As a research/diagnostic interviewer, it’s my job to determine if a patient’s symptoms are severe enough to be labeled “clinically significant” and thus to warrant a psychiatric diagnosis. This is much easier said than done.
Diagnosing clinical syndromes, such as depression or anxiety, is much more straightforward than diagnosing personality disorders. To meet criteria for a personality disorder diagnosis, the patient must have several traits characteristic of that particular disorder – a whole pattern of traits. Thus, diagnosing personality disorders is a two-step process. The first step is to determine if the patient meets the threshold for various individual traits. The second step is to determine if the patient has a sufficient number of traits within each category to qualify for the diagnosis.
Common personality disorder traits
Recently, I have been entering information about personality disorder traits that patients have met into a database, and I have noticed several personality disorder traits that are the most common among patients at The Menninger Clinic. One is “rigidity or stubbornness,” which is one of the traits considered in the diagnosis of obsessive-compulsive personality disorder. According to the current data, more than a third of patients meet the criteria for the “stubbornness” trait. The Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) gives no guidelines regarding the prevalence of this trait. Based on our findings, a substantial minority of patients either believe they are stubborn or have been told by others that they are stubborn. This begs the question: Exactly how stubborn does someone have to be to meet the criteria for the stubbornness trait?
The Merriam-Webster Dictionary defines stubborn as “unreasonably and perversely unyielding.” The DSM-IV description is a tad more in-depth. Persons who are stubborn are so concerned about having things done the one “correct” way that they have trouble going along with anyone else’s ideas. These individuals meticulously plan ahead and are unwilling to consider changes in plans. Such persons are wrapped up in their own perspective and have difficulty acknowledging the viewpoints of others. Their rigidity frustrates friends and colleagues. Furthermore, persons with this trait might recognize that it is in their best interest to compromise, but they stubbornly (for lack of a better term) refuse, arguing that it is “the principle of the thing.” The diagnostic trait of stubbornness or rigidity means more than simply being “unreasonably and perversely unyielding.”
Borderline personality disorder
Another common trait I observe is “chronic feelings of emptiness,” one of the traits of borderline personality disorder. In fact, one third of patients have this trait. Merriam-Webster defines empty as “having no purpose or result” or “marked by the absence of human life, activity or comfort.” The DSM-IV adds little to this definition beyond the point that people who suffer from chronic feelings of emptiness get easily bored and are continually seeking something to do. “Emptiness” is left to the eye of the beholder.
The DSM-IV offers some explication of stubbornness and emptiness, but the decision is left to the interviewer as to whether a patient indeed has the trait at a clinically significant level. There is no clear line distinguishing normal from clinically significant levels of a trait. This is a judgment call for the interviewer, taking into account the degree of functional impairment that the trait causes. For example, a person’s stubbornness may be so extreme that it inhibits him or her from maintaining mutually satisfying relationships. Similarly, persons may feel so empty inside that nothing provides them with joy. For a trait to be functionally impairing, there must be an enduring and pervasive influence on the person’s behavior or attitude. It is important to note that traits are only a part of the constellation of the associated personality disorder.
Traits vs. clusters
Moreover, the distress or impairment is not based on any simple trait but rather several traits that make up the disorder. For example, other traits of obsessive-compulsive personality disorder include preoccupation with details, perfectionism, excessive devotion to work, unwillingness to delegate tasks and so forth. We must also keep in mind that individual traits (stubbornness) and clusters (obsessive-compulsive personality disorder) can be beneficial in moderation. Having too little stubbornness might lead to being too easily swayed or influenced.
Other obsessive-compulsive characteristics such as a need for order, structure and organization can certainly be helpful. Think of Steve Jobs: He was notorious for his need to have things exactly right, and he was tremendously successful because of it. Once again, it all comes down to the level of clinical functional impairment that a trait or cluster causes. In personality disorders, this occurs mainly in the context of relationships. As I have illustrated, the diagnostic manual goes beyond the textbook definition found in the dictionary.
More generally, there is an inherent difficulty in drawing a bright line when all traits come in degrees. It is important to avoid overdiagnosing. When we overdiagnose we risk stigmatizing the patient. When given the diagnosis of a personality disorder, patients are liable to misinterpret it, thinking they are being told they have a “bad personality.” Not true: The diagnosis refers to a specific problematic aspect of personality functioning, not the entire personality. A person might have a personality disorder coupled with many positive personality traits. In my work as a diagnostic interviewer, I aspire to pinpoint problems to help guide treatment. Yet treatment must be based on a full understanding of the whole person.