Etiology / DSM 5 BP (BPD, HPD & NPD) vs. AsPD

orion8591 wrote:Hi Wisdom

Didn't know whether to start a new thread over in the NPD forum or subsume this question to you in this thread "assorted topics." So erring on the conservative side...

I wondered if you or anyone else could explain why the latest DSM folks reclassified NPD as a subclass within BPD. Although I'm new to Psych Forums in the short time I've been I've got the distinct impression that NPD is a kind of weaker version of AsPD. My rationale:

AsPD: rock hard, self-centered feral personality free of delusions, hallucinations or other forms of psychosis, depression rare due to personal failures, highly resistant to change due to feelings of being special or entitled, extreme objectification of other people, SUPPLY derived from acquiring power, generating terror, fear or humiliation in others, or by taking their material possessions.

NPD: hard, self-centered feral personality free of delusions, hallucinations or other forms of psychosis, depression occaisional due to personal failures, highly resistant to change due to feelings of being special or entitled, objectification of other people, SUPPLY derived from acquiring power or by generating adulation and admiration for themselves through others.

I do see the new subclassification of HPD within BPD: the common link between most HPD's and BPD's seems to be splitting, and idealization and fantasy, if not dissociation and mild psychosis, features conspicuously absent in NPD's and AsPD's (?).

By the way while we are here it also seems more accurate to re-classify Millon's "Disingenuous Histrionic - Histrionic with anti-social features" as Somatic NPD's. What do you think?

Appreciate your feedback!

Orion,

Great question and I only have partial answers. Will do my best to relate Kernberg's thinking first.

See this chart and try to have it on screen for the following discussion.
Source: Kernberg, Otto PPT slide chart from a Grand Round's presentation, also included in various forms in some of his books. Note, this chart has evolved an there is zero guarantee this is the very most current.
http://i56.tinypic.com/2mmid0n.jpg

O.K., lets dive in.
On the horizontal (X) axis you have Introvert towards the EAST, Extrovert towards the WEST.
On the vertical (Y) axis you have severity with VERY LOW up NORTH (i.e. very close to "normal") and VERY HIGH down SOUTH

Step back in time to classic psychoanalysis. There were two divisions of people seeking psychotherapy:

Neurotics - basically "nervous types" who had minor internal conflict that was getting on their nerves, typically caused by fixations at various stages of development (oral, anal, phallic, etc.) You brought these people in, went back to work through the "fixations", dissolved them, and the neurosis / nervousness stopped. They were cured. (Recall that Freud was a neurologist)

vs.

Psychotic - basically so "out of it" they were in fact detached from reality. This is full blown "lost in their own world" situation with pretty much zero grounding in the here and now world: visual and audio hallucinations, voices inside calling out actions to be taken, extreme paranoia, catatonic states, very deranged thinking....

The concept of BORDERLINE was on the border in between Neurotic and Psychotic. That is, some elements of both. More than just neurotic, a twinge of psychotic thrown in there too, but intermittent, and not too much.

In Kernberg's world:

NPO - Neurotic Personality ORGANIZATION
PPO - Psychotic Personality ORGANIZATION

Here, roughly:
personality == organization == structure == plasticity
(might be frozen, might be melted, can be changed but "difficult" to, entrenched and "established")

"Atypical" Psychosis - means exactly what you would guess - very sever disorder, not able to function at all in society in any meaningful way, absolutely needs to be institutionalized 24/7 - otherwise a clear harm to themselves and/or others.

The chart is condensed and "folded" a bit to reduce its size. Basically the etiology starts with either

SCHIZOID (more introverted, roughly SPD)
or
BORDERLINE (more extroverted, roughly BPD)

Following the BORDERLINE "origin" moving in the NORTH direction (decreasing severity) you have four "flavors" of basically BORDERLINE

1. an odd track to sado-masochistic which when even less sever is OC or Depressive-Masochistic (self defeating)
2. a track that is Hypomanic, Cyclothymic, and Depressive-Masochistic (seems pretty bi-polar like)
3. a track that is Histrionic (Major HPD), Dependent, or Hysterical (Minor HPD)
4. a track that is Narcissistic (but notice how this moves in severity)

Again, at the macro level BORDERLINE PERSONALITY ORGANIZATION is the origin for each of those flavors.

In Kernberg's book, AsP is really very SEVERE BORDERLINE specializing in narcissism.
Start at BORDERLINE and specialize from there in narcissism:

• if mild severity then call it Narcissistic
• if more severe call it Malignant Narcissism
• and if its really severe switch out the name for it a label it Antisocial.

