It is a sign of the inadequacy of our current knowledge of personality disorders that both the American Diagnostic and Statistical Manual (DSM) and its international counterpart, the ICD, maintain a "Personality Disorders Not Otherwise Specified (NOS)" diagnostic category. It is a catch-all, meaningless, "diagnosis", a testament to the diagnostician's helplessness and ignorance in the face of human complexity which often defies neat classification.
Even the rudiments of this diagnostic category are in dispute. There is no agreement as to what traits and behaviors it applies to. The ICD, for instance, includes the Narcissistic Personality Disorder in the NOS category, insisting that it is not a full-fledged personality disorder.
The NOS diagnosis is a laundry list of all personality-related dysfunctions, signs, symptoms, and complaints that do not fit a specific personality disorder. Some people satisfy one or more diagnostic criteria of a few personality disorders ("mixed personality"), but do not run the full gamut of any of them. The only requirement is that the personality be somehow impaired and cause distress and dysfunctions in one or more important areas of life: social, occupational, sexual, interpersonal, and so on.
Personality disorders not yet recognized by the DSM Committee - e.g., depressive, negativistic, or passive-aggressive - are also NOS.
Adverse Outcomes Associated With Personality Disorder Not Otherwise Specified in a Community Sample
Jeffrey G. Johnson, Ph.D., Michael B. First, M.D., Patricia Cohen, Ph.D., Andrew E. Skodol, M.D., Stephanie Kasen, Ph.D. and Judith S. Brook, Ed.D.
OBJECTIVE: The authors investigated 1) whether adolescents and adults in the community diagnosed with personality disorder not otherwise specified are at elevated risk for adverse outcomes, and 2) whether this elevation in risk is comparable with that associated with the DSM-IV cluster A, B, and C personality disorders. METHOD: A community-based sample of 693 mothers and their offspring were interviewed during the offspring’s childhood, adolescence, and early adulthood. Offspring psychopathology, aggressive behavior, educational and interpersonal difficulties, and suicidal behavior were assessed. RESULTS: Individuals who met DSM-IV criteria for personality disorder not otherwise specified were significantly more likely than those without personality disorders to have concurrent axis I disorders and behavioral, educational, or interpersonal problems during adolescence and early adulthood. In addition, adolescents with personality disorder not otherwise specified were at significantly elevated risk for subsequent educational failure, numerous interpersonal difficulties, psychiatric disorders, and serious acts of physical aggression by early adulthood. Adolescents with personality disorder not otherwise specified were as likely to have these adverse outcomes as those with cluster A, B, or C personality disorders or those with axis I disorders. CONCLUSIONS: Adolescents and young adults in the general population diagnosed with personality disorder not otherwise specified may be as likely as those with DSM-IV cluster A, B, or C personality disorders to have axis I psychopathology and to have behavioral, educational, or interpersonal problems that are not attributable to co-occurring psychiatric disorders. Individuals with personality disorder not otherwise specified and individuals with DSM-IV cluster A, B, or C personality disorders are likely to be at substantially elevated risk for a wide range of adverse outcomes.
Introduction
TOP
Abstract
Introduction
Method
Results
Discussion
References
Personality disorders are relatively common in the general population. Personality disorder prevalence estimates, based on DSM-III, DSM-III-R, and DSM-IV criteria for specific personality disorders, have ranged from approximately 7% to 15% of the adult population, depending on the diagnostic procedure and the range of personality disorders assessed (1–5). Among adolescents and adults, personality disorders have been found to be associated with 1) impairment and distress not attributable to co-occurring axis I disorders and 2) elevated risk for poor outcomes after accounting for co-occurring axis I disorders (6–12). Previous research (13) has indicated that most personality disorders can be treated effectively with psychotherapy, although there is considerable variability in the methodological rigor, sample size, and scope of the studies that have investigated the effectiveness of psychotherapy for personality disorders (e.g., many individuals require extensive treatment and some personality disorders, such as antisocial personality disorder, may be particularly difficult to treat effectively due in part to the lack of insight and motivation to change that tends to be present among many individuals with antisocial personality disorder). In any event, increased recognition and treatment of personality disorders is likely to have beneficial consequences for many persons with these disorders.
