Personality Disorders in the DSM-5: proposed revisions and critiques.
|Author:||Good, Emily M.|
|Publication:||Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2012 American Mental Health Counselors Association ISSN: 1040-2861|
|Issue:||Date: Jan, 2012 Source Volume: 34 Source Issue: 1|
|Topic:||NamedWork: Diagnostic and Statistical Manual of Mental Disorders (Reference work)|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
This article discusses the Personality and Personality Disorder
Work Group's proposed changes for Personality Disorders in the
DSM-5: (a) adoption of a hybrid dimensional-categorical model; (b)
utilization of 6 personality disorder types instead of the previous 10
personality disorders; (c) addition of personality traits and facets to
define personality disorders; (d) addition of a rating scale for levels
of personality functioning; (e) revised diagnostic criteria; and (f) the
collapsing of Axes I, II, and III. Also discussed are ways in which the
DSM-5 proposals are reactions to criticisms of the DSM-IV-TR (APA, 2000)
and criticisms of the proposed changes.
The Diagnostic and Statistical Manual of Mental Disorders (DSM; 4th ed. Text Revision [DSM-IV-TR], American Psychiatric Association [APA], 2000) is arguably the most influential classification system for mental disorders (Krueger & Eaton, 2010). Because the conceptualization of Personality Disorders (PDs) in the current DSM has been criticized, substantial changes have been proposed for this area. Several of the proposals alleviate issues associated with the DSM-IV-TR (APA, 2000); others are stirring up new controversy. The final version of the DSM-5 is slated to be presented at the APA Annual Meeting in May 2013. What it will consist of is not yet clear.
The DSM-5 Personality and PD Work Group has "recommended a significant reformulation of the approach to the assessment and diagnosis of personality psychopathology" (APA, 2010b, para. 1). A paper published by Frances (head of the DSM-IV Task Force), Mack, Ross, and First (2000) pointed out that in revising the previous version of the DSM the Task Force had been very conservative in order to maintain continuity between the different volumes of the DSM. The DSM-5 Work Group has adopted a very different approach, the outcome of which is difficult to predict.
Historically, great leaps in science have been met with opposition. Take Galileo, the man who could be called the father of modern science, for example. His proposal that the sun was the center of the universe was in stark contrast to what was understood at that time. He was harshly criticized by his peers and labeled a heretic by the church. Nevertheless, his conception is central to our current understanding of astronomy (Biagioli, 1993). Perhaps the Work Group, like Galileo, is making a dramatic leap. However, historically a large number of leaps in science have been failures--Thomas Edison's invention of the incandescent light bulb, for example. He thought the project would take him a few months. Instead, it took thousands of failed attempts and several years (Delano, 2006).
The risks associated with leaps of science cause significant concern for the DSM-5 revision: in using the finalized method it is individuals, people, who will be diagnosed, or not diagnosed. A PD diagnosis can have a significant impact on a person's life. It can dictate eligibility for social services or for certain jobs, for instance. There is also significant social stigma that attaches to an individual with any DSM diagnosis, but especially a PD diagnosis. Conversely, not being diagnosed with a PD when there is one can prevent individuals from receiving treatment from which they, and those around them, could benefit. Lack of treatment can undermine the physical as well as the mental health of clients (Pilkonis, Hallquist, Morse, & Stepp, 2011). As a result, it is important that diagnosis be judicious and accurate.
Most of the reconceptualizations of PDs, found on Axis II, appear to be in response to problems raised with the current version of the text, the DSM-IV-TR (APA, 2000). The Work Group's proposed format for PDs in the DSM-5 has five components: (a) a hybrid dimensional-categorical model of PDs; (b) addition of a measure to determine level of personality functioning; (c) replacement of the 10 PDs in the current version with 6 personality types; (d) addition of a measure to rate dimensions of personality traits; and (e) a revision of the general diagnostic criteria for PDs (APA, 2011a). Proposals have also been made to restructure the axial system of the DSM, collapsing Axes I, II, and III (APA, 2010a).
