What's New (and Old) in the DSM-5 Personality Disorders

When DSM-5.0 (Diagnostic and Statistical Manual) is published in May of 2013 by the American Psychiatric Association, mental health professionals will face the task of learning a new classification system to use when they provide diagnoses of their clients. The draft versions of the DSM were available for comment and review until December 2012, when final changes were voted into effect.

Highly anticipated were proposed changes in the section of the DSM dealing with long-standing personality disturbances, known as "Personality Disorders." After reviewing the extensive studies available on the website and in the psychiatric literature, all of which suggested that changes were all but certain to occur I had expected the personality disorder section to be radically revamped. It wasn't. Here you will learn the background to the proposed changes and what the ultimate decision not to change the system (for now) will mean for you. I should note that many of the people who worked on the DSM-5 are hopeful that their recommendations will ultimately be adopted in some form, perhaps a "DSM-5.1" (hence my use of the term "5.0"). In the meantime, the system that was proposed, but not approved, appears in a section of the manual intended to guide further research.

Before I get to explaining more about the personality disorders, let's take a look at personality's general meaning. Personality is a complex set of characteristics that make us who we are, at least when it comes to our typical behaviors, ways of coping, and attitudes toward ourselves and others. Many regard our personalities as made up of dispositions or prominent tendencies that remain relatively consistent throughout our life situations and relationships. According to what is probably the most widely-accepted theory, the Five Factor Model, these personality traits divide up into a group of 30, with 5 major groupings (the Five Factors) that each contain 6 subtraits or facets. The traits fit nicely into the acronyms “CANOE” or “OCEAN” and are much like they sound: Conscientiousness, Agreeableness, Neuroticism, Openness to Experience, and Extraversion.

We see the world through the template of our personalities. As such, they both shape and are shaped by the many types of events we encounter, ranging from close interactions with people in our own homes and communities to the more distant but still relevant in the world at large. The neurotic can always find much to worry about, and the extravert tends to believe that others are equally social and gregarious. However, our personalities can be shaped by our experiences. Being constantly rejected by others for no obvious reason can make even the most emotionally stable of us start to develop the self-doubts and worry that characterize the individual high in neuroticism.

The Five Factor traits aren’t the sum and substance of our psychological makeup, but they do allow psychologists to quantify many of the inner forces that guide behavior. Within a short time after the Five Factor model appeared on the psychological landscape, clinicians began to wonder how they could be used to gain a better understanding of psychological disorders. The most natural area for the Five Factor Model to be applied was the group of what psychiatry calls “personality disorders.”

Ever since the days when Freudian psychoanalysts reigned over American psychiatry, peaking in the 1940s and 1950s, clinicians believed that they needed to distinguish longstanding maladaptive ways of relating to the world from the sorts of clinical “syndromes” such as mood and anxiety disorders that can rise and fall over the course of a person’s life. The DSM, introduced in 1952, was intended to give psychiatrists and other mental health professionals in the U.S. a way to provide diagnoses based on common definitions, though it was not until 1980 (with DSM-III) that specific criteria were introduced. The purpose of the DSM was to aid both diagnosis and “statistics,” in that with clearer labels, clinicians would be able to estimate the prevalence of major psychiatric disorders.

The personality disorders (called “disturbances” in the first DSM) didn’t fit quite as neatly into this illness-based system. Considered part of the “fabric” of the individual’s being, eventually, the personality disorders were put into a separate place in the manual, referred to as “Axis II.” Each personality disorder was given its own name and set of unique diagnostic criteria, leaving “Personality Disorder Not Otherwise Specified” as the catchall for people who didn’t tidily fit into one of the existing diagnoses.

All of this background is necessary for understanding what the DSM-5.0 authors wanted to do when assigned the charge of redoing the previous diagnostic system, which at that point was called DSM-IV-TR (“TR” meaning “text revision”). Work Groups were established comprised of experts in that particular field of clinical research, and given the charge of starting from scratch, if necessary, to improve what many agreed to be a set of diagnoses that no longer met the criteria for scientific rigor of being reliable (meaning that different clinicians would agree on the diagnoses and valid (meaning that if you were given a diagnosis, you actually had that very thing wrong with you). The model was based on the one that physicians use to assign medical (i.e. non-psychiatric) illnesses. If you have a broken finger, for example, you qualify for a diagnosis of broken finger, not stubbed toe. Diagnosticians don’t always agree on medical diagnoses, obviously, but with a clear set of diagnostic guidelines, they can reduce uncertainty for many cases, particularly those that are clear-cut such as the example of the broken finger and the toe.

