HONOLULU – When it comes to personality disorders, the DSM-5 might feature a reduction in the number of designated disorders, a greater emphasis on and rating of functional impairment, and a move from categorical to dimensional patient assessment, Dr. John M. Oldham said.
Antisocial, avoidant, borderline, obsessive-compulsive, and schizotypal are the personality disorders included in the current proposal for the next edition of the Diagnostic and Statistical Manual of Mental Disorder (DSM).
"The list is based on literature reviews and the robustness of evidence. We have good data for the five that are on here," Dr. Oldham, a member of the DSM-5 Personality and Personality Disorders Work Group, said at the annual meeting of the American Psychiatric Association.
This move would halve the number of categorical personality disorders featured in the DSM-IV-R. If this plan goes forward, schizoid, paranoid, histrionic, and dependent personality disorders would not appear in the DSM-5.
Dr. Oldham is a proponent of adding the remaining disorder in this section of the DSM-IV-R, narcissistic personality disorder, to the DSM-5 before its release in 2103.
"We got a lot of pushback from the comments that came in about narcissistic not being on the list." The work group did not include narcissistic personality disorder with initial revisions posted online in February 2010 at www.dsm5.org, citing a lack of robust research support.
"My argument here is ... how many patients with narcissistic personality disorder are going to line up to participate in a research protocol for a disorder they don’t think they have? It’s not surprising we don’t have a large database, but it doesn’t mean we don’t have to take care of these patients," said Dr. Oldham, American Psychiatric Association president and professor and executive vice chair of the Menninger department of psychiatry and behavioral sciences, Baylor University College of Medicine, Houston.
If someone does not meet criteria for one of these five disorders, you can use a "Personality Traits Assessment" to describe the patient, Dr. Oldham said. The work group developed specific, narrative definitions for 25 relevant traits. Negative affectivity, for example, would be defined as frequent experience of a wide range of negative emotions and interpersonal manifestations of those emotions.
Many of these new proposals will be featured in an update to the DSM-5 personality disorders page soon, Dr. Oldham said. At that time, a second comment period will begin.
A total of 18 dimensional assessment models were proposed. The one the work group chose begins with initial determination of a patient’s "levels of personality functioning." Ratings range from extreme impairment (1); to serious (2); moderate (3); some impairment (4); or healthy functioning (5).
"We’re trying to define a healthy sense of identity and self-directedness," Dr. Oldham said. Experiencing yourself as unique (with clear boundaries between you and others); being capable of accurate self appraisal; and showing a capacity to regulate a range of emotional experience are examples. Empathy; tolerance of difference; and a capacity to relate to others in a comfortable, intimate, in-depth way are examples of interpersonal factors.
"In our hybrid model, you do your assessment of levels, you then look at traits, and you see whether you have met the criteria for the five, or I hope six, personality disorders," Dr. Oldham said.
Minimizing use of the PDNOS or "personality disorder not otherwise specified" as a diagnosis is an aim of the new Personality Traits Assessment. "There is also a lot of use of PDNOS" and the designation often is used incorrectly, Dr. Oldham said. "It’s supposed to mean you don’t have any of the above [criteria]. Most people use it to mean ‘mixed.’ "
Although not as straightforward, trait assessment better addresses the heterogeneity of patient presentations, Dr. Oldham said.
"Then we have to make sure the patient meets the general criteria that are similar to what is in DSM-IV," Dr. Oldham said.
A dimensional approach is complex but better addresses the "excessive co-occurrence" of the personality disorders, compared with categorical assessment, Dr. Oldham said. Dimensional assessments are used in some research settings, but might not be as easy to apply in a fast-paced medical setting. "That was among the questions we wrestled with: How useful is this ... in a busy clinical practice?"
However, "this is hopefully a way to describe personality pathology of all patients." Improved tracking of patient progress over time is another advantage, he said.
No matter what the final outcome of revisions, "these are important disorders for us to know about. The clinical significance of the personality disorders in the DSM is quite significant," Dr. Oldham said. Using DSM-IV-R definitions, approximately 10%-13% of people have a personality disorder. "These are prevalent in clinical settings and in the general population."