Thursday, February 17, 2011

The DSM, Axis II and Cluster B

The DSM, Axis II and Cluster B
15% of Americans have one or more personality disorders.”  ~Mayo Clinic
“Up to 30 percent of people who require mental health services have at least one personality disorder (PD)--characterized by abnormal and maladaptive inner experience and behavior.” ~Sally Dingfelder
“PDs are present in 10 to 15 percent of the adult population, with Cluster B accounting for approximately 9 percent based on research…a failure to identify them may create significant risk.”  ~Joe Carver

The Diagnostic and Statistical Manual of Mental Disorders (DSM) categorizes psychological disorders on a multiaxial system comprised of five levels: Axis I, Axis II, Axis III, IV & V. If you've been learning about Narcissistic Personality Disorder, it's highly likely you've heard NPD referred to as an Axis II disorder. 
Now most likely, you're wondering why personality disorders are not grouped in with Axis I disorders like depression, schizophrenia, and substance dependence. Well, that’s because a personality disorder is a long-standing condition preceding a psychological crisis. A crisis big enough to force someone with a personality disorder into a psychologist's office. As most of us know however, it's usually the narcissist's family and friends who insist he or she get help.
It's important to know that insurance covers treatment for Axis I disorders since intervening treatments are considered to be cost-effective. Axis I disorders can be ameliorated with medical & psychological intervention, unlike personality disorders requiring intensive, long-term treatment.
Because of a poor prognosis for curing personality disorders, insurance companies have refused to pay for long-term treatment. Curing Narcissistic Personality Disorder is still uncertain which is why insurance companies are reluctant to throw money at treatment if treatment is not cost-effective.
The perception that personality disorders are untreatable is changing as results from intervening treatments like DBT, are proving to be successful. Particularly for people with Borderline Personality Disorder.
The following list will hopefully help you understand how personality disorders are categorized in the DSM-IV, sometimes called a psychologist's bible.

Axis I: Clinical disorders and conditions requiring clinical attention
Axis I mental disorders of significant impairment include: Depression, schizophrenia, social phobia, learning disorders, anxiety disorders, bipolar, ADHD, eating disorders, cognitive disorders, substance-related disorders, dissociative disorders, autism, etc. Just about everything someone sees a psychologist for goes on Axis I---with the exception of personality disorders and mental retardation. 
People with Axis I disorders are most generally ego-dystonic; in other words, they see their mental problem as being separate from themselves. Their condition is not consistent with self-perceptions. This short list illustrates how disorders are categorized in the DSM:
          296.80 Bipolar disorder
          303.90 Alcohol Dependence
          309.81 Posttraumatic stress disorder 

Axis II: Personality disorders and mental retardation
Axis II refers to Personality Disorders for the most part, manifesting significant impairment in how someone relates to the world. Only those with long-term rigid, inflexible, pervasive and exaggerated traits can be diagnosed with a personality disorder.
Another important distinction is that people with personality disorders do not perceive their problems to be related to themselves. In other words, they are ego-syntonic: They say, “There’s nothing wrong with me. Everyone else is the problem!”
People with Personality Disorders frequently present with Axis I disorders. Axis I disorders are more likely to cause a crisis requiring psychological intervention. Depression and substance abuse, for example, might be the only reason a narcissist would seek psychological help. So the psychologist treats the Axis I disorder(s) but generally does not treat the underlying personality disorder.
Also, people can be diagnosed with more than one personality disorder, sometimes crossing over into another ‘cluster’. These are the three groups, or ‘clusters’ of Axis II personality disorders: Cluster A, Cluster B, and Cluster C.

Cluster A: ‘Suspicious’. Odd, eccentric behavior.
          301.00 Paranoid personality disorder
          301.20 Schizoid personality disorder
          301.22 Schizotypal personality disorder

Cluster B: “Emotional/Impulsive". Dramatic behavior.
          301.50 Histrionic personality disorder
          301.81 Narcissistic personality disorder
          301.70 Antisocial personality disorder
          301.83 Borderline personality disorder

Cluster C: ‘Anxious’. Fearful behavior.
          301.40 Obsessive-Compulsive personality disorder
          301.82 Avoidant personality disorder
          301.6 Dependent personality disorder
Note: Dissociative Identity Disorder, DID, (formerly called 'multiple personality disorder') is not an Axis II disorder. DID is an Axis I diagnosis.
Note: Clinicians may refer to Mental retardation and Developmental Disabilities as MR/DD.

Axis III: General Medical Conditions
Medical conditions may influence management of Axis I and II disorders, such as: acute medical conditions, physical disorders, brain injuries aggravating disease or symptoms, and HIV/Aids, for example.

Axis IV: psychosocial and environmental problems contributing to the disorder
Axis IV problems also impact Axis I and II disorders, such as: unemployment, divorce, relocation, death, retirement, illiteracy, economic problems, lack of health care/insurance, victim of crime, births, academic problems, job dissatisfaction, homelessness, poverty, unsafe neighborhood, etc.

Axis V: Global Assessment of Functioning Scale (GAF)
The GAF is used by mental health clinicians and doctors to rate an individual’s overall social, occupational and psychological functioning.
The GAF is factored on a scale of 1-100 based on the psychologist’s judgment as to how well a client is managing his or her life. This scale ranges from harming the self or others (1-10) to no symptoms at all (91-100).
Low functioning range, 1-10: Persistent danger of severely hurting self or others OR persistent inability to maintain minimum personal hygiene OR serious suicidal act with clear expectation of death.
High-functioning range, 91-100: Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many qualities. No symptoms.

The following is an example of a typical diagnostic assessment

Axis I:

296.21 Major Depressive Disorder , Single Episode
303.90 Alcohol Dependence
Axis II:

301.6 Dependent Personality Disorder
Axis III:

Axis IV:

Recent Divorce, unemployment
Axis V:


I hope this helps explain what psychologists mean by Axis II disorders and Cluster B personality disorders. Because it's difficult for the layperson to distinguish between NPD and BPD, for example, it's useful to look at all the personality disorders grouped in the Cluster B category. 

I'd also like to recommend reading Joe Carver's article linked below. He writes, "...individuals who create the most damage to social and personal relationships, the abusers, manipulators, “players”, controllers, and losers are found in Cluster B."


Article published on The Narcissistic Continuum, 2008 

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