Thursday, May 5, 2011

Cluster Me

Huddle up. Cluster B.
I really hadn’t planned on doing a DSM-IV style series but as I’m already headed in that direction let’s keep on it.
Personality Disorders are described as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts” and “are inflexible and maladaptive, and cause significant functional impairment or subjective distress”.

According to the DSM-IV there are 10 different personality disorders + 1 catch all ‘personality disorder not otherwise specified’. These disorders are broken down into 3 Clusters (A,B, & C). The purpose of these Clusters is to further organize these disorders into groups that are related to each other by their symptoms.

Characterization:-------------------------------------------------------------------------------------------------------------
Cluster A – Odd or Eccentric Behavior - includes Schizoid, Paranoid, and Schizotypal Personality Disorders.
Schizoid Personality Disorder - A pervasive pattern of detachment from social relationships and a restricted range of expressions of emotions in interpersonal settings. Those with SPD may be perceived by others as somber and aloof, and often are referred to as "loners."

Schizotypal Personality Disorder - A pervasive pattern of social and interpersonal deficits marked by acute discomfort with reduced capacity for close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior. This disorder is characterized both by a need for isolation as well as odd, outlandish, or paranoid beliefs. In social situations, they may show inappropriate reaction or not react at all, or they may talk to themselves.

Paranoid Personality Disorder - A pervasive mistrust and suspiciousness of others such that their motives are interpreted as malevolent. Although they are prone to unjustified angry or aggressive outbursts when they perceive others as disloyal or deceitful, those with PPD more often come across as emotionally “cold” or excessively serious.

Cluster B – Dramatic, Emotional, or Erratic Behavior - includes Antisocial, Borderline, Narcissistic, and Histrionic Personality Disorders.
Antisocial Personality Disorder - A pervasive pattern of disregard for and violation of the rights of others. APD is characterized by lack of empathy or conscience, a difficulty controlling impulses and manipulative behaviors. This disorder is sometimes also referred to as psychopathy or sociopathy, however, Antisocial Personality Disorder is the clinical terminology used for diagnosis.

Borderline Personality Disorder - A pervasive pattern of instability of interpersonal relationships, self-image, affects, and control over impulses. This mental illness interferes with an individual’s ability to regulate emotion. Borderlines are highly sensitive to rejection, and fear of abandonment may result in frantic efforts to avoid being left alone, such a suicide threats and attempts.

Histrionic Personality Disorder - A pervasive pattern of excessive emotion and attention seeking often in unusual ways, such as bizarre appearance or speech. With rapidly shifting, shallow emotions, histrionics can be extremely theatrical, and constantly need to be the center of attention.

Narcissistic Personality Disorder - A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy. Narcissism occurs in a spectrum of severity, but the pathologically narcissistic tend to be extremely self-absorbed, intolerant of others’ perspectives, insensitive to others’ needs and indifferent to the effect of their own egocentric behavior.

Cluster C – Anxious, Fearful Behavior -  Avoidant, Dependent, and Obsessive-Compulsive Personality Disorders.
Avoidant Personality Disorder - A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation and are unwilling to take social risks. Avoidants display a high level of social discomfort, timidity, fear of criticism, avoidance of activities that involve interpersonal contact.

Dependent Personality Disorder - A pervasive and excessive need to be taken care of which leads to submissive and clinging behavior and fears of separation. Dependent personalities require excessive reassurance and advice, and are extremely sensitive to criticism or disapproval.

Obsessive-Compulsive Personality Disorder - Also called Anankastic Personality Disorder display a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. They can also be workaholics, preferring the control of working alone, as they are afraid that work completed by others will not be done correctly.

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My questions is: Are these clusters necessary?

Once you know which personality disorder someone has you’ve got it pegged. It would make more sense to use clusters to further narrow down behavior before diagnosis.

If the patient is obviously dramatic and emotional it is easier come to the Cluster B conclusions and therefore rule out disorders characterized by other clusters. However there can easily be overlap and therefore confusion. With Borderline (Cluster B) there’s an intense fear of abandonment, often paranoia that something will happen and people will leave, which is why we attach so hard to people regardless of there being any evidence to support this paranoia. To me this indicates anxious and fearful behavior which would be Cluster C, even though Paranoid PD is Cluster A. Confusing, no?

