Personality disorder - Definition problem

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The DSM attempts to represent a consensus view of the members of the American Psychiatric Association. However, more so than in other parts of the DSM, the classification of Axis II personality disorders—deeply ingrained, maladaptive, lifelong behaviour patterns—has come under sustained and serious criticism from its inception in 1952^{[How to reference and link to summary or text]}. The DSM adopts a categorical approach, assuming that personality disorders are "qualitatively distinct clinical syndromes" (p. 689). This is doubted by many^{[How to reference and link to summary or text]}. The polythetic form of the DSM's Diagnostic Criteria—only a subset of the criteria is adequate grounds for a diagnosis—generates diagnostic heterogeneity. In other words, people diagnosed with the same personality disorder may share only one criterion or none. Some people think that this is unacceptable^{[How to reference and link to summary or text]}.

The DSM has arbitrarily separated off Axes I and II so that it:

"... ensures that consideration will be given to the possible presence of Personality Disorders and Mental Retardation that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders. The coding of Personality Disorders on Axis II should not be taken to imply that their pathogenesis or range of appropriate treatment is fundamentally different from that of the disorders coded on Axis I. (American Psychiatric Association, 2000, p. 28)"

However, the DSM does not contain an explanation of the relationship between Axis II (personality) and Axis I (non-personality) disorders, or the way in which chronic childhood and developmental problems interact with personality disorders. It is possible that the arbitrary separation of Axes I and II, although well intended, has created the wide spread false impression that these are fundamentally and possibly even biologically different types of illnesses^{[How to reference and link to summary or text]}. This has contributed to the stigmatization of Axis II disorders in the mental health field^{[How to reference and link to summary or text]}.

One of the problems with diagnosis of personality disorder is that these such diagnosis typically has a lower reliability than most other disorders - indeed, Dahl (1986; cited in Marshall & Serin, 1997) found only modest test re-test reliability coefficients (between .5 and .6) for diagnoses of personality disorders over time, although as Marshall and Serin point out, evidence suggests that use of structured interviews can improve reliability of diagnosis. Improving breadth of information may also, as Marshall and Serin note, improve reliability of diagnosis.

Christine Warner, a neuroscientist, thinks that the differential diagnoses are vague and the personality disorders are insufficiently demarcated^{[How to reference and link to summary or text]}. This overlap is addressed in the DSM by grouping the personality disorders into three clusters, which contain similar disorders. The result of the overlap is excessive comorbidity: people often receive multiple Axis II diagnoses^{[How to reference and link to summary or text]}. This casts doubt on the assumption that the diagnostic categories correspond to independent disorders^{[How to reference and link to summary or text]}. The necessity of the "not otherwise specified" basket category can also be seen as an indication of poor construct validity^{[How to reference and link to summary or text]}; the current diagnostic categories are apparently insufficient to categorize all people with personality disorders.

The distinction made between "normal" and "disordered" personalities is also rejected by some^{[How to reference and link to summary or text]}. The "diagnostic thresholds" between normal and abnormal are either absent or weakly supported. The judgment whether a behavioural pattern is normal or disordered is also highly subjective. The DSM contains little discussion of what distinguishes personality styles (personality), from personality disorders and much is left to clinical judgment.

Cultural bias is evident in certain disorders such as Schizoid personality disorder, Antisocial personality disorder, and Schizotypal personality disorder^{[How to reference and link to summary or text]}. Also, diagnosis of some disorders may be vulnerable to bias because of gender role expectations.¹

The emergence of dimensional alternatives to the categorical approach is acknowledged in the DSM-IV-TR itself:

"An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another" (p.689)

Despite considering all of the above, the DSM continues for the present to prefer the use of a categorical approach over a dimensional approach which is seen as, "less useful than categorical systems in clinical practice and in stimulating research."

In the mental health field, the category of personality disorder has become a pejorative concept^{[How to reference and link to summary or text]}. Of all of the personality disorder categories, Borderline Personality Disorder, and Antisocial Personality Disorder, have become most negatively identified categories^{[How to reference and link to summary or text]}. Some clinicians refuse even to specify which Axis II category may be present, using instead the evasion, "Diagnosis Deferred"^{[How to reference and link to summary or text]}. Personality disorder symptoms, as with all mental disorders, can vary markedly over time and become much more acute during times of stress in an individual's life.

The following issues, long neglected in the DSM, are likely to be addressed in future editions as well as in current research:

• Development of disorders over time
• Genetic and biological underpinnings of personality disorders
• Development of personality psychopathology during childhood and its emergence in adolescence
• Interactions between physical health and disease and personality disorders
• Effectiveness of various treatments (talk therapies as well as psychopharmacology)

Finally, because the diagnostic categories are seen as less flexible than dimensional ones, a spin-off problem is created in managed care settings. Because personality disorders may be defined as enduring and inflexible behavioral patterns that are not as likely to change over time, insurance companies sometimes refuse to reimburse psychotherapy fees when the patient/client has received an Axis II diagnosis, i.e., a personality disorder diagnosis.

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