Notes
Hysterical and Histrionic fall on the less severe (NORTH) end of the entire disorder spectrum.
AsPD is darn close to psychotic (very difficult to treat, institutionalization frequently necessary)
Sado-Masochistic is pretty "lightweight" - not much trouble to treat at all!
Sado-Masochistic is far away from AsP however both have their roots in BORDERLINE.

Now on to DSM 5.

I'll note that John Gunderson, who CHAIRED the DSM IV group on PDs has taken a few serious hits on this Forum. Imperfect people doing good work?

Of course the experts can be wrong and there is considerable dissension right now on exactly how the DSM V PDs should go. Its a closed work group and no one outside is privy to the deliberations. However I've posted prior what some of the research finding have been of some of the key members. IMHO they will take a middle road position and try to please most everyone.

In DSM 5, as of the moment, basically, you have two different levels of granularity - coarse and fine.

See:
http://www.anythingtostopthepain.com/ds ... disorders/

The five disorders left at the "coarse" level are:

• Schizotypal
• AsP
• Borderline
• Avoidant
• Obsessive-Compulsive

At the "fine" level of granularity you have pretty much any combination or permutation of 37 or so personality traits, only one of which would be recognized as uniquely HPD.

See the relatively NEW CHART Updated January 21, 2011 at:
http://www.dsm5.org/ProposedRevisions/P ... -Walk.aspx

The following "traditional" personality disorders don't "appear" until you go to that "fine" level of DSM 5 granularity:

• Dependent
• Depressive
• Histrionic
• Narcissistic
• Paranoid
• Passive Aggressive
• Schizoid
• Other, new clusters...

Now here is the DSM5 weasel notation:
Whenever a patient’s impairment in personality functioning is sufficiently severe to warrant a PD diagnosis, but the patterns of impairments and associated traits do not match one of the five types, a diagnosis of PD Trait Specified (PDTS) is made.

So, HPD would become:

Personality Disorder Trait Specific - Histrionic

And in conclusion.... (not that anything is dead certain here...)

Kernberg's 20 year old charts don't match the new DSM 5 draft in every respect. However his look at HPD, NPD and BPD as likely all flowing out of BORDERLINE ORGANIZATION is still on target.

DSM clusters AsPD way away from "Personality Disorder Trait Specific - Narcissistic" - Kernberg postulates those AsPD traits are seen in steadily increasing Narcissism, when it hits the malignant narcissism point things are bad, and one more notch up you have AsPD! At that point Kernberg throws up his hands and says refer this client to "other qualified specialists" as our traditional borderline treatment approaches don't seem to have much impact.

Millon's taxonomy was also very interesting theoretically, yet it lacks large field trials (norms).

Now its time to put all of those "systems" to the test in large group studies by the DSM people. Until they have the data in from those large scale studies of the 37 or so Traits back, and cluster them (at various levels of granularity) there will not be definitive answers. Even when they get back a pile of data it still may not cluster into logical groupings.

Of course treatment follows diagnosis. If you only have 3-5 treatment approaches for 5-10-100-1000's of different PD trait "clusters" have you gained anything by your additional granularity?

For us nons with HPD exes, remembering that HPD is under the big BPD umbrella can actually be very helpful. Otherwise, we miss out on a whole lot of very relevant and helpful information/advice. The other day I re-discovered the gettinbetter.com site, which talks almost only of BPD but is must read stuff for anyone trying to get away from or over an HPD. I have never read so much stuff that fit my HPD ex to a tee!
The gettinbetter.com site is especially good on motivating the non to stay NC, explaining why it's the only way. Highly recommended.

Also:
Just thinking of your HPD ex as a Borderline instead of an HPD (which for some reason has a more benign reputation, like a PD Lite) will better help you realize the complete futility of trying to salvage anything from the relationship. At least that's what I've found in the past few weeks.

I find this very interesting that they've decided to look at it this way instead of giving some of the 'PD biproducts' of BPD their own true disordered status, they've almost belittled the 'lessor PD's' as not being as serious as the heavies: AsPD & BPD in their reorginazation of the disorders in this new charting/classification, and I'm not sure that's a good idea. By taking away the severity/classisifaction of these disorders aren't they in turn setting up the eflicted persons to not take them seriously?

If they 'discredit' the other disorders under the new classification, will that influence professionals not to treat them in the same manor as they have through the past?

I'm sorry, perhaps I'm confused here, but would it not be fair to say that those effected by NPD,HPD, and the other 'lessor' PD extentions are primarily effected with at least a type of BPD to even have these lessor disorders?

