Diagnostic and Statistical Manual of Mental Disorders, DSM-5

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Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 Author: American Psychiatric Association Publisher: American Psychiatric Publishing; 5 edition (May 27, 2013) Paperback: 991 pages ISBN-10: 0890425558 ISBN-13: 978-0890425558

Book Description
This new edition of the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (DSM-5), used by clinicians and researchers to diagnose and classify mental disorders, is the product of more  10 years of effort by hundreds of international experts in all aspects of mental health. Their dedication and hard work have yielded an authoritative volume that defines and classifies mental disorders in order to improve diagnoses, treatment, and research. This manual, which creates a common language for clinicians involved in the diagnosis of mental disorders, includes specific criteria intended to facilitate an objective assessment of symptom presentations in a variety of clinical settings. The information contained in the manual is also valuable to other physicians and health professionals, including social workers and forensic and legal specialists.

Cluster A Personality Disorders... ... ... ... ... ... ... ... ... ... ... ... ... ... .

Paranoid Personality Disorder (649) Schizoid Personality Disorder (652) Schizotypal Personality Disorder (655)

Cluster B Personality Disorders... ... ... ... ... ... ... ... ... ... ... ... ... ...

Antisocial Personality Disorder (659) Borderline Personality Disorder (663) Histrionic Personality Disorder (667) Narcissistic Personality Disorder (669)

Cluster C Personality Disorders... ... ... ... ... ... ... ... ... ... ... ... ... ...

Avoidant Personality Disorder (672) Dependent Personality Disorder (675) Obsessive-Compulsive Personality Disorder (678)

Emerging Measures and Models... ... ... ... ... ... ... ... ... ... ... ... ...

Alternate Model for Personality Disorders (788)

About the Authors
On July 23, 2007, the American Psychiatric Association announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests.

Task Force Chair Task Force Vice Chair Personality Disorders Work Group Co-Chair Personality Disorders Work Group Co-Chair ----------------------------------------------------------------------

David J. Kupfer, M.D., University of Pittsburgh Darrel A. Regier, M.D., M.P.H., American Psychiatric Association Andrew E. Skodol, M.D., University of Arizona John M. Oldham, M.D., The Menninger Clinic ------------------------------------------------------------------------

[jaynebrain]

Does anyone know whether the DSM V criteria of BPD differs significantly from DSM IV?  I have been searching for answers.  My DD22 is now telling me that she does not fulfill the criteria for BPD and that the traits she demonstrates when disregulated are really symptoms of a complex PTSD. (She has been going through Processing exposure Therapy for almost a year after 2 years of DBT)  I am so confused by this - all I know is that she is suffering and we are too!  We have been using our tools - validation, setting boundaries etc. but these are now met with anger and she has been suicidal for the first time in a few years.  We have a meeting with her therapist in a week and a half so I am trying to be as prepared as possible.  Thanks in advance for any pointers you may have.

[Skip]

Does anyone know whether the DSM V criteria of BPD differs significantly from DSM IV?

The short answer is that DSM IV and DSM 5 are the same. 

An alternate model is also published in the book. The alternate model was intended to replace the DSM IV criteria but at the last minute it was decided that it needed more study and it was published as a possible future replacement for the DSM IV criteria that needs more study. It was included in the manual for researchers.

[Turkish]

See this discussion:
 

REVISED May 2013 - The DSM-5, which came out in 2013, was anticipated to bring a number of changes to the definition of the personality disorders.  The working group did away with the complex multiaxial diagnostic approach and attempted to make the personality disorders more discrete (less overlap) - basically consolidated Axes I, II, III will be  to one -- reducing the 10 personality disorders to 6 -- with each PD will be "scored" on a rating system based on severity.
 
The proposed DSM 5 criteria was simpler than the DSM-IV - it looked something like this (note: no 5/9 criteria).  In the last days before the final draft, the APA over ruled the DSM committee and relegated this classification scheme to the appendix and encouraged researcher to evaluate it further in the coming years.  In the interim, the DSM -IV criteria was repeated without change.
 
