Evidence-Based Reviews

Redefining personality disorders: Proposed revisions for DSM-5

Current Psychiatry. 2011 September;10(9):26-38

References

1. DSM-5 revisions for personality disorders reflect major change. Public comment period for proposed diagnostic criteria extended through July 15 [news release]. Arlington, VA: American Psychiatric Association; July 7, 2011. http://www.psych.org/MainMenu/Newsroom/NewsReleases/2011-News-Releases_1/DSM-5-Revisions-for-Personality-Disorders-Reflect-Major-Change-.aspx?FT=.pdf. Accessed July 26, 2011.

2. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.

3. Personality disorders. American Psychiatric Association DSM-5 development. http://www.dsm5.org/proposedrevision/Pages/PersonalityDisorders.aspx. Updated June 21, 2011. Accessed July 26, 2011.

4. Oldham JM, Skodol AE, Kellman HD, et al. Diagnosis of DSM-III-R personality disorders by two structured interviews: patterns of comorbidity. Am J Psychiatry. 1992;149(2):213-220.

5. Zimmerman M. Is there adequate empirical justification for radically revising the personality disorders section for DSM-5? Personality Disorders: Theory, Research and Treatment. In press.

6. Zimmerman M, Chelminski I, Young D, et al. Does DSM-IV already capture the dimensional nature of personality disorders? J Clin Psychiatry. In press.

7. Zimmerman M, Chelminski I, Young D, et al. Does the presence of one feature of borderline personality disorder have clinical significance?: Implications for dimensional ratings of personality disorders. J Clin Psychiatry. In press.

8. Asnaani A, Chelminski I, Young D, et al. Heterogeneity of borderline personality disorder: do the number of criteria met make a difference? J Pers Disord. 2007;21(6):615-625.

9. Skodol AE, Oldham JM, Bender DS, et al. Dimensional representations of DSM-IV personality disorders: relationships to functional impairment. Am J Psychiatry. 2005;162:1919-1925.

10. Durbin CE, Klein DN. Ten-year stability of personality disorders among outpatients with mood disorders. J Abnorm Psychol. 2006;115:75-84.

11. Grilo CM, Sanislow CA, Gunderson JG, et al. Two-year stability and change of schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. J Consult Clin Psychol. 2004;72:767-775.

12. Morey LC, Hopwood CJ, Gunderson JG, et al. Comparison of alternative models for personality disorders. Psychol Med. 2007;37:983-994.

13. Zimmerman M, Chelminski I, Young D, et al. Is dimensional scoring of borderline personality disorder only important for subthreshold levels of severity? J Pers Disord. In press.

14. Gunderson JG, Shea MT, Skodol AE, et al. The Collaborative Longitudinal Personality Disorders Study: development, aims, design, and sample characteristics. J Pers Disord. 2000;14(4):300-315.

15. Zimmerman M, Chelminski I, Young D, et al. Impact of deleting 5 DSM-IV personality disorders on prevalence, comorbidity, and the association between personality disorder pathology and psychosocial morbidity. J Clin Psychiatry. In press.

Clinical Point

Using the proposed criteria, we found that 10% of those previously diagnosed with a PD would no longer be diagnosed

We found that the comorbidity rates did, in fact, drop from 30% to 21%. We found that the rate of PDs dropped only a little, but approximately 10% of individuals who previously would have been diagnosed with a PD would no longer be diagnosed. We compared individuals in the excluded group—those who had only 1 of the PDs that would no longer be considered a PD—with a group of patients who had a retained PD and also compared them to individuals with no PD. We found that the retained PD group and the excluded group did not differ on measures of psychosocial morbidity, such as Global Assessment of Functioning scores, hospitalizations, suicidality, number of current axis I disorders, etc. Also, the excluded group clearly was different than the no PD group. We questioned whether or not those in the excluded group might end up being false negative diagnoses in DSM-5. Certainly DSM-5 provides a provision to use trait ratings to still diagnose a PD, called personality disorder trait specified, which would be somewhat analogous to PD not otherwise specified (NOS).

Clinical Point

The proposal to eliminate some PDs could result in more PD not otherwise specified diagnoses

It’s ironic insofar as another of the issues considered by the DSM-5 Work Group to be a problem with axis II is lack of coverage and that too many individuals are diagnosed with PD NOS. Their proposal to exclude PDs could result in more individuals being diagnosed with PD NOS. I know the group would disagree with that perspective, but they provided no evidence to support its view.

As I said at the beginning of this interview, I think we should be talking about this from a scientific perspective and nothing more than that.

Related Resource

Widiger TA, Simonsen E, Sirovatka PJ, et al. Dimensional models of personality disorders: Refining the research agenda for DSM-V. Arlington, VA: American Psychiatric Publishing, Inc; 2007.

Disclosures

Dr. Zimmerman reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Black receives research support from AstraZeneca and Psyadon.