DIAGNOSIS: DSM-5.0 | Alternate Model for Personality Disorders

[BPDFamily.com]

No effect for drug companies. No drugs have ever even been tested on people with PDs. All drugs are given off-label

Randi, IF there were drugs available for PD's right now, would this change benefit them? It sounds like there is a lot of research going on, they are tieing the PD's to the brain not functioning correctly, so if they come up with a drug in the future, does this change benefit the drug companies? Or is there a potential benefit?

I would gladly make some drug company very rich if they came up with an effective drug treatment for BPD. They would deserve to be rich.

[Auspicious]

No effect for drug companies. No drugs have ever even been tested on people with PDs. All drugs are given off-label

Randi, IF there were drugs available for PD's right now, would this change benefit them? It sounds like there is a lot of research going on, they are tieing the PD's to the brain not functioning correctly, so if they come up with a drug in the future, does this change benefit the drug companies? Or is there a potential benefit?

I would gladly make some drug company very rich if they came up with an effective drug treatment for BPD. They would deserve to be rich.

[Skip]

there has been talk of eliminating the category as the psychiatrists behind the DSM are trying to knock down 10 PDs into 5.

This is the current list of 6.  

Antisocial/Psychopathic Type

Avoidant Type

Borderline Type

Narcissistic Type

Obsessive-Compulsive Type

Schizotypal Type

Severe PD types, such as schizotypal and borderline, have been found to have significantly more impairment at work, in social relationships, and at leisure than patients with less severe types, such as obsessive-compulsive disorder, or with major depressive disorder in the absence of personality disorder.

And they plan to define all of these using constellations of these 6 criteria:

• Negative Emotionality: Experiences a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, etc.), and the behavioral and interpersonal manifestations of those experiences
  
  Trait facets:  Emotional lability, anxiousness, submissiveness, separation insecurity, pessimism, low self-esteem, guilt/ shame, self-harm, depressivity, suspiciousness

• Introversion: Withdrawal from other people, ranging from intimate relationships to the world at large; restricted affective experience and expression; limited hedonic capacity
  
  Trait facets:  Social withdrawal, social detachment, restricted affectivity, anhedonia, intimacy avoidance

• Antagonism: Exhibits diverse manifestations of antipathy toward others, and a correspondingly exaggerated sense of self-importance
  
  Trait facets:  Callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, deceitfulness

• Disinhibition: Diverse manifestations of being present- (vs. future- or past-) oriented, so that behavior is driven by current internal and external stimuli, rather than by past learning and consideration of future consequences
  
  Trait facets:  Impulsivity, distractibility, recklessness, irresponsibility

• Compulsivity: The tendency to think and act according to a narrowly defined and unchanging ideal, and the expectation that this ideal  should be adhered to by everyone
  
  Trait facets:  Perfectionism, perseveration, rigidity, orderliness, risk aversion

• Schizotypy: Exhibits a range of odd or unusual behaviors and cognitions, including both process (e.g., perception) and content (e.g., beliefs)
  
  Trait facets:  Unusual perceptions, unusual beliefs, eccentricity, cognitive dysregulation, dissociation proneness

The other PDs will be in a general category - Paranoid Personality Disorder, Schizoid Personality Disorder, Histrionic Personality Disorder, Narcissistic Personality Disorder, Dependent Personality Disorder

[Blossom]

I think there are child protection implications when a parent has any kind of severe mental health condition. I hope the new DSM document recognises that when an adult is diagnosed with a PD, there is a significant risk that their children will be abused and/or neglected. Especially because so many adults with PDs seem to have a sadistic streak.

I'm new to this thread, but finding it interesting. Thoughts like that above though, do concern me. Like UKannie, my father has schizophrenia; my husband has BPD. I would hate to see this raised as a child protection issue though; it undermines nons and would put an immense stress and pressure on families that are already trying to do their best to avoid stress and pressure. Of course growing up with a mentally ill parent is different to having two 'normal' parents, but that doesn't warrant interference from social services where there is no indication of abuse other than the 'possibility' presented by a mental illness; it feels like a slippery slope.

