Mental health professionals' perceptions of clinical utility: a comparison of the current and alternate DSM-5 models for personality disorder

Abstract

Background: Despite its widespread international use, numerous criticisms have been aimed at the Diagnostic and Statistical Manual of Mental Disorders’ (DSM) categorical approach towards the conceptualisation and diagnosis of personality disorders (PD). A hybrid dimensional/categorical diagnostic model was therefore developed, which was intended to replace the existing categorical PD classification system. However, due to disagreement between leading professionals, it was instead placed in Section III, “Emerging Measures and Models” of the DSM-5 as an “Alternative DSM-5 Model for Personality Disorders” (DSM-5-AMPD). Study Objective: This research aimed to explore the perceived clinical utility of the current DSM-5 categorical model for personality disorders (DSM-5-PD) in comparison to the DSM-5-AMPD. Method: A sample of 13 mental health professionals applied four diagnostic instruments comprising personality disorder features listed in the DSM-5-PD model and DSM-5-AMPD to a common patient case file. Subsequent to the completion of each instrument, participants evaluated its clinical utility with respect to the following six areas: (1) ease of use, (2) professional communication, (3) patient communication, (4) comprehensive coverage, (5) treatment planning, and (6) global personality description. Appropriate decision rules for each model were then employed by the researcher to assign implied PD diagnoses. Information regarding the comparison of utility judgements and implied personality disorder diagnoses were then presented to the sample at a focus group discussion. During the discussion, professionals were requested to draw on this information, as well as the process of applying both diagnostic models to the common case file, to inform a more in-depth discussion regarding the perceived clinical utility of the DSM-5-PD model in relation to the DSM-5-AMPD. Results and Discussion: There were no statistically significant differences in perceived clinical utility between the DSM-5-PD model and the DSM-5-AMPD. However, a noticeable trend in the data revealed that using the DSM-5-AMPD may reduce the extensive co-occurrence of personality disorders in diagnosis, an often-cited criticism of the DSM-5-PD model. The qualitative analysis demonstrated advantages of both models: the DSM-5-PD model is more familiar, easier to use, and provides a shorthand, common diagnostic language for faster professional communication, while the DSM-5- AMPD provides more individualised and informative personality disorder descriptions. The latter may allow for more accurate personality disorder diagnoses, precise professional communication, improved patient communication, and effective treatment. Conclusion: A cost-benefit analysis between efficiency versus accuracy is required in order to determine which diagnostic model is more clinically useful. However, both the DSM-5-PD model and the DSM-5-AMPD fail to address cultural differences in relation to mental illness, such as South Africa’s collectivist and ancestral ideology and cultural practices. Therefore, future revisions of the DSM’s taxonomy of personality pathology should account for cultural differences with regard to mental illness.