Wednesday, May 4, 2011

Speaking of Changes: DSM-IV to DSM-V

What’s going to happen to Borderline Personality Disorder in the DSM-V? For that matter, what’s going to happen to any Personality Disorder in the DSM-V?
There is going to be a major reclassification of Personality Disorders in the DSM-V.  Apparently Axis-II disorders aren’t clear enough in terms of diagnosis in the DSM-IV so they need to be updated. Can’t completely disagree with their reasoning. The whole point of the DSMs are to accurately diagnosis disorders in order to aid the clinician and patient. Without proper classification and standardized diagnostic criteria it’s very difficult if not impossible to receive the most helpful treatment. If help is what you want that is. I’m sure we can all think of a few PD types that don’t need to change a thing ;)
The current DSM-IV:  Diagnosing disorders in the current edition of the DSM-IV involves two aspects.
First: Define what a personality disorder is. Currently, a Personality Disorder is defined as a pervasive pattern of "inner experience and behavior" that is deviant from a person's cultural norms. These may be deviations in thoughts, emotionality, interpersonal relatedness, and impulse control. Deviations need to be pervasive, stable, present at least since adolescence, and not due to substances or another mental disorder. Importantly, these ways of thinking, feeling, or behaving need to be significantly distressful and problematic.
Deviant from cultural norms. This is inappropriate on so many levels. The most obvious being that since there are so many different cultures in the world what is considered a PD in one culture may be considered a different PD in another or more severely it may not be considered a PD at all.  Some cultures promote cannibalism. It’s a non-concern. I bet if I tried to apply that here and claim it was my standard proclivity to chow down on my neighbor I’d be tossed right into the ASPD category. People are food? Anti-social. Check.
Second: Define what type of personality disorder is present. DSM-IV currently lists ten Personality Disorders with a catch-all "not otherwise specified category". Each personality disorder has a certain number of criteria, to which you must meet a cut-off. For example, To be Borderline you need to have five out of nine symptoms such as: self-harming, unstable relationships, fear of real/imagined abandonment, impulsivity, identity disturbance, etc.
There are a lot of problems with this system though.

First, the different personality types were poorly defined. They weren't based on research-derived criteria, the individual symptoms were vague, and the idea of checking off abstract criteria such as "an exaggerated sense of self-importance" were difficult.

It does seem that the number of criteria required is arbitrary. Why are 5 qualifications better than 4? 4 symptoms may be significantly severe. For that matter, who decides what is significantly severe? Why are 7 met criteria more accurate than 5 if many of the 7 criteria are relatively subdued. Who’s to judge? 4 = “normal”, 7 = “abnormal”.  Regardless. Oh, I’m sorry. You only have 4 majorly severe symptoms present? You’re fine, go about your day. Next!
Another problem is that the criteria overlapped heavily. A person meeting criteria for one personality disorder usually met criteria for 3 or 4 others, as well.
No disagreements here. I for one am sure I qualify for Histrionic PD in many ways. From a cultural stand point I cross over into Schizotypal (if not for my ‘spiritual’ beliefs alone), and so on. Hey! Check out the PD test, that’ll give an “accurate” crossover chart.

The proposed DSM-V:
The proposed revision for the DSM-V is relatively complicated and has 3 essential criteria for PDs.
(1)  A rating of mild impairment or greater on the Levels of Personality Functioning (criterion A),
(2)  A rating of 
        (a)  a “good match” or “very good match” to a Personality Disorder Type or
       (b)  “quite a bit” or “extremely” descriptive on one or more of six Personality Trait Domains (criterion B).
(3)  Diagnosis also requires relative stability of (1) and (2) across time and situations, and excludes culturally normative personality features and those due to the direct physiological effects of a substance or a general medical condition.
Quite complicated indeed. However when you think about it, it fits. Normal personalities are complicated. Personality Disorders are complicated to the order of {insert large magnitude}.
Let’s look at each of these 3 new criteria:
1.) First, the general definition of what a personality disorder is has changed. It will now suggest that instead of a pervasive pattern of thinking/emotionality/behaving, a personality disorder reflects "adaptive failure" involving: "Impaired sense of self-identity" or "Failure to develop effective interpersonal functioning".
See, now I disagree that it should be defined as {solely} an “adaptive failure”. This implies that Personality Disorders are strictly a product of your developmental environment. I’ve done a lot of research into biogenetic temperament, pathology, differences in brain affectations/structuring (all of which I’ll be posting on eventually) and there is a biological aspect to personality disorders. This definition seems to ignore those factors completely. Maybe they’re just focusing on the manifestations though. They can always do brain scans later. I for one want my brain scan.
The breakdown of “impaired sense of self-identity” and “failure to develop effective interpersonal functioning” is good though. They even have a little severity scoring system. I like all these scoring levels actually. It’s like a game of personality disorders. Step right up folks. Place your bets, put your credibility on the line. Spin the wheel of characteristic crazy and I’ll guess your personal pathology. Takers? Loser are the norm. Winners get a shiny new Personality Type. Woot!

