When Is a Personality Disorder Not a Personality Disorder?The essence of a personality disorder is harder to capture than you may realize.
- GAB NEWS
- 1 hour ago
- 4 min read
People whose very nature seems to interfere with their ability to adapt to life’s challenges may find themselves sitting in the office of a mental health professional seeking to change.
Diane drifts from romantic partner to romantic partner, at first idolizing them only to throw them away like a used Kleenex weeks or months later. She finally decides to seek therapy, only to learn from the therapist that she meets the criteria for borderline personality disorder. Therapy could very well work, she learns, but it’s going to be a rough road ahead.
The Problems With Diagnosing Personality Disorders
Throughout the last century or so, clinical psychologists and psychiatrists have grappled with identifying the central qualities of people who aren’t acutely disturbed with mental health issues, but nevertheless find life to be a constant challenge. The concept of a personality disorder (PD) eventually evolved into the psychiatric system we now have today, the Diagnostic and Statistical Manual of Mental Disorders in its current, Fifth Edition-Text Revision, form (DSM-5-TR).
The amount of debate over how (or if) to classify personality into neat categories that receive a particular label is impossible to overestimate. Most notably, in 2013, when the DSM-5 was being finalized, it appeared that personality disorders, as a diagnostic category, would finally be replaced with a system that better captured the reality that people don’t fit into neat little boxes. Unfortunately, this did not happen. Instead, an “Alternate Model of Personality Disorders” (AMPD) was proposed as a sort of beta idea, but it still hasn’t been adopted officially.
Maybe It’s in How You Ask the Questions
Thinking again about Diane, who may be like someone in your own life, how is it that her therapist decided she merits the diagnosis of having a “borderline” personality disorder? Undoubtedly, the therapist did their due diligence and asked a series of diagnostic questions based on the DSM-5-TR’s published criteria. Using a combination of clinical expertise and these criteria, mental health professionals try their best to apply the diagnostic ruler to the reports their patients provide of their symptoms.
As pointed out in a large international study headed by University of Kassel’s Steffen Müller (2026), attempts to put people in categories lack validity, but not only because the system is flawed. There are a host of measurement approaches, ranging from the clinical interview, like Diane’s, to highly quantified questionnaire (mostly self-report) methods. Then there are the variations in populations that were tested. In the words of the authors, “The impact of heterogeneity in assessment conditions and sampling designs on the...results is unclear.”
The authors wondered whether they could force the findings from their over 30,000 respondents into the existing DSM-5-TR categories, as well as those of the AMPD structure. Feeding all the data into a rigorous analysis could make it possible to see if one, both, or neither would emerge as valid. They also compared what happened when they used self-report (i.e., questionnaire) measures vs. diagnostic interviews as their instruments, along with a third approach in which an informant (someone who knows the person) provides the personality ratings.
The results provided bad news for the DSM-5-TR's current structure but good news for the AMPD. Attempts to bring questionnaires and interviews into alignment for the personality disorder categories simply didn’t work. People would receive one diagnosis with self-report and another with an interview. When it came to the AMPD, in contrast, the authors concluded that “this model is a defensible representation of the structure of PD criteria.”
Why there is this divergence in DSM-5-TR classification boils down simply to the fact that, when clinicians approach their patients who potentially have PDs, they fall prey to an “expectancy bias.” Diane’s therapist has a hunch that she has borderline PD, and so begins to ask questions that will support this hunch. It’s not that the therapist is incompetent; it’s just how that person was trained. But, it’s also possible that the therapist is better at recognizing symptoms for what they are than people are at reporting them.
Here’s an example of such a divergence. The clinical rating may ask the diagnostician to determine whether a person with histrionic personality disorder “talks in a vague way that lacks detail and is hard to understand.” The questionnaire may pose the same symptom as whether the person talks so much that “others tell them they have trouble getting to the point.” This problem adds “noise to the assessment” and contributes to the variation between the two forms of getting at the same symptom.
Where Does This All Lead?
This major study should have the effect of stimulating clinicians to wonder about how to get at the essence of a patient’s difficulties in life. It should also give the profession pause (or more pause) to wonder whether it’s worth putting people into discrete categories when, in fact, personality is a dynamic and complex quality.
For people like Diane, findings such as the Müller et al. study could be very helpful in understanding what to do when faced with all the interpersonal problems she reports having. Of course, seeking therapy is a good idea for her, especially since her patterns keep repeating. But maybe she should not get overly focused on the name given to her symptoms and instead focus on overcoming the difficulties they seem to cause.
To sum up, the purpose of diagnosis in psychological disorders is unquestionably that of providing viable routes to treatment. Knowing what goes into a diagnosis can only help make these treatments that much more effective.
References
Müller, S., Schroeders, U., Bachrach, N., Benecke, C., Cuevas, L., Doering, S., Elklit, A., Gutiérrez, F., Hengartner, M. P., Hogue, T. E., Hopwood, C. J., Mihura, J. L., Oltmanns, T. F., Paap, M. C. S., Pedersen, G., Renn, D., Ringwald, W. R., Rossi, G., Samuels, J., … Zimmermann, J. (2026). Revisiting the structure of Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Section II personality disorder criteria using individual participant data meta-analysis. Personality Disorders: Theory,
Published by Raphael Amorim
Comments