Archaic PD diagnoses

[NancyPansy]

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I was wondering what people's thoughts are on the older PD categories like Sadistic PD, Passive-aggressive PD, Self-Defeating PD. Do you think they had any merit or value? Do you agree with their removal or wish they had not been removed? I used to have an older psychology book (based on the DSM III) that was given to me by a family friend who studied a few decades ago so I read a little about them and it made me curious. I'm not yet in residency so don't have a strong opinion but would love to know what people in mental heath have to say about them, especially passive aggressive PD. This may be a silly or obvious question, but how is a pervasive pattern of passive aggressive behavior accounted for these days? Does it correlate with any of the newer PDs?

 

[OldPsychDoc]

You bill for "PD NOS", but note all those delicious traits in your formulation.

 

[splik]

personality disorders are among the least reliable and valid diagnoses in the DSM. Bizarrely, psychopathy is the most valid and is relegated to the appendix. the diagnostic criteria for antisocial personality disorder curiously do not even include any elements of personality! The problem is that these traits are supposed to be enduring and in the majority of cases, especially for cluster B disorders, this is not the case. As such many experts in personality pathology, such as Peter Tyrer have proposed we use the term personality functioning rather than personality disorder, as this accounts for the fact that patients may have at a given time impairments in interpersonal, cognitive style, affect-regulation, impulse-control etc that we call "personality" but this isn't necessarily the case in 5 years... The other major problem is the problem of comorbidity, it is the rule rather than exception for individuals to have traits for multiple diagnoses of PD. As such another proposal, for the ICD-11 especially has been to simplify personality disorders by severity of impairment rather than by type. So if you have lots of maladaptive personality traits you might get a dx of severe personality disorder vs. mild personality for only a few maladative traits, transcending the current diagnostic labels.

The psychoanalysts still use these sorts of personality diagnoses you mention and more (indeed it was at the behest of the analysts those older dx were ever featured in the DSM at all). They have their own dx manual now, the psychodynamic diagnostic manual (PDM). Any basic text of psychoanalytic diagnosis should also describe the different character types.

I would highly recommend Broken Structures by Salman Akhtar if you are interested in reading more about different personality disorders - he combines descriptive psychopathological and psychoanalytic perspectives on different personality disorders.

 

[Shikima]

You bill for "PD NOS", but note all those delicious traits in your formulation.

 

[erg923]

I was wondering what people's thoughts are on the older PD categories like Sadistic PD, Passive-aggressive PD, Self-Defeating PD. Do you think they had any merit or value? Do you agree with their removal or wish they had not been removed? I used to have an older psychology book (based on the DSM III) that was given to me by a family friend who studied a few decades ago so I read a little about them and it made me curious. I'm not yet in residency so don't have a strong opinion but would love to know what people in mental heath have to say about them, especially passive aggressive PD. This may be a silly or obvious question, but how is a pervasive pattern of passive aggressive behavior accounted for these days? Does it correlate with any of the newer PDs?

The death of descriptive psychopathology in American psychiatry/psychology is quite a shame. Older doesn't mean necessarily mean"archiac" in this field.

 

[NancyPansy]

Thanks so much, Splik, for the book recommendation! I will look for it 🙂

It's true about APD. There are no personality traits at all so I guess anybody with a tendency toward law breaking and other disruptive behavior (say a drug addict) can be given the diagnosis while totally lacking psychopathic traits. I always wondered, why come up with a PD that's not about personality at all? LOL And the flip side is even worse, because it makes it more likely for someone with serious psychopathic personality traits to escape diagnosis provided they don't ostensibly break the law.

I had some experience with psychopathy through a former relative (non-blood related) who did a number on my family and who may be a high-functioning psychopath (I could be wrong because of my lack of training, but knowing this person well I somehow doubt it). But anyway, I remember reading every book I could get my hands on about psychopathy and looking up articles on the net only to find that many people tended to use the terms APD and psychopathy interchangeably.

Maybe I'm missing something obvious here, but I was going through the questions on the MMPI the other day and I couldn't help but think that it would be extremely easy for a clever person to choose the 'correct' answers even when that's not how they personally feel at all. I read an article recently were the author claimed that psychopathy is best diagnosed through observation. Would you agree with that?

I think he was onto something because it's one thing to ask the person to admit to callousness (even if the test questions as worded to sound as morally neutral as possible) and another to observe them being callous or dishonest or unscrupulous which they usually can't help!

Hi erg923, I know what you mean categories. It seems like many people in mental health want those older PDs to make it back in the DSM from what I read. I'm holding off on a personal opinion because I'm not so familiar with this topic but it sounds to me like they probably weren't any more controversial than most current PD categories, especially APD, haha.