[Skip]

The underlying research on this work can be found here:

Research led by Michigan State University psychologist Christopher Hopwood proposes a new way to classify personality disorders.

EAST LANSING, Mich. — Research led by a Michigan State University psychologist is playing a key role in the effort to change the way mental health clinicians classify personality disorders. The study by Christopher Hopwood and colleagues calls for a more scientific and practical method of categorizing personality disorders – a proposal that ultimately could improve treatment, Hopwood said.  Hopwood and colleagues propose a new three-stage strategy for diagnosing personality disorders:

• Stage One: Consider a patient's normal personality traits, such as introversion/extroversion. "If a person is depressed and I'm a clinician, it might make a difference if I think they're extroverted depressive rather than introverted depressive," Hopwood said. "It may dictate the type of recommendations I make for them." These normal personality traits also may indicate patient strengths that could help in overcoming psychiatric difficulties; such strengths are not assessed in the current DSM.

• Stage Two: Create a numerical score to represent severity of the disorder. "We're arguing that one single score can represent that severity, so clinicians can easily communicate with one another about how severe a patient is," Hopwood said. "That may indicate decisions such as whether this person should be hospitalized or treated with outpatient care."

• Stage Three: Condense the list of 10 personality disorder categories to five dimensional ratings. Under this proposal, clinicians would diagnose how many symptoms of each disorder a patient has, rather than whether they have one or more of 10 disorders as in the current system. Hopwood said this is more reliable, valid and specific than the current system. He added that research has not sufficiently supported the validity of several current personality disorders. The proposed dimensional ratings are:
  
  Peculiarity. The defining characteristic here is oddness in thought or behavior. This dimension includes the diagnoses of paranoid, schizotypal and schizoid.
  
  Withdrawal. This includes avoidant personalities. "This may have to do with not wanting to leave the house," Hopwood said.
  
  Fearfulness. This combines disorders with opposite extremes of harm avoidance, such as antisocial (which involves fearlessness) and dependant or avoidant (which involves fearfulness).
  
  Unstable. This is similar to the diagnosis of borderline in DSM-IV. The defining characteristic is instability, such as with relationships, identity or emotional experience.
  
  Deliberate. This includes obsessive-compulsive disorder and other disorders defined by overly methodical behavior. "It's having a rigid sense of how life should happen – how I should behave and how other people should behave," Hopwood said.

"We're proposing a different way of thinking about personality and personality disorders," said Hopwood, MSU assistant professor of psychology and an experienced clinician. "There's widespread agreement among personality disorder researchers that the current way to conceptualize personality disorders is not working."

The study is being cited by the team of experts that currently is developing criteria for the manual used to diagnose personality disorders – the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, slated to come out in 2013.

The study is being considered for inclusion in the DSM-5. The DSM, published by the American Psychiatric Association, is considered the bible of the U.S. mental health industry and is used by insurance companies as the basis for treatment approval and payment. The study also will appear in an upcoming issue of the Journal of Personality Disorders.

The current method of classifying personality disorders, as spelled out in the fourth edition of the DSM, or DSM-IV, breaks personality disorders into 10 categories, Hopwood said. That system is flawed, he said, because it does not take into account severity of personality disorders in an efficient manner and often leads to overlapping diagnoses.

"It's just not true that there are 10 types of personalities disorders, and that they're all categorical – that you either have this personality disorder or you don't," Hopwood said. "Scientifically, it's just not true."

Ultimately, Hopwood said, the proposal could improve both the system for diagnosing personality disorders as well as the outcome. "Presumably, if this leads to better clinical efficiency it could lead to better clinical care, and that's in everybody's interest," he said.



Co-authors of the proposal include Andrew Skodol of the Sunbelt Collaborative, New York State Psychiatric Institute and Columbia Medical School, and Leslie Morey of Texas A&M University.

