Staff Perspective: Personality Disorders in the Military
Personality disorders refer to pervasive, stable patterns of behavior that leads to distress or impaired functioning. Such patterns often manifest during late adolescence or early adulthood and include:
- Thoughts (i.e., interpretation of self and others)
- Affect (range, intensity, lability or appropriateness)
- Interpersonal functioning
- Impulse control (usually lack thereof)
Cluster A (Odd or Eccentric)
Paranoid PD refers to individuals who are consistently suspicious of other people without a sound basis and often hold a grudge. They are preoccupied with doubts about the trustworthiness of others and often believe that others are exploiting or deceiving him. These individuals may not wish to be compliant with treatment planning but I encourage clinicians to help them focus on the positive in themselves and others. In military settings, it is helpful to note that such characteristics may be adaptive in combat. Clinicians may find I it most helpful to be quite clear in their interactions in an effort to minimize double meanings and misinterpretations.
Individuals with Schizoid PD tend to be loners who do not enjoy close relationships. Others often describe people with schizoid PD as being odd or peculiar and they may seem cool or detached to other people. They may be disinterested in sexual relationships and often prefer solitary activities, occupations and hobbies. Often they have difficulty discerning the subtleties of interpersonal relationships and may be uncomfortable in social situations.
Schizotypal PD is similar to schizoid in the lack of interpersonal relationships but dissimilar in perceptual problems and eccentric behavior. They may report ideas of reference, odd beliefs or magical thinking and unusual perceptual experiences. Many individuals with schizotypal PD display inappropriate affect, odd behaviors and a tendency to be suspicious. Such individuals should not be confused with individuals meeting diagnostic criteria for schizophrenia, as they are still able to discern reality.
Cluster B (Dramatic and Emotional)
Individuals with Antisocial PD often disregard the rights of others and have a history of conduct disorder before age 15. This PD is more frequently diagnosed in men than women. Such people do not conform to the norms of lawfulness, lack empathy and may impress others as being arrogant or superficially charming. Antisocial PD is often conflated with psychopathy, but I encourage clinicians to measure psychopathy using the Hare Psychopathy checklist http://www.hare.org/scales/pclr.html.
Borderline Personality Disorder (BPD) refers to a pervasive pattern of unstable personal relationships, self-image, affect and impulsivity. The hallmark feature is a heightened fear of abandonment and recurrent suicidal ideation and self-harm. Although, this PD is more common in women, men may also be diagnosed with BPD. Individuals with BPD report significant relationship problems and intense emotions. I encourage clinicians to be patient, be fair and consistent and to help them improve their emotion regulation and coping skills.
Individuals with Histrionic Personality Disorder are often attention-seeking with quickly changing affect. Many individuals with HPD are overly concerned with impressing other people and prone to periods of depressed mood. Others may describe those with HPD as insincere or theatrical.
People meeting diagnostic criteria for Narcissistic PD have a need to be adored and admired. They are often described as entitled or arrogant and rarely accept criticism gracefully. Working with patients demonstrating NPD can prove to be challenging, I encourage clinicians to seek additional training and consultation in these instances.
Cluster C (Anxious & fearful)
Individuals with avoidant PD are preoccupied with criticism and rejection. They are risk-averse for fear of being embarrassed. Others describe them as restrained in close relationships and distant. Clinicians working with individuals with avoidant PD should be particularly calm, reassuring and patient.
Individuals with a pervasive and excessive need to be taken care of may meet diagnostic criteria for dependent PD. Such individuals allow other people (usually one specific person) to make other important decisions for fear that they may make a critical mistake. This PD is equally distributed among women and men. Like individuals with BPD, they may be preoccupied with abandonment but for different reasons. Others often describe them as pessimistic and submissive. When working with dependent personalities, clinicians should help them to take an active role in treatment planning, empowering them to make good choices. Clinicians should also be careful to assess for abusive relationships and be aware that dependent PD’s may be vulnerable to manipulation by more aggressive personalities.
