A personality disorder (PD) is a mental disorder characterized by an enduring and pervasive maladaptive pattern of behavior, emotions, cognition, and inner experience, deviating from social norms. As a common feature, this manifests in significant impairment in interpersonal relationships and various aspects of functioning of the self, such as self-concept, in conjunction with pathological personality traits. These patterns develop early, are inflexible, and are associated with significant distress or disability. There are both dimensional and categorical approaches to the classification of personality disorders, with the former being implemented in the International Classification of Diseases (ICD), whereas the main model in the Diagnostic and Statistical Manual of Mental Disorders (DSM) is categorical; moreover, the Alternative DSM-5 model for personality disorders (AMPD) combines the two into a hybrid model. In accordance with the categorical approach, personality disorders are viewed as distinct types, such as avoidant or narcissistic; on the other hand, the dimensional systems employed in the ICD-11 and AMPD rate severity and pathological traits. For psychiatric patients, the prevalence of personality disorders is estimated between 40 and 60%. The behavior patterns of personality disorders are typically recognized by adolescence, the beginning of adulthood or sometimes even childhood and often have a pervasive negative impact on the quality of life. Treatment for personality disorders is primarily psychotherapeutic. Evidence-based psychotherapies for personality disorders include cognitive behavioral therapy and dialectical behavior therapy, especially for borderline personality disorder. A variety of psychoanalytic approaches are also used. Personality disorders are associated with considerable stigma in popular and clinical discourse alike. Despite various methodological schemas designed to categorize personality disorders, many issues occur with classifying a personality disorder because the theory and diagnosis of such disorders occur within prevailing cultural expectations; thus, their validity is contested by some experts on the basis of inevitable subjectivity. They argue that the theory and diagnosis of personality disorders are based strictly on social, or even sociopolitical and economic considerations. The definitions vary by source and remain a matter of controversy.
Classification
There are two main approaches – the dimensional and the categorical – to the classification of personality disorders, which occurs mainly in accordance with the International Classification of Diseases (11th revision, ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition, Text Revision; DSM-5-TR). The categorical approach views personality disorders as discrete entities that are distinct from each other as well as from normal personality. In contrast, the dimensional approach to personality disorders suggests that personality disorders exist on a continuum, with traits varying in degree rather than kind. The DSM-5-TR standard model is an example of the former, while the ICD-11 implements the latter. There has been a sustained movement toward replacing categorical models of personality disorder classification with dimensional approaches. The categorical model has been criticized for not being sufficiently evidence-based; for issues such as undue prevalence of comorbidity, with the majority of people with a PD being eligible for another PD diagnosis; as well as for heterogeneity within categories, and stigmatization. In response, dimensional models have been developed that assess personality disorders in terms of severity of impairment and maladaptive personality traits. Emerging research indicates that dimensional models may have the benefit of facilitating the personalization of psychotherapy by aligning treatment strategies with underlying trait dimensions rather than diagnostic categories. The shift towards a dimensional approach is reflected in the inclusion of the AMPD in Section III of the DSM-5, and in the ICD-11's adoption of a dimensional system.
DSM-5 In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, a categorical classification was retained for personality disorders. Located in Section II (Diagnostic Criteria and Codes), personality disorders are thus listed in the same way as other mental disorders, rather than on a separate "axis", as previously. Its ten specific personality disorders are grouped into three clusters, namely: cluster A (paranoid, schizoid, and schizotypal PD), cluster B (antisocial, borderline, histrionic, and narcissistic PD), and cluster C (avoidant, dependent, obsessive–compulsive PD). It also contains three diagnoses for other personality disorders (other specified, unspecified, and personality change due to another medical condition). The clusters are based on descriptive similarity between the disorders they encompass, and it is not proven that they possess clinical utility.
AMPD Introduced in section III of the DSM-5, the Alternative DSM-5 Model for Personality Disorders (AMPD) is a dimensional–categorical hybrid, yielding diagnoses based on combinations of impairment in personality functioning (criterion A), rated across identity, self-direction, empathy and intimacy; and pathological personality traits (criterion B) from the following trait domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. The AMPD includes six specific personality disorders, which are defined by specific combinations of criteria A and B; these are: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal. There is also a diagnosis of personality disorder–trait specified available for cases not matching the aforementioned categories. Created with the aim of ameliorating issues such as arbitrary thresholds and excessive comorbidity, the AMPD was intended to replace the categorical model in the DSM-5; however, upon its rejection, it was instead placed in Section III (Emerging Measures and Models).
ICD-11
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