The Inadequate Personality Disorder description in DSM-II included ineffectual responses to any physical, intellectual, social, or emotional demands placed on the individual. Despite the lack of any real physical or intellectual deficits, these patients appear poorly adapted to their environment, are inept, have poor judgment, are socially unstable, lack physical and emotional stamina, and chronically cannot cope with everyday stress and strain. Detailed, behaviorally specific criteria were not provided for any of the disorders in DSM-II.
Our hypothesis is that the inadequate personality disorder may be alternately conceptualized (and labeled) as the frontal lobe syndrome. Whereas there is no official DSM frontal lobe syndrome, a substantial literature supports many consistent behavioral correlates of frontal lobe damage and dysfunction (see Miller & Cummings, 1999; also see Gaz-zaniga, Ivry, & Mangun, 2002, for reviews of this literature). There is also provocative evidence that indecisiveness, inept-ness, and social misjudgments not only occur after brain insult and injury but may even be highly heritable in the normal population (Coolidge, Thede, & Young, 2000) and possess a bivariate heritability with some personality disorders (Coolidge, Thede, & Jang, 2004). First, we briefly describe some of the characteristics of the frontal lobe syndrome, and then explain how these symptoms may form a reliable grouping of inadequate behaviors without the presence of brain injury or damage.
Since Phineas Gage suffered a severe frontal lobe head injury in 1848 as the result of an iron tamping rod passing through the front section of his skull, scientists have associated personality change to frontal lobe injuries. Gage's personality changes included childishness, erratic behavior, and a definite fall from his position of responsibility (as foreman of a railroad crew) to, sadly, a circus sideshow performer. Within 5 or so decades of Gage's injury, the first frontal lobotomies were being performed that resulted in apathy (if not death) in formerly violent psychiatric patients. In other words, it became well known that frontal lobe insult would reliably result in dramatically reduced spontaneity, creativity, and general social effectiveness.
By the middle of the twentieth century, the behaviors associated with frontal lobe function and dysfunction became known as the executive functions of the frontal lobes, and they included the ability to inhibit, plan, organize, strategize, and very importantly, maintain and attain goals. Evidence from a study of twins has suggested that these functions might be highly heritable in normal populations (Coolidge, Thede, et al. 2000). Executive functions were also found to be normally distributed in the population. In other words, some people would be extraordinarily able to plan, organize, strategize, and attain their goals, whereas others would be unable to navigate adequately in society despite adequate intelligence and memory abilities. A subsequent study (Coolidge, Thede, et al., 2004) demonstrated that the executive functions were not only heritable but quite probably shared a common genetic origin with particular personality traits that resulted in personal and social disruption. They found that inherited executive dysfunction would result in personality disorders associated with chronic difficulties in making everyday decisions, inattention to important or relevant stimuli, repeated poor judgments and choices, inadequate planning and organization, and inflexibility. In summary, many of the features of the archaic inadequate personality disorder from DSM-II appear to mimic patients with frontal lobe insult and injuries. Moreover, it now ap pears that there is normal variation in the cluster of these behaviors without any evidence of frontal lobe injury or disease. Thus, the validity of a diagnosis of Inadequate Personality Disorder may be empirically and theoretically justified. Features of this type are certainly seen in clinical practice with individuals simply unable to cope with the demands of the late-life stage.
Because the Inadequate Personality Disorder diagnosis was dropped from DSM-III in 1980 and because no criteria were listed for it in DSM-II (only a short list of common features), there is little room to examine potential problems with the disorder. Throughout our clinical experiences, however, we have found patients who seem to meet the original picture for Inadequate Personality Disorder in DSM-II or at least show some features of the disorder. The reader should note that it is entirely justified to use the DSM-IV-TR diagnosis 301.9 Personality Disorder Not Otherwise Specified for those persons whose behavior does not meet criteria for any specific personality disorder yet whose behavior is chronic and causes significant distress or impairment in their current social milieu, such as would be seen by the inadequate type.
Theorized Pattern in Later Life and Possible Impact of Aging
The pattern we have seen clinically on several occasions is for the person with features of this disorder to become more inadequate and dysfunctional in later life. Indeed, the cognitive and physical declines associated with normal aging seem, in some cases, to further limit the effectiveness of patients who have a lifetime history of marginal social and occupational functioning. One of our patients, a 76-year-old woman, had a long history of psychiatric problems labeled as "depression." She dropped out of high school because she "could not handle" the stress associated with academic assignments. She married after a brief courtship and had three children. Despite not ever having a job outside the home (her husband supported the family), the patient reportedly had minimal responsibilities for cooking, cleaning, managing the household, and raising the children. A sister of the husband largely assumed these duties for the family, although with some resentment. The patient told a story of being "taken care of" by her husband (and after his death, by her children) and achieved only a minimal amount of social success throughout life. Her later years were characterized by even greater despondency and helplessness, especially in adjusting to a new community after a daughter moved the patient to be nearer to her.
It might be expected that the inadequate personality type would have drifted from job to job that appeared to be obviously below their intellectual capabilities. Their occupation, should their job history be relatively stable, might also be far beneath what would appear to be their potential. The patient's indecisiveness might also extend to interpersonal issues such as the choice of friends and even self-concept. It would not be surprising that such patients would have dim or nonexistent views of their place in the world and who they were and are. They would not have been expected to have led creative or spectacularly successful lives. These inadequacies might even become more apparent should the person have married someone far more competent and achieving; on that person's death, it might be expected that the person with Inadequate Personality Disorder might be unable to attain even minimal self-sufficiency (e.g., paying the bills, shopping, cooking, and cleaning). This pattern was evident in our example.
Because there is reasonable evidence that this general cluster of inadequate and insufficient behaviors might have a strongly heritable basis, traditional psychotherapies might have a weak impact on the patient's ultimate prognosis. A lifetime of failure is difficult to overcome in later life. Cognitive, reasoning, and intellectual declines that accompany the normal aging process might well be much more pronounced in the inadequate personality disordered patient. Should this diagnosis be suspected in an older patient, it will be important for the clinician to provide greater structure than is typical with most older patients. Behavioral treatment approaches may be more beneficial to the patient than traditional insight-oriented therapies, with an emphasis on support, encouragement, and arrangements for resources.
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