Being Borderline I’m grouped into Cluster B. I can tell you with absolute certainty that my personality characteristics fit almost all Cluster A criteria. In Cluster B I obviously hit Borderline but also Histrionic PD. As far as ASPD goes, I have at least the difficulty controlling impulses and manipulative behavior. For NPD a case could be made for being self-absorbed, intolerant of others’ perspectives (if they don’t satisfy what I need at the moment), and indifference to the effect of egocentric behavior. For ASPD and NPD my motivations are fundamentally different though. Maybe that’s the deciding factor. Motivation. Not consciously of course, but those underlying factors that set us apart from the other PDs that we’re not diagnosed with. To me this conclusion is obvious. It boils down to which behaviors are most predominant. This still doesn’t explain what the point of further breaking personality disorders into clusters is. In all of my research, so far, I have not found a single reason why these clusters are necessary.

Who’s to say what the difference between these traits are anyways? Who defines what is erratic (Cluster B) and not eccentric (Cluster A)?  Lack of interest in social relationships (Cluster A) and social inhibition (Cluster C)? There is no solid, scientific way of distinguishing between clusters. There is a lot of overlap between the Clusters so they don’t help narrow down the playing field. Any conclusions reached about a person will point directly to a personality disorder(s) regardless of which cluster they fall into, especially as symptoms may indicate multiple clusters. In fact, the cluster groupings may work to limit the consideration treatment options that other personality disorders could provide insight to.

My conclusion is that they’re basically erroneous.

Hah, Ok. I just found this abstract on Neuropsychological, Psychophysiological, and Personality Assessment of DSM-IV Clusters:

Testing the construct validity of the three DSM-IV cluster groupings of personality disorders, in terms of neuropsychological, psychophysiological, and personality traits measures, was the purpose of this study. The results hardly confirm significant differences between B and C cluster groups in their neuropsychological functioning, but, instead, suggest that Cluster A could have some empirical validity based on executive prefrontal deficits (concept formation and sustained attention tasks) and clinical features. Similarly, no consistent differences among groups emerge when psychophysiological measures are compared. With regard to the Big-Five personality dimensions, the results also indicate that clusters may be more heterogeneous than the DSM-IV suggests. It appears, therefore, that the categorical division of DSM personality disorders into three discrete clusters may not be empirically justified.

See, no real reason for the Clusters. I win. (Apparently this was a competition.)


10 comments:

  1. I honestly had no idea that PD's were grouped in such idiotic ways. It appears as if they are attempting to categorize mental illness the same way they do any other disease. While it is easy to do that with physical illnesses, it is nearly impossible with mental illness. Simply because there is so much overlap. Even though I have bipolar and you have BPD, we have so many similarities, but also some striking differences. While having a criteria is important, it needs to be set up differently. How differently? I don't know but I definitely don't think you can approach it the same way you do other diseases because it just doesn't work that way.

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  2. Yeah, there's really no reason for this approach. From what I'm gathering of the new DSM-V approach to diagnosis these cluster groups will be removed. Diagnosing PDs will be much more systematic and this dumb categorization will be irrelevant.

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  3. i never understood why psychopaths with flat effect were cluster B, emotional dramatic behaviour...
    soon enough there'll be tricorders to just look at brain structure and function to use in a diagnosis, rather than the arbitrary distinctions made by the dsm.
    BTW did you do anything special for star wars day yesterday?

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  4. I was always confused by that as well. In the DSM-V that will be corrected. At least to an extent. No more clusters and ASPD/Psychopathy will be grouped separate from Borderline. I still want my brain scan.

    TOTALLY did something for May the 4th =) I ordered the electronics and components for my new lightsabers! For the Con I only had constructed hilts. I'm going to build two new light sabers with full LED electronics and polycarbonate tubing for the blade. Two because I wield dual shoto blades. I'm stoked! Of course I'll have to create new hilts as well to accommodate the electronics and power button but I'm happy about that too. I can refine the hilt style I devised before and perfect it =)

    I also fell asleep reading my latest Star Wars book =)

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  5. Wow. I haven't read the DSM in a while...not since my son was diagnosed on the autistic spectrum. Without meaning to sound lame, I have to ask: Aren't we all in there...somewhere?

