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

The criteria used to classify PDs have been highly questioned because of their overlap.

The various updates published by the American Psychiatric Association that have shaped the versions of the Diagnostic and Statistical Manual of Mental Disorders have traditionally been subject to criticism and discrepancies. Despite the fact that each new publication has attempted to achieve a higher rate of consensus among experts, the fact is that there is a sector of the community of psychology and psychiatry professionals who have reservations about this system. reservations about this system of classification of mental pathologies..

With regard to the most current versions of the DSM (DSM-IV TR of 2000 and DSM-5 of 2013), several renowned authors such as Echeburúa, from the University of the Basque Country, have already shown that the controversial classification of Personality Disorders (PD) in the predecessor manual to the current one, DSM-IV-TR. in the predecessor manual to the current one, the DSM-IV-TR. Thus, in a paper 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.

Problems of classification of Personality Disorders in DSM 5.

In addition to Echeburúa, other experts in the field such as Rodríguez-Testal et al. (2014) claim that there are several elements that, despite having little theoretical support, have been maintained in the passage of the DSM 5, have been maintained in the transition from DSM-IV-TR to DSM-5.The authors claim that there are problems in the operational definition of each diagnostic label, such as 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 several entities there is a significant overlap between some of the criteria included in certain 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 a minimum number of criteria to be met (half plus one) but does not indicate any of them as necessarily mandatory. More specifically, a strong 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 impairment 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 to the second.

Another important point refers to the validity indexes obtained in scientific research that support the present classification. Simply put, no studies have been carried out to support such data.nor does the differentiation between the clusters (clusters A, B and C) seem justified:

In addition, as for the correspondence between the descriptions given to each diagnosis of Personality Disorders, they do not maintain sufficient correspondence with the signs observed in the 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 deleterious effect on the diagnosis of personality disorders.This phenomenon has a harmful and stigmatizing effect on the patients themselves, as well as complications in terms of communication between the mental health professionals who attend to this clinical group.

Finally, it seems that there is also insufficient scientific rigor to validate the temporal stability of some personality traits. the temporal stability of some personality traits. For example, research indicates that the symptomatology of cluster B PDs tends to decrease over time, while the signs of cluster A and C PDs tend to increase.

Proposals to improve the PT grading system

In order to overcome some of the above difficulties, Tyrer and Johnson (1996) had already proposed a couple of decades ago a system that added to the previous traditional methodology a graded assessment to establish more specifically the severity of a personality disorder. in order to establish more specifically the severity of the presence of a Personality Disorder:

Another type of measure addressed in the APA meetings during the development of the final version of the DSM-5, was to consider the inclusion of six more specific personality domains. six more specific personality domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity and schizotypy) specified from 37 more specific facets. Both domains and facets were to be rated in intensity on a scale of 0-3 to further ensure the presence of each trait in the individual in question.

Finally, in relation to the reduction of overlap between diagnostic categories, over-diagnosis and the elimination of less theoretically supported nosologies, Echeburúa and Esbec have presented the APA's contemplation of reducing from the ten included in the DSM-IV-TR to five, which are described below together with their most idiosyncratic features:

Schizotypal Personality Disorder 2.

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

2. Antisocial/Psychopathic Personality Disorder

Insensitivity, aggression, manipulation, hostility, deceitfulness, narcissism, irresponsibility, recklessness and impulsivity..

3. Borderline Personality Disorder

Emotional lability, self-injury, fear of loss, anxiety, low self-esteem, depressivity, hostility, aggression, impulsivity and propensity to dissociate.

4. Avoidant Personality Disorder

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

5. Obsessive-Compulsive Personality Disorder

Perfectionism, rigidity, orderliness, perseveration, anxiety, pessimism, guilt or shameRestricted affect and negativism.

By way of conclusion

In spite of the interesting proposals described here, the DSM-V has maintained the same structure of its previous version.This fact makes the disagreements or problems derived from the description of personality disorders and their diagnostic criteria persist. 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 elaboration process) may be incorporated in order to facilitate the future performance of the clinical practice of the professional collective of psychology and psychiatry.

• Simple Personality Disorder (one or two PDs of the same cluster).
• Complex personality disorder (two or more TPs of different clusters).
• Severe personality disorder (in addition, severe social dysfunction is present).
Bibliographic references
• • American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
  • Esbec, E., & Echeburúa, E. (2011). The reformulation of personality disorders in the DSM-V. Actas Españolas de Psiquiatría, 39, 1-11.
  • Esbec, E., and Echeburúa, E. (2015). The hybrid model of personality disorder classification in DSM-5: a critical analysis. Actas Españolas de Psiquiatría, 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).