Because of their history, their inherent difference from clinical syndromes, and a mystique that developed around many of their names (e.g. “Psychopath,” “Histrionic,” “Borderline”), the personality disorders were always particularly difficult to diagnose. You might be diagnosed as having Narcissistic Personality Disorder by one mental health professional, only to be told by another that you were actually Histrionic. From your vantage point, this could mean that you were be given two entirely different treatment plans depending on which diagnosis best suited you. What’s worse, the terms had acquired a great deal extra meaning because of their long history and seemed almost pejorative to some individuals.

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These problems led those in the Personality and Personality Disorders Work Group to look long and hard at plucking the personality disorders off the diagnostic tree. Here was the Five Factor model, growing in acceptance, providing a ready rubric that could be easily quantified. Scientists who had worked on the model were themselves busily developing systems that would allow clinicians to throw aside the categorical terms in the DSM-IV-TR.

As the DSM-5.0 Personality and Personality Disorder Work Groupbegan to convene, they were well versed in these issues and seemed prepared to consider anything and everything for the new improved system. In addition to objecting on scientific and clinical grounds, many preferred a dimensional system because of the inherent problems in a categorical system. When you give someone a categorical diagnosis, they either have the disorder or not. When it comes to personality, however, the reality is that people have a little more of this and a little less of that. There are no categories in the Five Factor Model. Moreover, the personality disorders diagnoses don’t say which symptoms you have to show in order to receive a diagnosis. Out of a collection of a possible 9, for example, you would need to have 5- just any of the 5. This seemed, to the Work Group, to introduce a certain arbitrariness into the categorical system.

In the process of revising the DSM-IV-TR, the personality disorders panel developed a number of alternative models to get away from the categorical diagnostic system. The most extreme was to dispense with the named categorical diagnoses entirely. However, this idea was dispensed with relatively early in the process because many commentators, viewing the information on the DSM5 website, believed that the categories had inherent value. The DSM-5.0 Work Group members then proposed a compromise in which six would be retained (plus one called “personality disorder-trait specified to replace “not otherwise specified”).

To maintain the spirit of their original intent, however, the work group came up with empirically-based criteria representing each personality disorder to allow clinicians to perform some dimensional ratings. In this framework, clinicians would evaluate all clients on elements of personality functioning (e.g., identity, self-direction, empathy, and intimacy) and on five sets of personality traits. All of this seemed like a reasonable compromise. Some clinicians criticized the cobbled-together DSM-5.0 for being too confusing and not clinically useful despite the fact that DSM-5 Field Trials and surveys of clinicians gave the new system high marks for usefulness.

When it came time for the American Psychiatric Association Board of Trustees to approve the final draft (which had previously been published on the APA website), they voted down the new proposal, relegating the new system to a section of the manual to be used for research purposes in what will be called “Section III: Emerging Measures and Models.” Although the vote was publicly announced to the media, the details were kept relatively quiet, and it would take another nearly 3 months for the association to post the new Table of Contents on its website (having removed all prior content posted during the revision phase).

The tension between the categorical and dimensional approaches to disorders will most likely persist for the upcoming decade, if not longer. By revising the personality disorders so dramatically, researchers had hoped to provide a system that would have diagnostic and empirical utility, ultimately, improving the nature of treatment to offer clients with these forms of psychopathology. For the moment, however, we will be left with a system that is at least 30 years old and, according to some, was in need of repair.

How could the decision to keep the DSM-5.0 personality disorders the same affect you? In one sense, it won’t affect you at all. You (or someone you love) will still receive a diagnosis, the same one that you would have received with the DSM-IV-TR. Clinicians are familiar with the current system and researchers have collected decades’ worth of data based on the current categories. There are empirically validated treatments that are pegged to the current labels, such as those available for people with Borderline Personality Disorder. What you may not be able to benefit from, however, were the changes that the work group proposed which would have provided dimensional ratings and removed some of the disorders whose reliability and validity were not as well-established as others.

If DSM-5.0 becomes a true “5.0,” meaning that it will be updated with more research and clinical studies, you may very well be able to benefit from greater insight into these disorders and, as a result, more effective interventions.

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Copyright Susan Krauss Whitbourne, Ph.D. 2013

Reference:

Skodol, A.E. (2012). Personality disorders in DSM-5. Annual Review of Clinical Psychology, 8,317-344.