It was my origional understanding that you had to FIRST have BPD and then it branched out into the other areas of PD traits and associations- is that not true? No longer the case???

I'm confused

Because if I am right in thinking that you had to first have a case of BPD before you could begin to look into having other PD traits as a diagnosis, then haven't they just made the whole damn thing backwards now?

Can someone please clarify this for me.

I'm certain that in a clinical aspect, you first had to have some standing in a BPD arena (or minimally it was thought to be a second attatchment in diagnostics) to have another form of PD???

A little help here?

wait your telling me I'm as cracked up in my head as I thought? I always sorta suspected a BPD or something similar given my manic like feelings.

- Labor.

thisislabor wrote:wait your telling me I'm as cracked up in my head as I thought? I always sorta suspected a BPD or something similar given my manic like feelings.

- Labor.

I could be wrong here Labor, but I think I remember my shrink saying something about this when he diagnosed me. Or I may have seen it somewhere as I looked into it quickly, saw it was a mess of a diagnosis to have gotten and ran for cover

I wish someone would correct or support my idea in thinking this though, because I'm not 100% sure...

Sorry, I wish I had a better answer for here

Wisdom
Thanks for a wealth of great information and a robust discussion. There's a division in the chart that does seems to partly confirm my impression: the Histrionic track [Histrionic /Dependent / Hysterical } is indeed discrete with respect to the Narcissistic track [Narcissistic / Malignant Narcissitic / Antisocial}, and "Narcissitic (=NPD?) does seem connected to AsPD: merely a less severe version of Malignant Narcissism, and finally AsPD.

Interesting how Borderline is where it all starts.

However, still can't connect AsPD / psychopathy /malignant narcissism /NPD to true psychosis (i.e, catatonic schizophrenia). Although as you mention many of the AsPD folks are institutionalized, I had always believed that rather than actual psychotics they were extremely grounded in external reality: they knew exactly what they were doing, knew what was legal or illegal, and were only institutionalized by way of malingering / faking psychosis - trying to play the 'not guilty by reason of insanity' game so they wouldn't have to do harder time in jail or prison. Or, they would stay holed up in a mental hospital until public interest in their criminal cases died down, and then suddenly miraculously recover from their 'psychosis' and be released from the mental hospital into the public space.

orion8591 wrote:There's a division in the chart that does seems to partly confirm my impression: the Histrionic track [Histrionic /Dependent / Hysterical ] is indeed discrete

Yes, what's remarkable is that Kernberg seems to have nailed it 20 years ahead of the DSM5. At the coarse level of granularity its all borderline, however, look more closely and you can see the quite distinct different ways that borderline gets individually expressed. No wonder at the close-in zoom level so many specific traits are shared across all the "specific" disorders.

Imagine I start with n=40 NPD and n=40 HPD (both groups with roughly the same severity on the neurosis-psychosis axis) and I form three different treatment groups, plus a control:

1. Borderline "in general" treatments - (nothing specific to HPD or NPD): 10 NPD, 10 HPD
2. Treatment highly focused on NPD: 10 NPD (specific match), 10 HPD (mismatch)
3. Treatment highly focused on HPD: 10 NPD(mismatch), 10 HPD (specific match)
4. Control Group (no treatment): 10 NPD, 10 HPD

I run my program and what do I find? Any of the following could be the result (or of course inconsistent results...):

• The specific diagnosis just didn't matter, each treatment group achieved similar results?
• Generalized treatment did best?
• Specific treatment did best?
• Oddly, mismatched treatment ended up working best?

However, still can't connect [neurosis] narcissism -> malignant narcissism- > AsPD [psychosis].
[especially true psychosis] (i.e, catatonic schizophrenia).

Kernberg spent tons of time on Narcisism and Borderline. I would not hold him out as a huge luminary of the criminal mind however. Remember, just as soon as the AsPD traits scored too high he "packed and shipped". So, while his model may be good in the middle, out on the edges it may be more underspecified or even miss-specified.

Recall too the potential "guilt feelings" inside the judicial system. For it to be easy, all would like clear cut judicial decisions - guy was criminal, lock him up, vs guy was psychotic and wasn't capable of controlling himself, so pen him up until hes no longer a danger to himself or others. All that in the context of life, liberty and the [individual/narcissistic] pursuit of happiness means for tough justice calls, not infrequent mistakes, and yes, of course guilty feelings.