The Personality and PD Work Group has recommended a shift to a dimensional-categorical PD model because use of a categorical model in DSM-IV-TR (APA, 2000) has been heavily criticized. That model has been labeled categorical because disorders are assumed to be discrete psychological phenomena that are identified when specific diagnostic criteria are met, placing individuals into categories of pathology (e.g., Borderline PD [BPD]). A dimensional model, on the other hand, uses a series of scales to determine whether pathology is present.
The categorical model has attracted criticism about inaccurate representation of PDs, high instances of comorbidity, and arbitrary thresholds for diagnosis. Skodol et al. (2005) suggested that a categorical model cannot accurately represent the impairment seen in PDs. Currently 12 distinct PDs are described, 10 in the full text and 2 in the appendices; they are diagnosed when a client first meets a general diagnostic criterion (e.g., "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture," APA, 2000, p. 689) and then the more specific criteria for each PD (e.g., "frantic efforts to avoid real or imagined abandonment," APA, 2000, p. 710). However, there is little evidence that the structure of personality pathology is best characterized by these 12 discrete disorders (Widiger, Simonsen, Krueger, Livesley, & Verheul, 2005).
Substantial comorbidity of PD diagnosis with clinical disorders (Axis I) has been found, as well as significant overlap among the PDs themselves (Axis II; Dolan-Sewell, Krueger, & Shea, 2001). In one study, 60.4% of those with a PD diagnosis met the criteria for more than one PD, and 25.2% met the criteria for two or more (Zimmerman, Rothschild, & Chelminski, 2005). This complicates both research design and clinical case conceptualization (Krueger & Eaton, 2010, p. 98). Associated with this issue is the high prevalence of the diagnosis PD "not otherwise specified" (NOS). Verheul and Widiger (2004) and Zimmerman et al. (2005) found that NOS was found in more than 10% of PD diagnoses. This is not clinically useful for numerous reasons, including the paucity of research on PD NOS diagnoses and the lack of information about possible treatments (Krueger & Eaton, 2010).
In response the DSM-5 Personality and PD Work Group has proposed a shift in how PDs are conceptualized. They have proposed retaining only six of the DSM-IV-TR (APA, 2000) PDs (Borderline, Antisocial, Schizotypal, Avoidant, Narcissistic, and Obsessive-compulsive--see the Personality Types section for details). To replace PD NOS, they have proposed a trait system. Each individual with personality pathology, including those who fall into the six retained categories, will be identified by a series of PD traits (see the Personality Traits section for details).
Another problem with the categorical method is the use of arbitrary cutoffs. There has been little to no empirical justification for the thresholds set out in the DSM-IV-TR (APA, 2000; e.g., Kamphuis & Noordhof, 2009), which have resulted in dramatic heterogeneity within disorders. For example, to meet the diagnostic criteria for BPD, an individual must meet five of nine criteria. This means there are 256 different combinations of criteria that can be used to justify a BPD diagnosis. In theory, two clients with that diagnosis might share only one diagnostic criterion (Krueger & Eaton, 2010).
Moreover, with the cut-off points clients may not meet the criteria for a PD diagnosis even though personality pathology is present. Westen (1997) found that 86.5% of clinicians treat individuals for personality problems that do not meet the criteria for an Axis II disorder. Maladaptive personality traits can be listed on Axis II (e.g., listing Borderline traits when the client meets three of the criteria for BPD, but not the five required for that diagnosis), but the DSM-IV-TR (APA, 2000) does not list empirically derived personality traits that can be used for this purpose (Krueger, Skodol, Livesley, & Shrout, 2007).
In response to these problems, the DSM-5 Work Group has proposed adoption of several assessments using dimensional scales (e.g., 5-point Likert scale). The first of these is related to the level of personality functioning, which is a major problem associated with PDs. The next has been created to measure the proposed personality types. Each personality type is further identified by personality traits, which are also identified using a dimensional scale assessment. These changes related to assessments will be discussed in more detail throughout this article.
