Some 20 years and two editions later, much has changed in clinician attitudes and practice patterns. Indeed, the paradigm has shifted. While not every clinician believes that they can help every personality-disordered individual âwith confidence,â there is, nevertheless, an increasing consensus among clinicians that many patients can be helped with current treatment interventions, even those meeting DSM-5 criteria for Borderline Personality Disorder.
This chapter provides an introduction and overview to the diagnosis and treatment of the personality disorders. It begins with a description of changes in DSM-5, emphasizing those involving the personality disorders, particularly the âAlternative DSM-5 Model of Personality Disordersâ and the Levels of Personality Functioning Scale. Following this is a brief description and illustration of the Psychodynamic Diagnostic Manual, another alternative way of conceptualizing personality disorders. The main part of this chapter details several exciting, cutting-edge trendsâin both diagnosis and treatmentâthat are further effecting this paradigm shift. Prior to detailing these trends, the chapter begins by explaining the nature of the paradigm shift underway in the diagnosis and treatment of the personality disorders. Finally, the chapter concludes with an overview of the structure of Chapters 3â12.
DSM-5 and the Personality Disorders
The DSM diagnostic system has undergone some major changes since the second edition of this book was published in 2003. Most of these changes have involved adding or removing diagnoses and criteria. However, there are also some major changes in the structure of the DSM-5 (American Psychiatric Association, 2013), and these are briefly noted here.
DSM-5: General Changes
The most obvious change in DSM-5 is the return to a single-axis diagnosis, as it was in DSM-I and DSM-II. The multiaxial (5-axes) system was introduced in DSM-III and continued through DSM-IV-TR. Of particular relevance for the personality disorders were Axis II and Axis V. Axis II was added for the coding of personality disorders, while Axis V was added for coding the individual's current level of functioning and impairment on the Global Assessment of Functioning Scale. There were several reasons for eliminating the multiaxial system. Among these was an unexpected drawback to adding Axis II. Although it was not the intent of earlier editions of DSM, the opportunity to specify a diagnosis of a personality disorder became problematic for many clinicians. Out of concern that the diagnosis of a personality disorder would stigmatize an individual, some clinicians refused to specify an Axis II diagnosis when it was present. This was complicated by the mistaken notion among therapists and third party payers that personality disorders were untreatable. As a result, some individuals who were diagnosed with personality disorders encountered problems securing treatment. Today, however, individuals who met the criteria for a personality disorder diagnosis may now find it easier to navigate mental health treatment, since they are less likely to be viewed as having a diagnosis that is more difficult to treat than of other disorders.
By eliminating Axis V, the Global Assessment of Functioning (GAF) score is gone. GAF was the numeric measure used by clinicians to rate an individual's social, occupational, and psychological functioning and well-being. It is a subjective measure of the degree of adaptivity (well-being) or maladaptivity (impaired functioning) an individual demonstrates in dealing with various problems-in-living. In place of this largely unreliable measure of functioning and impairment, DSM-5 encourages the use of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Nevertheless, GAF continues to be used by some clinicians. It provides a continuum (1âlowest, to 100âhighest) on which to rate overall functioning and well-being. Clinicians can also utilize the Level of Psychological Functioning Scale (LPFS), which is described below.
DSM-5 Section on Personality Disorders
While there were a number of significant changes in many diagnoses in DSM-5, there were very few changes involving the personality disorders. Retained in DSM-5 was the earlier DSM definition of a personality disorder as an âenduring pattern of inner experience and behaviors that deviates markedly from the expectations of the individual' s culture, is pervasive and inflexible ⊠is stable over time, and leads to distress or impairmentâ (American Psychiatric Association, 2013, p. 645). While DSM-IV-TR diagnostic criteria have been retained, there has been some updating of descriptions of the various disorders. However, there is one notable change. The diagnosis of Personality Disorder Not Otherwise Specified (NOS) has been replaced with Other Specified Personality Disorder (301.89) and Unspecified Personality Disorder (301.9).
Despite the efforts of the DSM-5 Personality Disorders Work Group to effect major change, the 10 âofficialâ personality disorder diagnoses remain unchanged from DSM-IV-TR. The Work Group proposed that a âdimensionalâ model replace the existing âcategoricalâ model due to its numerous and significant problems. However, that proposal was ultimately rejected by the Board of Directors of the American Psychiatric Association. Instead, it was relegated to âSection III: Emerging Measures and Modelsâ of the DSM-5 manual. The new dimensional model developed by the Work Group is referred to as the âAlternative DSM-5 Model for Personality Disorders,â in contrast to the DSM-IV-TR Model of Personality Disorders, also known as the categorical model.
