Thursday, July 21, 2011

The Dimensional Side to Personality

We have been looking at Take Two (from June 21) in the DSM-5’s proposed update to personality disorders. In Take One (from Feb 2010), the DSM-5 attempted to combine categories (as in “which one?) with dimensions (as in “how much?”) into a hybrid system, using interchangeable parts that could best be described as modular. The concept was far-reaching. The catch was that it appeared to be very unwieldy in practice.

Yesterday, we looked at how the DSM-5’s Take Two tackled the categorical side of personality, using a dimensional twist. Today, we look at the DSM-5’s Take Two of the dimensional model, built on categorical pieces, but a different set of categorical pieces from Take One.

Take One, in essence, was based on a sort of reverse Five-Factor Model (such as “antagonism” in place of “agreeableness”) measuring 37 different trait facets on a four-point scale. Take Two is far more modest in scale, but may be much more useful.

Consider, for instance, the following four individuals:

Jane, 28, displays classic borderline symptoms - unstable self-image, trouble maintaining relationships, and so on. But she is working as a manager in a city government. Does the borderline label really apply?

Bill, in his 20s, flies off the handle, uses drugs, and has run-ins with the law, but does not meet the criteria for antisocial. But clearly, his behavior warrants clinical attention.

Sally, 14, is acting out like someone with borderline, but is her behavior more attributable to being a teen?

Joey, in his 50s, deals with major depression and diabetes, and has major issues getting along with his caregivers. Is there a diagnosis that doctors can apply to patients they don’t like?

Enter the Levels of Personality Functioning Scale. This employs the self and interpersonal functions from Criterion A used in all six categorical diagnoses and rates them in terms of severity from 0 to 4. Thus, in 0 (well-adjusted), we see these kind of qualities: “ongoing awareness of a unique self”, “sets and aspires to reasonable goals”, “capable of understanding others”, “maintains multiple, satisfying, and enduring relationships”, and so on.

Meanwhile, way over on 4, we see “boundaries with others are confused and lacking”, “poor differentiation of thoughts from actions” - well, you get the picture.

Then we’re asked to consider the six (mostly interchangeable) trait domains that form the basis of the six personality disorders: Negative Affectivity, Disinhibition, Antagonism, Psychoticism, and Compulsivity. Only this time we are viewing these domains as stand-alone entities rather than in the context of a full-blown personality disorder.

Let’s return to our individuals, who represent abbreviated versions of the examples served up by the DSM-5.

Jane, according to the DSM-5, would rate a diagnosis of borderline, “but her level of personality functioning might be rated as less impaired than that of the more typical borderline patient, with enhanced prospects for successful treatment.” In other words, Jane is a good prognosis patient.

Bill, under the old DSM, would probably sail under the diagnostic radar or fall through the cracks. Perhaps he would be diagnosed as Personality Disorder NOS (not otherwise specified), which tells us nothing. Under the DSM-5, we are told, Bill would be coded as “Personality Disorder Trait Specified,” emphasis on trait specified, such as hostility and impulsivity. These traits would then “serve as specific foci of clinical attention.”

Sally may show signs of emerging borderline, but the DSM-5 indicates the wise course is to hold off on this diagnosis, and instead note her as having a low level of personality functioning, with reference to specific traits such as emotional lability. These features can then be closely tracked as Sally matures.

Joey may not have a personality disorder, but he could be written up for “antagonism,” and impairment in interpersonal personality function. The DSM-5 doesn’t say this, but the best way of treating Joey’s depression and diabetes is to treat the personality issues that sabotage his being a successful patient.


Thus, in terms of functional impairment and various traits, in all four cases we are seeing evidence of “something” going on - from a personality disorder with a good prognosis to a clinical condition as serious as any personality disorder to a situation of wait-and-see to a pressing concern that merits some sort of intervention.

This may not be a perfect system, and already a predictably rotten tomato review has come in from Allen Frances, head of the criminally horrendous DSM-IV, who characterized Take Two as “an impossible mess to the rest of us.”

