Clinician's Digest - Page 4

The DSM Revisits Personality Disorders

In the March issue of the Networker, Senior Editor Mary Wylie pointed out that the DSM exerts a powerful impact on how both therapists and the public think about specific disorders and the people who have them. Accordingly, with so much at stake, the different work groups deliberating over DSM-5 due out in 2013, have tried to stay ahead of critics by giving the professional community advance notice of changes currently under discussion, along with a chance to respond to them. One of the diagnoses due for a major overhaul in DSM-5 is personality disorders (PDs).

Laymen often consider PDs as falling somewhere between neuroses—the less "serious" conditions—and psychoses. Having their own DSM axis, separate from other disorders and clinical conditions, reinforces the popular notion that PDs aren't conditions a person has, like depression or anxiety, but something a person is—a part of their personality structure far less amenable to treatment. Reinforcing that viewpoint, DSM-IV characterizes PDs as "enduring," "inflexible," and "pervasive across a broad range of personal and social situations."

Although it's still being debated whether PDs will remain on their own axis in DSM-5, the latest proposal characterizes them less extremely as "relatively stable across time." This brings the description more in line with recent research, which finds that some PDs abate when life stressors or coexisting conditions are alleviated. In addition, watch for fewer distinct diagnoses within the PD category. The 11 current types may become only 5: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal.

But the most significant proposed diagnostic changes are ones already incorporated by the Psychodynamic Diagnostic Manual, the alternative manual to the DSM. Discussions are under way to include resilient traits of PDs as well as symptoms. And DSM-5 will likely replace the current characterization of PDs as something a person either does or doesn't have with a continuum perspective. For example, DSM-5 proposes for borderline personality disorder that therapists use a 5-point scale to assess how well a person fits the overall criteria, and then additional 3-point scales to assess each of 10 traits, such as emotional lability, self-harm, and separation insecurity. DSM-5 advocates believe the result will be a more nuanced diagnosis that provides clearer guidelines regarding the symptoms on which treatment should focus.

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