Personality Disorders in the DSM-5: controversies

The various updates published by the American Psychiatric Association that have shaped the versions of the Diagnostic and Statistical Manual of Mental Disorders have been the object of criticism and discrepancies traditional. Despite the fact that each new publication has tried to achieve a higher consensus rate among the experts, the truth is that the existence of a sector of the professional community of Psychology and Psychiatry that shows its reservations about this system of classification of 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 evidenced the controversial 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) have revealed the need to carry out a Complete reformulation of both the diagnostic nosologies and the criteria to be included for each one of them. they. According to the authors, this process could have a positive impact on an increase in the validity indices of the diagnoses as well as a reduction in the overlap of multiple diagnoses applied to the population clinic.

• Related article: "The 10 types of Personality Disorders"

Classification problems of Personality Disorders in DSM 5

In addition to Echeburúa, other experts in the field such as Rodríguez-Testal et al. (2014) allege that there are various elements that, despite providing little theoretical support, have been maintained in the transition from DSM-IV-TR to DSM-5, such as the categorical methodology in three groups of personality disorders (the so-called clusters), in instead of opting for a more dimensional approach where severity scales 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 due to the fact that 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 the Schizotypal personality disorder and Schizophrenia; between Paranoid Personality Disorder and the 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 trait continuum of marked personality (normality) and extreme and pathological personality trait (disorder of personality). 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 psychological repertoire and stable behavior over time of an inflexible and maladaptive nature, it is arduous and complex to identify which population profiles belong to the first category or to the second category. second.

Another important point refers to the validity indices obtained in the scientific investigations that support this classification. simply, No studies have been conducted to support these data., just as the differentiation between the clusters (clusters A, B and C) does not seem justified either:

In addition, 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 clinical pictures excessively wide. The result of all this is over-diagnosis., a phenomenon that presents a harmful and stigmatizing effect for the patient himself, in addition to complications to level of communication between professionals in the field of mental health who care for this group clinical.

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 typical of cluster B PDs tend to decrease with the passage of time, while the signs of cluster A and C PDs tend to increase.

Proposals to improve the TP classification system

In order to solve some of the difficulties exposed, Tyrer and Johnson (1996) had already proposed a couple of decades ago, a system that added to the previous traditional methodology a valuation graduated to establish more specifically the severity of the presence of a Personality Disorder:

1. Accentuation of personality traits without being considered PD.
2. simple personality disorder (one or two TPs from the same cluster).
3. Complex personality disorder (two or more PDs from different clusters).
4. 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, compulsiveness 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 reduction of the overlap between diagnostic categories, the over-diagnosis and the elimination of minor nosologies supported at a theoretical level, Echeburúa and Esbec have exposed the APA's contemplation of reducing from the ten collected in the DSM-IV-TR to five, which are described below along with their most important features. idiosyncratic:

1. Schizotypal personality disorder

Eccentricity, impaired cognitive regulation, unusual perceptions, unusual beliefs, social isolation, restricted affect, avoidance of intimacy, suspiciousness, and anxiety.

2. Antisocial/Psychopathic Personality Disorder

Callousness, aggression, manipulation, hostility, deceit, narcissism, irresponsibility, recklessness and impulsiveness.

3. Borderline personality disorder

Emotional lability, self-harm, fear of loss, anxiety, low self-esteem, depressiveness, hostility, aggression, impulsivity and propensity to 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, perseveration, 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 in 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 it will be possible to gradually incorporate some of the indicated initiatives (or others that may be formulated during the elaboration process) in order to facilitate, in the future, the performance of the clinical practice of the professional group of psychology and psychiatry.

Bibliographic references

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
• Esbec, E., and Echeburúa, E. (2011). The reformulation of personality disorders in the DSM-V. Spanish Acts of Psychiatry, 39, 1-11.
• Esbec, E., and Echeburúa, E. (2015). The hybrid model of classification of personality disorders in the DSM-5: a critical analysis. Spanish Acts of Psychiatry, 39, 1-11.
• Rodríguez Testal, J. F., Senín Calderón, C. and Perona Garcelán, S. (2014). From DSM-IV-TR to DSM-5: analysis of some changes. International Journal of Clinical and Health Psychology, 14 (September-December).