The goal of any diagnostic classification is to create an information basis for a correct assessment of the situation and effective action. In the field of medicine, in particular psychiatric and addictive pathology, this means that the diagnostic system should form an information statement on the basis of which clinical decisions are made, and therapeutic practices are implemented. In this case, diagnostic criteria do not form an exhaustive definition of basic disorders; they only generalize the sets of characteristics that characterize individual diseases. In other words, the disease itself does not depend on the classification. However, on how accurately the diagnostic criteria reflect this independent clinical reality, our therapeutic efforts will be justified and targeted.
In the spring of 2013, the 5th edition of the Diagnostic Manual on Mental Disorders – DSM-5, published by the American Psychiatric Association, was published. This classification is the culmination of many years of work to improve the previous guidance – DSM-IV, which has often been compared with ICD-10 and has been used in research projects, as DSM more carefully describes the diagnostic criteria for certain disorders and the criteria for evaluating treatment outcomes.
From the very beginning, the creators of the DSM-5 sought to maintain and, if possible, enhance the consistency of the classification with the ICD-11 being developed. In particular, a coordination group was established to harmonize the DSM-5 and ICD-11 under the leadership of S. Hyman, the chairman of the WHO consultants on the audit of the head of mental and behavioral disorders at ICD-10 and, at the same time, a member of the DSM-5 problem commission. More than 400 experts from 13 countries representing various specialties from psychiatry and neurology to epidemiology and statistics participated in the preparation of the DSM-5.
Problems arising in the translation of the name of the section ( Substance-Related and Addictive Disorders ) are due to the fact that in DSM-5, the term “substance” is used without the usual “psychoactive” (SAA) specification. And although there are certain substantive reasons for this, the literal translation of “substance-related disorders” sounds clearly unsatisfactory. The wording of “substance use disorders” sounds better, but there is still a lack of clarifying definition. What substance? Of course, in almost all cases, it is a matter of substances with psychotropic effects, but only in the narrative part of the manual is it indicated mainly in psychoactive substances.
The entire section of substance-related disorders in DSM-5 is proposed to be divided into substance use disorders ( Substance Use Disorder ), and disorders induced by this use ( Substance-Induced Disorder ). At the same time, eating disorders are defined as problematic use, leading to clinically significant harm or distress.
At the same time, consumption-induced disorders include intoxication, withdrawal syndrome, and almost the entire spectrum of psychopathological disorders from psychotic forms to neurocognitive deficits. Thus, all clinical consequences of use are considered as induced. But in this case, the share of disorders associated with use, there are only social consequences. However, this contradicts the definition, which indicates the clinically relevant violations that characterize Substance Use Disorder. As a result, there is some confusion with the terminology, which in reality is offset by the fact that Substance-Related and Substance Use Disorders are used as synonyms, and the term Substance-Induced is usually used to describe psychotic complications of use (whether white fever or paranoid outbreak induced by stimulants). In its most general form, these disorders are characterized in DSM-5 as a set of symptoms resulting from the use of the substance and the continuation of its use despite the negative consequences.
The most important conceptual change in DSM-5 in comparison with DSM-IV is the rejection of the terms “abuse” and “dependence.” In DSM-IV, abuse was often thought to be a lighter form or a posture of subsequent dependence, although the very manifestations of abuse could be quite destructive. At the same time, the abuse criteria in DSM-IV reflected only the social consequences of the use of surfactants, i.e., “Abuse” in DSM-IV did not coincide with the notion of “harmful use” in the WHO classification, since ICD-10, with harmful consequences, means exclusively medical complications.
With the term “addiction,” there was even more confusion since when using narcotic substances, it became identified with the concept of drug addiction, not only among medical officials but also among narcologists. At the same time, dependence in its pure form has no addictive content but represents a normal physiological adaptation reaction. When the physical dependence on opioids began to be identified with opium addiction, this led to tragic consequences – suicides of cancer patients who were deprived of access to pain medication because of fears of dependence. Someone thought that a dying patient in this way could be injected with addiction.
Dependence can arise not only from a surfactant, it, for example, can appear as a result of the reception of beta-blockers. Even signs of physical dependence on opioids do not automatically lead to a diagnosis of addictive disorder. Such cases are sometimes observed in surgical practice. Overcoming the withdrawal syndrome in these patients often leads to a complete withdrawal from use in the future, as there are no drug-related motivations and signs of mental dependence.
