Harieshwar Vetri
We
live in a society of norms. Norms that prescribe, if not dictate, a certain way
of how we are expected to live our lives. We must think a certain way, act a
certain way and adhere to those norms whenever we are expected to do so.
However, there are instances where people are unable to follow these norms,
whether it is through deliberate choice or because they are simply unable to
abide by these norms in certain situations. We view these people as having
‘abnormal’ personalities and suffering from some kind of personality disorder.
Now
we need to decide, what these abnormal personalities are and how do we find
them in the crowd. Realising that people behave and think differently is not
simple, however. People may not notice that their behaviour is deviant and the
range of this deviancy can make it hard for the people around them to notice as
well. Detecting and categorising personality disorders has been done since the
days of the ancient Greeks. Hippocrates believed that the disorders were caused
by imbalances of yellow bile, black bile, phlegm and blood in the body with
Galen going to classify the disorders based on which of the above was present
in excess (Tyrer et al., 2007).
The
next notable development in the assessment and classification of personality
disorders was that of the psychopathic personalities and their distinction from
the other mental illnesses by Schneider (1950). After this was the development
of the DSM-III and ICD-10. These two systems classified personality disorders
differently. DSM-III separated them from that of other clinical disorders while
ICD-10 retained them as being related. This was also the system that
implemented the idea of the continuum for a personality disorder (Tyrer et al,
2007). On one side is what is considered normal behaviour and at the other we
have the personality disorder manifesting at its full strength.
Currently,
personality assessment is done broadly through three methods- self-report
questionnaires, the use of check-lists and through interviews, the latter of
which is considered the most robust (Tyrer et al., 2007). However, as per
research, it would seem that these assessments are not as reliable as the field
would like them to be (Clark & Harrison, 2001). They are effective at
ascertaining whether a patient is suffering from a personality disorder, but
when attempting to narrow down the diagnosis to a single disorder they run into
certain problems such as the problem of comorbidity. The symptoms are indicative
of multiple disorders, making a reliable and absolute diagnosis difficult.
In
an attempt to address this problem, the DSM made use of a cluster model.
Cluster A categorized the disorders that result in the “odd and eccentric”
personality types (paranoid, schizoid and schizotypal) (Hoermann et al., n.d.),
Cluster B categorized those that manifested as “dramatic, emotional and
erratic” (antisocial, borderline, histrionic and narcissistic) (DSM-5: The Ten
Personality Disorders: Cluster B, n.d.) while Cluster C categorized those that
manifested as “anxious and fearful” (avoidant, dependent and
obsessive-compulsive) (DSM-5 the Ten Personality Disorders: Cluster C, n.d.). However,
Tyrer et al. (2007) proposed that a fourth cluster be added exclusively for obsessive-compulsive
disorder to better fit the 4-dimension model akin to that of the one proposed
by Hippocrates and Galen.
Going
forward, efforts are being made to simplify the process of assessment of
personality through the use of a screening test that can be employed in routine
psychiatric assessments (Moran et al., 2003) as well as through the use of
computerized models (Simms et al., 2011).
The
Standardized Assessment of Personality: Abbreviated Scale (SAPAS) is a
simplified version of the Standardized Assessment of Personality (SAP),
containing 8 questions from the opening section of SAP. Moran et al. (2003) ran
a preliminary test to check for the assessment’s validity by scoring patients
against another scale, the SCID-II. The results indicated a preliminary
usefulness of the SAPAS with its ability to detect a personality disorder in
80% of patients suffering from one. A similar study conducted by Hesse &
Moran (2010), testing against other scales such as K6, ASRS, PRISM, AUDADIS-IV
and NPI-16, added further validity to the use of the test as a routine
assessment tool. However, the authors cautioned that the samples were not
representative of the population at large and that the scale’s validity may
diminish (Moran et al., 2003) and that the correlation with antisocial,
histrionic and obsessive-compulsive disorders were not satisfactory (Hesse
& Moran, 2010).
The
Computerized Adaptive Test of Personality Disorder (CAT-PD) was a system of
assessment developed to complement the implementation of DSM-V’s dimensional
model instead of the categorical model in DSM-IV. Simms et al. (2011) were
attempting to “identify a comprehensive and integrative set of higher and lower
order traits relevant to personality pathology” and “develop a computerized system,
based on the principles of adaptive testing to measure the resultant traits
efficiently.” As of the writing of the paper referred to, they were in Phase 2 of
its development- collection of patient data and refinement of scale. Phase 1
was centred around the first objective mentioned above- identifying the traits
that can be used for assessment. The project identified over 2500 items as well
as 59 PD traits. A recent testing of the assessment (Long et al., 2020) showed
that it was in fact a reliable tool to measure personality types.
Personality
is a complex topic and it is not easily defined or understood. We still have problems
deciding how these personality disorders need to be categorised and assessed.
However, we have come a long way in our understanding and detection of these
disorders. As we come to better understand the origins of behaviour and how
they stem from the internal workings of the brain, our ability to respond and
care for people affected by these disorders will become better as well.
Clark, L. A. & Harrison, J. A. (2001) Assessment instruments. In Handbook of Personality Disorders: Theory, Research, and Treatment (ed. W. J. Livesley), pp. 277-306. Guilford
DSM-5: The Ten Personality Disorders: Cluster B. (n.d.). Retrieved October 7, 2022, from https://www.mentalhelp.net/personality-disorders/cluster-b/
DSM-5 The Ten Personality Disorders: Cluster C. (n.d.). Retrieved October 7, 2022, from https://www.mentalhelp.net/personality-disorders/cluster-c/
Hesse, M., & Moran, P. (2010, January 28). Screening for personality disorder with the Standardised Assessment of Personality: Abbreviated Scale (SAPAS): further evidence of concurrent validity. BMC Psychiatry, 10(1). https://doi.org/10.1186/1471-244x-10-10
Hoermann, S., Zupanick, C.E., Dombeck, M., (n.d.). DSM-5: The Ten Personality Disorders: Cluster A. Retrieved October 7, 2022, from https://www.mentalhelp.net/personality-disorders/cluster-a/
Long, T. A., Reinhard, E., Sellbom, M., & Anderson, J. L. (2020, March 3). An Examination of the Reliability and Validity of the Comprehensive Assessment of Traits Relevant to Personality Disorder–Static Form (CAT-PD-SF). Assessment, 28(5), 1345–1357. https://doi.org/10.1177/1073191120907957
Moran, P., Leese, M., Lee, T., Walters, P., Thornicroft, G., & Mann, A. (2003). Standardised Assessment of Personality–Abbreviated Scale (SAPAS): preliminary validation of a brief screen for personality disorder. The British Journal of Psychiatry, 183(3), 228-232.
Tyrer, P., Coombs, N., Ibrahimi, F., Mathilakath, A., Bajaj, P., Ranger, M., Rao, B., & Din, R. (2007, May). Critical developments in the assessment of personality disorder. British Journal of Psychiatry, 190(S49), s51–s59. https://doi.org/10.1192/bjp.190.5.s51
Schneider, K. (1950). Die psychopathischen Persönlichkeiten. [Psychopathic personalities]. Franz Deuticke.
Simms, L. J., Goldberg, L. R., Roberts, J. E., Watson, D., Welte, J., & Rotterman, J. H. (2011, July). Computerized Adaptive Assessment of Personality Disorder: Introducing the CAT–PD Project. Journal of Personality Assessment, 93(4), 380–389. https://doi.org/10.1080/00223891.2011.577475
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