Simone Hoermann, Ph.D., is a Psychologist in private practice in New York City. She specializes in providing psychotherapy for Personality Disorders, Anxiety, and Depression ...Read More
I wrote last week about the proposal for a revision of the psychiatric diagnostic manual (DSM) published by the American Psychiatric Association for public commentary on February 10. The proposal for DSM 5 includes some significant changes regarding the definition and conceptualization of personality disorders.
The current version of the manual, DSM IV, requires mental health professionals to establish a psychiatric diagnosis on 5 separate axes. Essentially, this constitutes a distinction between major psychiatric disorders that are mostly considered episodic and transient on axis I, and personality disorders, viewed as pervasive and stable over time, on axis II. While DSM IV has many advantages and has significantly spurred research, there are also many difficulties that illustrate just how hard it is to define concepts as elusive as mental health or mental illness, let alone “healthy” or “disordered” personality. Therefore, ever since the inception of DSM IV, there has been massive debate amongst experts about whether the axes were useful and valid, and whether personality disorders were well-defined.
Amongst the most intensively debated questions is whether or not personality disorders are distinct categories that are different from healthy personalities, or whether personality disorders and healthy personalities exist on a continuum. In case of the latter, personality disorders would constitute extreme variations along dimensions of characteristics. In other words, take the example of pregnancy: You are either pregnant or you’re not (categorical). Compare that to blood pressure, which is measured on a continuum (dimensional). Low blood pressure would mean that the value is on one extreme end of the continuum, and high blood pressure means that the value is on the other extreme end.
DSM IV ‘s approach to personality disorders is categorical: A person has a personality disorder, or they don’t. For each of the 10 personality disorders recognized in DSM IV, a specific set of criteria has been defined. In order to be given a personality disorder diagnosis, a person needs to meet a certain number of those defined criteria. If a person does not meet enough criteria for a specific personality disorder, but meets a certain number of criteria of different personality disorders, the diagnosis is Personality Disorder Not Otherwise Specified.
Research has shown that there are many problems with the DSM IV approach: Many people with personality disorders meet criteria for more than just one personality disorder, a phenomenon called “high co-occurrence”. In addition, people diagnosed with the same personality disorder can have very different characteristics, depending of which criteria they meet. For example, for Borderline Personality Disorder, a person has to meet 5 out of 9 criteria. This means that any 2 people diagnosed with Borderline Personality Disorder could potentially only have 1 criterion on common. This phenomenon is referred to as “high heterogeneity”. Lastly, the diagnosis of Personality Disorder Not Otherwise Specified appears to be one of the most commonly given diagnoses when it comes to personality disorders. This is an indication that a lot of people appear to meet criteria for more than 1 personality disorder, but not sufficient criteria for a specific personality disorder.
What all of this means that the definition of personality disorders in DSM IV has many difficulties, and that there has been much debate about how accurate and useful its definition of personality disorders is.
So let’s look at the current proposal for DSM 5. The general definition of personality disorder has been completely revamped. DSM IV defined personality disorders by talking about deficits in 4 areas: thinking, impulse control, emotion regulation, and interpersonal relationships. In comparison, the new DSM 5 definition of a personality disorder has only 2 domains, namely identity (sense of self) and interpersonal functioning (relationships).
The idea is that someone with a personality disorder typically has difficulties with identity, that is, with establishing a coherent sense of self over time. A poorly integrated sense of sense means that someone has intensely shifting internal states, or feels like they are completely different from one moment to the next. This concept of identity also includes being able to describe oneself in a way that gives a rich and nuanced image and includes both positive and negative attributes, and has to do with a sense of goals and direction in life.
The second area of functioning, interpersonal relationships, can be impacted in someone with a personality disorder in that they lack empathy, or they may lack the ability to understand the internal state of other people; They may have difficulties with establishing and maintaining close relationships, may have difficulties to develop moral or altruistic behaviors, and may hold poorly developed internal images of other people.
In addition, DSM 5 suggests that clinicians should rate the person on 6 different domains of personality traits: Negative emotionality (anger, anxiety, depression, guilt, worry, shame) , introversion, antagonisms, disinhibition, compulsivity, and schizotypy. Negative emotionality means a person has a strong tendency to frequently and intensely experience negative feelings such as anger, anxiety, depression, guilt, worry, shame. Introversion has to do with being withdrawn and detached. Antagonism has to do with antipathy and aggression towards others. Disinhibition has to do with difficulties in controlling impulses. The terms compulsivity describes a rigid and narrow style that is focused on strict ideals, and lastly, schizotypy covers odd and unusual behaviors. Each of these trait domains can be subdivided into 4-10 facets, totaling 37 trait facets to be rated.
Finally, the diagnosis of a personality disorder according to DSM 5 is warranted if a person shows significant difficulties in one or both functional areas (identity and interpersonal relationships), and they have extreme ratings on the personality trait domains, and the problems have been present for a long time, and cannot be explained by another condition or the use of a substance.
As you can see, the newly proposed definition in DSM 5 is very different from DSM IV. The focus in DSM 5 seems to be on rating dimensions rather than thinking about categories. The clinician is supposed to rate dimensions of personality traits, of functioning, and to what degree a person meets the description of a prototype. This is in sharp contrast to the categorical approach of DSM IV, in which criteria sets are provided for each of the 10 personality disorders and a person has to meet a certain number of criteria.
While some clinicians are puzzled by the reduction of 10 personality disorders to only 5 prototypes (particularly the disappearance of narcissistic personality disorder has received some reaction), Allen Francis, a former driving force behind DSM IV, reprimanded the authors of DSM 5 in his recent article in the Psychiatric Times for “its unnecessary secretiveness, its risky ambitions, its disorganized methods, and its unrealistic deadlines.” Deploring the loss of the multi-axial diagnostic system of DSM IV, his main word of caution regarding the new conceptualization of personality disorders is that “the multiple, complicated, confusing, and cumbersome systems suggested for DSM 5 would be far too unfamiliar and time consuming to ever be used by clinicians.”
The proposal of DSM 5 states clearly that the section on personality disorders is not yet firmed up, and that some of these suggestions are still preliminary. Field trials are supposed to establish whether the new approach can be considered valid and clinically useful. More debate is to be expected, and it will be interesting to observe what transpires over the next few years.