The Work Group has prescribed an order in which clinicians should use the assessments (APA, 2011a). First, they should determine if personality functioning is impaired. If so, the individual should be assessed to determine if the impairment is consistent with one of the personality types. If not, the personality traits should be used to diagnose PD Trait Specified (PDTS). If a detailed personality profile is desirable, the trait facets can be used to further describe the PD. Even if personality psychopathology is not identified, the personality traits and facets reportedly could be used in case conceptualization.
The Work Group has labeled the resulting diagnostic system for PDs "dimensional-categorical." The dimensional element is found in the use of continuums to identify personality types, personality traits, and levels of personality functioning. The categorical element is largely composed of aspects the Work Group decided to retain from the DSM-/V-TR (APA, 2000), such as the use of certain PDs (e.g., Borderline).
In response to the criticisms of the categorical model in the DSM-IV-TR (APA, 2000), the Work Group has proposed several areas in which to adopt a dimensional model of assessment, one of which concerns levels of personality functioning. The proposed measure and its rationale have been favorably received (e.g., Shedler et al., 2010).
The Work Group proposed a measure to assess personality functioning in both self- and interpersonal functioning. In this assessment, each area of personality functioning contains two subcategories. The subcategories are identity and self-direction for self-functioning, and empathy and intimacy for interpersonal functioning. Each of the subcategories is assessed on a 5-point scale, with "0" representing healthy functioning and "4" severe impairment (APA, 2011b). For example, to receive a "4" in empathy, a client must meet such criteria as inability to contemplate and comprehend the motivations and experiences of others (APA, 2011b).
Hopwood and colleagues (2011) found that in assessing personality psychopathology, generalized severity is the most important single predictor of current and potential dysfunction. They concluded that PDs are best characterized on a personality severity continuum. In the DSM-IV-TR (APA, 2000) neither the general severity specifiers (mild, moderate, and severe) nor the Axis V GAF Scale is sufficient to capture the range of severity seen in PDs (APA, 2011c; Skodol, Clark, et al., 2011). As a result, the Work Group considered it advisable that both self- and interpersonal functioning be assessed for the new version of the DSM.
The personality functioning assessment is prescribed for every individual assessed with the DSM-5. The Work Group asserts that the proposed continuum allows for better understanding of both "normal" and pathological personalities. Impairment in interpersonal function, a key component of the areas targeted by the assessment, has been shown to occur in normal individuals (e.g., Anderson & Cole, 1990) as well as those with PD. An assessment of personality dysfunction may give mental health clinicians an abundance of information for both normal individuals and those diagnosed with a PD, which may be useful in clinical case conceptualization and treatments for all DSM disorders (Clarkin & Huprich, 2011).
THE FIVE PERSONALITY TYPES
The DSM-5 Work Group has proposed that the 10 PDs, PD NOS, and the 2 PDs in the appendices (dependent PD and passive-aggressive PD) be replaced by PDTS and 6 personality prototypes: Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-compulsive, and Schizotypal. Each prototype is defined by several personality traits and facets (see below). The scale upon which clients are assessed is currently being revised (APA, 2011d). This section will describe the proposed prototypes with the Work Group's rationale for them.
Several of the PDs defined in the DSM-IV-TR (APA, 2000) have been reformulated to operate within the proposed trait system: Antisocial PD becomes the Antisocial prototype, defined by the personality traits of antagonism and disinhibition. Avoidant PD is replaced by the Avoidant prototype, defined by detachment and negative affectivity. BPD is reformulated as Borderline prototype, identified by negative affectivity, disinhibition, and antagonism. Obsessive-compulsive PD is renamed Obsessive-compulsive prototype, associated with compulsivity and negative affectivity. Schizotypal PD is reformulated as Schizotypal prototype, defined by psychoticism, detachment, and negative affectivity. (For more detailed description of the personality traits and facets, see the DSM-5 website http://www.dsm5.org/ProposedRevisions/ pages/proposedrevision.aspx?rid=470.)
