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Commentary: Inadequacy of the Categorical Approach of the DSM for Diagnosing Female Inmates With Borderline Personality Disorder and/or PTSD

Dr. Oguntoye is a third-year resident in the Harvard Longwood Psychiatry Residency Training Program and Dr. Bursztajn is Associate Clinical Professor of Psychiatry and Co-Founder of the Program in Psychiatry and the Law in the Beth Israel Deaconess Medical Center Department of Psychiatry, Harvard Medical School, Boston, MA. Address correspondence to: Harold J. Bursztajn, MD, 96 Larchwood Drive, Cambridge, MA 02138. E-mail: harold_bursztajn{at}hms.harvard.edu

Warren and her colleagues’ timely exploration of the difficulties and uncertainties in diagnosing PTSD and personality disorders in the female inmate population raises fundamental questions for clinical as well as forensic analysis. Questions of under-reporting, over-reporting, and comorbidity in this population point to serious inadequacies in the scheme of categorical, context-independent diagnosis in the Diagnostic and Statistical Manual of Mental Disorders. The interplay of predisposition, life history, and current setting and circumstances can best be captured by a progressive refining of probability estimates. Such a diagnostic process calls for psychodynamically informed clinical and forensic interviewing. Additional recommendations are made for the purpose of achieving multidimensional, context-sensitive diagnosis and forensic evaluation.