Proposed DSM 5 criteria:
 
1 Impairments  The must be impairments in self functioning AND impairments in interpersonal functioning (more on this later)
 
2 Negative Affectivity, characterized by:
 

• Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

• Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

• Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.

• Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.

3 Disinhibition, characterized by:
 

• Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

• Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.

4 Hostility:  Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

[enlighten me]

One thing that has become apparent to me is that comorbidity of personality dissorders makes it difficult to place a correct diagnosis. Whilst I agree if someone only has the traits of one dissorder then they fit nicely into that box but the problem as I see it is that a lot of dissordrrs overlap so there are grey areas. If somelne ticks all of the traits for BPD at a level of 6 out of 10 but has half the traits of NPD at 10/ 10 then what are they?

I dont have the answers but was curious if anyone else had thoughts on this?

[HappyChappy]

Hi Enlighten me,

You make a good point, comorbitity is common and hence precise diagnosis tricky.
The approved clinical route in my country is “treat the behaviour not the label”. I would also say about PD behaviour is that they all have similar foundations that run through all PD. And that PD behaviour is more predictable than nons behaviour. But you raise a good point and I’m interested to know what benefits you see in more accurate diagnosis ?

[enlighten me]

Hi Happy

I was imagining a list of all relevant traits with scores of 1-10. Depending on the severity of the traits it plots an area of severity. I did a similar thing for a job interview where they give a psycological profile.

With this in mind I think treatment would be able to be tailored for the character type. For instance if BPD was the main dissorder but there where strong NPD traits then working on the NPD might make treatment for BPD easier. Probably a poor example but im no shrink. The other advantage would be to get rid of labels. The stigma with being labelled BPD can put a lot of people off of treatment. If you where told you had a type 3 personaltiy of a blue level it may not be so intimidating. My final plus point would be medical insurance. If someone has a personality type that has more than a certain amount of points then insurance should cover it no matter what the dissorder.

Just my pondering thoughts.

[Skip]

The problem of co-morbidity and a dimensional model (what your describe) was proposed in 2010 and was widely discussed in the media prior to the 2013 release of  the DSM 5:
https://bpdfamily.com/message_board/index.php?topic=114843.msg1105063#msg1105063

The  dimensional model appears in Section III: Emerging Measures and Models (Alternative DSM-5 Model for Personality Disorders) of the DSM 5 and researchers have been gathering data its applicability.

Summary:

The alternative DSM-5 model for personality disorders
John M Oldham
Author information ► Copyright and License information ►

Differences among personality types and styles have been observed for centuries. What accounts for these differences – what makes each person's personality unique – has been debated for a very long time as well. As far back as the days of Hippocrates, it was recognized that there must be correlations between behavior patterns and human biology, and personality types and styles such as melancholic, phlegmatic and sanguine were thought to correlate with differential levels of “body humors” such as bile, phlegm and blood. These principles have stood the test of time, but today we have moved from theory to science and we speak of levels of neurotransmitters such as dopamine, serotonin and norepinephrine that correlate with different personality types and styles. And we recognize that a given individual's personality emerges from at least two sources: temperament (the “hardwired” genetic component) and character (the shaping and molding effects of experience – either healthy or disruptive – during early development, particularly childhood attachment processes).

While great progress has been made, it remains challenging to reach a broad consensus on the best way to classify different personality types, and to differentiate the normal range and variety of personality types from what we call personality disorders. A central feature of this debate has been whether to use a dimensional or a categorical system. The Five-Factor Model has been studied extensively in factor-analytic trait psychology research and has been widely heralded as a valid dimensional system to capture main variations in personality styles (1). This model, however, was derived mostly from studies of normal populations and has not been easily applicable to patient populations.

