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Learn how personality disorders diagnosed and the behavior patterns that characterize a person with a personality disorder.
A doctor bases the diagnosis of a personality disorder on a person's history, specifically, on repetition of maladaptive thought or behavior patterns. These patterns tend to become apparent because the person tenaciously resists changing them despite their negative consequences. In addition, a doctor is likely to notice the person's immature and maladaptive use of mental coping mechanisms, which interferes with their daily functioning. A doctor may also talk with people who interact with the person.
One thing that complicates the diagnosis of personality disorders is the fact that affected persons rarely seek help until they are in serious trouble or until their families (or the law) pressure them to get treatment. The reason for this slowness is that the problematic traits are so deeply entrenched that they seem normal to the patient.
Diagnosis of a personality disorder depends, in part, on the patient's age. Although personality disorders originate during the childhood years, they are considered adult disorders. Some patients, in fact, are not diagnosed until late in life because their symptoms had been modified by the demands of their job or by marriage. After retirement or the spouse's death, however, these patients' personality disorders become fully apparent. In general, however, if the onset of the patient's problem is in mid- or late-life, the doctor will rule out substance abuse or personality change caused by medical or neurological problems before considering the diagnosis of a personality disorder. It is unusual for people to develop personality disorders "out of the blue" in mid-life.
What, specifically, does the doctor use to determine a personality disorder?
There are no tests that can provide a definitive diagnosis of personality disorder. Most doctors will evaluate a patient on the basis of several sources of information collected over a period of time in order to determine how long the patient has been having difficulties, how many areas of life are affected, and how severe the dysfunction is. These sources of information may include:
Interviews
The doctor may schedule two or three interviews with the patient, spaced over several weeks or months, in order to rule out an adjustment disorder caused by job loss, bereavement, or a similar problem. An office interview allows the doctor to form an impression of the patient's overall personality as well as obtain information about his or her occupation and family. During the interview, the doctor will note the patient's appearance, tone of voice, body language, eye contact, and other important non-verbal signals, as well as the content of the conversation. In some cases, the doctor may contact other people (family members, employers, close friends) who know the patient well in order to assess the accuracy of the patient's perception of his or her difficulties. It is quite common for people with personality disorders to have distorted views of their situations or to be unaware of the impact of their behavior on others.
Psychological testing
Doctors use psychological testing to help in the diagnosis of a personality disorder. Most of these tests require interpretation by a professional with specialized training. Doctors usually refer patients to a clinical psychologist for this type of test.
- Personality Inventories: Personality inventories are tests with true/false or yes/no answers that can be used to compare the patient's scores with those of people with known personality distortions. The single most commonly used test of this type is the Minnesota Multiphasic Personality Inventory, or MMPI. Another test that is often used is the Millon Clinical Multiaxial Inventory, or MCMI.
- Projective Tests: Projective tests are unstructured. Unstructured means that instead of giving one-word answers to questions, the patient is asked to talk at some length about a picture that the psychologist has shown him or her, or to supply an ending for the beginning of a story. Projective tests allow the clinician to assess the patient's patterns of thinking, fantasies, worries or anxieties, moral concerns, values, and habits. Common projective tests include the Rorschach, in which the patient responds to a set of ten inkblots; and the Thematic Apperception Test (TAT), in which the patient is shown drawings of people in different situations and then tells a story about the picture.
Coping Mechanisms Used by People with Personality Disorders
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Common Coping Mechanisms
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| Mechanism |
Definition |
Result |
Personality Disorders Involved |
| Projection |
Attributing one's own feelings or thoughts to others |
Leads to prejudice, suspiciousness, and excessive worrying about external dangers |
Typical of paranoid and schizotypal personalities; used by people with borderline, antisocial, or narcissistic personality when under acute stress |
| Splitting |
Use of black-or-white, all-or-nothing thinking to divide people into groups of idealized all-good saviors and vilified all-bad evildoers |
Allows a person to avoid the discomfort of having both loving and hateful feelings for the same person as well as feelings of uncertainty and helplessness |
Typical of borderline personality |
| Acting out |
A direct behavioral expression of an unconscious wish or impulse that enables a person to avoid thinking about a painful situation or experiencing a painful emotion |
Leads to acts that are often irresponsible, reckless, and foolish. Includes many delinquent, promiscuous, and substance-abusing acts, which can become so habitual that the person remains unaware and dismissive of the feelings that initiated the acts |
Very common in people with antisocial or borderline personality |
| Turning aggression against self |
Expressing the angry feelings one has toward others by hurting one's self directly (for example, through self-mutilation) or indirectly (for example, in body dysmorphic disorder); when indirect, it is called passive aggression |
Includes failures and illnesses that affect others more than oneself and silly, provocative clowning |
Dramatic in people with borderline personality |
| Fantasizing |
Use of imaginary relationships and private belief systems to resolve conflict and to escape from painful realities, such as loneliness |
Is associated with eccentricity, avoidance of interpersonal intimacy, and avoidance of involvement with the outside world |
Used by people with an avoidant or schizoid personality, who, in contrast to people with psychoses, do not believe and thus do not act on their fantasies |
| Hypochondriasis |
Use of health complaints to gain attention |
Provides a person with nurturing attention from others; may be a passive expression of anger toward others |
Used by people with dependent, histrionic, or borderline personality |
Source: Merck Manual
next: Types of Personality Disorders
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