Skodol is chairperson and Morey is a member of the committee that will determine the criteria for diagnosing personality disorders in the upcoming DSM.[/size]

[PotentiallyKevin]

"Stage One: Consider a patient's normal personality traits, such as introversion/extroversion. "If a person is depressed and I'm a clinician, it might make a difference if I think they're extroverted depressive rather than introverted depressive," Hopwood said. "It may dictate the type of recommendations I make for them." These normal personality traits also may indicate patient strengths that could help in overcoming psychiatric difficulties; such strengths are not assessed in the current DSM."

I  absolutely agree with this, personality definitely needs to be taken into consideration. We, as individuals, have different priorities, strengths and weaknesses that are innate and unique to our personality types. It is just not logical to treat an extrovert with depression the same way you treat an introvert with depression - their triggers and responses are usually opposite.

Stage two makes sense as well, but stage three is confusing... .

[Skip]

DSM-5 Field Trials Begin: Proposed Diagnostic Criteria Put to the Test

October 19, 2010 — The American Psychiatric Association (APA) has announced that standardized field trials have now started in preparation for the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

The trials were created to assess the practical use of proposed DSM-5 diagnostic criteria in real-world clinical settings before the manual is published in 2013.

Dr. David Kupfer

"The process for developing DSM-5 continues to be deliberative, thoughtful, and inclusive," said Darrel Regier, MD, MPH, vice chair of the DSM-5 Task Force and APA research director, in a release.

"Large-scale field trials are the next critical phase in this important process and will give us the information we need to ensure the diagnostic criteria are both useful and accurate," he added.

More than 8000 comments by clinicians, researchers, and advocates submitted on the DSM-5 Website regarding the draft criteria were reviewed by the DSM-5 Work Groups. The new field trials will reflect criteria adjustments based on these comments — and will have 2 separate study designs, depending on type of clinical setting.

Although all field trial clinicians will assess new and existing patients at different stages of treatment using the proposed DSM-5 diagnostic criteria and measures, academic and other large clinical settings will use one design, whereas individual practitioners and smaller clinical practices will follow the other.

"It is important that the proposed criteria are subjected to rigorous and empirically sound field trials," David Kupfer, MD, chair of the DSM-5 Task Force, said in the same release. "The 2 field trial designs will allow us to better understand how the proposed revisions affect clinicians' practices and, most importantly, patient care."

11 Large Centers

Of approximately 60 academic or large centers that responded to the APA's call for proposal, 11 pediatric and adult sites were selected. These include the following:

   * Baystate Medical Center in Springfield, Massachusetts;

   * Child Psychiatry Division, Columbia University/New York State Psychiatric Institute in New York City;

   * Lucile Packard Children's Hospital at Stanford University in Palo Alto, California;

   * The Children's Hospital in Aurora, Colorado;

   * Centre for Addiction and Mental Health in Toronto, Ontario, Canada;

   * Dallas Veterans Affairs Medical Center in Texas;

   * DeBakey Veterans Affairs Medical Center and Menniger Clinic, Baylor College of Medicine in Houston, Texas;

   * Mayo Clinic in Rochester, Minnesota;

   * University of California, Los Angeles;

   * University of Pennsylvania in Philadelphia; and

   * University of Texas Health Science Center in San Antonio

Field trial patient evaluations in these settings will start with a baseline assessment by a clinician followed by a second assessment 4 hours to 2 weeks later by a different clinicianto test the reliability of the proposed diagnostic criteria. At 4- to 12-week follow-up, the assessment will be repeated.

Clinicians in these larger settings will also be allowed to conduct videotaped evaluations for a small subset of patients.

In an article published in the October 15 issue of Psychiatric News, Dr. Kupfer writes that it is important that draft criteria are examined in sizable, diverse populations.

"These large settings provide an ideal backdrop for recruiting high volumes of psychiatric patients who represent a wide array of characteristics, including various ages, cultures and ethnicities, socioeconomic backgrounds, and potential diagnoses," he adds.