The DSM adopted a categorical system more compatible with disease classification systems used in the world of medicine. In its third edition, published in 1980, diagnostic criteria were developed that defined a set of eleven personality disorders, and these were placed on the second “axis” (Axis II) of the multi-axial system introduced in that edition of the manual (2). Later editions of the DSM reduced the number of personality disorders to 10 and established a uniform polythetic format for the diagnostic criteria of each disorder, requiring a designated number of criteria to be present to make a given diagnosis (e.g., any 5 of 9 criteria are required for a diagnosis of borderline personality disorder). Personality disorders in DSM-IV are organized in what I refer to as a “dimensionally-flavored categorical system”, reflected in the three “cluster” groupings: Cluster A (“odd-eccentric”), Cluster B (“dramatic-emotional”), and Cluster C (“anxious-fearful”) (3).

The criteria-defined DSM categorical system has been widely utilized worldwide and has served as a stimulus to research. Nevertheless, a number of problems and shortcomings of this approach have been identified (4,5). For most personality disorders, the number of criteria, or threshold, required to make the diagnosis was arbitrary, yet the categorical approach conveys the impression that the disorder is either present or it is not, rather than that a symptom and trait pattern can vary along a gradient of severity. Furthermore, the polythetic nature of the criteria sets involves extensive heterogeneity within diagnoses. For example, there are 256 ways that five out of nine criteria for the diagnosis of borderline personality disorder can be configured (5), and two patients could receive this diagnosis but share only one criterion.

Work began on DSM-5 over a decade ago, and in an early monograph entitled “A research agenda for DSM-V” it was noted that “well-informed clinicians and researchers have suggested that variation in psychiatric symptomatology may be better represented by dimensions than by a set of categories, especially in the area of personality traits” ((6), p. 12). Once convened, the Work Group for Personality and Personality Disorders was charged to review the literature and explore the possibility of developing a dimensional approach to classification of personality disorders.

An initial draft of a prototype model was developed and posted on the DSM-5 website in 2010, along with all proposed changes being considered for DSM-5. After extensive feedback from written responses, professional audiences, and the DSM-5 Task Force itself, it was decided that the prototype model would not be workable. A criteria-based “hybrid” model was then developed and posted in 2011, followed by a final posted version in 2012. This model was studied in the DSM-5 field trials. The new model for borderline personality disorder, for example, showed good test-retest reliability (7) and was judged to be preferable to the DSM-IV model by clinicians in routine clinical practice and at academic centers participating in the field trials. Data were obtained (and later published) from an independent group of practitioners showing similar results (8).

The new model for personality disorders was presented to the entire DSM-5 Task Force, consisting of the overall chair and co-chair of the DSM-5 effort, along with the chairs of all of the DSM-5 Work Groups, and it was strongly and unanimously approved. However, several scientific and clinical committees that the American Psychiatric Association (APA) had established to review all proposed changes in the diagnostic manual felt that there was not sufficient evidence at the time to validate the proposed new personality disorder model and to establish its clinical utility. The APA Board of Trustees then voted to sustain the DSM-IV diagnostic system for personality disorders, virtually unchanged, in the main section of DSM-5 and to include the proposed new model as an “alternative DSM-5 model for personality disorders” in Section III of DSM-5, the section referred to as “Emerging measures and models” (9). Although this result was a disappointment to the Work Group, it is encouraging that the new model is included in DSM-5 as an “alternative model”, thus “officially” allowing its use by those who are interested, and stimulating research on it (see 5,10,11).

In the alternative model, the essential criteria to define any personality disorder are: a) moderate or greater impairment in personality functioning, and b) the presence of pathological personality traits. A “level of functioning” scale is provided, and sensitivity and specificity data supported the designation of “moderate impairment” as the appropriate threshold to indicate the presence of a personality disorder (12). As defined in the alternative model, personality functioning consists of the degree to which there is an intact sense of self (involving a clear, coherent identity and effective self-directedness) and interpersonal functioning (reflecting a good capacity for empathy and for mature, mutually rewarding intimacy with others). Pathological personality traits are organized into five trait domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism), each of which is further explicated by a set of trait facets reflecting aspects of the domain itself. This trait system has been shown to correlate well with the Five Factor Model (13).