Given such findings, it is of considerable interest that an important category of personality disorders, referred to in DSM-IV as personality disorder not otherwise specified, has thus far been investigated by few epidemiological studies. According to DSM-IV-TR, individuals are appropriately diagnosed with personality disorder not otherwise specified if there is a disorder of personality functioning that does not meet the criteria for a cluster A, B, or C personality disorder. Research has indicated that personality disorder not otherwise specified may be the most common personality disorder diagnosis in many clinical settings (14–18) and that it may be as prevalent as many common axis I disorders (19). However, the high prevalence of personality disorder not otherwise specified may be partially attributable to the fact that comprehensive diagnostic assessments are not conducted in some clinical settings. Most of the epidemiological studies that have assessed personality disorders have not provided findings regarding the prevalence of personality disorder not otherwise specified, and little is currently known about characteristics associated with personality disorder not otherwise specified in the general population. One reason for the lack of systematic population-based research is that there is not yet a clear scientific consensus regarding how to identify individuals with personality disorder not otherwise specified.
In order for large-scale studies to investigate personality disorder not otherwise specified in a systematic manner, and in order for the findings of these studies to be compared and evaluated, it is necessary to develop an operational definition that can be utilized with any validated personality disorder assessment instrument. One way to develop diagnostic criteria that can be implemented with data from any systematic assessment of personality disorder features is to define, in a precise and operational manner, the two examples of personality disorder not otherwise specified set forth in DSM-IV-TR. Accordingly, when the criteria for a cluster A, B, or C personality disorder are not met, personality disorder not otherwise specified may be diagnosed if 1) there are personality disorder features that come within one diagnostic criterion of meeting DSM-IV thresholds for two or more personality disorders (e.g., four borderline personality disorder features and four schizotypal personality disorder features), or 2) diagnostic criteria are met for depressive or passive-aggressive personality disorder. Further research may determine that the definition should be expanded by diagnosing personality disorder not otherwise specified when the total number of personality disorder features exceeds a specified threshold. However, while this kind of threshold has been used in some studies (20), a clear consensus about the threshold that should be used will require further investigation. It is also important to investigate the characteristics of personality disorder not otherwise specified that are operationally defined based on the information and examples in DSM-IV-TR. Our review of the literature indicates that the present study is the first community-based longitudinal investigation to examine mental health outcomes associated with personality disorder not otherwise specified (1–5).
Question
Josephine
It is a sign of the inadequacy of our current knowledge of personality disorders that both the American Diagnostic and Statistical Manual (DSM) and its international counterpart, the ICD, maintain a "Personality Disorders Not Otherwise Specified (NOS)" diagnostic category. It is a catch-all, meaningless, "diagnosis", a testament to the diagnostician's helplessness and ignorance in the face of human complexity which often defies neat classification.
Even the rudiments of this diagnostic category are in dispute. There is no agreement as to what traits and behaviors it applies to. The ICD, for instance, includes the Narcissistic Personality Disorder in the NOS category, insisting that it is not a full-fledged personality disorder.
The NOS diagnosis is a laundry list of all personality-related dysfunctions, signs, symptoms, and complaints that do not fit a specific personality disorder. Some people satisfy one or more diagnostic criteria of a few personality disorders ("mixed personality"), but do not run the full gamut of any of them. The only requirement is that the personality be somehow impaired and cause distress and dysfunctions in one or more important areas of life: social, occupational, sexual, interpersonal, and so on.
Personality disorders not yet recognized by the DSM Committee - e.g., depressive, negativistic, or passive-aggressive - are also NOS.
Am J Psychiatry 162:1926-1932, October 2005
doi: 10.1176/appi.ajp.162.10.1926
© 2005 American Psychiatric Association
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Adverse Outcomes Associated With Personality Disorder Not Otherwise Specified in a Community Sample
Jeffrey G. Johnson, Ph.D., Michael B. First, M.D., Patricia Cohen, Ph.D., Andrew E. Skodol, M.D., Stephanie Kasen, Ph.D. and Judith S. Brook, Ed.D.
