The American Psychiatric Association is scheduled to publish the much-delayed fifth edition of the Diagnostic and Statistical Manual (DSM) by May 2013. With its worldwide influence, changes in a reference work as influential as the DSM, often called the bible of the mental health field, was bound to provoke controversy and concern, and the revision process has been short on neither. Among the fears are that new proposals haven't had adequate time for rigorous scientific testing, that expanded diagnostic criteria will lead to over-diagnosis and pathologizing of normal behavior, and that rampant financial conflicts of interest (some 70 percent of DSM-5 task force members have disclosed financial relationships with pharmaceutical companies) will tarnish what should be an impeccably scientific and independent endeavor.
While there have been a series of public outcries about different DSM diagnoses, proposed changes to the personality disorders section for DSM-5 have been a particular target for criticism. "As it stands now, the DSM-5 personality section is not readable, much less usable," writes psychiatrist Allen Frances for his blog, DSM5 in Distress. Frances, once chair of the DSM-IV Task Force, is now one of DSM-5's most vocal opponents. The personality disorder section, he says, "will be ignored by clinicians and will do grave harm to research."
The central conflict in the personality-disorders debate revolves around how best to implement a new, more dimensional approach to diagnosis. To understand the problem, picture how we typically think about height and weight. Broad classifications such as tall or overweight make clear, easy-to-understand distinctions, but tend to ignore subtle gradations and lead to stereotyping. However, a dimensional approach may not be much more helpful because of the room for personal interpretation--taller than average, moderately tall, extremely tall. Applied to a personality system, a dimensional approach can be unnecessarily complex and cumbersome for everyday use (one previous DSM-5 proposal would have required clinicians to rate more than 30 separate personality variables just to make a diagnosis). Also, diagnostic labels such as "narcissistic" or "borderline personality" convey clinical meaning and understanding which isn't necessarily captured by numerical scales of "immodesty" or "disinhibitedness."
While most agree that a drastic revision to DSM-IV's personality-disorder algorithms and vague definitional criteria was in order, debates have continued to flare over the best alternative approach. Recently, two members of the DSM-5 Personality and Personality Disorders Work Group, Roel Verheul and John Livesley, resigned in protest, decrying the work group's current proposal as "unnecessarily complex, incoherent, and inconsistent" and "display[ing] a truly stunning disregard for evidence."
So how did personality-disorder diagnosis become such a contentious flashpoint? Of all the diagnostic phenomena encompassed by DSM, personality disorders would seem to have the fewest reasons for ideological division and political conflict. The usual financial motives would not appear to apply. Most insurance companies deny reimbursement for personality-disorder treatment, pharmaceutical treatments for the disorders are limited or nonexistent, and many clinicians pay little attention to formal documentation of personality disorders in records and billings. But the underlying competing interests are still not so far to seek. While pharmaceutical approaches play a reduced role in treating personality disorders, the commercially available assessment tools for diagnosing them could be affected by changes to the diagnostic manual, including instruments authored by current members of the DSM-5 personality work group. A new DSM-5 personality system could influence the curriculum of future training workshops, sales of test materials, and major research grants. Additionally, getting the stamp of approval for an assessment model from the industry's diagnostic bible is a mark of career distinction that few researchers would pass up.
Even with a looming publication deadline, the DSM-5 personality-disorders proposal is still a draft in progress. With a final review due this fall, major changes are possible, and even likely. The architects of the proposal are tasked with creating a diagnostic system for personality which is empirically supported, pragmatic, clinically useful, and reliable for research and practice. But an already difficult process has turned out to be even more tumultuous and contentious than expected. We have yet to see in what ways DSM-5 will turn out to be a help or a hindrance to research, training, and clinical care, but one thing is near certain: the clamoring for DSM-6 seems poised to begin.
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