Irresistible joys and discouraging pitfalls in diagnosing personality disorders.

Abstract

We humans seem to have an inherent urge to describe and label personalitiesin individuals we meet in everyday life, both professionally and personally.Unfortunately, neither lay descriptors nor psychiatric diagnoses easilycapture the sense we often have of others. In fact, describing andcategorizing personality and personality disorders have been among the weakestlinks in psychiatric nosology since the introduction of the Diagnostic andStatistical Manuals of Mental Disorders (DSMs). Even with the atheoretic,primarily descriptive approaches of DSM-III (published in 1980),DSM-III-R, andDSM-IV,1the section on personality disorders is the most problematic. Still, theinherent attraction of personality labeling is often too great to resist. In his essay, Walling uses the descriptions of Achilles' behaviors andpersonality traits in The Iliad to diagnose him according toDSM-IV criteria. Although the author selects passages from the textthat are consistent with his conclusion that Achilles had antisocialpersonality disorder, we should view this conclusion with great cautionbecause it illustrates some of the pitfalls of personality diagnoses. A personality disorder is an enduring and stable pattern of innerexperience and behavior that deviates markedly from cultural expectations, ispervasive and inflexible, begins in early adolescence or early adulthood, andleads to distress andimpairment.1 Becausepersonality disorders are longitudinal and stable, diagnoses based oncross-sectional examinations are fraught with difficulties. Thus, Achilles mayhave thought and acted as described in The Iliad and noted byWalling, but what do we know about his patterns of behavior throughout hislife? The DSM-IV criteria for antisocial personality disorder requiresymptoms of conduct disorder (similar to adult antisocial behaviors) beforeage 15. Was Achilles a destructive, aggressive, deceitful child or adolescent?Without this information, it is impossible to make an accurate diagnosis. In addition, diagnoses of personality disorders can be made only byexamining the individual's behavior in the context of his culture. AlthoughWalling describes some examples of Achilles' behavior that seem at variancewith his cultural norm, without a fuller knowledge of the culture, suchinterpretations are suspect. An explicit rule for diagnosing personality disorders requires that thetraits and behaviors used to make the diagnosis be due not simply to theeffect of transient stressors or another psychiatric disorder such asdepression, mania, or anxiety disorders. Achilles' behaviors during wartimemay not reflect his typical behaviors at other times. Again, the hallmark ofpersonality and its disorders is the predictable, consistent, enduring patternof traits and behavior, not a series of behaviors during a time of crisis.Similarly, a fixation on honor and revenge and excessive mourning could hardlyqualify as obsessive-compulsive personality traits without further informationabout the culture, his relationship to the deceased, and so forth. Diagnosing personality disorders by literary text is seductivelyinteresting and creative but must be done with caution and a skeptical eye toavoid overgeneralizing from cross-sectional information.