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Most of today’s clinicians believe that personality disorders are important and
troubling patterns, yet these disorders are particularly hard to diagnose and easy
to misdiagnose. These difficulties indicate serious problems with the validity (accuracy)
and reliability (consistency) of the DSM categories (Jablensky, 2002).
One problem is that some of the criteria used to diagnose personality disorders
cannot be observed directly. To separate paranoid from schizoid personality
disorder, for example, clinicians must ask not only whether people avoid forming
close relationships but also why. In other words, the diagnoses often rely heavily
on the impressions of the individual clinician. A related problem is that clinicians
differ widely in their judgments about when a normal personality style crosses the
line and deserves to be called a disorder (Clark, 2002). Some even believe that it
is wrong ever to think of personality styles as mental disorders, however troublesome
they may be (Kendell, 2002).
The similarity of personality disorders within a cluster, or even between
clusters, poses yet another problem (Grilo et al., 2002). Within the “anxious” cluster,
for example, there is considerable overlap between the symptoms of avoidant
personality disorder and those of dependent personality disorder. When clinicians
see similar feelings of inadequacy, fear of disapproval, and the like, is it reasonable
to consider them separate disorders (Bornstein, 1998; Livesley et al., 1994)?
Also, the many borderline traits (“dramatic” cluster) found among some people
with dependent personality disorder (“anxious” cluster) may indicate that these
two disorders are but different versions of one basic pattern (Dolan et al., 1995;
Flick et al., 1993).
Another problem is that people with quite different personalities may be given
the same personality disorder diagnosis. Individuals must meet a certain number
of criteria from DSM-IV to receive a given diagnosis, but no single feature is necessary
for any diagnosis (Millon, 2002, 1999; Costello, 1996).
Partly because of these problems, diagnosticians keep changing the criteria
used to assess each of the personality disorders. In fact, the diagnostic categories
themselves have changed more than once, and they will no doubt change again.
For example, DSM-IV dropped a past category, passive-aggressive personality
disorder, a pattern of negative attitudes and resistance to the demands of others,
because research failed to show that this was more than a single trait. The pattern
is now being studied more carefully and may be included once again in future editions
of the DSM.
1. To separate paranoid from schizoid personality disorder, for example, clinicians must ask not only whether people avoid forming close relationships but also why.
2. Within the “anxious” cluster,
for example, there is considerable overlap between the symptoms of avoidant personality disorder and those of dependent personality disorder.
I'm sure you can find examples for the other two questions.
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