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Problems with the Diagnostic System for Personality Disorders

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

No diagnostic system can be perfectly constructed. Therefore, it should come as no surprise that the current DSM-5 (APA, 2013) diagnostic system for personality disorders has its fair share of problems. Researchers and clinicians have identified several, significant, diagnostic difficulties that can be summarized as follows:

doctor and patient1. The DSM-5 method for diagnosing personality disorders is called a categorical approach. However, an alternative method, called the dimensional approach, is also presented in DSM-5 for consideration and future research. There have been numerous problems with the categorical method that the dimensional approach attempts to resolve.

2. The DSM does not account for the relative importance of various symptoms, and the descriptions of symptom criteria are overly broad. This means that patients diagnosed with the same disorder may have very dissimilar clinical presentations.

3. There is a high degree of overlap or co-occurrence of personality disorders with each other, and other mental disorders.

4. Each of these difficulties will be further discussed in the following sections.

1. A categorical versus dimensional approach to personality diagnosis:

The DSM-5 (APA, 2013) includes two types of diagnostic models for personality disorders. The first type is called a categorical model. This is the "official" diagnostic method listed in the section called, Diagnostic Criteria and Codes. However, an alternative dimensional model is also presented in DSM-5 for future consideration. This alternative dimensional model is described in the DSM-5 chapter called Emerging Measures and Models.

Let's review and contrast these two different diagnostic methods. The current and "official" diagnostic method derives from a categorical model of disease, disorders, and conditions. In this model, you either have a disorder, or you do not. Pregnancy is one such condition. You either are pregnant or you are not. You cannot be a little bit pregnant. It's much like the traditional light switch. It is either on, or it is off. For some conditions, such as pregnancy, a categorical model is very suitable.

In contrast, a dimensional model allows for varying degrees of impairment or severity. The dimensional model is more like a light switch on a dimmer. It has a range from being completely off, to somewhat on/off, to completely on. This model is more suited for conditions where there is a continuum ranging from healthy to unhealthy. Unlike pregnancy which is an absolute condition, we cannot say you either have a personality or you do not. Everyone has a personality. Therefore, it is more accurate to consider personality on a continuum ranging from very healthy to very unhealthy/impaired.

As we previously mentioned, personality disorders are somewhat dissimilar to other types of psychiatric conditions. This is because while everyone has a personality of some sort or another, not everyone has depression, anxiety, schizophrenia, etc. Those disorders lend themselves to a categorical approach to diagnosis. In contrast, a dimensional model may be more suitable for personality disorders because personalities can range from healthy to disordered/impaired. The categorical model assumes each personality disorder is a separate and distinct category; i.e., separate from other personality disorders, and distinct from "normal" personalities. In contrast, the dimensional model views various personality features along several continuous dimensions (or continuums). In this dimensional approach, personality disorders would represent the extremes along a continuum of otherwise normal, healthy personality dimensions.

The benefit of a dimensional approach can be illustrated by contrasting two people; one who has a Narcissistic Personality Disorder and one who does not. The Narcissistic Personality Disorder is characterized by rather extreme forms of self-centeredness and grandiosity. However, even ordinary, healthy people will sometimes act in ways that are self-centered and grandiose. Though the dimension of self-centeredness is the same, the difference is in the extremity of expression. People with Narcissistic Personality Disorder behave in a self-centered manner most all the time, while people without this disorder behave this way only some of the time. In this case, it makes sense to talk about a continuum or dimension of self-centeredness, which varies from low to high. Thus, we can use this dimension of self-centeredness to distinguish between people with Narcissistic Personality Disorder from those without this disorder, by plotting their degree of self-centeredness along this dimension.

While we may gain greater accuracy and precision when we view personality disorders as dimensional or continuous in nature, we lose a large degree of diagnostic simplicity. With a dimensional approach, everything becomes more complicated. How many dimensions are important to take into account? Is it possible to establish a "cut off" on relevant dimensions beyond which we can say a particular disorder is present? For instance, just how self-centered do you need to be in order to reach the level of a Narcissistic Personality Disorder?


Reader Comments
Discuss this issue below or in our forums.

Paranoid Ex-girlfriend - Gerard Nugent - Sep 27th 2014

I have only just come accross this article and feel that it fits in with the behaviour of my ex-girlfriend. Some years ago when I first noticed the symtoms I was unaware of personality disorders and couldn't recognise or understand what was going on.

There was a time when I was a Retained (Part-Time) Firefighter and as monday night was our training night I needed to be there by 19.00, every time I left to attend training she would be on the phone to the station checking to see if I had arrived. Time after time she would accuse me of having affairs and she even went to the extreme measure of checking my credit card and bank statements, even hiding them under the mattress in her son's room.

I wanted to take my son to Ireland on holiday and she accused me of trying to leave the country with him, permanantly. My son scratched his own face as a baby and she accused my older daughter of doing it, banning her from the house forever.

In the end I had to leave her and now I don't see my son, the medical profession never diagnosed her with PD even thought the signs were obvious. The courts took her word for everything so I was without support from anyone, they believed all of her lies and when I think back to that time and I see now that the signs and symptoms I was observing were that of a woman with a Paranoid Personality Disorder.

The traits mentioned are only a few of the things that she showed  back then even though there were many more, too many to list. Even though I cannot see my son my own health is far better than it was back then and I am a much happier person.

You blew it. - Rudy - Feb 6th 2014

As a guy that never cheated on his girlfriends, and has several personality disorders trust/issues...., I can tell you it will NEVER BE THE SAME if you lied to him.  If he's anything like I was...., he may want to try and stay with you and work it out, BUT IT NEVER WILL AND THE DISTRUDT WILL ALWAYS REMAIN. I give everyone one chance. It seems he's given you several to tell the truth.  I'm sorry, but don't lie to your next boyfriend.