Obsessive-Compulsive PD is often confused with obsessive-compulsive disorder (OCD). Individuals with OCPD are preoccupied with details, lists, rules and orders. Some people with OCPD may be so detail oriented that they are unable to complete projects or miss deadlines. Individuals with OCPD may be reluctant to delegate work to others and are often very self-critical. Many people with OCPD are focused on work to the extent that relationships suffer.
Special Considerations for Active Duty Personnel
The paragraphs above serve as an overview of some of the key personality traits associated with each of the personality disorders. I strongly encourage all clinicians to carefully consider traits, context and cultural factors when diagnosing individuals with PD, particularly in military settings.
Many military behavioral health providers are aware that over 31,000 service members were discharged due to a personality disorder diagnosis between FY01 and FY10. Although these numbers have dipped appropriately in recent years, the possibility of misdiagnosis still exists. I encourage behavioral health providers to be careful when diagnosing personality disorders, as the consequences may be severe for our men and women in uniform. All providers should consider the chronicity and context of behaviors as well as the psychosocial history and co-morbid diagnoses.
Prior to formal diagnosis, providers should obtain confirming information from long-term friends and family, consult with the current DSM diagnostic criteria, and use a normed psychological test (i.e., SCID-II or MMPI-II). Additionally, when diagnosing a service member, please consider the following:
- Observations of specific problems from peers and supervisors must be documented in the counseling or personnel records
- Service member must be informed of such difficulties formally
- Problematic behavior must continue, despite counseling and an opportunity to overcome such behavioral problems
- Service member should be diagnosed by a doctoral level clinician
- The personality disorder must severely impair their occupational functioning
Additional information is available in DoDI 1332.14. As there is far too much information to include in this blog, please review the DoDI for more detail. Consultation with other behavioral health providers is also wise during the assessment and documentation process. In brief, I emphasize the importance of using current diagnostic criteria, documentation of impaired functioning and consideration of context as well as co-morbid conditions.
Behavioral health providers…how do you diagnose personality disorders given the revised DoDI? What assessment tools do you recommend for other military behavioral health providers? What resources do you recommend to other behavioral health providers diagnosing personality disorders?
Holly N. O’Reilly, Ph.D., is a clinical psychologist and Lead on Traumatic Stress and Sexual Assault at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Personality disorders refer to pervasive, stable patterns of behavior that leads to distress or impaired functioning. Such patterns often manifest during late adolescence or early adulthood and include:
- Thoughts (i.e., interpretation of self and others)
- Affect (range, intensity, lability or appropriateness)
- Interpersonal functioning
- Impulse control (usually lack thereof)
Cluster A (Odd or Eccentric)
Paranoid PD refers to individuals who are consistently suspicious of other people without a sound basis and often hold a grudge. They are preoccupied with doubts about the trustworthiness of others and often believe that others are exploiting or deceiving him. These individuals may not wish to be compliant with treatment planning but I encourage clinicians to help them focus on the positive in themselves and others. In military settings, it is helpful to note that such characteristics may be adaptive in combat. Clinicians may find I it most helpful to be quite clear in their interactions in an effort to minimize double meanings and misinterpretations.
Individuals with Schizoid PD tend to be loners who do not enjoy close relationships. Others often describe people with schizoid PD as being odd or peculiar and they may seem cool or detached to other people. They may be disinterested in sexual relationships and often prefer solitary activities, occupations and hobbies. Often they have difficulty discerning the subtleties of interpersonal relationships and may be uncomfortable in social situations.
Schizotypal PD is similar to schizoid in the lack of interpersonal relationships but dissimilar in perceptual problems and eccentric behavior. They may report ideas of reference, odd beliefs or magical thinking and unusual perceptual experiences. Many individuals with schizotypal PD display inappropriate affect, odd behaviors and a tendency to be suspicious. Such individuals should not be confused with individuals meeting diagnostic criteria for schizophrenia, as they are still able to discern reality.
Cluster B (Dramatic and Emotional)
Individuals with Antisocial PD often disregard the rights of others and have a history of conduct disorder before age 15. This PD is more frequently diagnosed in men than women. Such people do not conform to the norms of lawfulness, lack empathy and may impress others as being arrogant or superficially charming. Antisocial PD is often conflated with psychopathy, but I encourage clinicians to measure psychopathy using the Hare Psychopathy checklist http://www.hare.org/scales/pclr.html.
