Giving personality disorders their due
Donald W. Black, MD
“All is caprice, they love without measure those whom they will soon hate without reason.”—Thomas Sydenham
This issue of Annals of Clinical Psychiatry presents a series of articles exploring personality disorders, which clinicians often underappreciate. With DSM-III in 1980, personality disorders were accorded new status on a separate axis (Axis II), which I believe had the unintentional effect of devaluing personality disorders’ importance by suggesting they are lesser disorders. Many of our patients’ primary problem is a personality disorder, not dysthymia, panic disorder, or adjustment disorder coded on Axis I.
The current system for diagnosing personality disorders is imperfect, yet the DSM-5 draft represents a major change that involves creating 5 personality “types”—rather than the currently recognized 10—and dimensionally coding up to 37 “trait facets.” I have argued that psychiatrists think categorically and, although psychologists and researchers favor dimensional systems, such systems are cumbersome for busy clinicians. In addition, clinicians worry about reimbursement, which generally is tied to a diagnostic code. I encourage readers to see for themselves and submit their comments at www.dsm5.org.
In this issue, we begin with a review of methodological considerations for treatment trials in persons with borderline personality disorder (BPD) by Mary C. Zanarini, EdD, and colleagues. This article describes the problems of conducting research with BPD patients and makes useful recommendations. Frederick W. Reimherr, MD, and colleagues, including Reid J. Robison, MD, and Erika D. Williams, MSW, contribute 3 articles describing personality disorders in persons with attention-deficit/hyperactivity disorder, including prevalence, social adjustment, and the effect of personality disorder symptoms on antidepressant response. My colleagues and I describe the impact of antisocial personality disorder on incarcerated offenders. Zoltán Rihmer, MD, PhD, DSc, and the late Franco Benazzi, MD, PhD, DTMH, explore the effect of specific BPD traits (impulsivity and affective instability) on suicidality and confirm that impulsivity is a strong independent predictor. Patrick J. Marsh, MD, in collaboration with Jon E. Grant, JD, MD, MPH, and his team, presents data on the prevalence of paraphilia and shows its alarming frequency in adult psychiatric inpatients.
I was saddened to learn that Dr. Benazzi passed away on August 22, 2009, at age 52. He was a remarkably productive researcher and writer, committed to gaining a better understanding of mood disorders. Few know that he was a solo practitioner in a small Italian community who systematically reported clinical observations from his own patients.
It was great to see many friends and colleagues at the recent American Academy of Clinical Psychiatrists (AACP)/Current Psychiatry meeting April 8 to 10, 2010. Chicago is a great place in the spring, and the meeting, “Mood and anxiety disorders: Solving clinical challenges, improving patient care,” was our best attended ever. The quality of the speakers and topics attracted clinicians from around the country. I hope that attending our annual meeting will become a habit for our friends and new AACP members.