DSM-5 Eliminates 5 of 10 Personality Disorders

 

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (due out in 2013, and known as DSM-5) has eliminated five of the 10 personality disorders that are listed in the current edition. Narcissistic personality disorder is the most well-known of the five, and its absence has caused the most stir in professional circles.

Many experts in the field are not happy about it. Actually, they aren’t happy about the elimination of the other four disorders either, and they’re not shy about saying so.

One of the sharpest critics of the DSM committee on personality disorders is a Harvard psychiatrist, Dr. John Gunderson, an old lion in the field of personality disorders and the person who led the personality disorders committee for the current manual. Asked what he thought about the elimination of narcissistic personality disorder, he said “They have little appreciation for the damage they could be doing.” He said the diagnosis is important in terms of organizing and planning treatment. “It’s draconian,” he said of the decision, “and the first of its kind, I think, that half of a group of disorders are eliminated by committee.”

He also blamed a so-called dimensional approach, which is a method of diagnosing personality disorders that is new to the DSM. It consists of making an overall, general diagnosis of personality disorder for a given patient, and then selecting particular traits from a long list in order to best describe that specific patient.

This is in contrast to the prototype approach that has been used for the past 30 years: the narcissistic syndrome is defined by a cluster of related traits, and the clinician matches patients to that profile. The dimensional approach has the appeal of ordering à la carte — you get what you want, no more and no less. But it is precisely because of this narrow focus that it has never gained much traction with clinicians. The idea of replacing the prototypic diagnosis of narcissistic personality disorder with a dimensional diagnosis like “personality disorder with narcissistic and manipulative traits” just doesn’t cut it.

Jonathan Shedler, a psychologist at the University of Colorado Medical School, said: “Clinicians are accustomed to thinking in terms of syndromes, not deconstructed trait ratings. Researchers think in terms of variables, and there’s just a huge schism.” He said the committee was stacked “with a lot of academic researchers who really don’t do a lot of clinical work. We’re seeing yet another manifestation of what’s called in psychology the science-practice schism.”

Schism is probably not an overstatement. For 30 years the DSM has been the undisputed standard that clinicians consult when diagnosing mental disorders. When a new diagnosis is introduced, or an established diagnosis is substantially modified or deleted, it is not a small deal. As Dr. Gunderson said, it will affect the way professionals think about and treat patients.

Given the stakes, the blow-back from experts in personality disorders should come as no surprise. Dr. Gunderson has written a letter co-signed by other clinical and research leaders to the trustees of the American Psychiatric Association and the task force that governs DSM-5. And Dr. Shedler and seven colleagues published an editorial in the September issue of The American Journal of Psychiatry. In the relatively small world of mental health diagnostics, this is most certainly a battle worth watching.

Charles Zanor is a psychologist in West Springfield, Mass.

More Information

-From “A Fate That Narcissists Will Hate: Being Ignored”, by Charles Zanor, The New York Times, November 29, 2010, http://www.nytimes.com/2010/11/30/health/views/30mind.html, retrieved 12/6/10.

 

 

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