It is estimated that 2500 to 3000 patients will be recruited to participate in this setting.

Smaller Settings

A total of 3900 mental health professionals, including 1400 psychiatrists from a randomly selected sample of those registered with the American Medical Association Masterfile and 2500 volunteer clinicians (including psychiatrists, psychologists, social workers, and nurses), will participate in the field trials scheduled to be conducted in smaller, routine clinical settings.

Recruitment for these smaller settings will continue through October and November. Those selected will need to complete Web-based training before participating and will then recruit and evaluate 2 patients each.

"Having practitioners, such as solo clinicians and those in independent group practices, test proposed revisions is important for examining DSM-5 in the context of its everyday use," writes Dr. Kupfer.

The main difference between the 2 study designs is that the routine clinical settings will use just 2 evaluation visits for patients compared with 3 for the larger institutions.

"Although the use of 2 field-trial designs increases the complexity of this project, the tradeoff is a more precise understanding of how the future of psychiatric diagnosis might impact patients and clinicians," Dr. Kupfer adds.

Evaluation Measures

The DSM-5 Task Force reports that results from all field trials will address several important measures regarding the diagnostic criteria, including the following:

   * Feasibility: are the proposed criteria easy for clinicians to understand and use?

   * Clinical utility: do they help in describing psychiatric problems and in making treatment plan decisions?

   * Validity: how accurate are they in reflecting the mental disorders they are designed to describe? and

   * Reliability: are the same conclusions reached when the criteria are used by different doctors?

Severity measures, through the use of questionnaires and other tools to help assess patient symptom severity on a rating scale, will also be examined during the field trials, as will "cross-cutting dimensional measures." These are tools for "assessing symptoms that occur across a wide range of diagnoses, such as anxiety or sleep problems."

This first phase of field trials is scheduled to run through the end of March 2011, after which the results will be presented in scientific meeting presentations and in articles in scientific journals and DSM-5 source books.

After these initial field trials, another period of public comments through the DSM-5 Website, and more draft criteria adjustments by the Work Groups, a second set of field trials is scheduled to take place later in 2011 and in 2012.

[Totoro13]

"Stage One: Consider a patient's normal personality traits, such as introversion/extroversion. "If a person is depressed and I'm a clinician, it might make a difference if I think they're extroverted depressive rather than introverted depressive," Hopwood said. "It may dictate the type of recommendations I make for them." These normal personality traits also may indicate patient strengths that could help in overcoming psychiatric difficulties; such strengths are not assessed in the current DSM."

I  absolutely agree with this, personality definitely needs to be taken into consideration. We, as individuals, have different priorities, strengths and weaknesses that are innate and unique to our personality types. It is just not logical to treat an extrovert with depression the same way you treat an introvert with depression - their triggers and responses are usually opposite.

Stage two makes sense as well, but stage three is confusing... .

Stage 3 sounds interesting... .  It seems to be focusing on the behaviors instead of a label.  When looking at some of the PDs I think my ex has, there are many overlaps and that made it difficult for me to decided exactly which PD best fits him. 

[RowJimmy]

If I could just throw my layman's 2 cents in here. 

It seems to me that the biggest problem we have today is that psychiatrists and psychotherapists are unable, and/or unwilling to make a diagnosis of BPD today, in part because 1) it is extremely difficult to make such a diagnosis with the current DSM criteria, and 2) because of the stigma attached with the term "Borderline Personality Disorder."

The new criteria listed in the OP seem to be even more confusing and tend to leave out what I have come to understand as some of the defining and distinctive behavior patterns, such as splitting, mirroring, projection, tendency to abuse those in close relationships, etc.  What is desperately needed by both BPD's and their loved ones, is EASIER diagnosis, not more complex.