Five personality types
2.a.) DSM-V has simplified the system by cutting down Personality Disorders from10 to 5:
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder (ASPD)
Borderline Personality Disorder (BPD)
Histrionic Personality Disorder (HPD)
Narcissistic Personality Disorder (NPD)
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder

They plan to collapse these 10 into the following 5 buckets:
Antisocial/Psychopathic Type
Avoidant Type
Obsessive-Compulsive Type
Schizotypal Type

Avoidant, O-C, and Schizotypal haven’t changed much. A/P Type and Borderline are apparently still pretty complex but hey! We made the cut! Take that Paranoid PD. Who’s watching you now? No one? Now you’ll never know. I’m actually not sure that this will make it easier to identify potential Personality Disorders. I don’t see why they couldn’t keep the established Personality Disorders and simply apply the new diagnostic techniques to them. This is supposed to be most helpful to clinicians who I suppose the DSM is specifically designed for, but it will make the information less accessible to the population at. Or, maybe the APA is trying to boost therapy sales by making it so confusing that patients need to seek professional help to figure out what’s wrong with them.
2.b.) Personality trait domains and facets
Finally there are a series of six personality "trait domains". The six domains include: Negative Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity and Schizotypy. Clinicians would be asked to rate each of the six domains on a 0-3 scale depending on how descriptive each is of the patient. The rating game continues.
Each of the six trait domains also comes with a subset of trait facets.  These are more descriptive indicators to help you decide which domains you fall under. I’m not sure these are enough. I fit all of these in some way, but then again, I have a Borderline Personality Disorder so Good Job! I think I just disproved my own concern. I guess when you pull the whole system together it will be able to distinguish maladaptive personalities versus, say, non-PD abuse victims, true A/P types versus your everyday douchebag.  Only time will tell I suppose.
3.)  And time is what it’s all about. One thing that has been kept from the DSM-IV is the fact that these characteristics need to be “stable”. I love that they use the term stable. Especially since the nature of half of these disorders is how generally unstable people with PDs can be. I know what they mean of course; these problems are persistent and unchanging over time and not situation dependent.
So there you have it. The new DSM-V.
I am curious as to where Narcissistic Personality Disorder will fall. Traditionally it’s a Cluster B group with BPD, Histrionic, and ASPD. My first inclination would be to say it will fall under the Borderline Type. BPD/HPD are highly reactive, often characterized by narc traits and there’s a more prevalent sense of needing people in some manner than is ASPD.  The inflated grandiosity and a pervasive pattern of taking advantage of other people suggests the A/P Type definition though(so obviously defined with narc traits). Maybe since narcissism is so pervasive in the PD spectrum the DSM believes it’s a symptom, a not a distinct problem. Sorry narcs, apparently you’re not important enough to have your own group anymore. Wow, that’s going to piss someone off; take that their egos! And for that matter, ASPD is also Cluster B and is even more commonly associated with BPD as a male/female flip side. It’s just so typical that the ASPDs would leave BPDs and take up with a more aggressive group. At least we still have the Histrionics. It’s gonna be a sexy fun time for the Borderline Types. Just sayin’.


  1. Very informative. I would never know any of this stuff if you didn't explain it so well. Usually these type articles go way over my head, but you explain it so well in terms I can understand. I have one question though. If you have answered it before, then maybe you can give me the post. What exactly is Axis 1 and Axis II? I have seen you use those terms a lot but don't really understand what they mean.

  2. I have actually talked about Axis I vs Axis II before :

    That was in my Controversy series. Hm. I should go back and add some better labels.

  3. Thanks. No it's mostly me. I have CRS (can't remember shit). I had actually read that before, but couldn't remember what you had said. I need to get a book or something and write stuff down as I read it especially on your blog. I have learned so much here, but I swear I can't remember anything for more than 5 mins.

  4. Haha, that's why I blog! Because I read so much bloody stuff that I need it to be all in one place so I don't forget it =) I need to work out some more descriptive side labels so it's easier to search for things I think. Like I just added an Axis one for this stuff (need to go through my blogs and update any others where I reference it though).


Leave me a comment! It makes me feel good and less paranoid about talking to myself =)

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