Dr Frances may well be right, but for all the wrong reasons. Dr Frances has indicated in all his DSM-5 writings to date that he sees himself as merely as the keeper of his precious DSM-IV, which is a very different proposition than lending his professional wisdom to improving the lives of those dealing with serious personality issues. In the final analysis, any attempt to pin down something as infinitely complex as personality is doomed to be flawed. Success, then, is modest, to be measured in terms of less flawed than the effort before.

Could the DSM-5 have done a better job? Of course it could have. Is the version it turned in way better than the sorry DSM-IV mess that Dr Frances is so in denial about? Don’t make me answer that.

Previous pieces:

Personality Disorders - The DSM-5 Has Another Go
Take Two on Personality Disorders


Anonymous said...

<< John, I submitted my last comment … late yesterday/Saturday evening … to the wrong post of yours, to which I cannot recall.
I wrote it in response to your "Rerun: What If No One Noticed I Was Crazy?" post, hopefully it will make some sense in that context.
Am so sorry for this.
All the best,
Neil >>

Lizabeth said...

Hey John, it sounds like the new DSM is really trying to make the personality disorders easier to diagnose but does that make them easier to treat?

Jane may well seek treatment on her own, especially if urged by family/friends. The first thing my tdoc would probably suggest is a different job. Again, why are those of us with Mental Health issues attracted to jobs that make things worse?

Bill reads more like he has untreated Bipolar, or drug addiction. Or both.

Sally should probably also be checked for severe PMS or PMDD. From my own experienc I know 14 is not too young for it. Ah for the 20-20 vision of hindsight, not to mention that sometimes real advances are made.

Joey--well you called it with his problems. The thing is there are ethical difficulties with actually getting him treated. He would undoubtedly refuse treatment. Is his diagnosis such that he could be ruled incompetent? Under the Patients Bill of Rights, anyone ruled competent has the right to refuse treatment.
I am not sure why I am posting all this other than I am still annoyed that a Manual trumps real life knowledge of pdocs and tdocs in getting insurance companies to pay up.

John McManamy said...

Hey, Lizabeth. Really good comments. My view - good diagnosis does not guarantee good treatment, and nowhere is this more apparent than with child bipolar. You get the diagnosis right, only to treat the kid with mood stabilizers and antipsychotics?

But it tends to work the other way - in other words, there can be no good treatment if the diagnosis is wrong. Just ask anyone with bipolar misdiagnosed with unipolar.

Hopefully, with personality disorders, the DSM-5 will encourage clinicians to zero in on specific facets of one's personality that need attention but not clinical over-kill.

Re Jane: Good points. Maybe she does need a less stressful job. The other way of looking at is is maybe if she became more adept at handling her dealings with people she would be less stressed and thus achieve her full potential in a job that matched her talents. Since she is a good prognosis, a few minor tweaks may be all that is needed.

Yep with Bill, interesting with Sally. And Joey raised all the ethical issues you mentioned.

As for a manual trumping real-life knowledge - say no more. When all is said and done, this is little to distinguish the DSM due to come out in 2013 from the DSM that came out in 1980. A 1980 depression symptom list is absurd. Yet it trumps modern clinical wisdom. How crazy is that?

Lizabeth said...

Oh be yes, I was one of them---the misdiagnosed with unipolar while really having BP2. For 10 years. Of course thats partly because I didn't report my crotched, cranky hypomanias because I thought they were a character flaw, not a symptom.

iambipolar2 said...

Sounds like we shouldn't expect a lot from DSM V. But maybe some good and some not so good changes. Which kind of sounds like what happens when things get updated!

robbin said...


The DSM-IV have affected very much where and on what attentions is put in scientific research about personality and personality disorder.

How do you think this will change with the new DSM-V if this revision proposal goes through?

robbin said...


The DSM-IV have affected very much where and on what attentions is put in scientific research about personality and personality disorder.

How do you think this will change with the new DSM-V if this revision proposal goes through?

Also, I wish to read up more about personality theories, do you have any recommendation of concise literature on the subject?