For a guy like Kernberg "psychotic" likely includes things like disorder so severe that normal human empathy is lacking or nonexistent. The person is then capable of harming themselves or others with no shame / guilt / remorse as inhibitors. You would not need full blown audio and visual hallucinations, paranoia resulting in catatonic states, or total "detachment" from reality to get to the "psychotic" level of severity in Kernberg's mind. A huge empathy deficit would likely score "psychotic" with him.

orion8591 wrote:I had always believed that rather than actual psychotics they were extremely grounded in external reality: they knew exactly what they were doing, knew what was legal or illegal, and were only institutionalized by way of malingering / faking psychosis - trying to play the 'not guilty by reason of insanity' game so they wouldn't have to do harder time in jail or prison. Or, they would stay holed up in a mental hospital until public interest in their criminal cases died down, and then suddenly miraculously recover from their 'psychosis' and be released from the mental hospital into the public space.

"they were extremely grounded in external reality: they knew exactly what they were doing, knew what was legal or illegal" - That type of criminal is easy to convict, hard to rehabilitate. AsP is hard to treat. Yes, they will "do it again" and just as soon as possible. Only fear is getting caught. All external "contrition" is just an act designed to play on others sympathy to the max (while they laugh inside) - get as lenient treatment as possible. Remorse / guilt / shame are totally just an act. None of that is felt deep inside.

The public likely has a very strange view of "psychotic" made up from dramatic psychodrama movies. Most psychotics are not criminals - not "organized enough" inside to plan out crimes and not at all "out to exploit others" -- just dealing with major internal turmoil. Most are minds that have been "blown apart" by personal trauma, or actual head injury, major drug abuse, etc. Void of all empathy in the mind is also, clearly an abnormal condition.

psychosis
1847, "mental derangement," from Gk. psykhe- "mind" (see psyche) + Mod.L. -osis "abnormal condition."

A hard core AsP with no empathy is likely not to respond to rehab. Jail and or heavy probation are likely very good, if not the only, options. Should this group qualify for an "insanity" plea, institutionalization at a psych hospital vs a regular jail - that depends. How safe are the other inmates from this guy? Are the guards good enough not to be duped?

If BPDs who are not hard criminals are extreemly hard to manage in "halfway houses" with highly trained clinical staff divided (50% feeling "lock 'em up and throw away the key" and 50% feeling "they are just misunderstood and actually have a strong potential for recovery"), I can't imagine how hard it would be to safely contain severe AsP hardened criminals?

***
Also wanted to make one more point. Everyone, including norms have an occasional psychotic experience. In fact as you dip a bit into the subconscious and semi-conscious you can feel a bit psychotic in that dreamy, watery, often extreem and violent areas of the mind.

One guy after Freud & Klein (Object relations) wrote a lot about it - W Bion. He was a WWII psychiatric medical officer. As part of that he was "placed in a hospital for officers who had been sent home for cracking up. He devised a way of working with groups of them that gave them back their self-esteem and willingness to fight". Obviously he treated a lot of PTSD related full blown psychosis! The quote comes from Robert Young, talking about Bion's book Experiences in Groups. . Here is a larger quote.

Robert Young re W Bion wrote:one is also left with a mind-altering sense that he has somehow written about the unconscious and primitive mental processes and conveyed their strangeness, frighteningness and quality in a way and to a degree that is unique. Freud wrote best about the structure of the mind. Melanie Klein wrote best about the content of primitive anxieties. One could say that Bion integrated the structure of primitive processes with their contents, however odd and bizarre. Klein showed how crazy we are; Bion charted the geographies of our psychotic unconscious processes and how they are always at work and sometimes take charge of individual lives, groups and institutions

Have to watch exploring too far, or too long in this type stuff. Attach a rope firmly to your waist before descending into that potential "black hole" ...psychosis is pretty far off the trail, you can get lost for days (or longer) in that type of bushwhacking.

[quote]For a guy like Kernberg "psychotic" likely includes things like disorder so severe that normal human empathy is lacking or nonexistent. The person is then capable of harming themselves or others with no shame / guilt / remorse as inhibitors. You would not need full blown audio and visual hallucinations, paranoia resulting in catatonic states, or total "detachment" from reality to get to the "psychotic" level of severity in Kernberg's mind. A huge empathy deficit would likely score "psychotic" with him.[quote]

Wisdom got the difference in Kernberg's terms and meanings now. What I was stuck on was reality sensing and its implications: for example I recall an African-American man in the midwest a few years back who had murdered several elderly white women because he was convinced they were witches trying to harm him with magic. Classic paranoid schizophrenia, albeit the rare psychotic involved in violent crime. A few minutes after he had murdered his last victim a couple of cops on patrol spotted him near the crime scene, stumbling down the street with the murder weapon in his hand, and with the victim's blood all over him. No attempt to escape or evade; in his mind what he did was self-defense. Now contrast that arrest with a classic AsPD like Ted Bundy who killed many women with sadistic pleasure, yet who also understood that what he did was seen to be wrong, at least by the dominant ethical sytem in his culture [/i]and accordingly to avoid punishment he tried to evade detection, escape from jails, etc., and even cooperate with law enforcement officials attempting to capture other serial murderers in order to gain clemency from the death penalty.

