Personality disorders in DSM-5: controversies in the classification system

The various updates released by the American Psychiatric Association that shaped the versions of the Diagnostic and Statistical Manual of Mental Disorders have traditionally been the subject of criticism and divergence. While each new publication has attempted to achieve a higher rate of consensus among experts, the truth is that it is undeniable that there is a sector of the professional psychology and psychiatry community that expresses its reservations about this classification system for mental pathologies.

Regarding the most recent versions of the DSM (DSM-IV TR from 2000 and DSM-5 from 2013) several renowned authors such as Echeburúa, from the University of the Basque Country, have already shown the controversial classification of personality disorders (PTSD) in the previous manual in force, the DSM-IV-TR. Thus, in a work with Esbec (2011), they highlighted the need for a complete reformulation of both the diagnostic nosologies and the criteria to be included for each of them. According to the authors, this process could have a positive impact on an increase in diagnostic validity indices as well as a reduction in the overlap of multiple diagnoses applied to the clinical population.

    Problems with classification of personality disorders in the DSM 5

    Besides Echeburúa, other experts in the field such as Rodríguez-Testal et al. (2014) claim that there are several elements which, although they provide little theoretical support, were maintained during the transition from DSM-IV-TR to DSM-5Like the categorical methodology in three groups of personality disorders (the so-called clusters), instead opting for a more dimensional type approach where scales of symptom severity or intensity are added.

    The authors indicate the presence of problems in the operational definition of each diagnostic label by arguing that in several entities, there is a significant overlap between some of the criteria included in some mental disorders listed in Axis I of the manual, as well as the heterogeneity of profiles obtainable in the clinical population under the same common diagnosis.

    The latter is due to the fact that the DSM requires a minimum number of criteria to be fulfilled (half plus one) but does not indicate any of them as necessarily mandatory. More specifically, a great correspondence has been found between schizotypal personality disorder and schizophrenia; between paranoid personality disorder and delusional disorder; between borderline personality disorder and mood disorders; Obsessive-compulsive personality disorder and obsessive-compulsive disorder, mainly.

    On the other hand, it is very complex to differentiate between the marked continuum of marked personality traits (normality) and the extreme and pathological personality trait (personality disorder). While specifying that there must be a significant functional impairment in the personal and social exercise of the individual, as well as the manifestation of a stable psychological and behavioral repertoire over time of an inflexible and unsuitable nature, it is difficult and difficult to identify which population profiles belong to the first or the second category.

    Another important point concerns the validity indices obtained in the scientific research which supports this classification. simply no studies have been conducted to support these data, As does not seem justified the differentiation between the clusters (conglomerates A, B and C):

    In addition, with regard to the correspondence between the descriptions given to each diagnosis of personality disorders, they do not maintain a sufficient correspondence with the signs observed in clinical patients in consultation, as well as too large overlaps of the clinical picture are also observed. The result of all of this is overdiagnosis, A phenomenon that has a detrimental and stigmatizing effect on the patient himself, as well as complications in communication between professionals in the field of mental health who deal with this clinical group.

    Finally, it seems that there is not enough scientific rigor to validate it either. the temporal stability of certain personality traits. For example, research indicates that the symptoms of cluster B PTs tend to decrease over time, while the signs of cluster A and C PTs tend to increase.

    Proposals to improve the TP classification system

    In order to resolve some of the difficulties presented, Tyrer and Johnson (1996) had already proposed some twenty years ago a system which added to the previous traditional methodology a graduated evaluation. to more precisely establish the severity of the presence of a personality disorder:

    1. Emphasis on personality traits without even considering TP.
    2. Simple personality disorder (One or two labs from the same cluster).
    3. Complex personality disorder (two or more EPs from different groups).
    4. Severe personality disorder (there is also a great social dysfunction).

    Another type of measure discussed at APA meetings when developing the final version of DSM-5 was to consider the inclusion of 06:00 more specific personality areas (Negative emotionality, introversion, antagonism, disinhibition, compulsivity and schizotypy) specified from 37 more specific facets. Domains and facets were to be rated for intensity on a scale of 0 to 3 to further ensure the presence of each trait in the individual in question.

    Finally, with regard to reducing the overlap between diagnostic categories, over-diagnosis and eliminating minor nosologies supported at the theoretical level, Echeburúa and Esbec exposed the contemplation of APA to decrease compared to the ten collected in the DSM -IV -tr to five, which are described below with their most idiosyncratic characteristics:

    1. Schizotypal personality disorder

    Eccentricity, altered cognitive regulation, unusual perceptions, unusual beliefs, social isolation, restricted affection, avoidance of intimacy, suspicion and anxiety.

    2. Antisocial / psychopathic personality disorder

    Insensitivity, aggressiveness, manipulation, hostility, deception, narcissism, irresponsibility, recklessness and impulsiveness.

    3. Borderline personality disorder

    Emotional lability, self-harm, fear of loss, anxiety, low self-esteem, depression, hostility, aggressiveness, impulsiveness and propensity to dissociation.

    4. Avoiding Personality Disorder

    Anxiety, fear of loss, pessimism, low self-esteem, guilt or shame, avoidance of intimacy, social isolation, restricted affection, anhedonia, social disaffection and risk aversion.

    5. Obsessive-compulsive personality disorder

    Perfectionism, rigidity, order, perseverance, anxiety, pessimism, guilt or shame, Restricted affection and negativity.

    To conclude

    Despite the interesting proposals described here, the DSM-V has kept the same structure as its previous version, Persistent fact of disagreements or problems arising from the description of personality disorders and their diagnostic criteria. It remains to be seen whether, in a new wording of the manual, they will be able to incorporate some of the initiatives indicated (or others that might be formulated during the development process) to facilitate the execution of clinical practice for the patient. future of the professional collective of psychology and psychiatry.

    bibliographical references

    • American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (ed. 5a). Washington, DC: author.
    • Esbec, I., and Echeburúa, E. (2011). The reformulation of personality disorders in the DSM-V. Spanish acts of psychiatry, 39, 1-11.
    • Esbec, I., and Echeburúa, E. (2015). The hybrid classification model Personality Disorders in DSM-5: A Critical Analysis. Spanish acts of psychiatry, 39, 1-11.
    • Rodríguez Testal, JF, Senín Calderón, C. and Perona Garcelán, S. (2014). From DSM-IV-TR to DSM-5: analysis of some evolutions. International Journal of Clinical and Health Psychology, 14 (September-December).

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