The other DSM-IV-TR PDs (Paranoid, Schizoid, Histrionic, Dependent, Depressive, and Passive-aggressive) and the diagnosis PD NOS are also described in terms of personality traits and levels of impairment (APA, 2010b). PDTS replaces these categories of diagnoses. The Work Group has created a "cross-walk" to help practitioners transition from the DSM-IV-TR (APA, 2000) to the DSM-5 conceptualization of PDs. The cross-walk identifies each of the DSM-IV-TR (APA, 2000) PDs by its traits and facets (see http://www.dsm5.org/ ProposedRevisions/Pages/DSM-STypeandTraitCross-Walk.aspx).
Skodol (2010) explained the rationale for the changes: First, they should reduce excessive comorbidity among PDs. Second, the current DSM-IV-TR PD categories have been found to be unstable. Third, there is limited validity for some current PDs (see below). Finally, the change will eliminate the problem of arbitrary cut-offs.
PDs have an incredibly high comorbidity rate (Zimmerman et al., 2005). The Work Group believes that reducing the number of PDs will likely reduce comorbidity (Skodol, 2010). Westen, Shedler, and Bradley (2006) found that a prototype matching system like that proposed for the DSM-5 reduced issues of comorbidity compared with the DSM-IV, though the prototype matching system proposed by the Work Group has yet to be empirically validated.
The stability of PD diagnoses has long been a concern. A longitudinal study showed that DSM-IV-TR PDs were less stable over time than their definition suggested (e.g., Grilo et al., 2004). Personality traits are more stable, a rationale for their use. Support for description of specified PD types, such as those proposed by the Work Group, comes from the work of Rottman, Ahn, Sanislow, and Kim (2009).They found that clinicians made fewer accurate and more inaccurate PD diagnoses based on the 30 facets of the five-factor model (FFM) than when they were given a prototype description.
The Work Group has recommended addition of a series of personality traits: negative affectivity, detachment, antagonism, disinhibition, and psychoticism:
* Negative affectivity is defined by the frequent experience of intense negative emotions.
* Detachment is defined by isolation where there are fewer relationships with others and social interactions than would be expected.
* Antagonism is defined by harsh animosity toward others and an inflated sense of self-importance.
* Disinhibition is defined by behaviors that create controversy with others.
* Psychoticism is defined by strange and unusual experiences (APA, 2011e).
Each personality trait is identified by 3 to 9 lower-level facet traits, for a total of 25 (see the DSM-5 website http://www.dsm5.org/Proposed% 20Revision%20Attachments/APA%20Clinician%20Trait%20Rating%20Form.pdf for a detailed description of their arrangement). Each personality trait is rated on a 4-point scale, with "0" indicating very little or no presence of the personality disordered trait and "3" indicating that the trait is extremely descriptive of a particular client (APA, 2011e). Depending on how personality contributes to the client's presenting issue, the traits and facets are prescribed for use in one of three ways: (a) the five traits can be used to produce a "personality overview"; (b) all the facets can be used to produce a "comprehensive personality profile"; or (c) all five traits are rated using the clinical scale followed by all of the facets for categories in which an individual is rated with a "2" or "3" (APA, 2011e).
Citing several reasons for the proposed changes, Clark and Krueger (2010) explained that using traits in diagnosing PDs (a) eliminates the problems associated with comorbidity and PD NOS diagnoses; (b) clarifies within-diagnosis heterogeneity; (c) increases diagnostic stability; (d) acknowledges the continuum of personality and PDs; and (e) improves the convergent and discriminative validity of PD assessment. They also explained the rationale for the specific personality traits prescribed. The DSM-IV-TR (APA, 2000) PDs have been found (see, e.g., Malouff, Thorsteinsson, & Schutte, 2005; O'Connor, 2005; Saulsman & Page, 2004; Widiger & Simonsen, 2005) to be highly correlated with four FFM personality traits: neuroticism, extraversion, agreeableness, and conscientiousness. The Work Group has adapted these four traits, with neuroticism becoming negative affectivity, extraversion detachment, agreeableness antagonism, and conscientiousness disinhibition. Each reformulation represents one of the extremes of the FFM. However, because these factors relate to only some of the problems associated with schizotypal PD, the psychoticism trait was added. Clark and Krueger (2010) warned that while these traits and facets are representative of both normal and abnormal personality, they are provisional and their structural validity is still being tested.