 

[Ceke2002]

I had some experience with psychopathy through a former relative (non-blood related) who did a number on my family and who may be a high-functioning psychopath (I could be wrong because of my lack of training, but knowing this person well I somehow doubt it). But anyway, I remember reading every book I could get my hands on about psychopathy and looking up articles on the net only to find that many people tended to use the terms APD and psychopathy interchangeably.

I remember my Psychiatrist once saying something along the lines of being in the presence of someone who is truly psychopathic, as opposed to someone who just has some psychopathic type tendencies, can make it feel like the hairs on the back of your neck are standing up, like there's something almost chilling about being confronted with someone who has absolutely no clear capacity for empathy or a normal range of human emotions apart from what they can successfully mimic. I wish I could remember exactly how he described it, but it was a while ago now.

 

[NancyPansy]

I remember my Psychiatrist once saying something along the lines of being in the presence of someone who is truly psychopathic, as opposed to someone who just has some psychopathic type tendencies, can make it feel like the hairs on the back of your neck are standing up, like there's something almost chilling about being confronted with someone who has absolutely no clear capacity for empathy or a normal range of human emotions apart from what they can successfully mimic. I wish I could remember exactly how he described it, but it was a while ago now.

Yes, they totally are! I've had to deal with angry, physically intimidating men but they IMO can't hold a candle to even a petite woman with psychopathy. There's something about being in the presence of someone who is unburdened by a conscience that makes them extremely intimidating. It has nothing to do with gender or body size, it's the realization that here's someone who is limited by absolutely nothing and who is capable of literally anything provided they won't get caught. Definitely chilling.

 

[MacDonaldTriad]

I really miss inadequate personality disorder. The only thing worse than our clusters and labels is that spectrum attempt in DSM-5. Our validity may not be very good,and I may not be able to define it, but I know it when I see it.

 

[smalltownpsych]

I really miss inadequate personality disorder. The only thing worse than our clusters and labels is that spectrum attempt in DSM-5. Our validity may not be very good,and I may not be able to define it, but I know it when I see it.

We had major problems with the validity and reliability of these diagnoses so the solution was to get rid of them and pretend that they don't exist. Voila! No more problem! I have patients that use that same technique to deal with their problems when it seems too difficult to come up with a solution. Not exactly an adaptive coping strategy.

 

[MacDonaldTriad]

Off topic a bit, but if you dislike Tom C, you will love this:
https://www.youtube.com/watch?v=JntioiLg0-c

 

[whopper]

As mentioned above, if you use a PD not in the DSM IV or V be very descriptive with why you think it is so.

I know someone that has some of the following traits:
-Finds amusement in coincidental points of data that others do not and expects others to be entertained by her mentioning it. "OMG your name starts with an H? So does someone else I know. Wow!" (Other person rolls their eyes).
-Pattern of telling jokes that are not funny but expects others to laugh or she feels inadequate.
-Overly sensitive to social rejection even when the rejection is more imagined than real.
-Frequent pattern of being sexually attracted to men outside her marriage based on propinquity despite that she wants her marriage to survive, she flirts with the other men, pushing the boundaries as far she she could go without actually engaging in sexual intercourse leaving the other men feeling uncomfortable.

Doesn't fit any of the DSM-IV categories. Seems to have a touch of cluster B.

 

[Member 1337]

I really got a kick out of Nancy McWilliams' formulations - Amazon product ASIN 1609184947
Very well thought out and a much more helpful model than the DSM. IMO, anyway... if you're interested in phenomenology and describing all this indescribable dynamic-y... stuff.

Edit: Not that I would document these diagnoses in my notes... just that they are more helpful for understanding ourselves.

 

[DD214_DOC]

I think many physicians mistake antisocial behavior with ASPD. A true high-functioning psychopath should never be able to be labeled as a psychopath. Isn't part of the whole, "psychopathy" thing their charming quality, ability to manipulate, and ability to hide their true nature?

 

[hamstergang]

I think many physicians mistake antisocial behavior with ASPD. A true high-functioning psychopath should never be able to be labeled as a psychopath. Isn't part of the whole, "psychopathy" thing their charming quality, ability to manipulate, and ability to hide their true nature?

If they're so high functioning that we can't detect their symptoms then I don't know how they'd qualify for a psychiatric disorder since it requires significant dysfunction or distress.

 

[Ceke2002]

I think many physicians mistake antisocial behavior with ASPD. A true high-functioning psychopath should never be able to be labeled as a psychopath. Isn't part of the whole, "psychopathy" thing their charming quality, ability to manipulate, and ability to hide their true nature?

Everyone's mask slips eventually though. The Psychiatrist who abused me was well known in the Psychiatric community as a 'charming Psychopath', and I'd hazard a guess that wasn't just a colourful description of his known behaviours either. He was the epitome of the cunning, charming, manipulative, charismatic, high functioning, intelligent, feels no guilt or remorse type Psychopathic personality, but he still couldn't completely hide that look of sheer pleasure I saw on his face when he put one of my friends into a sudden and severe narcotic withdrawal and then sat and watched as he writhed around in pain and begged for help.