OBJECTIVE: The authors investigated 1) whether adolescents and adults in the community diagnosed with personality disorder not otherwise specified are at elevated risk for adverse outcomes, and 2) whether this elevation in risk is comparable with that associated with the DSM-IV cluster A, B, and C personality disorders. METHOD: A community-based sample of 693 mothers and their offspring were interviewed during the offspring’s childhood, adolescence, and early adulthood. Offspring psychopathology, aggressive behavior, educational and interpersonal difficulties, and suicidal behavior were assessed. RESULTS: Individuals who met DSM-IV criteria for personality disorder not otherwise specified were significantly more likely than those without personality disorders to have concurrent axis I disorders and behavioral, educational, or interpersonal problems during adolescence and early adulthood. In addition, adolescents with personality disorder not otherwise specified were at significantly elevated risk for subsequent educational failure, numerous interpersonal difficulties, psychiatric disorders, and serious acts of physical aggression by early adulthood. Adolescents with personality disorder not otherwise specified were as likely to have these adverse outcomes as those with cluster A, B, or C personality disorders or those with axis I disorders. CONCLUSIONS: Adolescents and young adults in the general population diagnosed with personality disorder not otherwise specified may be as likely as those with DSM-IV cluster A, B, or C personality disorders to have axis I psychopathology and to have behavioral, educational, or interpersonal problems that are not attributable to co-occurring psychiatric disorders. Individuals with personality disorder not otherwise specified and individuals with DSM-IV cluster A, B, or C personality disorders are likely to be at substantially elevated risk for a wide range of adverse outcomes.
Introduction
TOP
Abstract
Introduction
Method
Results
Discussion
References
Personality disorders are relatively common in the general population. Personality disorder prevalence estimates, based on DSM-III, DSM-III-R, and DSM-IV criteria for specific personality disorders, have ranged from approximately 7% to 15% of the adult population, depending on the diagnostic procedure and the range of personality disorders assessed (1–5). Among adolescents and adults, personality disorders have been found to be associated with 1) impairment and distress not attributable to co-occurring axis I disorders and 2) elevated risk for poor outcomes after accounting for co-occurring axis I disorders (6–12). Previous research (13) has indicated that most personality disorders can be treated effectively with psychotherapy, although there is considerable variability in the methodological rigor, sample size, and scope of the studies that have investigated the effectiveness of psychotherapy for personality disorders (e.g., many individuals require extensive treatment and some personality disorders, such as antisocial personality disorder, may be particularly difficult to treat effectively due in part to the lack of insight and motivation to change that tends to be present among many individuals with antisocial personality disorder). In any event, increased recognition and treatment of personality disorders is likely to have beneficial consequences for many persons with these disorders.
Given such findings, it is of considerable interest that an important category of personality disorders, referred to in DSM-IV as personality disorder not otherwise specified, has thus far been investigated by few epidemiological studies. According to DSM-IV-TR, individuals are appropriately diagnosed with personality disorder not otherwise specified if there is a disorder of personality functioning that does not meet the criteria for a cluster A, B, or C personality disorder. Research has indicated that personality disorder not otherwise specified may be the most common personality disorder diagnosis in many clinical settings (14–18) and that it may be as prevalent as many common axis I disorders (19). However, the high prevalence of personality disorder not otherwise specified may be partially attributable to the fact that comprehensive diagnostic assessments are not conducted in some clinical settings. Most of the epidemiological studies that have assessed personality disorders have not provided findings regarding the prevalence of personality disorder not otherwise specified, and little is currently known about characteristics associated with personality disorder not otherwise specified in the general population. One reason for the lack of systematic population-based research is that there is not yet a clear scientific consensus regarding how to identify individuals with personality disorder not otherwise specified.
In order for large-scale studies to investigate personality disorder not otherwise specified in a systematic manner, and in order for the findings of these studies to be compared and evaluated, it is necessary to develop an operational definition that can be utilized with any validated personality disorder assessment instrument. One way to develop diagnostic criteria that can be implemented with data from any systematic assessment of personality disorder features is to define, in a precise and operational manner, the two examples of personality disorder not otherwise specified set forth in DSM-IV-TR. Accordingly, when the criteria for a cluster A, B, or C personality disorder are not met, personality disorder not otherwise specified may be diagnosed if 1) there are personality disorder features that come within one diagnostic criterion of meeting DSM-IV thresholds for two or more personality disorders (e.g., four borderline personality disorder features and four schizotypal personality disorder features), or 2) diagnostic criteria are met for depressive or passive-aggressive personality disorder. Further research may determine that the definition should be expanded by diagnosing personality disorder not otherwise specified when the total number of personality disorder features exceeds a specified threshold. However, while this kind of threshold has been used in some studies (20), a clear consensus about the threshold that should be used will require further investigation. It is also important to investigate the characteristics of personality disorder not otherwise specified that are operationally defined based on the information and examples in DSM-IV-TR. Our review of the literature indicates that the present study is the first community-based longitudinal investigation to examine mental health outcomes associated with personality disorder not otherwise specified (1–5).
Does this mean it isn't worth a crap?
Josephine
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