My concern is that no only is the name not changing, but it is now going to be even HARDER to diagnose, which is going to lead to a lot more people coming on her with undiagnosed loved ones than there already is.  It has been noted that there are more people with BPD than bipolar and schizophrenia combined, yet psychiatrists seem to diagnose Bipolar like they are giving out candy while ignoring BPD for the most part.  And because recovery rates have been reported as fairly good with techniques like DBT, I think it is critical that the psychiatric community both make an effort to remove the stigma associated with the word borderline AND make diagnosis simpler and NOT more complex. 

Mistakes are inevitable, but my feeling is that it is much better to err on the side of the disease that afflicts more people.  It might be better to misdiagnose someone with BPD who might have bipolar or NPD for example, because the treatment of DBT can be beneficial to all of these illnesses, whereas the medication treatments are generally much less effective on personality disroders.  Generally, there is much greater risk (side effects, suicide, depression, etc) associated with mistakenly giving someone heavy doses of various anti-psychotics, anti-depressants, and so forth than mistakenly giving them therapy.

[ThursdayNext]

Have to say I think I agree with RowJimmy, that more pwPDs are likely to slip through the diagnostic net with this.

I think my (appearance of) high-functioning uNPD father would be hard to diagnose under the current criteria and there is no way he would score sufficiently highly using the new diagnostic criteria. Yet just from description of his behaviour and listening to a letter from him that I read aloud, my T was able to say, 'I think your father has NPD'. (I'd already worked that out through internet diagnosis!)

My point is that with the new criteria I think that both families and patients are possibily disadvantaged - patients because there are more who will not 'fit the criteria' sufficiently for diagnosis and families because their pwPD is 'missed'. I've seen this happen in the education system when they change criteria and it's almost always related to funding - they want to cut funding for support, so the criteria are made more general or changed so that fewer can be identified as needing the funding/support. Result: less treatment, not more.

Nothing we can do about it, of course, but I am seriously concerned.

[Skip]

It might be better to misdiagnose someone with BPD who might have bipolar or NPD for example, because the treatment of DBT can be beneficial to all of these illnesses, whereas the medication treatments are generally much less effective on personality disroders.  Generally, there is much greater risk (side effects, suicide, depression, etc) associated with mistakenly giving someone heavy doses of various anti-psychotics, anti-depressants, and so forth than mistakenly giving them therapy.

I think the bias is for Bipolar over BPD because bipolar is so responsive to medication. If in doubt, most clinicians would treat for bipolar and look for short term improvement before pursuing BPD.  This make more sense to me than trying a two year course of DBT (with a reasonably high drop out rate) first.

[jak33]

Wow, yes, interesting revisions.  What's interesting is that I can see some of this stuff in me!  

What is really helpful is the empathy thing.  Looking at him.  And looking at me.

[jak33]

Just following on from my posts above about the "a or b" thing under "Impairments in interpersonal functioning" ("a" being to do with empathy and "b" being to do with intimacy), when it comes to the "a or b" under "Impairments in self functioning" here, "a" being to do with identity and "b" being to do with self-direction, I would say my H fits both of these, but with the identity issues fitting in a particularly strong way.

[iluminati]

I like this batch of criteria.  It's a lot simpler to explain, and the scales can help you tease out differences easier.  After all the controversy with the DSM 5, I like.

[qcarolr]

The new view seems much more straightforward with its clear definitions of each component. I will be interested to learn of the results of the clinical trials. It reconfirms for me the severity of my DD25's classification. It helps me understand her resistance to therapy - except that the prozac does help moderate her rage episods and panic attacks. I look forward to seeing more about this as the release date approaches.

Just think of all the books out there that will need new editions!

qcr

[victim15]

I think I may have misunderstood this, I initially thought it was to do with their level of intelligence but now think it is to do with how well they cope with everyday life.

Would welcome any further explanation please... .

[RefugeeFromOz]

A high functioning pwBPD is generally successful in life outside of intimate relationships.  They can be smart, witty, attractive, accomplished, talented, high wager earners, etc.  They hide their dysfunction and dysregulation from all except those with whom they share close emotional relationships.

