- The view that personality disorders fall into distinct categories continues to be challenged by experts in the field.
- Research identifies the critical role of anankastia in revamping this view of personality disorders.
- By moving beyond categories and into dimensions, you can gain a more accurate view of what goes wrong in personality disorders.
When most people think about personality disorders, they use category names such as “borderline,” “narcissist,” or “psychopath.” These category names are part of the conventional diagnostic naming system used in the United States and Canada, known as the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 (representing the fifth edition).
However, even as the DSM-5 was being completed nearly a decade ago, personality disorder experts challenged this conventional approach, arguing that people don’t come in nice neat categories. Instead, these critics maintain that people’s personalities are better understood as a set of continuous qualities, or traits. You can't segment a quality as complex as human behavior into discrete units, according to this view, because people just aren't built that way.
As Heinrich Heine University Düsseldorf’s Johannes Stricker and colleagues (2022) note in a new study, not only are there serious criticisms of the DSM-5’s framework, but the World Health Organization (WHO) has even abandoned the personality disorder categories completely. The International Classification of Diseases 11th Edition (ICD-11) replaces the categories with “an innovative personality disorder model” based on how an individual rates in five maladaptive “personality trait domains.”
What Would a New Diagnostic Method Look Like?
It’s worthwhile to think for a moment about this new general approach to personality disorders and why it matters. Begin by imagining or recalling from your own experience the behavior of someone technically considered to be a “narcissist” (i.e., a person who is diagnosed with narcissistic personality disorder). This individual may seem exploitative and self-aggrandizing, looking for ways to occupy the center of everyone else’s attention. Those behaviors might veer into the territory of conning people in order to get their way. However, now think about someone who would be labeled a “psychopath.” Aren’t they also exploitative? If people from two distinct categories share a very basic quality, why do they end up in different diagnostic buckets?
If, instead of categories, the five maladaptive trait domains were to be used, people working in the field of mental health could scrap the old DSM-5 system entirely. The question is: which five to use? One possibility stems from the Five-Factor Model (FFM), a well-accepted personality theory proposing that personality falls into the five areas of neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. However, the German researchers questioned whether the FFM, since it was developed to measure "normal" personality, could provide an exact fit to the ICD-11 trait domains.
Unlike the FFM, then, the ICD-11's traits need to account for the maladaptive behaviors seen in people with personality disorders. Developed by previous researchers (Oltmanns and Widiger, 2018), a new instrument called the PiCD (Personality Inventory for ICD-11) renames many of the FFM traits into terms more consistent with psychopathology. One doesn't translate easily from the FFM, however. This is the trait known as anankastia. Derived from the Greek word anankastikos, meaning “compulsion,” ICD used it as the basis for anankastic personality disorder, known in the DSM-5 as obsessive-compulsive personality disorder.
As defined by the developers of the PiCD, “traits in this domain [anankastia] include perfectionism, perseveration, emotional and behavioral constraint, stubbornness, deliberativeness, orderliness, and concern with following rules and meeting obligations” (Oltmanns and Widiger, 2018). Although this set of qualities might remind you of conscientiousness, they don't neatly fit into that generally adaptive trait, nor even to its opposite. At its core, the authors go on to note, it involves "a narrow focus on the control of...behavior to ensure that things conform to the individual’s particularistic ideal."
Putting the overlap between these two sets of personality traits to the test, Stricker and his colleagues recruited an online sample of 480 German adults (average age 32 years) to complete both a measure derived from the FFM and the PiCD.
The findings indeed supported the existence of some overlap between scores on each of the respective scales of the two measures. However, the FFM fell short when it came to incorporating anankastia. Although sharing some of the features of conscientiousness, anankastia retained its unique contribution in tapping into this highly controlled, rigid, and maladaptive set of behaviors.
Other FFM scales loaded onto PiCD scales in ways that suggested greater empirical overlap. For example, a PiCD factor labeled “negative affectivity” included FFM measures of anxiety, depression, and emotional volatility. A PiCD factor tapping “detachment” had relationships to FFM measures (negatively) of sociability, assertiveness, and energy level. The fourth PiCD factor, “dissociality” included FFM scales of compassion, trust, and respectfulness. As you can see, the ICD-11's five-factor framework held up and, with the exception of anankastia, actually mapped onto the well-regarded FFM theory of normal personality.
How to Use These New Findings
The quality of anankastia seems to stand out in its own right, then, but it doesn't exist independently of other personality traits. A person high on this quality may have other adaptive qualities associated with their extreme rigidity and perfectionism. Furthermore, people aren't either "anankastic" or not. They may have varying degrees of this quality and, by extension, could potentially be moved up and down the scale through psychological interventions targeting this one maladaptive feature of their personalities.
At a broader level, the Stricker et al. study reinforces the importance of thinking of people not as diagnostic labels but instead in terms of their personality strengths and weaknesses. Attempts to bring the FFM and ICD-11 into alignment have the general advantage of reducing terminology overload as well as improving diagnostic precision and utility. If you have a difficult time separating people into categories, imagine how much more challenging it is for a mental health professional to state with certainty that someone with five out of seven symptoms has a different psychological makeup than someone who has four of those seven, plus a fifth of another set of symptoms. Using personality traits rather than categories eliminates this potential for misdiagnosis.
To sum up, adding anankastia to your existing list of psychological terms could very well prove worthwhile in understanding the maladaptive qualities of people whose rigidity and perfectionism don't simply represent conscientiousness. More generally, the German research shows that thinking of people in terms of their underlying qualities rather than their outward labels can help you appreciate the many complexities of personality and its disorders.
Oltmanns, J. R., & Widiger, T. A. (2018). A self-report measure for the ICD-11 dimensional trait model proposal: The personality inventory for ICD-11. Psychological Assessment, 30(2), 154–169. https://doi.org/10 .1037/pas0000459
Stricker, J., Buecker, S., & Pietrowsky, R. (2022, May 5). Alignment of the Personality Inventory for ICD-11 With the Five Factor Model of Personality. Psychological Assessment. Advance online publication. http://dx.doi.org/10.1037/pas0001141