[quote]Also wanted to make one more point. Everyone, including norms have an occasional psychotic experience. In fact as you dip a bit into the subconscious and semi-conscious you can feel a bit psychotic in that dreamy, watery, often extreem and violent areas of the mind.[quote]

Yeah every night or so I have a psychotic episode complete with fantastic non-sensical imagery: I think a lot of people would probably agree that these are called dreams

And as far as AsPD, I've always thought that if you wanted to experience low-grade psychopathy first hand, one could effectively do so by becoming drunk

imho it makes sense to me that they're all linked.

but i think its also more helpful to treat symptoms i.e. abandonment issues, mood swings, problems with empathy or remorse, through whatever caused them for individuals, as they're parts of a disorder rather than symptoms of an underlying illness - i.e. the symptoms are the problem.

im not a professional, and this is just a personal opinion, so i may be wrong in some places, but here's what i think:

those underlying issues are protected by defence mechanisms... the higher up the severity scale you go, the more defence mechanisms are protecting the person from feeling that underlying pain - not just negative ways of dealing with it, but eventually they don't even know that they feel at all. the only way through that is tearing down those defence mechanisms, which is what makes therapy, and work on that original pain so difficult in disorders where more is blocked - the work needs to be done on taking those defence mechanisms down before therapy can get anywhere - and then there is the challenge of keeping them down, which is hard especially when dealing with the reasons they exist in the first place. (no such thing as failure only setbacks.) but professionals try to give someone therapy, then when they can't connect with it, just assume therapy isn't working for the patient, when the truth is more likely that they're still incapable of connecting with their own feelings and need to work on getting there before they can get any benefit from the therapy.

A lot of the stuff used, like CBT/DBT etc seems useful for helping people manage thoughts and feelings so they can begin to deal with them, which is why there is more treatment for "typical BPD" where there isn't the need to break through stuff in the same way. i reckon once any cluster B gets through to the feelings underneath, they're gonna feel a lot more BPD-like. Making sense of accounts of people with e.g. NPD seeming very rational/functional but breaking down under therapy.

i think people are too hung up on categorising things to fit - its almost like everyone is spending so much time saying "what have i got", when all they really have to do is list their symptoms, and there is the answer. labels are of some help for professionals to communicate with, but there's too much emphasis on assigning them. it makes more sense to say where is this person right now? on a scale of complete inability to access feelings, struggling to maintain/access that ability, negative defences making extreme emotion hard to deal with and being able to deal with that emotion and process it in therapy (where non-PD people with issues are.)

i think its also a little more complex than just layers - people without PDs dont develop PDs because the trauma (obvious or not obvious) wasn't severe enough for them to need to create those defences. so someone who breaks through a PD to deal with their issues is going to have a hell of a lot more to deal with once they can start to access it than someone who just had a few issues. to make it worse, they've never had the chance to develop the ability to process and deal with emotion the way non-disordered people do. which explains why people who try to deal with a PD can end up flying between high functioning with defence mechanisms up, then completely breaking down and being unable to function at all and feeling completely crazy.

once those defences have been broken through, they probably can't ever be put back in the same way, making trying to take them back like grasping frantically at denial to avoid pain.

also its interesting how those emotional blocking mechanisms work - (personally) i put different emotions in parts of me, separating them from myself using some sort of dissociation - like some sort of DDNOS, but instead of manifesting as DID with full alters, i dissociate to shut out parts of me with different feelings. getting in touch with some of those feelings gradually revealled that, and made sense of behaviour that i had just thought of as being flexible. id also say it isn't that i dont have a sense of self, i do, but my sense of self is split into separate pieces.

again, just my thoughts - opinion not fact, & comments welcome.

AliceWonders wrote:It was my origional understanding that you had to FIRST have BPD and then it branched out into the other areas of PD traits and associations- is that not true? No longer the case???

if ive read it right, i think that's what they're trying to say - that the DSM is now recognising BPD as a base for all cluster B PDs.