Personality Disorders In The DSM-5: Controversies In The Classification System
The different updates published by the American Psychiatric Association that have made up the versions of the Diagnostic and Statistical Manual of Mental Disorders have traditionally been the subject of criticism and discrepancies. Although each new publication has attempted to achieve a higher consensus rate among experts, the truth is that the existence of a sector of the community of Psychology and Psychiatry professionals cannot be denied. shows its reservations about this classification system for mental pathologies
Regarding the most current versions of the DSM (DSM-IV TR of 2000 and DSM-5 of 2013), various renowned authors such as Echeburúa, from the University of the Basque Country, have already shown the controversy of the classification of Personality Disorders (PD) in the predecessor manual to the current one, the DSM-IV-TR. Thus, in one work together with Esbec (2011) they have highlighted the need to carry out 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 rates as well as a reduction in the overlap of multiple diagnoses applied to the clinical population.
Classification problems of Personality Disorders in the DSM 5
In addition to Echeburúa, other experts in the field such as Rodríguez-Testal et al. (2014) argue that there are various elements that, despite having little theoretical support, have been maintained in the transition from DSM-IV-TR to DSM-5 such as for example the categorical methodology in three groups of personality disorders (the so-called clusters), instead of opting for a more dimensional approach where scales of severity or symptomatic intensity are added.
The authors affirm the presence of problems in the operational definition of each diagnostic label, arguing that In various entities there is a significant overlap between some of the criteria included in certain mental disorders included in Axis I of the manual, as well as the heterogeneity of profiles that can be obtained in the clinical population under the same common diagnosis.
The latter is because the DSM requires meeting a minimum number of criteria (half plus one) but does not indicate any 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 establish the differentiation between the continuum of marked personality trait (normality) and extreme and pathological personality trait (personality disorder). Even specifying that there must be a significant functional deterioration in the personal and social performance of the individual, as well as the manifestation of a stable psychological and behavioral repertoire over time of an inflexible and maladaptive nature, it is difficult and complex to identify which population profiles belong to the first. category or the second.
Another important point refers to the validity indices obtained in scientific research that support this classification. Simply, no studies have been carried out to support these data just as the differentiation between the clusters (conglomerates A, B and C) does not seem justified either:
Furthermore, regarding the correspondence between the descriptions given to each diagnosis of Personality Disorders, they do not maintain sufficient correspondence with the signs observed in clinical patients in consultation, as well as overlapping of excessively broad clinical pictures. The result of all this is over-diagnosis a phenomenon that has a harmful and stigmatizing effect for the patient himself, in addition to complications at the level of communication between professionals in the field of mental health who care for said clinical group.
Finally, it seems that there is not enough scientific rigor to validate the temporal stability of some personality traits For example, research indicates that the symptoms of cluster B PDs tend to decrease over time, while the signs of cluster A and C PDs tend to increase.
Proposals to improve the PD classification system
In order to solve some of the difficulties presented, Tyrer and Johnson (1996) had already proposed a couple of decades ago a system that added a graded assessment to the previous traditional methodology. to establish more specifically the severity of the presence of a Personality Disorder:
Accentuation of personality traits without being considered PD.
Simple personality disorder (one or two TPs from the same cluster).
Complex personality disorder (two or more PDs from different clusters).
Severe personality disorder (in addition, there is great social dysfunction).
Another type of measure addressed in the APA meetings during the preparation of the final version of the DSM-5 consisted of considering the inclusion of six more specific personality domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity and schizotypy) specified from 37 more specific facets. Both the domains and the facets had to be rated in intensity on a scale of 0-3 to ensure in more detail the presence of each trait in the individual in question.
Finally, in relation to the decrease in overlap between diagnostic categories, over-diagnosis and the elimination of minor nosologies supported at a theoretical level, Echeburúa and Esbec have exposed the APA’s contemplation of decreasing from the ten included in the DSM-IV -TR to five, which are described below along with their most idiosyncratic features:
Eccentricity, altered cognitive regulation, unusual perceptions, unusual beliefs, social isolation, restricted affect, avoidance of intimacy, suspicion and anxiety.
2. Antisocial/Psychopathic Personality Disorder
Callousness, aggression, manipulation, hostility, deception, narcissism, irresponsibility, recklessness and impulsivity
3. Borderline Personality Disorder
Emotional lability, self-harm, fear of loss, anxiety, low self-esteem, depressiveness, hostility, aggression, impulsivity and propensity for dissociation.
4. Avoidant Personality Disorder
Anxiety, fear of loss, pessimism, low self-esteem, guilt or shame, avoidance of intimacy, social isolation, restricted affect, anhedonia, social detachment and risk aversion.
5. Obsessive-Compulsive Personality Disorder
Perfectionism, rigidity, order, perseverance, anxiety, pessimism, guilt or shame restricted affect and negativism.
In conclusion
Despite the interesting proposals described here, The DSM-V has maintained the same structure of its previous version, a fact that persists the disagreements or problems derived from the description of personality disorders and their diagnostic criteria. It remains to be seen whether in a new formulation of the manual some of the indicated initiatives (or others that may be formulated during the development process) can be incorporated in order to facilitate, in the future, the performance of the clinical practice of the professional group of psychology and psychiatry.
