cruelty or violence for the purpose of establishing dominance in a relationship (not merely to achieve some noninterpersonal goal, such as striking someone in order to rob them);

humiliates or demeans people in the presence of others;

has treated or disciplined someone under their control unusually harshly, e.g., a child, student, prisoner, or patient;

is amused by, or takes pleasure in, the psychological or physical suffering of others (including animals);

has lied for the purpose of harming or inflicting pain on others (not merely to achieve some other goal);

gets other people to do what they want by frightening them (through intimidation or even terror);

restricts the autonomy of people with whom they have a close relationship, e.g., will not let spouse leave the house unaccompanied or permit teen-age daughter to attend social functions;

is fascinated by violence, weapons, martial arts, injury, or torture

B. The behavior in A has not been directed toward only one person (e.g., spouse, one child) and has not been solely for the purpose of sexual arousal (as in Sexual Sadism).

Millon's subtypes:

(Millon, ed.).

About SaPD

SaPD is similar to antisocial, negativistic / passive-aggressive, paranoid, and narcissistic PDs. It's part of what Millon & Bloom term the "Aggressive Personality Patterns", along with AsPD, NPD, & Negativistic / Passive-Aggressive PD.

Differential diagnoses include anxiety disorders, mood disorders, substance abuse, AsPD, psychotic disorders (especially with paranoid & persecutory features), and coercive sexual sadism disorder.

The most common PD comorbidities with SaPD are AsPD (36.45%), Negativistic / Passive-Aggressive PD (24.04%), & NPD (14.09%). The least common was OCPD (0.77%). Less than 1 percent (0.31%) had only ("pure") SaPD [less than those who had comorbid OCPD] (Millon & Bloom).

Millon defines it on a spectrum from assertive -> negativistic (Millon Personality Group); or alternatively from assertive [personality type] -> denigrating [style] -> sadistic [disorder] (Millon).

In the DSM-III-R it was described as being “characterized by pervasive cruel, demeaning, humiliating, and aggressive behavior directed toward others, along with a basic lack of empathy and respect for others" (Coolidge & Segal).

Millon also calls it "Aggressive Personality Disorder" (Millon & Bloom).

People with this disorder "might engage in risky behavior undaunted by danger, and [they] might be forward and inhibiting to others. This kind of person is often described as strongly opinionated, closed-minded, unbending, energetic, hardheaded, competitive, and malicious. [They] might be cold-blooded and detached from awareness of the impact of [their] own actions. Sexual energy might lead to imprudent and unseemly behavior" (Millon & Bloom).

People with SaPD are "socially aggressive and seek to dominate those around them", and "are likely to identify vulnerabilities in [people] and exploit them, producing strong fearful or painful emotional responses" (Millon & Bloom).

Not everyone with SaPD is violent, and some inflict pain by other non-physical means; "[t]he person may inflict pain or suffering by lying; for example, a woman may call her former husband and lie to him about their son's having been seriously hurt" (DSM-II-R).

"People with this disorder rarely experience depression, and their reaction to feeling abandoned is usually anger" (DSM-III-R).

SaPD is often caused by childhood trauma, especially domestic abuse (DSM-III-R). The underlying reason for symptoms is often pain avoidance; "[a]lthough sadistic individuals do seem to acquire a perverse pleasure in inflicting pain on others, the underlying motivation seems to be in their own pain avoidance by inflicting overwhelming pain on others before it can be done to them" (Millon & Bloom).

"... sadists may think of themselves as energetic, assertive, and realistic. What is dominating and callous to others is competitive and not overly sentimental to the sadist" (Millon, ed.).

SaPD only ever appeared in the appendix of the DSM-III-R, and if a person met criteria for this PD they were diagnosed with PDNOS (Coolidge & Segal).

"... it was dropped because of scientific concerns, such as the relatively low prevalence rate of the disorder in many settings. However, there were also political reasons. Physically abusive, sadistic personalities are most often male, and it was felt that any such diagnosis might have the paradoxical effect of legally excusing cruel behavior” (Millon, ed.).

References

Coolidge, Frederick L., & Segal, Daniel L., ‘Evolution of Personality Disorder Diagnoses in the Diagnostic and Statistical Manual of Mental Disorders’, Clinical Psychology Review, 1998, vol. 18, no. 5, pp. 585-599.

Millon, Theodore, & Bloom, Caryl, The Millon Inventories, 2008.

Millon, Theodore, Disorders of Personality, 2011.

Millon, Theodore, ed., Personality Disorders in Modern Life, 2004.

'Assertive / Sadistic Personality', Millon Personality Group, 2015, https://www.millonpersonality.com/theory/diagnostic-taxonomy/sadistic.htm.

