Wednesday, December 15, 2010

Personality Disorder: Decisions, Decisions ...

The story so far:

In the one thing those charged with the DSM-5 did right, personality disorders will receive a major overhaul. Five of the ten current personality disorders will be axed and the current “categorical” system will be supplemented by a “dimensional” model.

Let’s look at the categorical reforms. The wisdom of the DSM-5 is readily apparent in relieving clinicians of the agony of having to decide between the likes of “schizotypal” and “schizoid” (schizotypal makes the cut, schizoid gets the axe). Similarly, only those prone to histrionic displays are shedding crocodile tears over the demise of “histrionic,” which is way too easy to confuse with “narcissism,” which will - Wait! What the f...? - you mean narcissism goes too?

Okay, we’ll get to the issue of narcissism later. In the meantime, sayonara, as well, to “paranoid” and “dependent.” And in a Nobel-worthy gesture (medicine or peace, take your pick), the foul and malignant NOS (“personality disorder not otherwise specified”) gets the deep-six. Clinicians will actually have to decide between the disorders left standing ("antisocial/psychopathy", "avoidant", "borderline", "obsessive-compulsive", "schizotypal"). But will they be happy making their choices? Let’s use the new borderline and antisocial/psychopathy as our examples:

The first thing readers will notice in the new borderline diagnosis is a lengthy narrative description of the illness. Thus:

Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness.  As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships. ...

And so on and so on. The checklist that follows roughly corresponds to the one in the DSM-IV, but looks a lot different. The following, for instance, is symptom #6 from the old checklist:

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).

Here’s how that same symptom (#1) in its new form will appear:

Negative Emotionality: Emotional Lability
Having unstable emotional experiences and mood changes; having emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

“Negative emotionality” is what the DSM-5 calls a “trait domain,” one of six for the five personality "types". (“Introversion”, “antagonism”, “disinhibition”, “compulsivity”, and “schizotypy” are the others.) Every symptom includes a trait domain, further modified by “trait facets,” such as “emotional lability.”

Borderline comes heavily loaded with negative emotionality, six symptoms of 10 in all involving, besides emotional lability, “self harm”, “separation insecurity”, “anxiousness”, “low self-esteem”, and “depressivity”. There are two “antagonism” domains (with “hostility” and aggression” as facets) to borderline, plus a “disinhibition” domain (“impulsivity” as a facet), and one “schizotypy” domain (with “dissociation proneness” as a facet).

A quick comparison to the new version of antisocial/psychopathic shows a very different loading, with six antagonism traits and zero negative emotionality traits. Right off the bat, clinicians are put on notice that they are dealing with two entirely different species of personality. The narrative highlights the contrast:

Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled.  They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals.  They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals. ...

In addition to hostility and aggression, the antisocial/psychopathic symptom list includes the antagonism traits of “callousness”, “manipulativeness”, “deceitfulness”, and “narcissism”. Intriguingly, hostility and aggression are word-for-word replicas of what appears in the borderline list. But the symptom overlap comes across as deliberate and in context rather than random and coincidental. In other words, in constructing the various categorical diagnoses, we appear to be looking at an ordered modular system with interchangeable parts.

(We see another interchangeable part in antisocial/psychopathy with “disinhibition-impulsivity”, but with the further emphasis of “irresponsibility” and  “recklessness”.)

Here’s where the DSM-5 personality symptom lists radically differ from those in the DSM-IV. Instead of just checking off the relevant symptoms and counting them to arrive at an arbitrary diagnostic threshold (such as five out of nine symptoms), the clinician rates each symptom on a five-point scale, from “very good match” to “no match”. Thus, from a severity perspective, a pair of fives may trump several threes. The current draft offers no magic threshold numbers, which suggests that in making the final call the clinician will be accorded a lot more discretion. Presumably, this works when when the clinician has clear guidelines.

Sounds good in theory.

Much more to come ...

Recent Personality Disorder Blog Pieces

Taking It Personally: The DSM-5 and the Narcissism Controversy

Let's Play Spot the Personality Disorder 

Why is Spotting the Personality Disorder So Damned Hard?

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