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Mental Disorders

Problems with the Current Diagnostic System Continued

Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D. Updated: Dec 6th 2013

2. Relative symptom importance and overly broad symptom descriptions:

In addition to being categorical, the diagnostic approach used in DSM-5 is also polythetic. This term refers to the fact that in order to be diagnosed with a personality disorder, a person must meet a certain number of symptom criteria from a defined criteria set. For instance, there are nine symptoms (criteria) that define Borderline Personality Disorder. In order to be diagnosed as having Borderline Personality Disorder, a person is required to meet five out of those nine symptom criteria. But, there are several pitfalls to this approach.

female student thinkingThe first problem has to do with the fact that a polythetic system presupposes all diagnostic symptoms carry the same weight, and are considered equally important when making a diagnostic determination. It might be reasonable to assume that the equality among symptoms makes the diagnostic process somewhat simpler, but this assumption may not be warranted. For instance, two of the possible nine criteria for the Borderline Personality Disorder include "suicidal and self-harming behavior" and "chronic feelings of emptiness." Whether these two criteria should be considered equally important is open to debate. However, today, many practicing clinicians would consider evidence of self-harming behavior to be a vastly more significant indicator of Borderline Personality Disorder than reported feelings of emptiness. It is true that reported feelings of emptiness are indeed an important symptom, but this symptom can be associated with several other diagnoses as well. Thus, the assumption that equality among symptoms makes for diagnostic simplicity is perhaps an inaccurate one.

Another problem with the polythetic approach is the issue of "high heterogeneity." This term refers to the fact that there is a great deal of variation among people with the same disorder. To illustrate this concept, let's examine the diagnostic requirements for the Borderline Personality Disorder. The Borderline Personality diagnosis requires a person must meet at least five out of nine possible symptom criteria. This means that there are more than 150 possible combinations of five criteria that can qualify a person for a diagnosis of Borderline Personality Disorder. In other words, 150 people with the same diagnosis of Borderline Personality would each have a different set of symptoms. Stated differently, this also means that any two people who are diagnosed with Borderline Personality Disorder need only have one single symptom in common! High heterogeneity is considered problematic because when people with the same disorder do not appear to share similar symptoms, the diagnostic label becomes less meaningful and less useful to clinicians, researchers, and patients alike. As a result, diagnostic labels are seen as unreliable indicators that a particular underlying problem is actually present in the individual bearing that diagnosis.

Another problem with high heterogeneity is a problem that is commonly observed in clinical practice. This problem occurs when a patient does not meet enough criteria for any one, single personality disorder diagnosis to merit that diagnosis being applied, but does meet some criteria within several different personality disorder diagnoses, usually within the same cluster. In this case, the clinician may make the diagnosis Other Specified Personality Disorder followed by "mixed personality features." Alternatively, the clinician may use Unspecified Personality Disorder if the clinician does not know, or chooses not to specify the reason the criteria were not met for a specified personality disorder.

3. The co-occurrence of personality disorders with other disorders

Another diagnostic difficulty is that we now know that people frequently meet criteria for more than one personality disorder at a time. When two or more disorders occur simultaneously, clinicians and researchers call this "co-occurrence." Research has shown that there is a tendency for personality disorders of the same cluster to co-occur (Skodol, 2005). This calls into question whether individual personality disorder diagnoses represent discrete entities.

This problem of high co-occurrence has also been observed between personality disorders and other psychiatric disorder categories. . Experts have proposed several different explanations for these findings. One explanation is that one disorder (e.g., Borderline Personality Disorder) may precede the other (e.g., Major Depression) and increases the risk of developing this second disorder. Another explanation is it may be possible that both disorders are best understood as different manifestations of the same underlying issue, with one disorder representing a milder version of the other. Ongoing research will attempt to make further sense of these and similar observations. For a more thorough discussion of this issue of co-occurrence please go to this section.


Reader Comments
Discuss this issue below or in our forums.

support - Lisa - Dec 29th 2010

I am currently married to someone with PPD.  There is an online support group called Out of the Fog.  It has been helpful to me and I would suggest it to anyone who loves someone with this problem.  You will find support whether it is your parent, spouse, or child.  This support group offers support whether you will be continuing a relationship or ending it.  It also has lots of info on all kinds of personality disorders.

 I think it is great when someone who has it recognizes it.  My husband will not.  If he did I might have some hope.