GENERAL DIAGNOSTIC CRITERIA FOR PD
Given the considerable proposed changes in diagnosis of PDs, the DSM-5 Work Group revised the general diagnostic criteria. The revision begins with a proposal for a new definition of PD: PD corresponds with a failure to establish a sense of self-identity and the ability for interpersonal functioning that are adaptive within the frame of an individual's cultural norms and expectations (APA, 2010b). PD is further conceptualized by several criteria, which are listed on the DSM-5 website (http://www.dsm5.org/proposedrevision/pages/personalitydisorders.aspx).
In discussing the changes in the diagnostic criteria for PD, Livesley (2010) cited the shift to a dimensional-categorical model as a significant rationale for them. Noting that "DSM-IV criteria are poorly defined and not specific to PD," he highlighted that extreme personality traits, though necessary, are not sufficient for a PD diagnosis (see Wakefield, 1992, 2008). Livesley explained that a Work Group literature review had identified pervasive disorganization in personality functioning and structure as central to the diagnosis of a PD. His research (Livesley, 1998) supports the focus in the new definition of PDs on self and interpersonal functioning.
COLLAPSING THE DSM AXIAL SYSTEM
A Work Group subgroup has been charged with examining the axial system of the DSM-IV-TR (APA, 2000). It has recommended that Axes I, II, and III be combined, on the theory that this will bring the DSM-5 into "greater harmony with the single-Axis approach used by the international community in the World Health Organization's International Classification of Diseases (ICD)" (APA, 2010a, para. 1).
This decision is supported by research demonstrating that the DSM-IV-TR (APA, 2000) distinction between Axis I and Axis II has little empirical basis (Krueger, 2005). Krueger et al. (2007) have argued that moving PDs to Axis I would give them a status equivalent to that of Axis I disorders. The change could have a serious impact on third-party repayment, because it would be an acknowledgment of the debilitating nature of PDs (Skodol et al., 2005).
Several concerns have been expressed about the proposed changes for diagnosing PDs. One large area of criticism relates to the proposed elimination of certain DSM-IV-TR (APA, 2000) disorders. Similarly, the proposed trait system, including the PDTS diagnosis, has raised major concerns. There have also been questions about the utility of the proposed system for both "normal" individuals and those with PDs and about the impact on research.
The lack of empirical support for certain PDs is cited as the reason for their elimination (Skodol, 2010). Skodol (2010) explained that there is substantial empirical support for Antisocial, Borderline, and Schizotypal PDs (e.g., Patrick, Fowles, & Krueger, 2009; Siever & Davis, 2004). What seems to be lacking, however, is any empirical support for eliminating any disorders. Moreover, some researchers have argued that there is empirical validation and clinical utility for some disorders that are to be eliminated: Bornstein (2011) cited several problems with studies conducted by the Work Group that resulted in this decision. He claims that the Work Group did not provide adequate information on the parameters of the literature search. Further, he noted only mixed empirical support for the proposed changes. Finally, he highlighted that selective attention is paid to certain disorders while others are ignored. To address some of these concerns, the Work Group has proposed use of the Personality Type and Trait Cross-Walk, enabling clinicians and researchers to identify PDs proposed for elimination by their traits and facets (see the DSM-5 website at http://www.dsm5.org/ProposedRevisions/Pages/DSM-5Typeand TraitCross-Walk.aspx).