A very destructive characteristic of a relationship with a high functioning pwBPD is that you experience profound and intense destructive behaviors, and yet everyone else sees what appears to be a successful, well adjusted, and healthy person.

It is an isolating experience because it is difficult to find validation and support from people outside your relationship because no one believes what you claim is happening.  In my case, it even took a therapist almost two years to realize that the facade presented by my exw was completely false.

I'm sure others will contribute more on this topic.

[PDQuick]

Summing it up... .

Good comments, all.  

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.

The DSM 5 makes this all more clear.  Clinically, BPD is about dysfunction.  What is "high functioning dysfunction"?  Probably similar to "intelligent mental retardation", which is low intelligence.

High functioning, or sub-clinical BPD means a lot of things. They are not as severe, are more responsive to therapy, and are more likely to self resolve. These are more obvious to the partners of the disorder sufferer, but not as obvious to others.

Because BPD and sub-clinical BPD are disorders of relationship instability, it makes sense that the problems are much more apparent to a relationship partner.

[Auspicious]

Clinically, BPD is about dysfunction.  What is "high functioning dysfunction"?  Probably similar to "intelligent mental retardation".

Yeah, but ... .

There is something to the "high functioning" concept. You can have the same kind of black and white thinking, the history of dysfunctional relationships, the unstable self-image, etc., and as long as in you they don't manifest with suicide attempts, cutting, and so forth the odds of even you seeing that you have a disorder drop, big time.

It's still dysfunctional, still destructive to your life and those around you (granted, not quite as dysfunctional as directly trying to kill yourself), but much less likely to be identified and treated.

And much harder to measure the treatment outcomes. We can measure, for example - does DBT reduce the number of hospitalizations, suicide attempts, mortality, etc.? Much harder to measure (and is anyone even trying?) does DBT produce greater relationship stability, better work performance, better parenting?

[PDQuick]

"Almost" borderline  personality disorder, "almost" narcissistic personality disorder and "almost" Schizophrenic states can make for very difficult people. There is no question.

However, it's not "much harder" to measure improvements in relationship stability in subclinical BPD than it is in clinical BPD - it is the same.  It's hard to measure in both and clinical studies show that this particialr aspect of the disorder is harder to resolve than suicidal behavior, for example.  Relatively speaking, it is easier to resolve traits in subclinical BPD than it is to resolve traits in clinical BPD, just like it easier to heal a sprain than a compound fracture.

All that said, your point that subclinical can be extremely destructive is true.  I agree.  The DSM-5's point is that it's all a continuum. It is not a unique and special circumstance as it is sometimes portrayed.

[Auspicious]

I guess I wasn't being clear. I wasn't referring to "almost" or subclinical situations. It's possible to have clinical BPD, and not be (just for example) actively suicidal. It's just harder to diagnose.

The core traits of BPD can manifest in different ways, in different people. Some ways are easier to see clinically. Some ways are easier to see outside of close relationships. Some ways can get you - accurately - diagnosed, if you are forthcoming about them to the professional, but not if you aren't.

People can also move between different types of functioning (moving from "high" to "low" is sometimes called "decompensating". My wife didn't "not have BPD" before she started a string of hospitalizations (and the actions that resulted in them) that got her that diagnosis. She had the same black and white thinking, the history of unstable relationships, the unstable self-image, etc. It just hadn't - yet - resulted in the kind of actions that get you identified and treated.

[bluebutterfly]

my partner has been diagnosed as having BPD personality traits with clusters b and c. Where would he fit into these categories. , does it mean that he doesnt have BPD . Or its just a nicer way to diagnose someone.

[GreenMango]

Bluebutterfly-the new criteria is supposed to be a more thorough look at the disorder and takes into account there is a continuum is severity that may manifest in a variety of behaviors.  Part of the new release trims out some of the other disorders and streamlined the possible diagnoses.  If your partner has the diagnosis now and you are seeing destructive behaviors that is the most pressing issue.

[Surnia]

This is very interesting.

