Study supports alternative model for personality disorders in upcoming DSM-5
A new “alternative model” included in the upcoming Fifth Edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM -5) lines up well with the current approach to diagnosis of personality disorder, according to a study in the May Journal of Psychiatric Practice. The journal is published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.
The findings lend support to the new “hybrid” model, which combines the “core” dimensions of personality disorder with various maladaptive personality traits found in individual patients, according to the report by Leslie C. Morey, PhD, of Texas A & M University and Andrew E. Skodol, MD, of the University of Arizona College of Medicine and Columbia University College of Physicians and Surgeons.
Hybrid Model Compares Well with DSM-IV Diagnosis of Personality Disorders
Experts working on the long-awaited DSM-5 - to be published later this month - recommended substantial revisions to the section on personality disorders. Specifically, they proposed a “hybrid categorical-dimensional model” including not only “core impairments in personality functioning” but also various combinations of “pathological personality traits” associated with these conditions. Goals of the proposal included:
Reducing overlap among personality disorder diagnoses
Reducing heterogeneity among patients receiving the same diagnosis
Eliminating arbitrary diagnostic thresholds with little or no research basis
Addressing the widespread use of the vague “personality disorder not otherwise specified” diagnosis
Providing diagnostic thresholds that are related to level of impairment in a meaningful way
Although the proposal was endorsed by the DSM-5 Task Force, it was decided that the hybrid model required more research support before being fully adopted. Therefore, the hybrid model will be referred to as an “alternative model” and placed in Section III of the DSM-5, which contains concepts for which further research is needed. Meanwhile, the main body of the DSM-5 will retain the DSM-IV criteria for personality disorders.
A key concern was whether the new model would lead to discrepancies between DSM-IV and DSM-5 definitions of the same disorder—especially for diagnoses such as borderline, antisocial, and schizotypal personality disorders for which a substantial body of research literature exists. “It is important to evaluate whether thresholds can be established that provide solid continuity between DSM-IV and proposed DSM-5 definitions,” Drs Morey and Skodol write.
Their study included a national sample of 337 patients, who were diagnosed under both systems by clinicians familiar with their cases. The results showed appreciable correspondence between the DSM-IV diagnosis of personality disorders and the hybrid categorical-dimensional diagnostic model proposed for DSM-5. The two models agreed well for various subtypes, including borderline, avoidant, obsessive-compulsive, antisocial, narcissistic, and schizotypal personality disorders.
“[T]raditional DSM-IV categories of personality disorder can be rendered in terms of core impairments in personality functioning and pathological personality traits with high fidelity,” Drs Morey and Skodol conclude. They believe their findings “should allay fears that translating PDs into personality functioning and trait terms will be disruptive to clinical practice or research.”
The researchers add, “[T]he definition of all personality disorders in terms of core impairments in personality functioning and pathological personality traits identifies personality pathology with high sensitivity and specificity and utility for treatment planning and prognosis.” If their results are borne out by future studies using other methods and samples, Drs Morey and Skodol believe their findings support adopting the new categorical-dimensional model for clinical diagnosis.
DSM-5 Overview: The Future Manual
The process for revising Diagnostic and Statistical Manual of Mental Disorders (DSM) began with a brief discussion between Steven Hyman, M.D., (then-director of the National Institute of Mental Health [NIMH]), Steven M. Mirin, M.D. (then-medical director of the American Psychiatric Association [APA]), and David J. Kupfer, M.D., (then-chair of the American Psychiatric Association Committee on Psychiatric Diagnosis and Assessment) at the NIMH in 1999. They believed it was important for the APA and NIMH to work together on an agenda to expand the scientific basis for psychiatric diagnosis and classification.
Under the joint sponsorship of the two organizations, an initial DSM-5 Research Planning Conference was convened in 1999 to set research priorities. Participants included experts in family and twin studies, molecular genetics, basic and clinical neuroscience, cognitive and behavioral science, development throughout the life-span, and disability. To encourage thinking beyond the current DSM-IV framework, many participants closely involved in the development of DSM-IV were not included at this conference. Through this process, participants recognized the need for a series of white papers that could guide future research and promote further discussion, covering over-arching topic areas that cut across many psychiatric disorders. Planning work groups were created, including groups covering developmental issues, gaps in the current system, disability and impairment, neuroscience, nomenclature, and cross-cultural issues.
In early 2000, Darrel A. Regier, M.D., M.P.H., was recruited from the NIMH to serve as the research director for the APA and to coordinate the development of DSM-5. Additional conferences were held later in July and October of 2000 to set the DSM-5 research agenda, propose planning the work groups’ membership, and to hold the first face-to-face meetings. These groups, which included liaisons from the National Institutes of Health (NIH) and the international psychiatric community, developed the series of white papers, published in “A Research Agenda for DSM-5” (2002, APA). A second series of cross-cutting white papers, entitled “Age and Gender Considerations in Psychiatric Diagnosis,” was subsequently commissioned and published by APA in 2007.
Leaders from the APA, the World Health Organization (WHO), and the World Psychiatric Association (WPA) determined that additional information and research planning was needed for specific diagnostic areas. Hence, in 2002, the American Psychiatric Institute for Research and Education (APIRE), with Executive Director Darrel A. Regier, M.D., M.P.H., as the Principal Investigator, applied for a grant from the NIMH to implement a series of research planning conferences that would focus on the scientific evidence for revisions of specific diagnostic areas. A $1.1 million cooperative agreement grant was approved with support provided by NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alcohol Abuse (NIAAA).
###
About Journal of Psychiatric Practice
Journal of Psychiatric Practice®, a peer reviewed journal, publishes reports on new research, clinically applicable reviews, articles on treatment advances, and case studies, with the goal of providing practical and informative guidance for clinicians. Mental health professionals will want access to this journal - for sharpening their clinical skills, discovering the best in treatment, and navigating this rapidly changing field. John M. Oldham, MD, is the editor in chief and past president of the American Psychiatric Association.
About Lippincott Williams & Wilkins
Lippincott Williams & Wilkins (LWW) is a leading international publisher of trusted content delivered in innovative ways to practitioners, professionals and students to learn new skills, stay current on their practice, and make important decisions to improve patient care and clinical outcomes.
LWW is part of Wolters Kluwer Health, a leading global provider of information, business intelligence and point-of-care solutions for the healthcare industry. Wolters Kluwer Health is part of Wolters Kluwer, a market-leading global information services company with 2012 annual revenues of €3.6 billion ($4.6 billion).