Methods of Personality and Personality Disorder Classification

Dr. Donna L. Roberts

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The classification of personality, and subsequently personality disorders, is a problematic and controversial area that has not been sufficiently resolved at this stage in evolution of the science of psychology. Various systems of classification for assessment and diagnosis exist, including, (1) categorical, (2) dimensional, (3) structural, (4) prototype/domain, and (5) relational/integrative. Each structure has both strengths and weaknesses and offers a limited perspective of the complex reality of human functioning (Widiger & Sankis, 2000; Kaplan & Saddock, 2002). (See Figure 1)

Figure 1: Models of Personality Classification

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Clarkin, J. F. & Lenzenweger, M. F. (Eds.) (2004). Major theories of personality disorder

Categorical Classification

The categorical classification is utilized predominantly by psychotherapists in research and in most psychiatric diagnosis. These classifications originate from clinical observations and posit essential core features that define personality syndromes and form the basis for diagnosis. For many clinicians, a standard categorical diagnosis is required to complete insurance forms for reimbursement of clinical services. The DSM-V diagnostic system uses a categorical model of classification which conceptualizes mental disorders as discrete syndromes that form homogeneous clusters of behavior patterns with distinct boundaries. These syndromes are defined by a limited set of symptoms - a certain constellation of which will warrant the diagnosis. This approach is consistent with the traditional conception of medical disorders (American Psychiatric Association, 2013).

The DSM-V categorical system relies on establishing the presence of behaviorally observable conglomerations of symptomatic criteria to indicate the presence of a diagnosable personality disorder. Specifically, the DSM-V categorizes personality disorders into three clusters according to descriptive similarities based primarily on the outward appearance of associated symptomology, as follows:

  • Cluster A is characterized by odd or eccentric behavior and includes paranoid, schizoid, and schizotypal personalities. This cluster tends to be the most treatment refractory and is probably the most likely to have underlying biogenetic factors.
  • Cluster B is characterized by erratic, emotional, and dramatic presentations and includes antisocial, borderline, histrionic, and narcissistic personalities. This cluster includes personality disorders often considered to be severe and that have mixed treatment results.
  • Cluster C is characterized by anxiety and fearfulness and includes avoidant, dependent, and obsessive-compulsive personalities. These are generally viewed as the most treatment responsive and have shown the best results with shorter duration treatment protocols (Kaplan & Saddock, 2002; American Psychiatric Association, 2013).

Dimensional Classification

The dimensional classification of personality maintains an approach in contrast to the categorical system. Dimensional perspectives are based on the premise that personality does not exist in discrete categories but rather along dimensions. Dimensional classification grew out of the study of normal personality using the trait approach developed by Gordon Allport (Allport & Odbert, 1936) that used factor analysis to describe personality. Personality disorders represent an example of normal traits amplified to the extreme point of being maladaptive, and thus are well suited to the dimensional system. This system has been used to investigate the construct of personality in both normal and disordered populations. The most dominant of the dimensional models is the five-factor model which has identified five empirically derived dimensions of personality that include: neuroticism, extraversion, openness, agreeableness, and conscientiousness (Costa & McCrae, 1992; Kaplan & Saddock, 2002).

Dimensional models of personality categorization conceptualize personality disorders in relation to normally occurring traits. In this way, they represent a comprehensive conceptual organization of personality characteristics in which pathological personality types are perceived as extreme variations. (See Figure 2). Dimensional models have the advantages of both empirical testability and broad generalizability, thus rendering them useful in a wide variety of clinical situations.

Figure 2 - Circumplex Dimensional Model for Classifying Personality

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Millon, T. (1987). On the nature of taxonomy in psychopathology.

Structural Dynamic Classification

The structural-dynamic classification of personality is based on a psychodynamic understanding of personality structure and organization (McWilliams, 1994). This system evolved from the character types developed by psychoanalytic pioneers of the last century and are still present in many of the current DSM-V categories. In this system, personality organization is placed on a continuum from psychotic, borderline, neurotic to normal with each point representing a varying degree of structural integrity - how well the system can handle anxiety, conflict, and emotional experience before becoming overloaded and symptomatic - called ego-adaptive capacity. Thus, someone functioning at the right of the borderline position would be able to handle more anxiety and conflict than someone on the left side, toward the psychotic range whose tolerance is much lower. Each type or mixture of personality types can be organized at any position along the continuum.

