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THE PSYCHOLOGY OF PERSONALITY DISORDERS
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Author Topic: Diagnosis: DSM-5.0 | Alternate Model for Personality Disorders  (Read 58484 times)
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« on: February 10, 2010, 07:00:41 PM »

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.
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« Reply #1 on: February 11, 2010, 11:10:15 AM »

We’re all so used to the 9 traits of borderline personality disorder as defined by the American Psychiatric Association’s current DSM-IV-TR that it’s hard to imagine it changing—even though the DSM-IV-TR is controversial and plagued with problems. Yet we know it will because for many years the APA has been working not only for a new description of BPD but the entire DSM: the DSM-5 will be out in 2013.  Now, we finally have a look at what they’re proposing.  
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« Reply #2 on: February 12, 2010, 10:02:41 AM »

Maybe the greatest change for non-professionals like ourselves, is the first criteria -  the APA is attempting to clearly define the line between personality disorder and personality style.

Here is a more detailed look at #1 criteria.

1 Impairments  The must be impairments in self functioning AND impairments in interpersonal functioning (more on this later)

In the DSM 5, the essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:

Self (impairment in at least 1):

Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience.  To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).

Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.   To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).

Interpersonal (impairment in at least 1):

Empathy*: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding of the effects of own behavior on others.    To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).

Intimacy*: Depth and duration of positive connections with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.   To be rated from healthy functioning (Level = 0) to extreme impairment (Level = 4).




Below is the scale for "empathy".  There are four scales in total (identity, self direction, empathy, intimacy).  To me, it is facinating to see "empathy" defined in such clear terms.

Healthy (0) Capable of accurately understanding others’ experiences and motivations in most situations. Comprehends and appreciates others’ perspectives, even if disagreeing.  Is aware of the effect of own actions on others.

Mild impairment (1) Somewhat compromised in ability to appreciate and understand others’ experiences; may tend to see others as having unreasonable expectations or a wish for control. Although capable of considering and understanding different perspectives, resists doing so. Inconsistent is awareness of effect of own behavior on others.

Impaired (2) Hyper-attuned to the experience of others, but only with respect to perceived relevance to self. Excessively self-referential; significantly compromised ability to appreciate and understand others’ experiences and to consider alternative perspectives. Generally unaware of or unconcerned about effect of own behavior on others, or unrealistic appraisal of own effect.

Very Impaired (3) Ability to consider and understand the thoughts, feelings and behavior of other people is significantly limited; may discern very specific aspects of others’ experience, particularly vulnerabilities and suffering.  Generally unable to consider alternative perspectives; highly threatened by differences of opinion or alternative viewpoints. Confusion or unawareness of impact of own actions on others; often bewildered about peoples’ thoughts and actions, with destructive motivations frequently misattributed to others.

Extreme Impairment (4)  Pronounced inability to consider and understand others’ experience and motivation. Attention to others' perspectives virtually absent (attention is hypervigilant, focused on need-fulfillment and harm avoidance).  Social interactions can be confusing and disorienting.





Here is the scale for intimacy.  There are four scales in total

Healthy (0) -Maintains multiple satisfying and enduring relationships in personal and community life. Desires and engages in a number of caring, close and reciprocal relationships. Strives for cooperation and mutual benefit and flexibly responds to a range of others’ ideas, emotions and behaviors.

Mild impairment (1) -Able to establish enduring relationships in personal and community life, with some limitations on degree of depth and satisfaction.Capacity and desire to form intimate and reciprocal relationships, but may be inhibited in meaningful expression and sometimes constrained if intense emotions or conflicts arise. Cooperation may be inhibited by unrealistic standards; somewhat limited in ability to respect or respond to others’ ideas, emotions and behaviors.

Impaired (2) Capacity and desire to form relationships in personal and community life, but connections may be largely superficial. Intimate relationships are largely based on meeting self-regulatory and self-esteem needs, with an unrealistic expectation of being perfectly understood by others. Tends not to view relationships in reciprocal terms, and cooperates predominantly for personal gain.

Very Impaired (3) Some desire to form relationships in community and personal life is present, but capacity for positive and enduring connection is significantly impaired. Relationships are based on a strong belief in the absolute need for the intimate other(s), and/or expectations of abandonment or abuse.  Feelings about intimate involvement with others alternate between fear/rejection and desperate desire for connection. Little mutuality: others are conceptualized primarily in terms of how they affect the self (negatively or positively); cooperative efforts are often disrupted due to the perception of slights from others.

Extreme Impairment (4)  Desire for affiliation is limited because of profound disinterest or expectation of harm.  Engagement with others is detached, disorganized or consistently negative. Relationships are conceptualized almost exclusively in terms of their ability to provide comfort or inflict pain and suffering. Social/interpersonal behavior is not reciprocal; rather, it seeks fulfillment of basic needs or escape from pain.





