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News About the DSM-V Revision Process

From the American Psychiatric Association:

Press Release
DSM-V Development Website
Proposed Draft Revisions

Structural, Cross-Cutting, and General Classification Issues
In addition to revising the diagnostic criteria, task force and work group members are also making recommendations to DSM-5 that are likely to affect many or all disorders. These recommendations include the ways in which the diagnostic categories are structured; use of the multi-axial system to record diagnoses and clinical variables of interest; consideration of factors that cut across all diagnoses; and the use of dimensional measures to refine diagnostic assessment and treatment planning......

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Personality and Personality Disorders
The work group has recommended a significant reformulation of the approach to the assessment and diagnosis of personality psychopathology, including the proposal of a revised general category of personality disorder, and the provision for clinicians to rate dimensions of personality traits, a limited set of personality types, and the overall severity of personality dysfunction. Personality disorder is diagnosed when core impairments and pathological traits are severe or extreme and other criteria are met.

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Published on Psychology Today

DSM-V offers new criteria for personality disorders
By Jared DeFife, Ph.D.
Created Feb 10 2010 - 12:17am

The American Psychiatric Association is in the middle of a historical revision to its diagnostic "Bible", the Diagnostic and Statistical Manual of Mental Disorders (or DSM). This book is used by clinicians, insurance companies, and even the legal system to define and identify the types and thresholds of mental illness that become the focus of treatment and research.

Following a very secretive process of review and revision that has been marked by criticism, the APA has created a website, and officially released its first draft of the new system to the public.

Below is a quick roadmap to the section on personality disorders (also known as "Axis II"), the section with perhaps the most considerable changes in the entire manual.

The current system:
Diagnosing disorders in the current edition of the DSM-IV involves two aspects. The first is defining what a personality disorder is. Currently, a personality disorder is defined as a pervasive pattern of "inner experience and behavior" that is deviant from a person's cultural norms. These may be deviations in thoughts, emotionality, interpersonal relatedness, and impulse control. Deviations in any of the above aspects need to be pervasive, stable, present at least since adolescence, and not due to substances or another mental disorder. Importantly, these ways of thinking, feeling, or behaving need to be significantly distressful and problematic.

The second aspect involves defining what type of personality disorder is present. DSM-IV currently lists ten: paranoid, schizoid, schizotypal, narcissistic, antisocial, borderline, histrionic, avoidant, dependent, obsessive-compulsive, with a catch-all "not otherwise specified category". Each personality disorder had a certain number of criteria, to which you must meet an artificial cut-off. So to be Borderline, for example, you need to have five symptoms out of nine possible symptoms such as: self-harming, unstable relationships, fear of real/imagined abandonment, impulsivity, identity disturbance, etc.

The problems with the existing system are many. First, the different personality types were poorly defined. They weren't based on research-derived criteria, the individual symptoms were vague, and the idea of checking off abstract criteria such as "an exaggerated sense of self-importance" were difficult. Don't we all, at SOME point or another, have an exaggerated sense of self-importance? Another problem is that the criteria overlapped heavily. A person meeting criteria for one personality disorder usually met criteria for 3 or 4 others, as well.

The proposed revision:
The proposed revision on the DSM-V website appears quite complicated and has three major facets.

A new definition for personality disorder
First, the definition of what a personality disorder is, in general, has changed. The proposed revision suggests that instead of a pervasive pattern of thinking/emotionality/behaving, a personality disorder reflects "adaptive failure" involving: "Impaired sense of self-identity" or "Failure to develop effective interpersonal functioning".

There are a couple of things I actually really like about this new definition. The first is the use of the term "adaptive failure". Every one of us has a personality, it's just a matter of how you use it. Your personality features only become a disorder when there is a pervasive failure to adapt who you are as a person to the demands of everyday life. The second is the newly detailed descriptions of failure to develop effective interpersonal functioning. These are fairly straightforward: problems with empathy, intimacy, cooperativeness with others, and inability to formulate a good working understanding or conceptualization of who others are as people.

There are two drawbacks, it seems to me. "Impaired sense of self-identity" is not quite as easily understood as someone who has pervasive failure in their relationships. The proposed revision breaks down identity problems into: poorly integrated identity (e.g. shifting self-states), poor integrity of self-concept (e.g. difficulty identifying and describing parts of oneself), and low self-directedness. The last part is great, and can be easily understood and observed as someone having trouble setting and achieving goals in life, showing a lack of direction, and feeling little meaning or purpose in life. Identity integration and integrity seem a little more "jargony" and a bit more difficult to explain or quantify in the real world.

Five personality types
Instead of the old ten personality types, DSM-V has simplified the system by cutting them down to just five: Antisocial/Psychopathic, Avoidant, Borderline, Obsessive-Compulsive, and Schizotypal types. Each type comes with a narrative paragraph description.

Antisocial/Psychopathic types have inflated grandiosity and a pervasive pattern of taking advantage of other people. Avoidant types are inhibited from forming and maintaining relationships out of fears of humiliation and rejection. Borderline types show intense emotionality, impulsivity, internal feelings of emptiness, and fears of rejection. Obsessive-compulsive types are hyperfocused on details and are excessively stubborn, rigid, and moralistic. Schizotypal types are characterized by odd thinking and appearances or confused states.

Clinicians simply read each paragraph length narrative description and rate on a 1-5 scale how much a patient matches each one (with 4 or 5 being a threshold for diagnosis). Research studies have found that clinicians tend to find this the most useful and comprehensive method for personality diagnosis, improving clinical description and treatment planning from the current system.

Personality trait domains and facets
The third and final element of the proposed system is a series of six personality "trait domains". These domains are based on the widely used five-factor model of personality. The six domains include: Negative Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity and Schizotypy. Clinicians would be asked to rate each of the six domains on a 0-3 scale depending on how descriptive each is of the patient.

To aid with this, each of the six domains comes with a subset of adjectives, or facets. Disinhibition, for example, encompasses: impulsivity, distractability, recklessness, irresponsibility. While there is a great deal of personality research on these factors, and they are useful for a variety of purposes, their greatest limitation is the sense of vagueness for clinical use. To compare, it would be like rating someone's level of usual sadness, as opposed to having a coherent syndrome of depression.

That's the roadmap to the new proposed system for personality disorder diagnosis. What do you think? Post your thoughts and opinions below!! For a limited time, you can check out the entire system and provide feedback to the American Psychiatric Association at

Published on NPR

'Cutting' Elevated From Symptom To Mental Disorder
by Kathleen Masterson
February 10, 2010

Cutting has been around for centuries and is best understood as a form of self-help, however misguided. People who cut, or intentionally injure their skin, often say it helps them relieve tension.

Up until now, cutting has been categorized as a symptom of borderline personality disorder an illness marked by unstable moods, impulsive actions and chaotic relationships. The problem is, the majority of those who cut don't have borderline personality disorder. And under the current diagnostic guidelines, sometimes a doctor who first sees the patient, say in the ER, might confuse cutting with a suicide attempt.

Reworking The Book Of Mental Disorders
When clinicians see a patient with mental health issues, part of their job is to determine if the patient is experiencing temporary emotional struggles or if the patient has an illness. To do this, doctors rely on the bible of psychiatry, a book called the Diagnostic and Statistical Manual of Mental Disorders. The DSM lists all the mental disorders recognized by the American Psychiatric Association.

The book is also used by insurance companies to decide which treatments they'll pay for, and by courts to help determine insanity or other mental conditions.

The APA is releasing a new draft of the DSM Wednesday, the first major revision since 1994. This latest version of the book, the DSM-V, proposes some significant changes to the following disorders:

Asperger's Syndrome

Binge Eating

But cutting is rarely related to suicide, and researchers haven't been able to trace it to any one disorder. For instance, it can show up among those who have eating disorders, substance abuse problems, anxiety or depression, says Dr. David Shaffer, chief of the division of child and adolescent psychiatry at Columbia University Medical Center.

That's why the working group behind the latest draft of the psychiatric community's diagnostic bible, the Diagnostic and Statistical Manual of Mental Disorders, wants to elevate cutting from a symptom to a disorder, which would be called nonsuicidal self-injury.

The conflation with suicide is perhaps one of the most harmful misconceptions surrounding the behavior. "We know that cutting accounts for far fewer than 1 percent of all suicides," says Shaffer. "And one of the characteristics of this disorder is that it's repeated very, very frequently, so presumably a young person knows it's not going to kill them."

The behavior is commonly, though not always, done by children and teens, and most grow out of it, says Shaffer. Cutting drops off dramatically when the kids reach age 16 or 17, he says. "The main reason we worry about it being regarded as a suicide attempt is that it often leads to quite inappropriate management," says Shaffer. For example, a common response is to admit a teen who is cutting to the hospital. But there's not much evidence this does any good in most cases, says Shaffer. And psychiatric admission to the hospital exposes the child to other youths with more serious conditions, is costly, and will give the teen a lasting record of having a psychiatric admission, he says.

Making cutting a disorder and giving it a category in the DSM could help clarify the condition. It also could bring more attention to the disorder, and more research, says Shaffer.

"On the whole, treatment [for cutting] is ... unsystematic and really quite poorly developed, partly because it's been so cloaked in other diagnoses," says Shaffer.

He says the new categorization will be a way to separate out kids whose behaviors are of greater concern.



The National Education Alliance for Borderline Personality Disorder does not provide medical advice. The contents are for informational purposes only and are not intended to substitute for professional medical advice, diagnosis or treatment. Always seek advice from a qualified physician or health care professional about any medical concern, and do not disregard professional medical advice because of anything you may read on this web site.

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