Shedler et al. (2010) have argued that the personality types proposed are not adequate to encompass the diversity of personality pathology seen in clinical practice. This is supported by research that suggests that the 10 PD categories in the DSM-IV-TR (APA, 2000) do not exhaust the varieties of personality pathology seen in clinical practice (Westen & Arkowitz-Westen, 1998). Why eliminate diagnoses that have clinical utility? Skodol, Bender, et al. (2011) cited lack of empirical validation and low clinical utility as the rationale for eliminating disorders. A study by Blashfield and Intoccia (2000) indicated, however, that there was very little research on most DSM-defined PDs. Shedler et al. (2010) similarly argued that absence of evidence supporting the existence of PDs is not the same as evidence that they do not exist.
Also criticized is the Work Group claim that clinicians "prefer" the trait system method for diagnosing PDs. Zimmerman (2011) pointed out that no study is cited to support this claim, and that in fact there is substantial evidence to indicate the opposite. Shedler et al. (2010) identified two studies (Spitzer, First, Shedler, Westen, & Skodol, 2008; and Rottman et al., 2009) that demonstrated that "clinicians find dimensional trait approaches significantly less relevant and useful, and consider them worse, than the current DSM-IV system" (p. 1027).
Another argument against the proposed system is that it is not useful with a normal population. Clark and Krueger (2010) argued that the proposed system can be utilized with both normal and PD clients because negative emotionality (now negative affectivity), introversion (now detachment), antagonism, and disinhibition represent polar extremes to the FFM (e.g., detachment is the opposite of the FFM extraversion). Although these traits are very similar to the traits identified in the pathological five model (PFM; Krueger & Eaton, 2010), the resemblance between the PFM and the FFM at the domain level is not perfectly isometric, which raises a concern that the proposed system cannot be used with a normal population--an issue compounded by the use of only one of the polar extremes of personality. Widiger (2011) argued that normal personality traits cannot be found anywhere in the proposal.
A final concern relates to the effect the proposed changes in PD definition will have on research. The Work Group suggested that the diagnosis PDTS will eliminate the use of PD NOS. Although the change seems to eliminate the clinical problem associated with wide variations in PD NOS diagnosis, it exacerbates a known problem: The proposed changes in PDs are not specific enough to identify the relevant populations. The pendulum may have swung to the other extreme. Now, instead of having 10 diagnoses, there are 31 arrangements of personality traits, including those used by the 6 retained disorders, and more than 33 million arrangements of personality facets. This is compounded by the elimination of six PDs found in the DSM-IV-TR.
Rather than using existing assessments of PDs that have empirical foundations and have undergone peer review, the Personality and Personality Disorder Work Group has decided to take on the cumbersome task of creating its own model. Producing valid and reliable measures could take years. However, the Work Group has decided to push the model into field trials. John Livesley, a respected member of the Work Group, has expressed concern about the lack of empirical support for the model (Jones, 2011).
Clinical use of the proposed system is daunting, with 3 different dimensional scales for rating personality functioning, 6 personality types, 5 personality traits, and 25 personality facets. Some researchers fear that the proposed system is so complicated that clinicians will only identify whether personality pathology is present, rather than completing the full process for diagnosis (Pincus, 2011). Pilkonis et al. (2011) have argued that such deferral of diagnosis could have drastic implications for identification and treatment of individuals with PDs.
The DSM-5 is scheduled for publication in 2013. Several of the proposals alleviate issues associated with the DSM-IV-TR (APA, 2000); others are arousing new controversy. Field trials testing the proposals have begun, and significant changes have already been made to the initial proposals, resolving some of the problems raised. However, others remain. If these are not worked out in the field trials, this leap in conceptualizing and diagnosing PDs may produce a system that is virtually unusable in either practice or research. Time will tell if these revisions represent a leap forward or a leap backward. The only thing that is clear at this point is that whatever is published needs to be treated as a living document rather than as diagnostic dogma.
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Emily M. Good is affiliated with Indiana University. Correspondence concerning this article should be directed to her at 4110 S. Grand Haven Dr., Bloomington, IN 47401. E-mail: email@example.com.
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