January 16, 2012

Unless you’re an academic psychiatrist with a niche interest within the diagnostic nomenclature of psychiatry, chances are you probably haven’t spent much time poking around the website of the DSM-5 Task Force at dsm5.org. In recent months, the publication date for this much-awaited tome has been pushed back to May 2013. In the meantime, the task force leadership and the diagnosis work groups have used the website to post updates, explanations, and rationales for proposed changes from the DSM-IV-TR framework.

The Personality and Personality Disorders Work Group, headed by Dr. Andrew E. Skodol of the Institute for Mental Health Research in Arizona, has received an outsized share of attention in the lay and professional press, including the New York Times (Nov. 29, 2010, page D1). The work group has proposed extensive and far-reaching changes to the diagnostic structure of Axis II, to the surprise of many observers and commentators.

By Dr. Michael Brodsky

It’s been widely reported that the DSM-5 work group plans to reduce the number of personality disorder diagnoses to six: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal. (The Times article reported on a proposal – since rescinded – to eliminate narcissistic personality disorder as well.) Eliminated from the DSM-5 would be the histrionic (hysterical), schizoid, and dependent personality disorders.

This change, although major, is less significant than two other modifications proposed for the DSM-5.

In a second key proposal, the work group adds an innovation previously unseen in the DSM but well known to generations of psychiatry residents from introductory psychotherapy textbooks: an assessment of whether the patient is functioning at a neurotic, borderline, or psychotic level of personality organization. In the DSM-5, this assessment is termed the Levels of Personality Functioning scale, and patients are rated from 0 (healthy) to 4 (extreme impairment). My review of the scale suggests that a 0 rating corresponds to mental health, a 1 rating corresponds to a neurotic level of personality organization, a 2 corresponds to a mild borderline level of personality organization, a 3 corresponds to a severely borderline level of personality organization, and a 4 corresponds to a psychotic level of personality organization.

The third major change proposed by the work group has attracted the most criticism. The work group proposed an entirely separate system of personality assessment, unrelated to the syndrome recognition system from DSM-IV-TR, in which clinicians are asked to rate individual patients on each of five "personality trait domains" (negative affectivity, detachment, antagonism, disinhibition, and psychoticism). These major categories each comprise four to nine "trait facets," each of which can also be assessed by the clinician. For example, the trait facets proposed for the negative affectivity domain include mood lability, anxiety, separation anxiety, perseveration, submissiveness, and depressivity. The dsm5.org website includes a 7-page "DSM-5 Clinicians' Personality Trait Rating Form" that details how each of these trait domains and trait facets should be rated.

So to review, the three major changes proposed by the personality work group are the following:

• Fewer personality syndromes.

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