In contrast to medical conditions like cancer, pneumonia, and nephritis--all unequivocally diseases, application of the medical model to the domain of personality disorders is necessarily controversial. Everyone has a personality. The dividing lines between peculiarities and quirks, occasional outbursts under stress, persistent abnormalities of a mild sort, and chronic disorders with severe consequences for self and others--cannot readily be drawn, certainly not to universal agreement. Even where there is widespread acceptance about criteria for a particular disorder, one cannot speak prescriptively about its "ideal" treatment. The current diagnostic manual in psychiatry (DSM-IV) will soon be replaced by DSM-V. Some of the deficiencies and ambiguities of the last edition will be corrected; new ones will appear. There will always be some disagreement, in effect--some "disorder" in the domain of personality disorders. In this article some of the more pervasive problem areas are outlined. Among them: the continuum between personality oddity, outright personality disorder, and the more disease-like symptom-disorder pertinent to almost all the currently recognized Axis II disorders. Also: the effects of culture on what is-or is not-recognized as a valid disorder of personality, the inherent complexities in the personality domain (which require attention to dimensional as well as category-based concepts), the overlap among the various categories, the tendency (especially in forensic work) toward diagnostic oversimplification (as though all narcissists or borderlines are alike), the interactions of genetic, prenatal, and environmental factors, and lastly, the importance of traits-including the often neglected positive traits modifying any given disorder. Awareness of these factors can help reduce, though not eliminate, the disorder in the personality disorder domain.
"Some studies argued for reconsideration (Cruz et al., 2000), while others failed to support its validity as a separate disorder, largely on the basis of comorbidity with borderline, avoidant, or dependent personality disorder or with depression (Huprich, Zimmerman, & Chelminski, 2006; Skodol, Oldham, Gallaher, & Bezirganian, 1994). Stone (2012) noted that this was true for many of the patients accepted into psychoanalytic treatment; that is, that they meet partial criteria for several personality disorders. Personality disorders overlap far more than they exist " pure " ; thus, the frequent reliance on such terms as " subthreshold, " " comorbid, " and " not otherwise specified (NOS). "
[Show abstract][Hide abstract] ABSTRACT: That all pathological gamblers have an "unconscious wish to lose," an idea first expressed by Freud and Bergler, is neither true nor useful; wrong as well, however, are the reasons for neglecting masochism in relation to gambling. There is a small but clinically significant subgroup of pathological gamblers who are masochistic. I present clinical vignettes and a more extended treatment account to illustrate its importance. Masochism has been a confusing concept. As used here it refers to the deliberate seeking of pain, loss, suffering, or humiliation. There may be pleasure in pain, or an obligatory combining of pleasure and pain. A sense of power and control may be achieved through suffering. The case material illustrates clinically useful types (sexual masochism, masochistic personality disorder, moral masochism, relational masochism) as well as some common masochistic dynamics encountered in the treatment of pathological gamblers. These masochistic patterns are often identifiable during the initial evaluation. Distinguishing features may include a reversal of normal attitudes about winning and losing, the absence of an early winning phase, sometimes a memorable early loss. Gamblers may sabotage opportunities for success or create unnecessary obstacles for themselves. Losing may be more comfortable than winning or may be overtly sexualized.
[Show abstract][Hide abstract] ABSTRACT: Abstract Borderline Personality Disorder (BPD) has been often described recently as a condition characterized by emotional dysregulation. Several other conditions share this attribute; namely, Bipolar Disorder (BD), Attention-Deficit/Hyperactivity Disorder (ADHD), Intermittent Explosive Disorder (IED), and Major Depressive Disorder (MDD). The dysregulation is not always in the same direction: BPD, BD, ADHD, and IED, for example, show over-reactivity or "hyperactivity" of emotional responses, whereas patients with MDD show emotional sluggishness and underactivity. At the clinical/descriptive level the "over-reactive" conditions appear separate and distinct. BPD constitutes a large domain within the psychopathological arena, appearing to contain within it a variety of etiologically diverse subtypes. Among the latter is a type of BPD linked closely with Bipolar Disorder; family studies of either condition show an overrepresentation of both: BPD patients with bipolar relatives; Bipolar patients with BPD relatives. A significant percentage of children with ADHD go on to develop either BPD or BD as they approach adulthood. If one shifts the spotlight to neurophysiology, as captured by MRI studies, however, it emerges that an important subtype of BPD, and also BD, ADHD, and IED-share common features of abnormalities and peculiarities in the limbic system and in the cortex, especially the prefrontal cortex. Deeper subcortical regions such as the periaqueductal gray may also be implicated in strong emotional reactions. The diversity of clinical "over-reactive" conditions appear to harken back to a kind of unity at the brain-change level. There are therapeutic implications here, such as the advisability of mood stabilizers in many cases of BPD, not just for Bipolar Disorder.
[Show abstract][Hide abstract] ABSTRACT: Borderline personality disorder (BPD) has been recognized as heterogeneous, etiologically, stemming from many combinations of genetic and environmental factors BPD never occurs alone: it is always accompanied by traits of other personality disorders and by various symptom-conditions, especially mood disorders. The controversy about linkage between BPD and bipolar disorder could not be resolved when the debate relied only on clinical description. Some twin-studies suggested modest overlap between BPD and bipolar disorder. Current neuroimaging research points to similarities in brain changes among several conditions characterized by emotional over-reactivity to stress: bipolar disorder, certain cases of BPD and attention-deficit hyperactivity (ADHD). These include alterations in the limbic system (e.g., amygdala and hippocampus) and neocortex (especially the prefrontal cortex). An important subset of BPD exists in which brain changes are essentially identical with those of bipolar disorder. Relevant brain-change findings and treatment implications are summarized in this article.
Current Psychiatry Reports 10/2013; 15(10):399. DOI:10.1007/s11920-013-0399-7 · 3.24 Impact Factor
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