One task taken up by the Work Group was to review the literature and assess the strength of the published data supporting the construct validity of each DSM-IV personality disorder, similar to the process carried out in the development of DSM-IV itself, which led to the removal of passive-aggressive personality disorder from the diagnostic manual as a discrete disorder, reconceptualizing it as a trait found in many different Axis I and Axis II conditions. The result of these reviews was to reduce the number of designated personality disorders to six (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal), and to specify the nature of the moderate or greater impairment in personality functioning, as well as to itemize the pathological personality trait domains and trait facets that characterize each disorder.

In addition, a new diagnosis called Personality Disorder-Trait Specified was established, replacing Personality Disorder Not Otherwise Specified in DSM-IV. This diagnosis can now be utilized as more than just a “rule-out” diagnosis – it indicates that a patient does meet the general criteria for a personality disorder, does not qualify for any of the six designated personality disorders, and has a pathological trait profile that can be individually portrayed (which can capture paranoid, schizoid, histrionic, and dependent traits if present, in addition to any other applicable trait facets).

Overall, there has been growing interest in this alternative model. Clinical experience and further research can help evaluate its validity, reliability, and clinical utility, and whether or not additional changes might be considered in future revisions of the diagnostic manual. One interesting model is being proposed for the ICD-11, i.e., to utilize a single diagnostic term of Personality Disorder rated on four levels of personality dysfunction: “personality difficulty” (a “Z” code implying no formal disorder), mild, moderate, and severe personality disorder (14). This proposal is somewhat analogous to the Personality Disorder-Trait Specified diagnosis of DSM-5.

One critique of the alternative model, voiced by a number of leaders in the personality disorder field, argued that the new model is too complicated and that clinicians will not use it (15). However, as described above, clinicians reported favorably on its clinical utility and its use for treatment planning and communication to colleagues, patients, and families. Also, a fair test of complexity is to compare all of DSM-IV personality disorder diagnoses with all of those in the new model. In fact, the number of criteria required to cover all diagnoses in the new model has been reduced by 43% compared to DSM-IV. Either version can be used prototypically as is common in clinical practice, so that the most prominent diagnostic pattern, such as borderline personality disorder, will command the highest priority in treatment planning, with the option to explore additional pathological features as appropriate.

[enlighten me]

Thanks skip an interesting read. I was concerned how complicated my idea was which is shown in that article. It is however a lot easier nowadays with vomputers to compile the information and get a result. I would not want to be writing the dimension model program for PDs though.

[Reforming]

To add to Skip's has useful information.

There are a number of health professionals who feel that comorbidity is one of the biggest problems with DSMV diagnostic criteria for personality disorders. Professor Peter Tyrer, a psychiatrist, an expert on personality disorders and former editor of the British Journal of Psychiatry - imperial.ac.uk/people/p.tyrer - discusses some of the challenges of diagnosing and categorising personality disorders www.bjp.rcpsych.org/content/179/1/81#ref-12

I've spoken to a number of therapists who no longer use the NPD or BPD labels because they feel that they are unhelpful for effective treatment.  The last DSMV made attempted to reform or clarify the diagnostic criteria for personality disorders and some of their proposals proved be very controversial, one of which was the removal of Narcissistic Personality Disorder as well as four other from the DSMV. www.nytimes.com/2010/11/30/health/views/30mind.html It's worth reading the wiki entry on the Diagnostic and Statistical Manual of Mental Disorders for more context. https://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders

The DSM is not the only organisation that provides a classification system for mental disorders. The ICD, the International Classification of Diseases is a global organisation and part WHO also publishes a classification system. www.apa.org/monitor/2009/10/icd-dsm.aspx

In February 2015 the ICD published a new proposed diagnostic model for diagnosing personality disorders. The opening paragraph states "Personality disorders are common and ubiquitous in all medical settings, so every medical practitioner will encounter them frequently. People with personality disorder have problems in interpersonal relationships but often attribute them wrongly to others. No clear threshold exists between types and degrees of personality dysfunction and its pathology is best classified by a single dimension, ranging from normal personality at one extreme through to severe personality disorder at the other. The description of personality disorders has been complicated over the years by undue adherence to overlapping and unvalidated categories that represent specific characteristics rather than the core components of personality disorder."

If you're interested in reading more I can send you the article

Reforming

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