Correlating DSM-V diagnoses with the structural continuum, Cluster C disorders are equivalent to those at the neurotic level, Cluster B at the borderline level, and Cluster A at the psychotic level. A crucial part of personality in the structural-dynamic classification is the organization and use of defense mechanisms. (See Table 1). Those at higher levels of organization and adaptation generally use more mature and neurotic defenses, those in the borderline range use more primitive defenses and those in the psychotic spectrum tend to use more primitive and psychotic mixes (Corsini & Wedding, 2004).

Table 1 – Millon’s Prototypal Classification

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(Millon, et. al., 2004)

Prototypal Classification

The prototypal classification of personality combines the categorical with the dimensional and lends itself to finer distinctions among various personality types and disorders. The most notable of the prototypal systems is Millon’s (Millon & Davis, 1995; Millon & Davis, 1996; Millon, et. al., 2004) that retains categories of personality disorder but assesses them on three primary dimensions: self/other, active/passive, and pleasure/pain. (See Table 1). Based on this categorization, Millon has developed highly valid and reliable instruments that are used to assess the personality using standardized objective tests. Millon describes the biopsychosocial continuum using five distinct levels or dimensions:

· Behavioral Appearance: describes what a person does and how they behave in ways that can be observed by other people.

· Interpersonal Conduct: describes how a person typically related to other people.  

· Cognitive Style: describes how a person organizes their thinking and decision-making rules that guide the conduct of the day-to-day living. 

· Affective Expression: describes how a person organizes themselves to manage their feelings and emotions.  

· Self-Perception: describes how a person perceives and thinks about himself/herself (Millon & Davis, 1996; Millon, et. al., 2004)

Relational Classification

The relational classification of personality examines patterns of communication, themes, multigenerational processes, feedback loops, and interpersonal processes such as complimentarity. Relational diagnosis has two main branches, the interpersonal model of Harry Stack Sullivan (1953) who dealt with dyadic configurations and the systemic model of Murray Bowen (1976) who dealt with triadic configurations. Recently, there has been a movement to develop and codify a comprehensive relational model (Kaslow, 1996) and another to expand the use of relational diagnoses in DMS-V (Beach, 2002).

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Patients with personality disorders present with problems that are among the most complex and challenging that clinicians encounter. This is due, in part, to the reality that the personality disorder characteristics do not simply represent a problem the patient has, but are in fact central to who that patient is. In this way, personality disorder patients often represent a population with limited capacity for complete eradication of symptoms and/or restoration of optimal adaptive functioning. However, this population can make significant strides when their therapists are able to develop a sophisticated treatment plan guided by an accurate cognitive conceptualization that emphasizes using the therapeutic relationship to test assumptions about others and that achieves a reasonable balance between current problem-solving, restructuring dysfunctional beliefs originating in childhood and adopting new, more flexible and appropriate behavioral strategies.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Beach, S. R. H. (2002). Family psychology and the new “relational diagnoses” of DSM-V. Family Psychologist, 18(2), 6–7.

Boeree, C. G. (2000). The Ultimate Theory of Personality. New York, NY: Allyn & Bacon.

Bowen, M. (1976). Theory and practice of family therapy. In P. J. Guerin Jr. (Ed.), Family therapy: Theory and practice (pp. 42–90). New York, NY: Gardner Press.

Clarkin, J. F. & Lenzenweger, M. F. (Eds.) (2004). Major theories of personality disorder, 2ed. New York, NY: Guilford.

Corsini, R. J. & Wedding, D. (2004). Current psychotherapies, 7e. Itasca, IL: F. E. Peacock Publishers, Inc.

Costa, P. T., & McCrae, R. R. (1992). The five-factor model of personality and its relevance to personality disorders. Journal of Personality Disorders, 6, 343–359.

Kaplan, H. I. & Saddock, B. J. (2002). Synopsis of Psychiatry, 9e. Baltimore, MA: Lippincott, Williams & Wilkins.

McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality structure in clinical practice. New York, NY: Guilford Press.

Millon, T. (1987). On the nature of taxonomy in psychopathology. In Last, C. & Herson, M. (Eds). Issues in diagnostic research. New York, NY: Plenum Publishing

Millon, T., & Davis, R. (1995). Personality disorders: DSM-IV and beyond. New York, NY: Wiley.

Millon, T. & Davis, R. D. (1996). An evolutionary theory of personality disorders. In Clarkin, J. F. & Lenzenweger, M. F. (Eds). Major theories of personality disorder. New York, NY: The Guilford Press.

Millon, T., Millon, C.M., Meagher, S. Grossman, S. & Ramnath, R. (2004). Personality disorders in modern life. New York, NY: Wiley.

Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY: Norton.

Widiger, T.A., & Sankis, L.M. (2000). Adult Psychopathology: Issues and controversies. Annual Review of Psychology, 51, 377-404

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