Tormented too - - Nov 29th 2010

I was raised by a very suspicious mother who CONSTANTLY accused my father of infidelity and was so controlling she glared at him until he left the room whenever a beautiful woman came on the tv.  My poor father is gone now, but my mother is alive.  Unfortunately, I am very much like her. I hate her for it. Whether or not is a bioligically inherited disease or learned behavior, it is so bad, I have considered suicide and even toyed with the idea of a lobotomy.   I'm 51 years old, have badgered every boyfriend I've ever had and my poor ex-husband of 22 years.  I've sought therapy many times but nothing removes the conviction that they are cheating on me.  It has ruined my life.  My most recent therapist  suggested I have PPD.  In a weird way, it's comforting to find that other people suffer from the same affliction.  I've just begun reading articles and comments and have forwarded one of them to my current boyfriend.  He's very supportive and understanding but I don't know how much longer he will be.  I wish everyone luck out there - those who are afflicted and those who have to put up with us.  It's torture on both ends.  Thank you all for posting your comments.

Is my daughter in law a paranoid personality? - Rudradeb - Oct 8th 2010

My daughter in law used to say there is a family of ghosts living in her flat. These ghosts have been sent by the members of my family .later on, she changed the version saying hat these ghosts have been sent by me and my wife .They are there to harm her and her son.

Once she spoke to my wife and said that whenever she had spoken to her, something bad had happened to her. She now refuses to speak to her . her mother in law.

She is oversuspicious too.She believes her friend ( who are all wealthy ) stole her purse. If a girl becomes a little more friendly with her husband ( my son) she will believe that the girl has fallen in love with him.

This has caused a lot of unhappiness in my family. Is there any cure and what is it ?

I guess I'm the Bad Guy - Crissy - Jul 5th 2010

I am a sufferer of PPD.  I experience a lot of the symptoms they describe here, from the delusional thinking someone is watching me, to incessantly accusing my bf of cheating and actually looking for stuff that he might say that alludes to it.  I HATE it.  I have had so many people walk in and right back out of my life when they find out this is the way I am.  Crazy.  Yeah.  That's what they call me.  It sucks.  Sometimes I can be logical.  Like, I KNOW something isn't right with me.  I KNOW this stuff is not real.  Yet I go believing it anyway.  It sneaks up on me when I'm taking a walk to the store.  I see a car two or three times and I'm certain they're following me.  I'm CERTAIN that the cops are after me.  Right this second it sounds ridiculous.  But tomorrow, when I take my daily walk, they'll be watching.  And they have cameras all over my house.  I know it SOUNDS stupid.  But I always feel like I have eyes on me.  I ask my bf repeated manipulative questions to see if he'll accidently drop some hint of an affair.  Because I'm CERTAIN he's having one.  Even though he works sixty hours a week and spends his only day off with me.  See what I mean people?  The confusion .... the contradiction ... the battle in my head rages on and its so hard to deal with.  So don't just knock people who have this issue.  Its not like we CHOOSE to be this way.  Its unhelpable.  Please, understand that if I think something, its coming out of my mouth.  And I just can't help it.  I have tried to contain doesn't work.  I try to be good ... i really do.

You are not alone..... - Jeff B. - Jun 5th 2010

 My mother is very much the same way, it makes it very hard to be around her.  You are right as far as being beat down, it does happen to all of us. She has always said that people are following her, people are trying to posion her in her home. She has lost her 3rd husband from this......Best man i ever met...He left...She is now living in the same city as i and i have her working for me so i can keep an eye on her. Man is it tuff tho...All the bull that comes with this and no one can help....All of us kids 3 of us use each other as support. I fear tho that the weight of this disorder will cause a break in that...I wish you and your the very best.....JB the lord for his help....