During the development of the DSM-5, the proposal to replace the terms “abuse” and “dependence” (” abuse ” and ” dependence “) with “addiction” was discussed. However, this idea had to be abandoned, first, because the very concept of “addiction” is not semantically limited; secondly, it has negative connotations that determine stigma, which is inadmissible in medical practice and, thirdly, the state of intoxication, withdrawal syndrome and other manifestations of the disorder may not be related to the phenomenon of addiction. As a result, the wording “eating disorder” was recognized as the most appropriate.
In the section on substance-related and addictive disorders, DSM-5 isolated forms of the disorder are classified into 10 classes of different surfactants and one specific behavioral addiction (Table 1).
Table 1
Diagnostic headings in DSM-5
| Disorders associated with the use of surfactants and gambling | Intoxication | The withdrawal syndrome | |
| Alcohol | + | + | + |
| Caffeine | – | + | + |
| Cannabis | + | + | + |
| Hallucinogens (including PCP) | + | + | – |
| Inhalants | + | + | – |
| Opioids | + | + | + |
| Sedatives, hypnotics, anxiolytics | + | + | + |
| Stimulants | + | + | + |
| Tobacco | + | – | + |
| Other/unknown substances | + | + | + |
| Combined use | – | – | – |
| Gambling | + | – | + |
In comparison with the previous classification (DSM-IV):
* For caffeine, withdrawal syndrome is added since it is recognized that refusal of the habitual use of coffee during the day can lead to increased lethargy and drowsiness. At the same time, there is no data to determine caffeine in the discharge of substances capable of causing clinically significant health disorders or manifestations of distress, so it is placed in a special section that requires additional research. In the same section, computer games are introduced, for which there is insufficient data to formalize them as an addictive disorder.
* The withdrawal syndrome is also added to cannabis. Perhaps this was due to the emergence of synthetic cannabinoids with higher addictive potential and increased pharmacodynamic activity.
* Hallucinogens, in addition to psychotomimetics, include a subcategory of phencyclidine (PCP) and the rest of arylcyclohexylamines, which include ketamine (in DSM-IV, these were separate headings). Despite certain differences in the clinical manifestations of intoxication and psychotic disorders, the disorders associated with the use of psychotomimetics and dissociatives are fairly close in their basic characteristics, so their convergence in the new classification seems quite logical.
* Stimulants (cocaine, amphetamines, methamphetamines) are grouped together because of the identity of clinical manifestations and cerebral mechanisms of exposure – this is also justifiable since the differences in the clinical effects of plant and synthetic stimulants are expressed no more than differences between plant and synthetic opioids.
* Combined use of surfactants (what we often call polydrug use) is completely removed from the classification. Not because there is no simultaneous and chaotic use of different surfactants, but because DSM-5 requires each substance to be indicated separately.
* For the first time in the section on addictive pathology, gambling appears as – behavioral addiction, which in the previous classification was related to driving disorders along with kleptomania. The placement of gambling in this section reflects the results of studies showing that this disorder has the same clinical manifestations, cerebral mechanisms, and comorbid psychopathology as chemical addictions. In addition, for the treatment of pathological predilection for gambling, the same approaches are used for the treatment of substance disorders, in particular naltrexone and various types of psychotherapy, primarily behavioral orientation. All this allowed the APA experts to combine substantive and behavioral addictions into a general section.
Instead of individual criteria for abuse and dependence, the DSM-5 has 11 common criteria. At the same time for the diagnosis of the disorder associated with the use of surfactants, you must have at least 2 criteria within 12 months.
1. The substance is often taken in large quantities or for a longer time than anticipated.
2. There is a constant desire or unsuccessful attempt to reduce or control the use of the substance.
3. The amount of time spent searching for, using substances, and overcoming the consequences of intoxication is greatly increased.
4. An irresistible attraction to substance use.
5. Repeated use of substances, leading to a loss of ability to fulfill basic obligations at work, at the place of study, and in the family (absenteeism, deterioration in the quality of work, and declining academic performance).
6. Continuation of the use of the substance, despite the constant or recurring social or interpersonal problems caused or exacerbated by the effects of the substance (family conflicts, quarrels with others, etc.).
7. As a result of the use of substances, important manifestations of social, professional, and leisure activity cease or diminish markedly.
8. Repeated use of the substance in situations involving physical hazards (for example, when driving, resting on water, etc.)
9. The use of substances continues, despite the knowledge of permanent or recurring problems with physical or mental health caused or aggravated by the ingestion of the substance.
10. Signs of tolerance are determined by any of the following phenomena: a) the need for a marked increase in the amount of substance to achieve intoxication or the desired effect;
b) a marked decrease in the effect when the same amount of substance is used (it does not apply to cases of taking medication under medical supervision).
