DSM versus ICD

There is much common ground between the two classifications in how they deal with personality disorder, but also a small number of significant differences. Probably the most significant difference is that DSM-IV includes schizotypal personality disorder; this does not appear in ICD.

Schizotypal personality disorder is said to be characterized by 'ideas of reference . . . magical thinking . . . unusual perceptual experiences, including bodily illusions . . . odd thinking and speech . . . suspiciousness or paranoid ideation'. It has been suggested that the category may serve to contain the excess of cases of schizophrenia diagnosed by US psychiatrists in previous years as compared with those from the UK and other countries (WHO, 1973).

(F21 schizotypal disorder does appear in the ICD-10; the list of clinical features is very similar, but it is included within the same block as schizophrenia. Confusingly, ICD indicates that its 'evolution and course are usually those of a personality disorder'. In any event, the diagnosis of schizotypal disorder is not frequently made in UK clinical practice; most clinicians would regard it as a mild or prodromal form of schizophrenia, and would advise standard management of that condition, including medication.)

By contrast, the DSM concept of borderline personality disorder (see below) has achieved clinical currency in the UK, even though it does not appear in ICD-10.

The DSM also includes narcissistic personality disorder, which overlaps with histrionic personality disorder, on the one hand, and with antisocial personality disorder, on the other hand. It is not separately coded in ICD-10.

The final main difference is that DSM groups the personality disorders into three clusters:

• Cluster A: odd-eccentric, including paranoid, schizoid, and schizotypal personality disorder

• Cluster B: dramatic-emotional-erratic, including antisocial, borderline, histrionic and narcissistic personality disorder

• Cluster C: anxious-fearful, including avoidant, dependent, and obsessional compulsive personality disorder.

There is no comparable grouping in ICD-10, and this concept is not, in my experience, in widespread use in clinical practice.

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