family just accepted her behavior - - Feb 28th 2010

I believe my mother in law suffers from PPD. The entire family just accepted her behavior in the past and tried to laugh it off. Things have drastically changed in the last year. She has always talked of seeing ghosts or spirits in the past that were basically harmless. Her husband of 30+ years has had all he can take and decided for safety reasons to leave her. She habitually accused him of having an elaborate affair with another woman which also involved money scandals. She invesitigates endlessly on the computer looking up court records of real estate transactions. She left horrible, belligerent and profane messages on his cell phone saying things like, "when are you gonna go ahead and kill me?" and "I am going to blow your brains out if you think your gonna get away with all this!!" Now the visions of harmless ghosts in the past has turned into seeing assassins in the backyard trying to kill her which were hired by her husband. Since my father in law is now living with his other son and spends alot of time with my sister in law,  my mother in law has suffocated my husband with this craziness. She is untrusting of her other kids, thinking they are on their dad's side. Since my husband has endured a lifetime of this behavior, he is pretty much beaten into submission when it comes to standing up to her and saying "this is not going to be tolerated and you need to stop this behavior." He just nods in agreement or disbelief when she goes on a tangent or he tries to change the subject altogether. He pays dearly if he does not pay his dues and suffer through a visit with her as often as she sees fit. It has put a tremendous strain on our marriage. We disagree on treatment for her and treatment from her. I see her capability of being dangerous. She has a house full of guns and thinks people are trying to kill her. My husband does not or does not WANT to believe she is dangerous. The whole situation seems hopeless. We don't know what to do. She does not believe she is disturbed at all. She has been violent in the past when things were fairly good in her life. She is a ticking bomb. Her house is under full video surveillance or we would have already rid her of the guns. I have been studying PPD and the only behavior that she and 2 of her sisters exhibit that is not discussed with this disorder is vulgarity. They are very sexually explicit vulgar people. She is not a hoarder but there are a lot of hoarders in the family. She is very tight with her money. She would never lend or give money to her kids or grandkids. She has done pretty much anything, including illegal acts, to gain financially. She was physically abusive to her children but raves on how loving and caring she has been to them. She starves for attention, but only from family because she has NO friends whatsoever. The entire community knows and understands that she, her parents and siblings are mentally disturbed and keep their distance. What do we have to wait on to happen here before we can do anything? I think my father in law should take a restraining order out on her. He has changed his cell phone number but won't go any further than that in fear of provoking her. We live in a very small town and this is very humiliating and stressful for my husband and everyone else involved. Is there anything we can do?

Is there Any Help? - SS - Feb 23rd 2010

I have a brother who has been married to a troubled spouse for 14 years. We have basically discovered this person has a paranoid personality disorder - after suspecting for years something wasn't right. She has been so secretive as to not ever let anyone  access or know about her medical history. She is VERY CONTROLLING, and has 3 children - one married daughter, one child in high school (who's struggling with dealing with this), and an elementary age daughter. This mom has terminal cancer. We definitely know this because my brother has seen the x-rays and has taken her for radiation treatments.  The problem is...she is getting crazier, and has called the police on my brother twice, claiming he was abusing her. The kids were at home, etc. so the little one marches into school that morning saying she was late and telling everybody that Mommy had to call the police because she said Daddy was abusing her. My brother had gone into their bedroom to retrieve a cell phone that was ringing, it was dark, and the lights were off, so he used a flashlight to see. She woke up screaming, asking if he was going to beat her with the flashlight. My brother is TERRIFIED of her, and is basically a prisoner in his own home. The entire family needs counseling, but there is no money, and if my brother took the kids to get help, then it would send his wife on another vindication campaign because he tried to get the kids some help, as well as himself. She stays out all hours of the night -- spends most of the time at IHOP instead of at home with her family. She also works. She is taking morphine to help with her cancer pain....but is not supposed to drive a car, which we recently found out.  She is a compulsive hoarder at home, you can barely walk in the house. Does anyone know what we can do to get this family help w/out having to wait for the cancer to take over her body? She is very mixed up. Went out and had a will made up w/o involving my brother, and plans to leave her share to her married daughter -- which means my brother will likely loose his house, while having to pay for her funeral too. She has her older daughter convinced that my brother is terribily abusive and mean. The daughter supports her mom, and behaves very much like her mom. I don't believe they've ever been told NO to anything they wanted to do. We don't know what to do! Can you offer me some suggestions to share with my brother? He's contacted lawyers -- they suggest a divorce -- but he doesn't want to do that due to the fact that she is dying, and it would be worse on the kids. There is also the risk of losing his alimony if a divorce occurred. As a solution, my bro invited the mother in law to come stay with them to observe all that is going on. She stayed one day, agreed her daughter was paranoid and left. I've told my bro to collect all the stuff she's been buying that has price tags on them to return to the store and get a cash rebate or something for them. We also demanded that he get a different checking account just to put his paycheck in so he can have some money to protect himself with. He's too chicken to even let her know he's on to her. HELP!!! This family lives in DFW. Anyone with advice for low-cost counseling....please let me know of a contact for them. Pyschiatric counselors have also told my brother that he can't get help for her because they claim the morphine is causing her to be crazy, and we probably can't prove she has a very serious mental problem.

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