11. Presence of withdrawal syndrome, manifested by one of the following phenomena: a) the appearance of physical symptoms when the dose is reduced or substance is withdrawn;
b) use of a substance to alleviate or avoid withdrawal symptoms (does not apply to cases of taking medication under medical supervision).
It is easy to see that the first 4 criteria reflect the loss of control over consumption. In this case, the need to introduce the 4th criterion (an irresistible attraction), which was not in the DSM-IV, was actively challenged. This may seem strange because in Russian narcology, the so-called “pathological attraction” is considered to be the core characteristic of the narcological disease, i.e., without pathological attraction – there is no addictive disorder. The paradox, however, is that the craving itself may be, and the clinical manifestations of the disorder may not be, as it happens in remission. But even with the existing disorder, the presence of craving is not necessary, although not everyone agrees with this. In fact, how is this possible, there is used, and there is no attraction to eating. Attraction to drinking can be found by participants in the festive feast, but in this case, it is a qualitatively different state. The need for a shift with the subsequent use of a surfactant can be realized without a conscious inclination. In the conditions of loss of control over the impulse for use, it is enough to lack the struggle of motives, which, incidentally, is also often a weak obstacle.
A personality disorder is a personality type or behavioral tendency characterized by considerable discomfort and deviations from the norms accepted in the given culture [1] [2] [3] . This is a serious violation of the characterological constitution and behavioral tendencies of the individual, involving usually several spheres of the personality and almost always accompanied by personal and social disintegration [4].
A personality disorder occurs usually in late childhood or adolescence and continues to manifest itself during the maturity period. Therefore, the diagnosis of personality disorder is unlikely to be adequate until 16-17 years of age [4]. Nevertheless, it is important to diagnose, what these or other personal changes in adolescents are related; this or that accentuation of personality can be revealed already in adolescence, as well as the degree of its expression and make a prediction about its development [5].
The term “personality disorder” replaced the outdated term “[constitutional] psychopathy” used in Soviet and Russian psychiatry before the official transition to ICD-10 in 1997. Previously, it was believed that psychopathy is due to the “inherent inferiority of the nervous system caused by factors of heredity, the harmful effects on the fetus, birth trauma, etc.” [6]. At this point in personality disorders, there are many possible causes. They vary depending on the type of disorder and individual characteristics of a person. They can be a genetic predisposition, certain life situations, or suffered traumas. The transferred mental, physical and sexual violence in childhood creates a risk for the development of personality disorders [7] .
Diagnosis by DSM-IV
Only when the individual personality traits are not adaptable, not adaptable and lead to a significant deterioration in life they can be called personality disorders:
- Internal experience and behavior deviate significantly from the requirements imposed by the culture to which the person belongs, and this manifests itself in two or more of the following areas:
- Cognitive (that is, the path of comprehension, interpretation of oneself, other people or events).
- Affective (degree, intensity, lability, and adequacy of emotional reactions).
- In the features of the internal functioning of the personality.
- In control of impulsivity.
- Patterns demonstrate inflexibility and extend to a wide range of personal and social situations.
- Patterns lead to serious clinical distress or problems in the social, professional, or other important areas of life.
- Patterns are stable over time and can be traced back to early adolescence or maturity.
- Patterns can not be considered a manifestation or consequence of another mental disorder.
- Patterns are not the result of direct exposure to substances or general health, such as head trauma.
Persons under the age of 18 who meet the criteria can not be diagnosed with the corresponding disorder. To diagnose at this age, symptoms should be recorded for at least one year. Antisocial personality disorder, in general, can not be diagnosed before age 18 [11] .
Personality disorders are a kind of mental disorder that affects how people manage their emotions, behaviors, and attitudes. Personality disorders can be diagnosed in 40-60% of cases, and they are characterized by a steady collection of behavioral patterns, often associated with significant personal, social and occupational disorders. This behavior can lead to non-adaptive coping skills and personal problems that cause extreme anxiety, malaise or depression.
- Paranoid personality disorder
- Schizoid personality disorder
- Schizotypal personality disorder
- Antisocial personality disorder
- Borderline personality disorder
- Hysterical personality disorder
- Narcissistic personality disorder
- Avoiding personality disorder
- Dependent personality disorder
- Obsessive-compulsive personality disorder
The concept of personality disorder itself is much later and tentatively appeared in 1801, described by psychiatrist Philippe Pinel, as a state of an outbreak of rage and violence in the absence of any symptoms of psychosis, such as delirium and hallucinations.