The remaining scales are listed here:  dsm5.org/ProposedRevisions.aspx?rid=468
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« Reply #3 on: February 13, 2010, 05:24:07 AM »

My late father showed a lot of empathy when we were kids to us and to others. As did the two BPDs I was and were involved with. But as the illness progressed it got worse and my sister described my father as sociopath. My warm and giving ex gf became extremely demanding. My wife focused on coping and raged. One characteristic of BPD (as currently understood) is high sensitivity and this sensitivity in combination with lack of emotional regulation is the breeding ground for trouble. Often BPDs are found in caring jobs.

So the lack of empathy in diagnostic criteria may be a good characteristic of later severe clinical cases but misleading or wrong in sub-clinical and earlier phases.

This illness is a chameleon. Any static system describing the color is flawed.
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« Reply #4 on: February 14, 2010, 01:44:41 PM »

You may know that borderline personality disorder is currently known as an “axis ll” disorder, a “permanent state” disorder and not a “temporary trait” disorder.Randi
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« Reply #5 on: February 15, 2010, 06:12:49 AM »

Below is the scale for "empathy".  There are four scales in total (identity, self direction, empathy, intimacy)

Healthy (0) Capable of accurately understanding others’ experiences and motivations in most situations. Comprehends and appreciates others’ perspectives, even if disagreeing.  Is aware of the effect of own actions on others.

Mild impairment (1) Somewhat compromised in ability to appreciate and understand others’ experiences; may tend to see others as having unreasonable expectations or a wish for control. Although capable of considering and understanding different perspectives, resists doing so. Inconsistent is awareness of effect of own behavior on others.

Impaired (2) Hyper-attuned to the experience of others, but only with respect to perceived relevance to self. Excessively self-referential; significantly compromised ability to appreciate and understand others’ experiences and to consider alternative perspectives. Generally unaware of or unconcerned about effect of own behavior on others, or unrealistic appraisal of own effect.

Very Impaired (3) Ability to consider and understand the thoughts, feelings and behavior of other people is significantly limited; may discern very specific aspects of others’ experience, particularly vulnerabilities and suffering.  Generally unable to consider alternative perspectives; highly threatened by differences of opinion or alternative viewpoints. Confusion or unawareness of impact of own actions on others; often bewildered about peoples’ thoughts and actions, with destructive motivations frequently misattributed to others.

Extreme Impairment (4)   Pronounced inability to consider and understand others’ experience and motivation. Attention to others' perspectives virtually absent (attention is hypervigilant, focused on need-fulfillment and harm avoidance).  Social interactions can be confusing and disorienting.

So, now there is a formula for rating impairment.  I find this proposal quite interesting.  It tackles the subjective nature of trying to diagnose these personality disorders, and the difficulty of even defining what the traits are.

Sometimes, I think we get too hung up on having a diagnosis.  We want it either because we hope for a cure for our pwBPD, or to give ourselves permission to give up.  

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« Reply #6 on: February 15, 2010, 09:24:01 AM »

I have just one simple comment and one simple question:

The comment is, I really wish they would change the name!  It's so misleading and confusing - one more barrier to acceptance by the sufferer.

The question is - and forgive me if this was explained already but I want to make sure I understand - by this system, would it be more likely that treatment would be covered by insurance?

Thanks!

Matt
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« Reply #7 on: February 15, 2010, 09:44:57 AM »

I really wish they would change the name!

A name change got lobbied pretty hard by the patient community.

My guess is that they didn't want to lose the connection to the recently completed large studies (and studies in process), the advocacy work done with Congress in declaring BPD awareness month, and the gains made with the insurance industry.  In fact, it seems that they are trying to leverage these gains to help with the other PDs that were previously classified separately.

It may have been just a very practical decision.
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Randi Kreger
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« Reply #8 on: February 15, 2010, 03:51:21 PM »

So, now there is a formula for rating impairment.  I find this proposal quite interesting.  It tackles the subjective nature of trying to diagnose these personality disorders, and the difficulty of even defining what the traits are.

The people who I talk to assume there will be lots of professional education to help people with whatever system they come up with. There has to be. Probably various books and seminars and such. I'm not surprised the name wasn't changed. I didn't like the alternatives because they focused on emotion and made it seem like a mood disorder, and we all know it's more complex than that! Randi
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« Reply #9 on: February 15, 2010, 05:47:22 PM »

Summing it up...

Good comments, all.  smiley

In summing up what we have learned so far, here is how the pieces fit together.  To be BPD all three must be true.  Anything less is not BPD per se' but rather "BPD leanings, or BPD style, or subclinical BPD, or "high functioning BPD".

(1) A rating of mild impairment or greater on the Levels of Personality Functioning

(2) A “good match” or “very good match” to a Personality Disorder Type (see BPD type)  

(3) 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.
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