What I do not understand, is that they will reduce the PDs. So what about NPD? If it is so, why? And what are the consequences about this? What do you think?

[SWLSR]

Surnia,

From what I have been told by my therapist, they have still not made all the decision on the DSM V so what I am hearing now can be changed.  I am not sure what is going to happen to NPD but it may be absored into BPD.  What I do know is they are discussing changes as to how to define BPD.  One of the things I have heard is they is going to be a stronger link to BPD and Bi-Polar.  How much of a link and what the details I am not sure.  They is also going to be some kind of disorder that is a mild case of BPD.  And the other thing I am hearing is BPD flair ups this is someone who has been in a BPD remission but has it return.  That is all I know for now but if I hear more I will let you know.

[MWMan]

Is it on a scale of 1-10?

Is 8 and above the truly severe where they hurt themselves physically?

Would a 6 or 7 be where they just get mad weekly at little things and cause issues in the relationship?

I'm wondering how to classify my exgfBPD whom I'm pretty sure is in the middle ground. Not severe, but it impacts her relationships - at least it did ours.

[motherof1yearold]

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

I really wish they would change the name too! It is VERY misleading and doesn't help people understand or grasp the seriousness of this disorder and how it affects all who come into contact with them.

[truly amazed]

Hi,

Well I look at the new criteria and even the old and scratch my head. BPD and having had a partner who was described by my psychiatrist who is a Uni lecturer and has 30 years in the field as being 8 if not 9 of the old criteria, I always come up short seeing the criteria. Same too having a mother who also is BPD but a milder all be no less destructive form and again I come up short.

Both are unlikely to ever seek help. Both even if they did seek help are high functioning and despite for my ex partner having a very high score, she will always fall through the diagnosed criteria for the simple reason she is not a cutter only one who threatens it.

Whilst I now have zero doubt as does my psychiatrist about the BPD diagnosis in my ex, having been there and not being aware of it until post relationship, if my ex was presented to even very experienced people in the field as a high functioning one I suspect in a blind test about half of them would fail to diagnose or call it a mild impairment at best.

Diagnosis actually comes down to the non BPD's I suspect in many cases vs the actual sufferer in those that are high functioning. The high functioning BPD suffers who will never seek help will like my 80 plus year old mother remain undiagnosed. What actually tipped the scales for even my own psychiatrist was I actually taped a few rage sessions and he listened in rapture and went oh my that is her personality splitting and made comments as the tirade was replayed to him over the course of a 30 minute attack. I didn't really remember my own actions until it was replayed but I didn't swear or abuse or even yell just asked she leave me alone whilst it went from bad to worse.

Unfortunately diagnosis for even very experienced health care professionals at times is impossible. I look at this criteria and even the new one and whilst my ex may have had relationships which have lasted 20 or more years with friends, post relationship with me she shredded those and discarded them at will. They were of course superficial and like me those discarded scratched their heads and wondered what had happened. They like myself were disposable. It may have appeared if asked my ex had long standing relationships but they were are as always sadly disposable. Even friends of such a long time who gave gifts to my ex's children every year for the past 15 years whilst any test might have had them disproving a BPD type personality, they too went out the window of late. How disposable are these people in their lives ? It was of course an enabling relationship they had where it was one sided on the main.

I do wonder after reading the new criteria and my own experiences with BPD what the real percentage of BPD suffers is out there vs those diagnosed ?

Many thanks for the great thread and discussion as always   

[GreenMango]

Is it on a scale of 1-10?

Is 8 and above the truly severe where they hurt themselves physically?

Would a 6 or 7 be where they just get mad weekly at little things and cause issues in the relationship?

I'm wondering how to classify my exgfBPD whom I'm pretty sure is in the middle ground. Not severe, but it impacts her relationships - at least it did ours.

