Challenges in assessing severity levels in personality disordersDear Editor,
Mental Disorders (MDs) comprise a set of symptoms that significantly affect patients’ thoughts, emotions, behaviors, and interactions with others, leading to suffering and impairment in work, personal relationships, education, and other daily activities. The impact on people’s lives occurs primarily through significant clinical consequences on an individual’s cognition, emotional regulation, and behavior. It should also be noted that the COVID-19 pandemic further exacerbated the impact of MDs on the population. In 2020, the global prevalence of anxiety and depression increased by 25%, associated with social isolation, socioeconomic stress, hospitalization, and the clinical effects of the infection.1,2 The rise in mental disorders during and after the COVID-19 pandemic highlights the importance of diagnostic processes in understanding and addressing the complexities of human psychological functioning. This includes considering social and cultural influences, diagnostic criteria, comorbidities, multidimensional assessment, and advances in mental health knowledge.3 In this context, personality disorders (PDs) are also included. Recent literature highlights significant changes in the 11th Revision of the International Classification of Diseases (ICD-11) regarding PDs.4 Unlike the categorical model of ICD-10, ICD-11 adopts a dimensional approach to personality factors for diagnosing PDs, including a subsyndromal condition referred to as “personality difficulty.”4 From a dimensional perspective, personality traits exist on a continuum, aligning with typical characteristics described in the Big Five model, which represents dimensions applicable to the personality structure of all individuals.4,5Therefore, psychological and psychiatric literature favors a continuum perspective over rigidly categorizing disorders, which distinguishes PDs from normal personality traits. This approach aligns with understanding personality and mental disorders dimensionally.6 Instruments within the dimensional model utilize scores to indicate the degree of symptom presence for each disorder, akin to applications found in the Big Five model.5 ICD-11 includes criteria for distinguishing normal functioning from PDs, a standard borderline qualifier, and guidance on the subsyndromal condition through five dominant trait specifiers: negative affectivity, detachment, dissociality, disinhibition, and anankastia (see Table 1).4 Interventions must consider the degree and pervasiveness of disturbances in a person’s relationships and self-perception, the intensity and breadth of their emotional, cognitive, and behavioral issues, the extent of distress or psychosocial impairment caused by these patterns, and the level of risk of harm to self and others.4The new diagnostic classification occurs in up to four stages: determining if the person meets general PD criteria, assessing the severity of the condition, describing personality trait domains, and evaluating the applicability of the borderline pattern specifier. The dimensional model offers a more comprehensive view of individual functioning and the heterogeneity of PD symptoms.6 This transition enhances diagnostic accuracy, reduces unspecified diagnoses, and addresses symptom overlap that leads to comorbidity. By focusing on symptom severity and dominant traits, the researchers have better insights into the impact of symptoms and dysfunctions, enabling optimized interventions and improved monitoring of clinical progress.7In this context, categorizing the severity of a condition as mild, moderate, or severe appears relevant. This classification underscores the importance of a therapeutic approach tailored to individual needs, even if it does not fit a single model. However, some theorists argue that dimensional models may not fully capture all PDs, suggesting a need for categorical distinctions for precise diagnosis and effective treatment. Additionally, there is debate about the accuracy of self-reported descriptions of traits, which form the basis of most personality assessments.8 Implementing this model poses substantial challenges, such as requiring research investment, adapting or creating personality assessment tools, and revising diagnostic protocols. Continuous training of mental health professionals is essential to overcome resistance, improve understanding of the dimensional model, address clinical skepticism, and foster familiarity to reduce uncertainty about its complexity. Therefore, transitioning to this dimensional approach in the assessment of PDs as outlined in ICD-11 marks a substantial conceptual shift in understanding and diagnosing these conditions. This shift can have profoundly positive implications for professionals and patients alike, spanning from diagnosis to intervention.
REFERENCES
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1 World Health Organization. COVID-19 pandemic triggers 25% increase in prevalence of anxiety and depression worldwide, 2 March 2022. World Health Organization. https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide
» https://www.who.int/news/item/02-03-2022-covid-19-pandemic-triggers-25-increase-in-prevalence-of-anxiety-and-depression-worldwide -
2 GBD 2019 Mental Disorders Collaborators. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Psychiatry. 2022;9(2):137-150. doi: 10.1016/S2215-0366(21)00395-3.
» https://doi.org/10.1016/S2215-0366(21)00395-3 -
3 Dragano N, Reuter M, Peters A, Engels M, Schmidt B, Greiser KH, et al. Increase in Mental Disorders During the COVID-19 Pandemic-The Role of Occupational and Financial Strains. Dtsch Arztebl Int. 2022;119(11):179-187. doi: 10.3238/arztebl.m2022.0133.
» https://doi.org/10.3238/arztebl.m2022.0133 - 4 Swales MA. Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice. Clin Psychol Eur. 2022;4(Spec Issue):e9635. doi: 10.32872/cpe.9635. PMID: 36760321; PMCID: PMC9881116.
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5 Trull TJ, Widiger TA. Dimensional models of personality: the five-factor model and the DSM-5. Dialogues Clin Neurosci. 2013;15(2):135-46. doi: 10.31887/DCNS.2013.15.2/ttrull.
» https://doi.org/10.31887/DCNS.2013.15.2/ttrull -
6 Widiger TA, Trull TJ. Plate tectonics in the classification of personality disorder: shifting to a dimensional model. Am Psychol. 2007 Feb-Mar;62(2):71-83. doi: 10.1037/0003-066X.62.2.71. PMID: 17324033.
» https://doi.org/10.1037/0003-066X.62.2.71 -
7 Monaghan, C., & Bizumic, B. Dimensional models of personality disorders: Challenges and opportunities. Frontiers in psychiatry, 2023; 14, 1098452. https://doi.org/10.3389/fpsyt.2023.1098452
» https://doi.org/10.3389/fpsyt.2023.1098452 -
8 Huprich, S. K., & Bornstein, R. F. An overview of issues related to categorical and dimensional models of personality disorder assessment. Journal of personality assessment, 2007; 89 (1):3-15. https://doi.org/10.1080/00223890701356904
» https://doi.org/10.1080/00223890701356904