[alreadyindepartures]

Dalhous - DSM-III

[shrinkrants]

A nice bit of history: The biological turn in American psychiatry

I came of age as a psychiatrist just as the DSM III was being published. During medical school, I had found that my interests and my talents overlapped best in that area of doctoring that had to do with talking to people, and that the doctors who got to talk to people most were psychiatrists. That's why I entered a residency program in psychiatry. In those days, at least in my program, we still got a lot of training in psychotherapy, including a compulsory course in psychoanalysis. I happened that my most influential teachers were a psychologist and a social worker, both of whom were excited about family therapy. This was in the early 70's, and the air was full of ideas about systems theory, communication theory, and ecology, including "the ecology of ideas."  

I didn't realize at the time what a critical turn was happening in my chosen profession. Our embrace of the DSM project went hand in hand with a turn (well-intentioned for the most part) toward empiricism and biology. That turn has played out in ways that sadden me. Mickey, the semi-retired psychiatrist who writes the 1 boring old man blog, tells the story of our turn toward scientism and becoming lackeys of Big Pharma very well. Today's installment is especially good.

1 boring old man: 

In the DSM-II, the Mental Disorders without known physical cause were partitioned into two groups: The Psychoses [III. PSYCHOSES NOT ATTRIBUTED TO PHYSICAL CONDITIONS LISTED PREVIOUSLY] and the Neuroses [IV. NEUROSES]. The Psychoses were Disorders that would more likely be found to have a biological cause  at some future juncture and were treated with biological interventions. The Neuroses probably developed from the circumstances of life, were less likely biological, and were treated at the time with psychotherapy and symptomatic medications. In the drive to remove psychoanalysis ["hypothetical but unproven theories about etiology"] from psychiatry with the DSM-III, the categorical distinctions of the DSM-II [psychosis vs neurosis], [probably·biological vs probably·not·biological] were ablated. That move had many roots: the speculative nature of psychoanalytic theories; the untestable clinical outcome of psychoanalysis or its derivatives; the threat posed to third party medical coverage by long therapies of any kind; the inflexibility of the analysts/psychotherapists around these issues; and the political dominance of the psychoanalysts in American psychiatry in general [to mention a few]. And we’re all aware of the neo-Kraepelinian Tenets that fueled that revision:

Psychiatry is a branch of medicine.

Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.

Psychiatry treats people who are sick and who require treatment.


There is a boundary between the normal and the sick.


There are discrete mental illnesses.  They are not myths, and there are many of them.


The focus of psychiatric physicians should be on the biological aspects of illness.


There should be an explicit and intentional concern with diagnosis and classification.


Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.


Statistical techniques should be used to improve reliability and validity.

The combination of the DSM-III’s etiological neutrality, the neo-Kraepelinian injunction ["The focus of psychiatric physicians should be on the biological aspects of illness"], and the third party payers limiting payment to psychiatrists for medication management created a fertile soil for the flowering of the psychopharmacologic treatment of mental illnesses. The change in mental health treatment was dramatic. Psychiatrists drifted to medication management and the other mental health disciplines who were much more amenable to negotiation than psychiatrists took over psychotherapy and counseling. Access to treatment was tied to diagnosis and determined by the third party carriers through contracted panels of approved providers. Many patients had both a therapist and a psychiatrist. Those practicing traditional psychotherapy practiced off the grid.

The idea of biological causation was both on the forefront [at least in the research laboratories] and in the background [in the ubiquitous Clinical Trials focused on symptomatic improvement rather than cause] – nowhere more apparent than in the treatment of depression. The DSM-III destroyed diagnostic distinctions among the clinical depressions – essentially shutting down biological research on the probably·biological depressive syndromes by diluting them with the larger group of probably·not·biological symptomatic depressions. The primary focus of psychiatric research turned from etiology to treatment effect and moved from academic centers to private enterprise – the clinical research industry.

Read the rest here.

[lyalljbcw027-blog]

Alcoholism in North America, Europe, and Asia

Alcoholism in North America, Europe, and Asia This volume represents a landmark in the important and rapidly expanding literature of cross-cultural epidemiology that has been made possible by the worldwide popularity of the DSM-III and the multi-national use of a single survey instrument: the Diagnostic Interview Schedule (DIS). Reviewing population survey findings across ten regions of North America, Europe, and Asia, this study is the first direct cross-national comparison of personal interview data on alcoholism, including prevalence rates and risk factors. The book carefully describes the background of the various surveys and the methods of analysis and comparison. Chapters on each region describe the prevalence of drinking problems, the symptomatic expression of alcoholism in that culture, aspects of the cultural background that are relevant to drinking behavior, and the association between alcoholism and other psychiatric disorders. Of particular importance in this volume is the inclusion of a chapter on alcoholism in the Socialist Republic of China, from which very little scientific information has been readily available. The inclusion of eastern and western cultural perspectives offers insight into both universal and culturally distinct aspects of alcoholism. The volume is essential reading for psychiatrists, epidemiologists, sociologists, and alcohol theorists, researchers and clinicians.