HUNTINGTON BEACH, CALIF. – In the opinion of Dr. John M. Oldham, clinicians who deem the alternative personality disorder model of the DSM-5 as too confusing are misguided.
“If you’re going to compare DSM-5 alternative personality disorder model with the DSM-IV model, you have to do a fair comparison,” Dr. Oldham told attendees at the annual meeting of the American College of Psychiatrists. ”In fact, we reduced the number of items that you have to measure by 43%.”
Dr. John M. Oldham
So when people describe the DSM-5’s personality disorders criteria as more complicated, he continued, “what they really mean is, ‘it’s more complicated than what I do,’ not that it’s more complicated than [the] DSM-IV.”
Along with Dr. Andrew E. Skodol, Dr. Oldham cochaired a work group of experts convened by the American Psychiatric Association to update diagnostic criteria related to personality and personality disorders for the DSM-5. “We took our work and our charge seriously,” recalled Dr. Oldham, senior vice president and chief of staff at the Menninger Clinic, Houston. “It was not easy. We had many challenges. A great deal of research has been done in the factor analytic research psychology world around things like the five-factor model of personality. Such terms are not always terribly familiar in clinical medicine, so there was a problem with the lack of familiarity. Then there were vested interests different groups had that were influential in some ways.”
Dr. Andrew E. Skodol
Ultimately, the alternative personality disorder model was placed in section III of the DSM-5. The model enables clinicians “to individually portray the dimensions of the patient’s pathology in a thorough and broad way,” Dr. Oldham explained. “We emphasize impairment in functioning. That’s an important new requirement. So you have to determine, by using the level of functioning scale, whether the person does or doesn’t have moderate or greater impairment. If you have a patient with mild impairment, you can describe what you’re concerned about, but you’re not putting that patient into a diagnostic box of pathology. There is a dimensional scope that enables you to capture many types of patients.”
An empirical study of 337 clinicians demonstrated that in 14 of 18 comparisons, respondents deemed the DSM-5 pathological personality traits as more clinical useful, compared with the DSM-IV, with respect to ease of use, communication of clinical information to other professionals, communication of clinical information to patients, comprehensiveness in describing pathology, and treatment planning (J. Abnorm. Psychol. 2013;122:836-41). “In fact, this was a preference to the new model, which was unfamiliar, compared to the model that these clinicians had been using for 20 years,” Dr. Oldham said.
The study also found that the new DSM-5 personality disorder model was more strongly related to clinical decision making in areas of global functioning, risk assessment, recommended treatment type and intensity, and prognosis.
According to unpublished data from the DSM-5 field trials conducted in the United States and Canada, more than 80% of clinicians in academic and routine clinical practice fields found the new personality disorder criteria “moderately” to “extremely” useful, compared with the DSM-IV. In fact, the respondents rated the new criteria as more useful than other changes to the DSM-5, including those related to bipolar and related disorders, schizophrenia spectrum and other psychotic disorders, and other conditions.
In addition, a test-retest reliability study conducted at 11 academic medical centers found that the new model for borderline personality disorder had a good test-retest reliability (.054), in the same ballpark as that for bipolar I disorder (0.56) and schizophrenia (.50) (Am. J. Psychiatry 2013;170:43-58). “This surprised a lot of people,” Dr. Oldham said.
About 1 year after the DSM-5’s release, Medscape Psychiatry surveyed almost 3,000 clinicians about their impressions of the new guidelines. Of the 2,828 respondents, nearly one-third (28%) were psychiatrists, 22% were psychologists, 13% were family medicine clinicians, and the rest were from other medical fields. The researchers found that 39% of survey respondents were considering the dimensional approaches offered in the new personality disorder criteria of the DSM-5.
“That’s not bad,” Dr. Oldham said.
He reported having no relevant financial conflicts.
On Twitter @dougbrunk