According to the Diagnostic and Statistical Manual for the 5th Revision of Mental Disorders (DSM-5), there are ten types of personality disorders, and they can be grouped into three clusters [1] :
Cluster A (unusual, strange, eccentric)
Paranoid, schizoid, schizotypic
Cluster B (dramatic, unstable)
Antisocial, borderline, hysterical, narcissistic
Cluster C (anxious, fearful)
Avoiding dependent, obsessive-compulsive
In general, personality disorders are dominant, rigid, stable stereotypes of thinking, perception, reactions, and interpersonal relationships that cause serious suffering and/or cause functional disturbances. Known a number of personality disorders, which differ significantly in their manifestations, but it is believed that they are all due to a combination of genetic and environmental factors. Most disorders occur less severely at an older age. The diagnosis is established clinically. Treatment – psychosocial therapy and, sometimes, drug treatment.
The personality trait is a complex of fairly stable stereotypes of thinking, perception, reactions, and interpersonal relationships in time. It is possible to speak about personality disorder when these characteristics become so severe, stiff, and dis-adaptive that they disrupt the person’s way of life, interfere with work,, and/or influence interpersonal interactions. Reducing social adaptability causes considerable inconvenience to persons with personality disorders and those around them. In individuals with personality disorders (in contrast to all others who seek psychological help), it is the stress caused by the consequences of socially-de-adaptive behavior that is usually the main reason why they seek medical help, and not because of discomfort in their thoughts and feelings. Thus, the task of the clinician is to let the patient know that it is the personality traits that are the root of the problems.
Personality disorders usually appear in late adolescence or early adulthood, and their characteristics and symptoms vary considerably depending on how long they last; many can eventually be resolved.
In accordance with the current Diagnostic and Statistical Manual on Mental Disorders, the 5th edition – DSM-5 ( Diagnostic and Statistical Manual of Mental Disorders ) personality disorders can be divided into two groups of problems:
- Authentication
- Interpersonal relationships
Violations of auto identification can be manifested by unstable self-esteem (for example, a person can not decide for himself, he is kind or cruel) or a contradiction of life values, goals in life, and his appearance (for example, a person behaves as a true believer within the walls of the church, but outside it expresses blasphemous considerations). Interpersonal problems are usually manifested in the form of the inability to create and/or maintain a close relationship or as a feeling of indifference to others (for example, a person is not able to empathize with his neighbor).
People with personality disorders often seem contradictory, strange, and unpleasant to others (including physicians). These people may have difficulties in determining the boundaries of communication with other people. Their self-esteem may be excessively high or unreasonably low. They differ in their contradictions, individualism, hyperemotionality, and abusive or irresponsible behavior, which leads to physical and mental problems in the family or with children. Personality disorders are often combined with mood disorders, anxiety, abuse of prohibited substances, somatization, and eating disorders. In patients with personality disorder and such concomitant circumstances, the prognosis is usually much worse, and the positive results of treatment are less likely.
Personality disorder occurs in about 13% of individuals in the general population. So far, no relationship has been established with gender, social status, and race. Nevertheless, with sociopathy, the ratio of men and women is 6: 1. In borderline psychopathy, on the contrary: there is 1 woman for 3 women (but only for clinical cases, not for the general population). For most types of personality disorders, the frequency of inheritance is about 50%, which is slightly higher than for other major mental disorders. This degree of heritability refutes the generally accepted opinion that personality disorders are manifested as a result of human deficiencies, which are formed under the influence of unfavorable external conditions.
Classification
DSM Manual 4th Edition (DSM-IV-TR) subdivides 10 personality disorders into 3 groups. The new version of DSM-5 allocates fewer disorders and does not divide them into groups; these disorders will be considered here.
Schizotypal personality disorder
The schizotypal personality disorder, as well as the close states – paranoid and schizoid personality types – is manifested by social detachment and emotional frigidity. In addition, a schizotypal personality disorder is characterized by the following peculiarities: strange thinking, perception, and communication, for example, archaic thinking, foresight, relationship ideas, and paranoid ideas. Patients, as a rule, are suspicious of any changes and often attribute hostile and unkind motives to other people. These oddities speak in favor of the diagnosis of schizophrenia ( schizophrenia ), but are usually light and blurred, which is not enough to make a diagnosis. It is believed that people with a schizotypical type of personality are suppressed expression of genes that cause schizophrenia.
Borderline psychopathy
With borderline psychopathy, doctors of both clinical and psychiatric hospitals are often found. Borderline psychopathy is characterized by unstable self-esteem, mood, behavior, and attitude of the patient to other people.
Hysterical personality disorder can be attributed to borderline psychopathy, in which patients are characterized by extreme emotional lability and instability of social relations.