Borderline Personality Disorder (BPD) refers to a pervasive pattern of unstable personal relationships, self-image, affect and impulsivity. The hallmark feature is a heightened fear of abandonment and recurrent suicidal ideation and self-harm. Although, this PD is more common in women, men may also be diagnosed with BPD. Individuals with BPD report significant relationship problems and intense emotions. I encourage clinicians to be patient, be fair and consistent and to help them improve their emotion regulation and coping skills.
Individuals with Histrionic Personality Disorder are often attention-seeking with quickly changing affect. Many individuals with HPD are overly concerned with impressing other people and prone to periods of depressed mood. Others may describe those with HPD as insincere or theatrical.
People meeting diagnostic criteria for Narcissistic PD have a need to be adored and admired. They are often described as entitled or arrogant and rarely accept criticism gracefully. Working with patients demonstrating NPD can prove to be challenging, I encourage clinicians to seek additional training and consultation in these instances.
Cluster C (Anxious & fearful)
Individuals with avoidant PD are preoccupied with criticism and rejection. They are risk-averse for fear of being embarrassed. Others describe them as restrained in close relationships and distant. Clinicians working with individuals with avoidant PD should be particularly calm, reassuring and patient.
Individuals with a pervasive and excessive need to be taken care of may meet diagnostic criteria for dependent PD. Such individuals allow other people (usually one specific person) to make other important decisions for fear that they may make a critical mistake. This PD is equally distributed among women and men. Like individuals with BPD, they may be preoccupied with abandonment but for different reasons. Others often describe them as pessimistic and submissive. When working with dependent personalities, clinicians should help them to take an active role in treatment planning, empowering them to make good choices. Clinicians should also be careful to assess for abusive relationships and be aware that dependent PD’s may be vulnerable to manipulation by more aggressive personalities.
Obsessive-Compulsive PD is often confused with obsessive-compulsive disorder (OCD). Individuals with OCPD are preoccupied with details, lists, rules and orders. Some people with OCPD may be so detail oriented that they are unable to complete projects or miss deadlines. Individuals with OCPD may be reluctant to delegate work to others and are often very self-critical. Many people with OCPD are focused on work to the extent that relationships suffer.
Special Considerations for Active Duty Personnel
The paragraphs above serve as an overview of some of the key personality traits associated with each of the personality disorders. I strongly encourage all clinicians to carefully consider traits, context and cultural factors when diagnosing individuals with PD, particularly in military settings.
Many military behavioral health providers are aware that over 31,000 service members were discharged due to a personality disorder diagnosis between FY01 and FY10. Although these numbers have dipped appropriately in recent years, the possibility of misdiagnosis still exists. I encourage behavioral health providers to be careful when diagnosing personality disorders, as the consequences may be severe for our men and women in uniform. All providers should consider the chronicity and context of behaviors as well as the psychosocial history and co-morbid diagnoses.
Prior to formal diagnosis, providers should obtain confirming information from long-term friends and family, consult with the current DSM diagnostic criteria, and use a normed psychological test (i.e., SCID-II or MMPI-II). Additionally, when diagnosing a service member, please consider the following:
- Observations of specific problems from peers and supervisors must be documented in the counseling or personnel records
- Service member must be informed of such difficulties formally
- Problematic behavior must continue, despite counseling and an opportunity to overcome such behavioral problems
- Service member should be diagnosed by a doctoral level clinician
- The personality disorder must severely impair their occupational functioning
Additional information is available in DoDI 1332.14. As there is far too much information to include in this blog, please review the DoDI for more detail. Consultation with other behavioral health providers is also wise during the assessment and documentation process. In brief, I emphasize the importance of using current diagnostic criteria, documentation of impaired functioning and consideration of context as well as co-morbid conditions.
Behavioral health providers…how do you diagnose personality disorders given the revised DoDI? What assessment tools do you recommend for other military behavioral health providers? What resources do you recommend to other behavioral health providers diagnosing personality disorders?
Holly N. O’Reilly, Ph.D., is a clinical psychologist and Lead on Traumatic Stress and Sexual Assault at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.