Finding the "person" in personality disorders
Authors: G O Gabbard
Journal: American Journal of Psychiatry (1997)

Finding the "Person" in Personality DisordersI n 1874 Hughlings Jackson endorsed a two-pronged diagnostic system-one for clinicians and another for researchers (1).The report by Drew Westen in this issue of the Journal suggests that at least with regard to personality disorders, Jackson's wish may have been granted unintentionally.In a small study of his colleagues at the Cambridge Hospital and in a larger survey of a randomly selected national sample of experienced psychiatrists and psychologists, Westen found that clinicians approach the diagnosis of patients with personality disorders in ways that diverge substantially from standard research instruments geared to DSM-IV classification.Direct questions based on criteria from DSM-IV were regarded as only minimally useful in making the diagnosis of a particular personality disorder.Instead, clinicians emphasized observation of the patient's behavior during the interview and descriptions of the patient's interactions with significant others.Westen also found that clinicians tend to apply only one axis II diagnosis, while the use of currently popular research instruments based on the DSM-IV system typically results in somewhere between three and six personality disorder diagnoses if subjects are thought to have any pathology at all on axis II.Research instruments using direct questions about personality traits are fraught with problems.The core of such questions is, "What kind of person are you?"These sorts of inquiries are bound to heighten defensiveness in a patient.Most of us are much better at observing traits in others than at describing ourselves.What we refer to as personality is a complex mixture of biologically based temperament, the internalized record of the ravages of experience, including internal representations of self and others, conflicts involving wishes and defenses against those wishes, and a variety of vulnerabilities and aspirations.Character traits tend to be unconscious and ego syntonic.Many patients with personality disorders create much more distress in others than in themselves.As Westen points out, the psychoanalytic construct of the unconscious dimensions of personality has now been legitimized by empirical research on implicit or nondeclarative memory and a host of studies showing that unconscious motivations influence our behavior.In the rest of medicine, much more is made of the distinction between signs and symptoms than in psychiatry.Classically, signs refer to phenomena observed by the physician in the course of a physical examination, while symptoms are subjective reports from the patient.The diagnosis of pathology on axis II depends much more on the observation of signs by the clinician than on the patient's highly defended answers to direct questions about traits.Clinicians have long known this, and Westen's findings confirm it.A host of criticisms have been levied against the categorical approach to the diagnosis of personality disorders (2-6).This model, based on a disease-oriented/medical model approach, makes a basic assumption that a disorder is either present or absent, even though most personality features occur on a continuum without a clear demarcation of what is normal from what is abnormal (7).These categorical distinctions between personality disorders do not hold up and result in high degrees of comorbidity, as Westen suggests.He offers three explanations for why clinicians are much more likely than researchers to diagnose only one person-