People with borderline psychopathy are hypersensitive. They tend to think that parents gave them too little time in their childhood and, therefore, feel empty, angry and feel that they have the right to attention to themselves from others. As a result, they constantly seek help and react very painfully to her absence. Their relationship with other people is rapid and dramatic. When they feel self-care, they behave like lonely street children who need help with their depression, substance abuse, eating disorders, somatic complaints, and past mistreatment. When they lose a person who cares about them, they often display inadequate, expressed anger. Such mood swings, as a rule, are accompanied by radical changes in their views on the surrounding world, on themselves and other people – for example, from bad to good, from hatred of love. When they are upset or feel self-loathing, they often harm themselves. When they feel abandoned, they exhibit dissociative symptoms, brief episodes of psychotic thinking, or become extremely impulsive, and sometimes commit suicidal actions.
Patients with a borderline personalities tend to cause an intense, caring reaction to their caregivers, but after repeated crises, vague, unreasonable complaints, and ineffective treatment, these patients can cause hostile negative feedback.
Borderline psychopathy often goes into remission (about 50% within the first 2 years, and 85% within 10 years), and after reaching a remission the development of relapse is extremely unlikely. Nevertheless, the observed resolution of the symptoms is not associated with an improvement in social activity. In 10 years only 20% of patients acquire good personal relationships and permanent work. (See also the Practical Guide for the Treatment of Patients with Borderline Personality Disorders of the American Association of Psychiatrists.
Dissocial personality disorder
Dissocial personality disorders (and associated psychopathic personality disorders) are characterized by a callous indifference to the rights and feelings of others. Such people exploit others for their own material gain or simply for personal satisfaction. They are easily disappointed and do not tolerate disappointment. What is characteristic is that such people conflict impulsively and irresponsibly, sometimes with hostility and violence. As a rule, they do not realize the consequences of their behavior and do not feel remorse or guilt. Many of them have a well-developed ability to rationally explain their behavior while blaming others. Dishonesty and lies are the basis of their relationship. Punishment rarely helps them change their behavior or way of thinking.
The sociopath often suffers from alcoholism, drug addiction, failure to fulfill his promises, frequent change of residence, and difficulties with the law. The average life expectancy decreases, but with age, the manifestations of the disturbance tend to fade or stabilize.
Narcissistic personality disorder
The main feature of narcissistic personality disorder is the feeling of greatness. Such people are distinguished by a hypertrophied sense of their superiority and expect respectful respect from others. They are inclined to suppress other people because they believe that their superiority justifies it. Their relationship with loved ones is marked by the need for constant admiration. They often believe that other people envy them, and are very sensitive to criticism, lack of attention, or life failures. Faced with difficulties that underestimate their high opinion of themselves, they can become furious or fall into a severe depression with a propensity for suicide.
Avoiding personality disorder
Avoiding personality disorder is distinguished by avoiding people or life situations where failures, failures, or conflicts can occur. Such people are afraid to start any personal relationship or any new business because of fear of failure or disappointment. Because such people constantly feel a strong conscious desire for love and care, they are constantly dejected by their isolation and the inability to establish comfortable relationships with other people.
Anancastric personality disorder
Anankastnoe personality disorder is characterized by conscientiousness, excessive tendency to order, and perfectionism. Nevertheless, people who suffer from this disorder often also have an inflexible character and, therefore, are not able to adapt to changes. They take responsibility very seriously, but because they do not want to make a mistake or miss the details, they often get bogged down in details and forget about the ultimate goal. As a result, it is difficult for them to make decisions and execute orders. A hypertrophied sense of responsibility becomes a source of concern, and such people rarely get satisfaction from their achievements. Nevertheless, most obsessive-compulsive traits are characterized by good adaptability; Until these features are hypertrophied, such people can achieve much, especially in the natural sciences and other scientific fields, which require high self-organization, exactingness, and perseverance. However, different negative feelings and interpersonal conflicts can cause them discomfort, as well as unpredictable situations, or situations over which they have no control or in which to rely on other people.
Diagnostics
Clinical criteria for DSM-5
Patients with personality disorders often can not objectively assess their condition and complain about anxiety, depression, the desire to abuse prohibited substances or to other symptoms that are not always associated with a person. For this reason, doctors should be attentive to the signs indicating the relationship of these complaints to the existing personality disorder. One of the first clues may be how the physician reacts to the patient. A feeling of discomfort (for example, irritation, anger, protective posture) in the patient often indicates the presence of a personality disorder; however, such reactions are subjective enough, and doctors should try to confirm their assumptions by other methods of diagnosis. In addition, one must understand that the patient’s problems are the fruit of his thinking activity (many doctors wonder why they simply do not stop doing it) or these problems, visibility, developed due to bad habits such as social isolation, perfectionism, impulsiveness, or because of excessive hostility.