    My middle son was diagnosed at 12 with bipolar. It didn't seem like bipolar to me...but surely, they knew more than me, right?

    Then & there, I began to think that maybe no matter who I took him to, they'd find something going on within their little world. I still believe this.

    Oh and it wasn't bipolar.

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  6. @katheryn.. Did he died?

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  7. @Kathryn ... I think a lot of doctors jump to conclusions nowadays. It's an age of immediate gratification. The sooner they can 'diagnose' the sooner they can get on to the next patient. It takes time to be accurate. My sister is bipolar, I'm glad your son doesn't have to deal with that.

    Absolutely, everyone does present these traits now and again. But the diagnosis of personality disorders has to do with the severity of the presentation and the utter disruption the presentation causes to someones life. Everyone gets angry, a little paranoid, self-conscious but after a little bit those feelings go away. PDs are pervasive lasting years before dianosis and take over your life.

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  8. You didn't comment on DSM IV's exciting catch all category "Personality Disorder Not Otherwise Specified". Last year I was in a very reputable hospital following a suicide attempt when I was told that I was not "Bipolar Type II", as I had believed for years, but rather was suffering from Major Depressive Episodes punctuated by dysthymia and also a highly unusual PD-NOS: Almost all of the features of Borderline Personality Disorder and Obsessive Compulsive Personality Disorder, some but not all of the features of Narcissistic Personality Disorder, and a few of the features of Histrionic Personality Disorder and Antisocial Personality Disorder. This was a shock. No doctor had ever told me that I had a significant Axis II disorder. Now I had a really nasty one. The first two PDs I could live with (although a man being treated for BPD feels strange since some clinicians feel that women, and only women, can have that disorder), but the last three are shocking. Setting fires, torturing animals, a career criminal, pathological lack of empathy - it goes on and on. For weeks I pestered my primary psychiatrist for an explanation. I didn't get one. None of my doctors wanted to talk about it. I persisted and was labeled "aggressive" and "manipulative". By making a nuisance of myself I was showing, they said, the undesirable traits of my PD. Finally a very senior psychoanalyst, a week or two from retirement, sat down with me. She said that most of my Axis II diagnosis, the joint product of four weeks work by several doctors, was meaningless except in a very broad, theoretical sense, and worrying about it would just make me unhappy. Yes, I had some features of BPD and OCPD, but forget the rest. I took her advice and have done pretty well since I left there. The final joke was that my discharge diagnosis was "Avoidant Disorder" - no depression and no PD-NOS. I was told that it would be better for me to have the hospital give the government, employers and insurance companies a meaningless false diagnosis. AD was chosen since people with AD don't do anything violent, disturbing or expensive.

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  9. @Anon... Wow. I would love to incorporate this comment into a completely separate post if that's ok? I think you bring up a really interesting point about diagnosis issues, how clinicians avoid uncomfortable diagnosis. Haha, and you're right, I did gloss over the PD NOS b/c, well, what exactly can you say about it ::smiles::? It actually would make an interesting topic for discussion.

    Whoever diagnosed you with ALL of these PD problems clearly was unaware of how to diagnose PDs in my opinion. NPD, ASPD, and BPD are all grouped together for a reason... they all share characteristics. To multi-diagnose in this spectrum though is a little outrageous. If I were to go through the list of PDs, like you, I would also be multi-diagnosed with ASPD and Histrionic, however, BPD is what suits me BEST, and that's what constitutes a true diagnosis as far as I can tell.

    The analyst you talked to at the end seems to have her head on straight. I'm glad you were able to find some closure on that.

    Avoidant, hah, that's almost funny. It's not uncommon to have a different diagnosis given to insurance companies. My psych/therapist actually bill me as Major Depressive b/c it's easier than trying to get them to pay for BPD.

    Here's a link you may be interested in. I talk about guys and BPD:
    http://downwardspiralintothevortex.blogspot.com/2011/03/where-are-all-men-controversy-in-bpd.html

    and

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  10. imho everything clusterB sould be on a spectrum
    the hole way they diagnos is wrong
    it's focused on the way we act
    not the proces of how we get there (2 hard to time consuming)

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Leave me a comment! It makes me feel good and less paranoid about talking to myself =)

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