PD Classification Schema

Multi-Axial System

• timeline

• what each 5 axis diagnose

• from DSM-3 to DSM-4

• assign diagnosis based on axis

• Axis 1: mental health and SUD 

• Axis 2: PDs and Neurodevelopmental and Organic conditions*** 

• Axis 3: medical or biological contributions  

• Axis 4: social/occupational/relational stressors 

• Axis 5: overall rating of functioning

PD categorical issues

• Comorbidity 

• Criterion Overlap – clinicians disagreed on diagnoses 

• Not empirically supported – on how many criteria are needed to reach threshold (not tested). Why 5 criteria needed out of 9? There was not much difference between 4 and 5 criteria minimum. Thresholds were arbitrary.  

  • Histrionic PD is not supported empirically 

  • Is the construct really valid for some PDs? 

Trait Theory

• how did these come about?

• which traits?

• pros and cons

• emerged due to categorical issues

• what became FFM (OCEAN traits)

• These factors were robust universally/cross-culturally --> argued we should use this as universal model 

• BUT pathology is best understood as a dimension and these OCEAN traits can be arbitrary too 

Why clinicians do not diagnose PDs

• PDs are stigmatizing 

• Clinicians are not familiar with DSM or don't reference much

Prototypes of DSM and Personality Pathology

• what does prototype do?

• pros/cons

• determines how well it fits shown in papers argued instead of arbitrary thresholds.

• But fell out of favor bc prototypes created based on what clinicians are thinking, but they're trained in categories so why should we rely on their thinking

• We need to rely on empirical research findings, not clinician thinking/opinion.  

DSM Section III AMPD

• Criterions

• Compare FFM and AMPD traits

• which PDs retained?

• Criterion A: Level of Personality Functioning (LPFS)  

  • AKA level of severity 

  • The more criteria they have for PD, the worse they function 

• Criterion B: Assessment of traits 

  • Traits are from Five Factor Model BUT in parallel versions 

  • FFM reflects "normal" personality within population at large 

  • DSM traits are pathological manifestations of FFM 

    • Negative Affectivity (neuroticism), detachment (extraversion), psychoticism (openness), antagonism (agreeableness), conscientiousness (disinhibition) 

    • + facets associated within trait domains 

  • 6 of 10 PDs were retained --> can still assign categorical diagnosis 

    • But these are not defined by criteria, but by LPFS and trait domains now 

Severity level differences in DSM-5 and ICD-11

Not considered a PD until Mild level (ICD-11) and Moderate level (DSM-5)

ICD-11

• What is it?

• How it helps?

• what does it do with PD categories?

• Represents diagnoses across the world 

• Access to mental health treatment is not as accessible in other countries 

  • Many clinicians recognize personality problems, but average PCP for a village won't know what constitutes a PD (which is an ICD term) 

  • --> So ICD tried to simplify diagnosis where a PCP could evaluate someone based on functioning and broad traits (help enhance access and treatment) 

• Insurance relies more so on ICD-11 

• Only in psychiatry do we have both DSM and ICD-11 

• ICD-11 removed all PD categories, but keep Borderline specifier 

PDM-2

• Personality syndromes 

• First established in 2006 

• Meant to complement DSM, but a core aspect is incorporating patient's subjective experience when understanding their pathology 

  • Based on Biological and Empirical influences  

• Each domain has 3 areas 

• Capitalizes on a psychoanalytic model 

• Explains types of personality organization 

  • Healthy level 

  • Neurotic 

  • Borderline 

  • Psychotic: primitive defenses (huge denial); distorted cognition 

• Personality Styles and Disorders 

  • May present one style, but not at a level of a disorder (themes in personality)  

• M (mental functioning) axis: ego functioning 

• Cognition/affect 

  • Regulation 

  • Attention 

  • Learning  

• Identities and relationships 

• Defenses 

• Self-awareness/ Self-direction