A profile analysis of personality disorders: beyond multiple diagnoses

Is DSM widely accepted by Japanese clinicians?

The Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III), a new standardized diagnostic system with multiaxial diagnosis, operational criteria and renewed definitions of mental disorders, was introduced in 1980 and prompted movements to reform conventions in Japanese psychiatry. This review overviews the initial response of Japanese clinicians to accept DSM-III, and its effects on the development of systematic research of psychiatric diagnosis. These new research activities include those on reliability of psychiatric diagnosis, application of various evaluation tools, discussion on the concept of mental disorders, relation of personality disorders with depressive disorders, and Taijin-kyofusho, or culturally distinctive phobia in Japan. A reference database search to survey the latest trend on psychiatric research indicated that the number of papers published by Japanese workers increased sharply after 1987, and DSM apparently greatly influenced their internationalization. Twenty years after the publication of DSM-III, a questionnaire on the use of DSM-IV was set out in 2000 to survey how widely DSM is utilized in clinical practice in Japan. Two hundred and twelve psychiatrists answered the questionnaire, and the results show that DSM has been accepted positively by the younger generation, while the older generation (over 40s) has still less interest in DSM, and DSM is used mainly for research purposes rather than in daily practice.

Personality disorders

Some general recommendations can be made, collected from these subjective descriptions of personality types. Because determining an accurate psychiatric diagnosis is not the internist's aim, it is better for him or her to have a stance that generalizes to all patients, which can be refined as personality characteristics emerge. Tolerate the patient's affect (such as anger or anxiety), being firm and kind, rather than punitive or overinvested. Accept dependency and vulnerability. Accept and respect the underlying coping style. Understand that the patient's personality style is the best (and usually only) way he or she knows to have a relationship, including a relationship with the physician. Understand that personality traits additionally may have a function (e.g., to guard against anxiety or depression). Recognize that personality traits do not come in pure form. One personality trait is likely to blend into or overlap with other traits. Identify and treat any underlying symptom disorder, such as anxiety, depression, irritability, or thought disorder. Educate the patient clearly (and without patronizing) about medical illness. Document what was explained to the patient and how the patient responded, including dispassionate observations about behavior and emotional expression. Appreciate the patient's possible attachment to medical symptoms. Avoid arguments with patients who make unreasonable demands. Make timely judgments about whether or not to accede to a demand. When in doubt about a patient's honesty, give the patient the benefit of the doubt. Do not worry about being used because all patients use their physicians to some extent. Go to the limits of your tolerance for a patient's personality, but know your limits and refer to a colleague when you cannot work with the patient. Terminate an interaction and get help if there is a risk (or fear) of violence. Given the time it takes to manage the relationship and the psychiatric elements of treatment, a referral to a psychiatrist or other mental health professional often is wise if the patient will accept it. Include the mental health professional as part of the medical team. Although these various recommendations have been emphasized in connection with certain personality types, one can be flexible about their application in a variety of patients. It is important also to reiterate the limits of subjective descriptions. It is rare to find any of the aforementioned subjective descriptions in unmodified form; characteristics of more than one personality type usually appear in the same person. The descriptions are composites that provide a starting point for the physician. The physician should edit the composites based on experience with real patients. This article has described human characteristics and rough guidelines for helpful human responses and possible pharmacologic interventions. So equipped, the primary care physician may find it less troubling and more interesting to face the wide variation in human character.