Personality Disorders Aren't

Before I comment on his article published in the New York Times, a word about psychologist Charles Zanor and how he is treated by the Times. His byline gives his name with no prefix or degree. In contrast, when he refers to John Gunderson, whom I believe has an M.D. degree, if not a few others, he writes "Dr. Gunderson." I had to Google Charles Zanor to confirm that he too has a doctorate degree, a PhD. Not only do I believe it is disrespectful of the New York Times to omit any reference to this, but I believe readers, myself included, also may want to know whether he has a doctorate degree or a lesser degree, perhaps even whether he has a PhD vs. an EdD or a PsyD.

Having said that, I disagree with much of what Dr. Zanor says in his article. He comments on another article reporting on the apparent direction of the committee addressing personality disorders for the upcoming DSM-V. He describes abandonment of the current 10 defined personality disorders in favor of a "dimensional" approach. He also describes Dr. Gunderson's opposition to this direction.

Dr. Zanor makes some good points, but he fails to adequately address two aspects of this problem. Personalities exist on a continuum of traits, and whether one's personality is labeled as disordered or not depends on where we decide to draw an arbitrary line. Under the current system a clinician makes a judgment call about the degree to which an individual's personality traits interfere with his functioning. Compare this to judging "how pregnant" a woman is. Unlike in "diagnosing" pregnancy there is no bright line.

Having decided to classify the patient as personality disordered one may then attempt to pigeonhole them in one category or another. All individuals with narcissistic (or other) personality disorder do not necessarily display the same pattern of personality traits. One individual may also display some dependent traits while another may display some obsessive compulsive traits. However, generally the narcissistic traits dominate the clinical picture. It's comparable to skin color. Nobody is really just black or white.

Dr. Zanor also errs in referring to "syndromes" of traits. Syndromes are collections of symptoms. Ill people complain of symptoms. Most people with personality traits (We all have them.), even the self-defeating ones, don't complain about them: "Help me doc. I've been feeling really generous for the last few days." or "Gee doc, I've noticed my speech is 'impressionistic and lacking in detail.' Do I need surgery?" Syndrome implies Axis I in the DSMs, at least from III on.

So despite what Dr. Gunderson says, a dimensional approach is more intellectually honest. And what difference does it make anyway? Nobody really believes any medication effectively treats a personality disorder. Imagine the FDA approving moxapoxatoxatine for the treatment of Avoidant Personality Disorder. Most don't believe psychotherapy works very well either. I suspect only the psychoanalysts care, and they probably approach every case the same way regardless.

Some addiction psychiatrist once said AA was the best treatment for personality disorder, and I tend to believe it, but you can bet that AA doesn't care how you classify them either.