Du catégoriel au dimensionnel : description et illustration clinique pour favoriser une transition harmonieuse dans la conceptualisation des troubles de la personnalité

Abstract

Introduction

Research and clinical practice in the field of personality disorders (PD) have taken a major and decisive turn in recent years with the publication of the Alternative Model of Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and with the introduction of a purely dimensional model in the latest edition of the International Classification of Diseases (ICD-11). Along with the general criteria of PD described in the previous versions of the DSM, the AMPD defines personality pathology based on two main dimensional criteria. The first one refers to the severity of personality dysfunction in the spheres of self (including Identity and Self-direction elements) and interpersonal relationships (referring to Empathy and Intimacy elements). Each element can be classified in a severity level ranging from 0 (few or no alteration) to 4 (extreme alteration). The second criterion describes five pathological domains of personality, broken down into 25 pathological facets: Negative affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. To diagnose a PD in the AMPD model, a person must present a moderate alteration (level 2) in at least two elements and a significant elevation in at least one pathological facet. The AMPD is considered a hybrid model as categorical diagnosis of six PDs (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypal) can be made using algorithms including specific pathological facets for each PD. For its part, the model developed in the ICD-11 relies on a general criterion of personality dysfunction to establish the presence and intensity of PD based on a five-point severity continuum: (a) no personality disorder, (b) presence of personality difficulties (without a clear personality disorder), (c) mild personality disorder, (d) moderate personality disorder, or (e) severe personality disorder. Optionally, the clinician can also indicate the presence of five trait domains qualifiers, akin to those found in the AMPD: Negative affectivity, Detachment, Dissociality, Disinhibition, and Anankastia. A specifier for borderline patterns can also be applied. Despite being relatively recent, these models have already generated a lot of interest in the PD research community; however, there are only limited published works devoted to these models intended for French-speaking researchers and clinicians.

Objective

The aim of this article is to provide a guide for French-speaking researchers and clinicians, to promote a smooth transition between the traditional categorical approach and the two emerging dimensional models of PD described above.

Method

After a brief introduction to the two dimensional models and their respective scoring procedures for the diagnosis of PD, the similarities and distinctions between categorical PD diagnoses and these new dimensional models will be outlined. A case study will illustrate the clinical application of the dimensional models in comparison with the categorical approach.

Conclusion

Despite a few limitations, the clinical utility of the two emerging dimensional models appears promising on several fronts, including treatment planning and course/outcome assessment, and various tools are available to clinicians to promote a smooth and seamless transition to these diagnostic approaches.