A Paranoid Woman - - Nov 18th 2010

My story: Im a 30 yr woman. When I was 25, I met my 2nd cousin on my mothers side of family at a wedding. She told me our family has a history of mental illness. I thought that this might be true cause my mother shows signs of this. As I aged i noticed I got paranoid at work. Always thinking someone was gossiping about me or that I was gonna get fired. Paranoid of germs, diseases, strangers, even close friends & family. I also started to get paranoid with my boyfried whos now my husband. I started to accuse him of drugs, being gay, unfaithful, etc. After prolonged searching, researching, investigating, I realized that I have a problem. I have not been diagnosed yet, but after reading ppd it seems clear I have a disorder thats progressing as I age. Once you realize your disorder, its easy to notice when your paranoia is invading your rational thoughts. I stay away from caffine, drink Green tea and try to promote seretonin. Brain & Memory tonic & Rhodiola seems to help. Don't give up. No one is perfect. We all have some imperfect genetic gene! Help your mate be aware of their illness. Eat healthy, take long walks, stay away of surgar/caffine brain stimulators. Once I became aware and realized I have a problem, my work, relationship, trusting friends/family/strangers has gotten a lot better. Im more rational, dont get upset right away, and think things through making sure not to dwell/repeat a paranoid thought over and over again. 

A Paranoid Woman...  

my nightmare - tally - Oct 26th 2010

OMG! this is my life.. i am loosing my patience with my boyfriend. i love him and i am faithful. the guy accuses me like 15 times a day of talking on phone to other guys and has gone as far as to say i have a secret phone and an ear piece that i talk on in the bathroom at his house, on the patio while he is inside, and once in bedroom lying next to him!!!! i want this to work and all else is good. WTF can i do?

run - vira - Sep 15th 2010

It is the right time to leave him.He will never be cured. It is aprogressive desease.Life will be miserable.Run away from him.

Paranoid Dad - Paula - Jul 28th 2010

My father has all the Symptoms of Paranoid Personality disorder..

He has had these Symtoms all his life and I have always known him this way.

Now at the age of almost seventy, he wants to divorce my mom..

The reasons he gives is due to his paranoia.. All unfounded reaons..

Sadly he feels now that everyone is against.

It feels like there is no where to go to, as he refuses to admit he has a problem..

To those younger people out there. If you are involved with someone that has PPD and are not yet married to this person. Run Run Run.

It only gets worse and family life can be hell.. Especially for the spouse.

high level minds thought - shine - May 1st 2010

hi..i don't know what is the name of my problems...i cant't tolarate others thinking way.i dont know why i think that i know the best way more then others..who r my related or friends.

My Boyfriend doesnt trust me... - - Mar 23rd 2010


I came across this website a few months ago and only now have mustard up the courage to write.  I have looking after my husband for 5 years we have been married for 3. When I first met him he was very angry and I could understand why but managed to clam him down and things were fine until 7 months later when he claimed the house was bugged and people / community was talking about us, his behaviour became very strange and he became very aggressive towards me, in the end I asked him to leave and told him that the relationship was over. He left for London and 2 days later a hospital in Brighton called me to say he was rescued from the sea and that he tried to commit suicide. To cut a long story short he was sectioned under the mental health act diagnose with (PPD) Paranoid Personality Disorder, however was fine for up to a year and we got married 3 years ago. Within the 3 years it has been the worst years of my life he calls me all names under the sun shouts and it constantly aggressive behaviour. He has never maintained a job for more than 6 months as “MI5” are always watching him, and maintains he wants to be a singer, which would be fine if he could sing. He has run up debts up to 7K and makes a nuisance of himself when he goes to the bank to kick off at the overdraft charges.   He tells me that i am cheating and i sleep around with every Tom Dick and Harry, but when i challenge him as to how can this be, he doesnt seem to have an answer.The last straw was my mum dying 8 weeks ago and I was crying and he told me that I was crying crocodile tears.  I cannot take it any more and have told him I want a divorce as our relationship has completely broken down, he has no friends and mine are slowly withdrawing as a result of his behaviour. I am 35 years old I cannot see a future with him anymore we have no children and I cannot see me having any with him to be brought up in this kind of environment. I am currently of work with stress ( which he doesn’t no ) and for the past 2days instead of staying at home I go to the library as I cant bear to be around him. Please help what should I do I cannot go on like this.

My Boyfriend doesnt trust me... - Valerie - Feb 12th 2010

I am 21 years old and I have been with my boyfriend for five months now.  Things have been going great between us until him and I had a little rough patch about lieing situations..Honestly I had lied to my boyfriend like 3 times over stupid reasons and it never had to do with cheating or being unfaithful to him but he takes it that way and well now he lost my trust over those reasons and now he thinks that I'm either cheating on him, or lieing to him about things that arent even true...I have been honest with him and at first it was hard to tell him things because he got mad or he would start assuming things without even hearing what I had to say and he was just constantly doubting me and til this day he still does...I try to explain to him that I'm not lieing to him at all or cheating on him but he just wants to believe what he wants to believe...I try talking to him about it but he still wouldnt believe me...He would also accuse me of things that I have never done like cheating or talking with other guys..It's really hard right now because I'm trying to prove to my boyfriend that I have nothing to hide from him and that I'm trying to prove to him that I'm a faithful person and a good person as well...I just wish that he could just stop accusing me for once and start trusting me..I love my boyfriend so much, but I'm starting to get aggrevated with all this doubting going on. Sometimes I just feel like its not even worth being in a relationship where he cant trust me at all and still doubts me all the time...I just dont know what to do???!!!!

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