Categorical Model of Personality Disorders
So why replace the categorical model? Three major concerns with the DSM-IV-TR Personality Disorder model involve comorbidity, heterogeneity, and the construct of personality.
The concern about comorbidity is that individuals can simultaneously meet criteria for more than one disorder. For instance, it was estimated that the modal number of personality disorder diagnoses possible for an individual who meets criteria for at least one DSM personality disorder is 3â4 diagnoses (Gunderson, 1996). Arguably, this is problematic for case conceptualization and planning tailored interventions: if there are 3 diagnoses, which one should be the initial focus of treatment, and why? The Alternative DSM-5 Personality Disorder model solves this problem through the diagnosis of Personality Disorder-Trait Specified (PD-TS). If the client is not a good match to a specific DSM-5 Personality Disorder (e.g., Narcissistic Personality Disorder), the clinician records PD-TS and details the client's clinically important personality features. For example, a client may have features of Narcissistic, Histrionic, Antisocial, and Borderline Personality Disorder. Instead of recording all four diagnoses, the clinician can record PD-TS and note the mix of grandiose, attention-seeking, antagonistic, and emotional lability.
The other concern involves heterogeneity. The premise of the DSM-IV-TR Personality Disorder model was that articulating specific personality disorder categories would facilitate accurate diagnoses. Unfortunately, individuals' personality and psychopathological features seldom fit such a categorical model. For example, individuals meeting DSM-IV-TR criteria for Borderline Personality Disorder are a highly heterogeneous group. In fact, there are six distinctive subgroups of clients who met these criteria and these subgroups differed markedly with regard to therapeutic concerns such as past suicide attempts, antisocial behavior, and self-injury (Wright et al., 2013). The Alternative DSM-5 Personality Disorder model greatly reduces this heterogeneity problem, because relevant heterogeneity is specified as part of the diagnostic process. For example, a client may meet the general Borderline Personality Disorder profile but also presents with other clinically significant personality features, such as unusual beliefs and experiences. In this case, the diagnosis of Borderline Personality Disorder can be given, while also recording the unusual beliefs and experiences.
The third concern is with the very nature of categorical diagnosis. As a categorical model it is expected to accurately determine whether an individual has or does not have a personality disorder. In many respects, such a model is not well suited for diagnosing personality disorders since personality is a continuous, multi-faceted dimension. To illustrate, consider the trait of grandiosity, a characteristic trait of the Narcissistic Personality Disorder. On a continuum from healthy self-esteem to self-centered entitlement, where does a clinician distinguish between health and disorder with regard to this trait? Utilizing a categorical model with a continuous dimension like grandiosity is akin to trying to force a round peg into a square hole.
Given these concerns, it is not surprising that many clinicians did not find the DSM-IV-TR Personality Disorder model to be very clinically useful. As a result they often deferred making meaningful personality description in clients' charts. Many also viewed DSM-IV-TR Personality Disorders as highly stigmatized conditions, leading to further reluctance to characterize personality disorder features accurately in clinical practice.
Presumably, the Alternative Model can solve these problems. A survey of 337 psychiatrists and psychologists found the Alternative Model to be considerably more useful than the DSM-IV-TR Personality Disorders model (Morey, Skodol, & Oldham, 2014). As clinicians become more familiar with the Alternative Model, clients are likely to receive more accurate assessments and diagnoses, which can lead to improved clinical care.
Alternative DSM-5 Model for Personality Disorders
So what is this alternative model? Recognizing the many limitations of the categorical model of DSM-IV, the DSM-5 Personality Disorders Work Group proposed a dimensional model to replace the categorical model. That dimensional model has two primary criteria: personality functioning and pathological personality traits (American Psychiatric Association, 2013).
Personality Functioning. Four elements of personality functioning are identified. There are two indicators of self-functioning: Identity and Self-direction. There are also two indicators of interpersonal functioning: Empathy and Intimacy. Impairment in these four elements of personality functioning is rated along a continuum from 0 to 4. Assessment of such impairment can be accomplished with the Levels of Personality Functioning Scale, which is provided below.
Pathological Personality Traits. Five broad trait domains are specified in a dimensional or continuous fashion. These traits are derived from the Five-Factor Model of Personality and Personality Psychopathology ( American Psychiatric Association, 2013, p. 773). These trait domains contain 25 specific personality trait facets. These domains and facets can be assessed with several psychometric tests. They are: Negative Affectivity vs. Emotional Stability; Detachment vs. Extraversion; Antagonism vs. Agreeableness; Disinhibition vs. Conscientiousness; and Psychoticism vs. Lucidity. In the Alternative Model, only six specific personality disorders are listed, compared to the current 10. These are Antisocial Personality Disorder, Avoidant Personality Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder...