Evidence-Based Reviews

Redefining personality disorders: Proposed revisions for DSM-5

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Latest proposal would change disorders into types, eliminate 4 disorders


 

References

A major update to the diagnostic manual used by mental health clinicians around the world is expected to inspire lively debate. Proposed revisions to the personality disorders (PD) section of the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is scheduled to be published in 2013, have generated great controversy because they would introduce a dimensional model to the categorical system and 4 PDs would be eliminated.

“The importance of personality functioning and personality traits is the major innovation here,” said Andrew Skodol, MD, the DSM-5 Personality and Personality Disorders Work Group’s chair and a Research Professor of Psychiatry at the University of Arizona College of Medicine. “In the past, we viewed personality disorders as binary. You either had one or you didn’t. But we now understand that personality pathology is a matter of degree.”1

Mark Zimmerman, MD, has written several papers—some of which are in press—about how these revisions might impact clinicians and whether the revisions are necessary. He is Director of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, an ongoing clinical research study involving the integration of research assessment methods into clinical practice.

Proposed revisions, rationale, and literature reviews for DSM-5 are available at www.DSM5.org and anyone, including the general public, was invited to provide feedback through the Web site. Current Psychiatry Associate Editor Donald W. Black, MD, interviewed Dr. Zimmerman on June 29, 2011, just a few days after the latest proposed revision was posted on June 21, 2011.

DR. BLACK: What is your understanding of the DSM-5 Personality Disorders Work Group proposal to revamp the PD category?

DR. ZIMMERMAN: The initial proposal, released in February 2010, was complex and generated a fair amount of critical commentary related to the marked changes in the approach toward diagnosis of PDs. That proposal replaced diagnostic criteria with a prototype description of personality types that patients would need to match. It also eliminated 5 PDs—paranoid, schizoid, histrionic, dependent, and narcissistic—retained antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal, and introduced trait level ratings. The June 21 revision proposes eliminating only 4 disorders—narcissistic was retained—and the Work Group is no longer suggesting using prototypes but instead have diagnostic criteria (Table).2,3 We do not know if this is the final proposal because similar to the first proposal, it is not presented with much supporting empirical evidence that demonstrates its superiority toward diagnosing PDs compared with the DSM-IV approach.

Table

Personality disorder criteria: DSM-IV vs DSM-5

DSM-IVDSM-5 proposal (posted June 21, 2011)
General diagnostic criteria
  1. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in 2 or more of the following areas:
    1. ognition (ie, ways of perceiving and interpreting self, other people, and events)
    2. affectivity (ie, the range, intensity, lability, and appropriateness of emotional response)
    3. interpersonal functioning
    4. impulse control
  2. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations
  3. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning
  4. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood
  5. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder
  6. The enduring pattern is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, head trauma)
  1. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning
  2. One or more pathological personality trait domains or trait facets
  3. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations
  4. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment
  5. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, severe head trauma)
Personality disorders included
Antisocial, avoidant, borderline, dependent, histrionic, narcissistic, obsessive-compulsive, paranoid, schizoid, schizotypal, personality disorder not otherwise specifiedAntisocial, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypal, personality disorder trait specified (requires a rating of significant impairment in personality functioning, combined with the presence of pathological trait domains or facets)
Source: References 2,3

I’m not suggesting that the DSM-IV approach is without problems. My attitude is that before going forward with a change to the official diagnostic nomenclature, you need to clearly establish that the new way of doing things is better than the previous way by whatever metric you use.

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