Personality disorder revamp ends in 'horrible waste'
A planned overhaul of the way in which personality disorders are diagnosed will not now appear in the manual dubbed "the bible of psychiatry".
The failure to agree a workable system for the next edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5 is bad news for people with serious personality difficulties, who are frequently misdiagnosed.
"It's a horrible wasted opportunity," says Jonathan Shedler of the University of Colorado School of Medicine in Denver, one of the fiercest critics of the rejected new system.
Personality disorders revolve around difficulties in relating to other people, but can manifest in different ways. Experts agree that the system in the current DSM, which dates from 1994, is seriously flawed. It features a bewildering set of symptoms and checklists that attempts to match patients to one of 10 disorders.
Symptoms, not cause
The problem is that patients may end up being diagnosed with several disorders at the same time, while others with seriously disturbed personalities don't clearly meet any of the diagnoses. Add this confusion to the commonly held but outdated view that personality disorders can't be treated, and many patients never get the help they need.
Rather than receiving intensive psychotherapy, which can be effective, patients with personality disorders often get treated for the anxiety and depression that can be triggered by their difficulties with social interaction. Others get misdiagnosed as suffering from attention-deficit hyperactivity disorder or even post-traumatic stress disorder.
"They go from therapist to therapist and don't get any help," says Valerie Porr, president of the non-profit organisation Treatment and Research Advancements Association for Personality Disorder in New York City.
The DSM-5 personality disorders work group developed a system that recognised that personalities don't come in black and white, but instead operate in shades of grey. It proposed two scales of "personality functioning" based on people's interpersonal interactions and sense of self, and said that patients should also be rated for five pathological personality traits, including antagonism and impulsivity.
The proposed system got even more complicated when the task force overseeing the entire DSM-5 revision asked the group to try and map the existing disorders onto the new framework – which was done for six of the 10 disorders.
The resulting hybrid was criticised for being too complex for use by busy doctors, and was given the thumbs down by two expert committees, asked to review the scientific basis and clinical value of all of the DSM-5 proposals.
As a result, when the APA's Board of Trustees on Saturday approved what should go into the final volume, due to be published in May 2013, the section on personality disorders was the main casualty. The board backed a recommendation to exclude it from the main text and instead publish it in a section describing diagnoses requiring further study.
Andrew Skodol of the University of Arizona in Tucson, who headed the work group responsible for the proposal, hopes that it may be shifted into the main DSM text after further research. "It's already being studied and ultimately I have faith the people will see its scientific soundness and clinical utility," he says.
David Kupfer of the University of Pittsburgh, who chairs the APA task force overseeing the development of DSM-5, says that further research to test the value of the new proposals will be top priority: "We really want them to be high on the agenda."
However, the main focus of attention will now shift to a group headed by Peter Tyrer of Imperial College London, which is working on a new system of diagnosing personality disorders for the next edition of the World Health Organization's International Classification of Diseases (ICD), due out in 2015. Although it holds less sway over psychiatry, particularly in the US, than the DSM, the ICD is the main system used for medical diagnosis across the globe.
Tyrer's group has also devised a system that rates the scale of patients' personality problems – but its proposal is simpler. It is based on a four-point scale rating people's problems relating to others, running from "personality difficulties" through mild, moderate and severe personality disorder.
This would be supported by ratings for "domains" of personality, linked to extremes on four of the "big five" personality traits recognised by psychologists: extraversion, agreeableness, conscientiousness, neuroticism and openness to experience. For example, patients who currently meet criteria for borderline personality disorder, whose relationships may swing between adulation and outbursts of anger, would be rated as having problems on a scale of negative emotion, linked to the trait of neuroticism.www.newscientist.com/article/dn22563-personality-disorder-revamp-ends-in-horrible-waste.html