Personality disorders: three classifications with a fly in the ointment

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The categorical model of personality disorders that had been adopted in previous revisions of the International Classification of Diseases (ICD) as well as in previous editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) is generally regarded as obsolete. The model has poor inter-rater reliability, poor stability over time, poor discriminate validity and poor general coverage of personality disorder [1,2]. In addition, and notwithstanding an impressive body of research on borderline personality disorder, very little to no research studies has been done on most of the other personality disorders [3]. In the meantime, attention has shifted to dimensional models [4] and the Personality and Personality Disorders Work Groups for both ICD-11 and DSM-5 have developed new models for classifying these disorders.
A new, hybrid, categorical–dimensional model that had been developed for DSM-5 was not, however, retained by the Board of Trustees of the American Psychiatric Association, who decided to ‘to preserve continuity with current clinical practice’ and ‘to maintain the current approach to personality disorders’, that is to keep the model that had been introduced in previous editions and maintained with only minor changes up to DSM-IV-TR. The new model was relegated to Section III, labeled ‘Emerging Measures and Models’ containing ‘tools and techniques to enhance the clinical decision-making process, understand the cultural context of mental disorders, and recognize emerging diagnoses for further study’. In the meantime, the personality disorders workgroup for ICD-11 has developed a dimensional model, which is slated to replace the categorical model that had been included in the ICD up to ICD-10.
As such, clinicians, researchers and other stakeholders, most notably patients, may choose, in the years to come and for an as yet unknown duration, between three widely different models for classifying personality disorders: a categorical model, a hybrid model and a dimensional model. Each of the three models has its advantages, but each also has its drawbacks or at the very least a ‘fly in the ointment’.
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