 

[NancyPansy]

I think many physicians mistake antisocial behavior with ASPD. A true high-functioning psychopath should never be able to be labeled as a psychopath. Isn't part of the whole, "psychopathy" thing their charming quality, ability to manipulate, and ability to hide their true nature?

I know. It would be difficult to diagnose a high-functioning psychopath, especially through psychological testing. I haven't seen the actual questions on the PCL-R but, having seen the ones on the MMPI, I was surprised this stuff is admitted in court. I mean I'm not psychopathic but I am pretty anxious/hypochondriachy and it would be very easy for me to pick out the questions that point to those tendencies and choosing the 'healthy' option. That's why I'd have trouble trusting a test.

I found a discussion about the PCL-R where someone says: "The PCL-R is a measure of antisocial/criminal potential and/or "criminal personality". It is decidedly NOT a very good measure of psychopathy. Scoring high on the PCL-R does NOT make an individual a psychopath."

http://forum.psychlinks.ca/showthread.php?23222-Validity-of-the-Psychopathy-Checklist

Although, I don't think Hare denies that there exists a type of psychopath that does not commit crime. I saw him in an interview saying that he wished he would have spent more of his time in Wall Street rather than prison, or something along those lines, in order to study the high-functioning ones.

What do you guys think about Cleckley's criteria? Isn't it more likely to apply to the high functioning type?

 

[splik]

i think Cleckley's criteria which was not based on any systematic study, he just made them up, were not even popular in the days and are only of historical interest now. not that The Mask of Sanity is not worth a look, it just doesn't mesh with our current concept of psychopathy. Also to confuse thing sociopathy does not equate with psychopathy in the current literature. and his use of sociopathy is not what sociopathy is defined as today (it is used more in the anthropological literature).

Hare recently co-authored Snakes in Suits which is all about the white collar psychopaths. it is definitely worth a reading. I find psychopaths very fascinating creatures. It is true that often it is hard to know you are dealing with a psychopath, but usually people know something isn't quite right. They make you feel really icky. Usually you have to talk to multiple people to put it together that the patient is a psychopath. I saw a patient last year who I felt something was off with but he was very pleasant, superficially charming, interest in psychotherapy. Only when I talked to the resident who saw him previously did we put together he was a psychopath. I have also interviewed several residency applicants each year who I suspect of being psychopathic. Usually just an odd feeling. I felt really bad this year about putting on someone's evaluation "I wouldn't be surprised if he were a psychopath". But all the other people who interviewed him also thought something was off too and I was vindicated.

 

[splik]

in terms of level of functioning in psychopathy, it is usual determined by the level of intelligence and impulse-control the individual has. if you start deviating away from the criteria for psychopathy then you are not talking about psychopathy.

Otto Kernberg has also written some interesting (if somewhat confusing) stuff on narcissism and he conceptualizes a spectrum of narcissism with psychopathy on one end, and malignant narcissism before that. so some of the individuals you might be thinking about as psychopaths, might be regarded as malignant narcissists.

This is what DSM-5 has to say on psychopathy: "A distinct variant often termed psychopathy (or “primary” psychopathy) is marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence). This psychopathic variant is characterized by low levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment domain) and high levels of attention seeking (Antagonism domain). High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/resilience) component."

 

[Psychobabbling]

As mentioned above, if you use a PD not in the DSM IV or V be very descriptive with why you think it is so.

I know someone that has some of the following traits:
-Finds amusement in coincidental points of data that others do not and expects others to be entertained by her mentioning it. "OMG your name starts with an H? So does someone else I know. Wow!" (Other person rolls their eyes).
-Pattern of telling jokes that are not funny but expects others to laugh or she feels inadequate.
-Overly sensitive to social rejection even when the rejection is more imagined than real.
-Frequent pattern of being sexually attracted to men outside her marriage based on propinquity despite that she wants her marriage to survive, she flirts with the other men, pushing the boundaries as far she she could go without actually engaging in sexual intercourse leaving the other men feeling uncomfortable.

Doesn't fit any of the DSM-IV categories. Seems to have a touch of cluster B.

Sounds Histrionic...

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To the OP:
"I was wondering what people's thoughts are on the older PD categories like Sadistic PD, Passive-aggressive PD, Self-Defeating PD...."

A lot of these may have been absorbed into other PDs. For example, "Self-Defeating PD" is considered a "type" of "Borderline Personality Disorder" Helene Deutsch's "As-If Personality" is considered to be a "type" of "Borderline Personality Disorder" (yes, disorder, not merely organization, see Kernberg or Masterson). Passive-Aggressive can be considered a Borderline PD type, or, to be an expression of "Covert Narcissistic Personality Disorder." Sadistic PD probably better fits malignant narcissism to some degree.