The new scale is a 0 to 4.  0 being healthy and 4 severly impaired.  There needs to be at least a 2 in one from each category of criteria Self (identity or self direction) and Interpersonal (intimacy or empathy) along with the other factors listed impulsivity, hostility, mood lability, etc for clinical diagnosis with a longstanding pervasive pattern.  The more severe the more likely the behavior is to affect a larger number of relationships and to see more severe emotional reactions outside of just romantic/family... .like work or acquaintances.

It could be a weekly thing, it could be monthly, daily.  It probably depends on if the person is triggered and by whom.  If you see an impaired relationships pattern because of the behavior its a pretty good indication that there is an impairment but it may not be a 2.

Most of the members partners don't qualify for clinical diagnosis but have traits.  These traits can still make the relationship very difficult with a lot of conflict.

[BPDFamily]

DSM-5 Wins APA Board Approval

Published: December 01, 2012

The American Psychiatric Association's board of trustees has approved the fifth edition of its influential diagnostic manual, named DSM-5.0, the group announced Saturday.

The board vote is the last step before the manual is formally released at the APA's annual meeting next May. The association's Diagnostic and Statistical Manual of Mental Disorders was last revised in 1994; that edition is known colloquially as DSM-IV.

According to an APA statement, changes include an end to the system of "axes" used to class diagnoses into broad groups, and an associated restructuring of diagnostic groups to bring disorders thought to be biologically related under the same headings.

Also, many of the diagnostic criteria will now include so-called dimensional assessments to indicate severity of symptoms.

Specific language in DSM-5 was not immediately released, and probably won't be until the formal unveiling in May. Detailed criteria that had been published on the APA's DSM5.org website for public review and comment have now been removed.

However, the statement released Saturday indicated that the manual will include many of the most controversial of the proposed changes from DSM-IV.

They included removal of the "bereavement exclusion" in the major depression section. In DSM-IV, a diagnosis of depression could not be made in patients who had suffered the death of a loved one until two months had elapsed. Under DSM-5, such patients may be called clinically depressed sooner, although the criteria will include advice to clinicians about distinguishing normal grief from depression that should be treated.

DSM-5 will also add a diagnosis of "disruptive mood dysregulation disorder" for children older than 6 who show frequent bursts of anger along with chronic irritability.

In fact, it appeared from the statement announcing the approval that most of the changes from DSM-IV discussed at the APA's 2012 meeting were ratified by the board.

One outside interest group lost no time in reacting to the APA's announcement.

In a statement issued barely an hour after the APA's release, the chief science officer for Autism Speaks, Geraldine Dawson, PhD, said the group remained "concerned about the impact of the new DSM-5 criteria when they are used in real world settings. The field trials are somewhat reassuring that the criteria are working well, but these trials are based on a relatively small number of children. We still have very little information about the impact of the DSM-5 on diagnosis of autism spectrum disorder in young children and adults."

Dawson said the group believes it is "crucial" that diagnosis and access to services be monitored once DSM-5 is in use. "We want to make sure that no one is excluded from obtaining a diagnosis and accessing services who needs them."

In fact, some of the changes proposed for DSM-5 would loosen the criteria, as the head of the APA's work group on autism spectrum disorders explained at the 2012 APA meeting.

Susan Swedo, MD, of the National Institute of Mental Health, noted that the work group was seeking to drop an age-based exclusion in the DSM-IV criteria.

The other major change proposed for DSM-5 was a reorganization that would collapse a number of autism-related conditions treated as separate disorders in DSM-IV into a single "autism spectrum disorder" category.

Those changes were blasted by some in the autism advocacy community, but Swedo argued that the criticisms were unfounded.

In announcing the APA board's action, James H. Scully, MD, medical director and chief executive officer of APA, said, "At every step of development, we have worked to make the process as open and independent as possible. The level of transparency we have strived for is not seen in any other area of medicine."

The group also noted that more than 160 clinicians and researchers had worked to develop DSM-5, with help from hundreds of other clinical investigators as well as thousands of comments from health professionals and the general public offered during open-comment periods.

[BPDFamily]

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.

Five traits

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.

Top priority

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