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New criteria proposed for personality disorders: dimensional model 'focuses attention on identifying pathology with increasing degrees of specificity.'.

SAN FRANCISCO -- Diagnosis of personality disorders would rely on a dimensional approach rather than on the conventional categorical approach under proposed revisions to the Diagnostic and Statistical Manual of Mental Disorders.

The new general criteria for personality disorders would rely on rating a patient's level of personality functioning plus either rating how well the patient matches one of five described personality types or performing a personality-trait assessment, Dr. Andrew E. Skodol said at the meeting.

The section on personality disorders is considered a "test case" for possible use of a dimensional approach to the diagnosis of all mental disorders eventually, said Dr. Skodol, chair of the DSM-5 Personality Disorders Work Group. "People who worked in the personality field had had discomfort with the categorical approach for decades and had been struggling with how to incorporate or integrate or replace categories with dimensions. We were a little bit ahead of the rest of the field."

Online posting of proposed revisions for the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-5) at www.dsm5.org in 2010 drew many comments and suggestions, some of which have been incorporated into the current proposal. Others did not shift the new model, such as an outcry about narcissistic personality disorder being represented as a trait instead of a type of disorder, according to Dr. Skodol, a research professor of psychiatry at the University of Arizona, Tucson.

The proposed DSM-5 defines a personality disorder as impairments in identity and sense of self, and in the capacity for effective interpersonal functioning. For diagnosis, the disorder must be manifested by a rating of mild impairment or greater in self- and interpersonal functioning on a 5-point "Levels of Personality Functioning" scale. In addition, the patient must be associated with a "good match" or "very good match" to a personality disorder type (antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, or schizotypal), or must receive a rating of "extremely descriptive" when compared with one or more personality trait domains.

The personality must be relatively stable across time and consistent across situations, and must not be better understood as a norm within the patient's dominant culture or be attributable solely to the direct physiologic effects of a general medical condition or a drug or other substance.

The conventional categorical model of diagnosing personality disorders results in excessive diagnostic co-occurrence and heterogeneity, said Dr. Skodol, also of Columbia University, New York. There are 256 ways to meet criteria for borderline personality disorder in the DSM-IV, for example. Most patients who are diagnosed with personality disorder meet criteria for more than one personality disorder and, in some cases, for five or six personality disorders.

"That doesn't make a huge amount of sense," he said.

The DSM-IV sets "arbitrary" diagnostic thresholds, with no empirical rationale for a patient who meets four criteria for borderline personality disorder being considered normal while someone who meets five criteria gets the diagnosis, Dr. Skodol said.

Dimensional models seem to be a more rational approach, though they are unfamiliar to most physicians who trained in the medical model, and are more complex and difficult to use, he said. The most commonly used dimensional model in personality psychology, the Five Factor Model, employs five large factors of personality and 30 independent traits. The DSM-5 model employs six large factors and 37 traits, though the number of traits probably will be winnowed, he said.

"Our proposed system focuses attention on identifying pathology with increasing degrees of specificity" he said. The new model could be used to describe personality psychopathology in all patients whether they meet the level of having a personality disorder or not.

The proposed rating system for levels of personality functioning have been well received, he said. The proposed personality disorder types and traits have been more controversial.

Clinicians would rate how well a patient's personality matches a detailed narrative describing one of the five personality disorder types (half the number of types in DSM-IV). "The fact is, this is what clinicians do. They don't like criteria. Researchers might, but clinicians examine the patient, think about the pathology as a whole, and make a diagnosis. They approximate what the criteria represent, but they don't count them," Dr. Skodol said. He expects that most patients will match only one type, reducing the problem of co-occurring diagnoses.

When a clinician wants more detail on a patient's characteristics within a personality disorder type or for patients who don't match one of the five types, a trait assessment can be performed. The model employs six large domains of personality traits with facets ("subtraits, if you will") under each. The domains are negative emotionality (with 10 trait facets), detachment (5 facets), antagonism (8 facets), disinhibition (4 facets), compulsivity (5 facets), and schizotypy (5 facets).

The model eliminates today's most frequently diagnosed personality disorder--"not otherwise specified," he said. "You will always be able to specify what the personality disorder pattern is like. If it's not a type-based, it will be a trait-based" disorder, Dr. Skodol said.

In a later session at the meeting, Dr. John G. Gunderson expressed reservations about the proposed alterations to borderline personality disorder in the DSM-5.

"I worry that there are changes that are. being made which are very dramatic in the definition of this disorder and which will undermine both the progress we've made in terms of research and undermine the confidence that patients and families can have in the diagnosis we give," said Dr. Gunderson of Harvard Medical School, Boston.

Dr. Skodol responded, "I think we really haven't changed the content of the construct as much as the format." Studies will assess the impact of the proposed revisions on the prevalence of the disorder, he said.

The DSM-5 is expected to be published in 2013.

Dr. Skodol and Dr. Gunderson said they had no relevant financial disclosures.

BY SHERRY BOSCHERT

FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF PSYCHIATRISTS
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Title Annotation:ADULT PSYCHIATRY
Author:Boschert, Sherry
Publication:Clinical Psychiatry News
Article Type:Disease/Disorder overview
Date:Apr 1, 2011
Words:980
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