II. Personality Disorders

Indeed, personality disorders are an excellent example of kaleidoscopic landscape of "objective" psychiatry.

The classification of Axis II personality disorders – deeply ingrained, maladaptive, lifelong behavior patterns – in Diagnostic and Statistical Manual, fourth edition, text revision [American Psychiatric Association. DSM-IV-TR, Washington, 2000] – or DSM-IV-TR for short – has come under sustained and serious criticism from its inception in 1952, in first edition of DSM. The DSM IV-TR adopts a categorical approach, postulating that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is widely doubted. Even distinction made between "normal" and "disordered" personalities is increasingly being rejected. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported. The polythetic form of DSM's Diagnostic Criteria – only a subset of criteria is adequate grounds for a diagnosis – generates unacceptable diagnostic heterogeneity. In other words, people diagnosed with same personality disorder may share only one criterion or none. The DSM fails to clarify exact relationship between Axis II and Axis I disorders and way chronic childhood and developmental problems interact with personality disorders.

The differential diagnoses are vague and personality disorders are insufficiently demarcated. The result is excessive co-morbidity (multiple Axis II diagnoses). The DSM contains little discussion of what distinguishes normal character (personality), personality traits, or personality style (Millon) – from personality disorders.

A dearth of documented clinical experience regarding both disorders themselves and utility of various treatment modalities. Numerous personality disorders are "not otherwise specified" – a catchall, basket "category".

Cultural bias is evident in certain disorders (such as Antisocial and Schizotypal). The emergence of dimensional alternatives to categorical approach is acknowledged in DSM-IV-TR itself:

“An alternative to categorical approach is dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another” (p.689)

The following issues – long neglected in DSM – are likely to be tackled in future editions as well as in current research. But their omission from official discourse hitherto is both startling and telling:

The longitudinal course of disorder(s) and their temporal stability from early childhood onwards;

The genetic and biological underpinnings of personality disorder(s);

The development of personality psychopathology during childhood and its emergence in adolescence;

The interactions between physical health and disease and personality disorders;

The effectiveness of various treatments – talk therapies as well as psychopharmacology.

III. The Biochemistry and Genetics of Mental Health

Certain mental health afflictions are either correlated with a statistically abnormal biochemical activity in brain – or are ameliorated with medication. Yet two facts are not ineludibly facets of same underlying phenomenon. In other words, that a given medicine reduces or abolishes certain symptoms does not necessarily mean they were caused by processes or substances affected by drug administered. Causation is only one of many possible connections and chains of events.

To designate a pattern of behaviour as a mental health disorder is a value judgment, or at best a statistical observation. Such designation is effected regardless of facts of brain science. Moreover, correlation is not causation. Deviant brain or body biochemistry (once called "polluted animal spirits") do exist – but are they truly roots of mental perversion? Nor is it clear which triggers what: do aberrant neurochemistry or biochemistry cause mental illness – or other way around?

(continued)

Sam Vaknin is the author of Malignant Self Love - Narcissism Revisited and After the Rain - How the West Lost the East. He is a columnist for Central Europe Review, PopMatters, and eBookWeb , a United Press International (UPI) Senior Business Correspondent, and the editor of mental health and Central East Europe categories in The Open Directory Bellaonline, and Suite101 .

Visit Sam's Web site at http://samvak.tripod.com

People sometimes seek sex reassignment because of advantages and opportunities which, they believe, are enjoyed by other sex. This rather unrealistic (fantastic) view of other is faintly narcissistic. It includes elements of idealised over-valuation, of self-preoccupation, and of objectification of one's self. It demonstrates a deficient ability to empathise and some grandiose sense of entitlement ("I deserve to have best opportunities/advantages") and omnipotence ("I can be whatever I want to be – despite nature/God").

This feeling of entitlement is especially manifest in some gender dysphoric individuals who aggressively pursue hormonal or surgical treatment. They feel that it is their inalienable right to receive it on demand and without any strictures or restrictions. For instance, they oftentimes refuse to undergo psychological evaluation or treatment as a condition for hormonal or surgical treatment.

It is interesting to note that both narcissism and gender dysphoria are early childhood phenomena. This could be explained by problematic Primary Objects, dysfunctional families, or a common genetic or biochemical problem. It is too early to say which. As yet, there isn't even an agreed typology of gender identity disorders – let alone an in-depth comprehension of their sources.

There are mental disorders, which afflict a specific sex more often. This has to do with hormonal or other physiological dispositions, with social and cultural conditioning through socialisation process, and with role assignment through gender differentiation process. None of these seem to be strongly correlated to formation of malignant narcissism. The Narcissistic Personality Disorder (as opposed, for instance, to Borderline or Histrionic Personality Disorders, which afflict women more than men) seems to conform to social mores and to prevailing ethos of capitalism. Social thinkers like Lasch speculated that modern American culture – a narcissistic, self-centred one – increases rate of incidence of Narcissistic Personality Disorder. As Kernberg observed:

"The most I would be willing to say is that society can make serious psychological abnormalities, which already exist in some percentage of population, seem to be at least superficially appropriate."

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Quotes from Literature

"Specifically, past research suggests that exploitive tendencies and open displays of feelings of entitlement will be less integral to narcissism for females than for males. For females such displays may carry a greater possibility of negative social sanctions because they would violate stereotypical gender-role expectancies for women, who are expected to engage in such positive social behavior as being tender, compassionate, warm, sympathetic, sensitive, and understanding.

In females, Exploitiveness/Entitlement is less well-integrated with other components of narcissism as measured by Narcissistic Personality Inventory (NPI) - Leadership/Authority, Self-absorption/Self-admiration, and Superiority/Arrogance- than in males - though 'male and female narcissists in general showed striking similarities in manner in which most of facets of narcissism were integrated with each other'."

Gender differences in structure of narcissism: a multi-sample analysis of narcissistic personality inventory - Brian T. Tschanz, Carolyn C. Morf, Charles W. Turner - Sex Roles: A Journal of Research - Issue: May, 1998

"Women leaders are evaluated negatively if they exercise their authority and are perceived as autocratic."

Eagly, A. H., Makhijani, M. G., & Klonsky, B. G. (1992). Gender and evaluation of leaders: A meta-analysis. Psychological Bulletin, 111, 3-22, and ...

Butler, D., & Gels, F. L. (1990). Nonverbal affect responses to male and female leaders: Implications for leadership evaluations. Journal of Personality and Social Psychology, 58, 48-59.

"Competent women must also appear to be sociable and likable in order to influence men - men must only appear to be competent to achieve same results with both genders."

Carli, L. L., Lafleur, S. J., & Loeber, C. C. (1995). Nonverbal behavior, gender, and influence. Journal of Personality and Social Psychology, 68, 1030-1041.

Sam Vaknin is the author of Malignant Self Love - Narcissism Revisited and After the Rain - How the West Lost the East. He is a columnist for Central Europe Review, PopMatters, and eBookWeb , a United Press International (UPI) Senior Business Correspondent, and the editor of mental health and Central East Europe categories in The Open Directory Bellaonline, and Suite101 .

Visit Sam's Web site at http://samvak.tripod.com