Perish the Paranoid: Personality Disorders Pulverized in New Mental Health Manual

Some parts of life can be so simple.

Take high school math. You had two intersecting lines, and, to be fancy, you called them ‘axes.’ To sound real mathematically sophisticated, you didn’t just call them ‘this axis’ and ‘that axis.’ Oh, no. They were the (remember?) ‘x-axis’ and ‘y-axis.’ And once you got down that terminology, and figured out that one axis went across and one went up and down, you were pretty much set in graphing, even when they tried to fool you by throwing about those negative numbers.

Now take the field of mental health. Apparently no one’s concerned that you mastered coordinate graphing on two axes. You have entered the realm of the human mind.

And what should greet you? Five–count ’em–five axes, when it comes to diagnosing mental disorders. As innovated and utilized by the standard mental health diagnostic text (many call it the mental health bible), the Diagnostic and Statistical Manual of Mental Disorders (or DSM), you’ve got the following:

Axis I: Clinical Disorders (think schizophrenia, bipolar disorder, depression, eating disorders, anxiety disorder, substance abuse disorders)
Axis II: Personality Disorders (discussed below)
Axis III: General Medical Conditions (that, clearly, might have an impact on the patient’s mental well-being)
Axis IV: Psychosocial and Environmental Stressors (economic problems, problems with access to healthcare, occupational problems, etc.)
Axis V: Global Assessment of Functioning (A number from 1-100 indicating the clinician’s or caregiver’s assessment of the patient’s level of functioning)

It’s a coordinate graphing nightmare.

But that’s not the only concern. If you’ve been following my posts–or any mental health-related news at all–you know that the newest edition of the DSM, the DSM-5, is slated to come out, after over a decade without revision since the last version, in 2013–and it’s raised concerns galore.

Let’s leave aside for now the problematic financial connections of many of the committee members to pharmaceutical companies, causing a big brouhaha, with editorials and counter-editorials, and not repeat some particularly troubling decisions made in the Axis I arena. (Warning to the uninitiated: Steer clear of the phrase ‘bereavement exemption.’ I ask you to trust me on this one. You open this conversation at your own peril, and, if you’re conflict-averse, you’d best line up a therapist to help you work through what your curiosity has wrought.]

For now, let’s let the Axis I kerfuffle rage on in different media. Let’s pay a visit, instead, to Axis II, the personality disorders. And as we have no DSM-5 to rely upon yet, I offer you the definition of a personality disorder from the DSM-4, which I’m sure you’ll find particularly illuminating. A personality disorder is, and I quote

an enduring pattern of inner experience and behavior that deviates markedly from the expectation of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

There you have, in action, that good old method of clarifying the complicated that we’ve come to know and love in diagnostic manuals.

If you left defining it to me, you’d get this: Basically personality disorders are patterns of thought and behavior that are problematic. And we don’t know why they occur.

Now you know why no one invited me to sit on a committee for DSM-5 planning, but if I tell you that these patterns of thoughts and behaviors cause difficulty in relationships and make functioning in work and social settings a challenge, you may have as good a hold on the definition of a personality disorder as most.

Anyway, despite some ambiguity in defining the term at large–and a lot of ambiguity surrounding the best treatments–personality disorders are pervasive in our society, and much time, research, energy and money is spent trying to treat those who suffer from them.

Up until now, if you could accept that your days of 2-axis graphing were over, this DSM approach to diagnosis seemed fine. And perhaps all could have gone on fine–somewhat chaotically, it’s true, but still–if we [meaning the DSM-5 committee, not really we as in me] had left well enough alone.

But once again the editors of the DSM-5 jumped in to make a change–and I’m certain the intention was for the best. Here, in an effort to streamline diagnosis, and prevent too many sufferers from double-dipping in the personality disorder fondue–they decided to cut 5 personality disorders out of the newest manual.

For real. One day you’d have paranoid personality disorder, with professionals willing to treat your conviction that you’re facing a hostile world, your suspicions that your office mate steals your erasers when you’re out to lunch break, and your concern that the neighbor who lives above you purposely goes to the bathroom when you do, just to let you know he can track your movements. The next day, if the DSM-5 has its way, all your suspicions will remain–but, without a proper diagnosis, you’ve simply become, well, a loon.

And paranoid personality disorder is one of those on its way out the door.

Really, the aim isn’t just to chuck diagnosis, hoping against hope that the behaviors will go away with their terminology. Rather, goes the claim, it’s more of a condensing of the diagnoses, an effort to avoid something called ‘comorbidity,’ the doubling up of disorders for a given person.

Currently, the DSM-IV-R recognizes 10 personality disorders plus Personality Disorder Not Otherwise Specified [meaning we know something’s wrong but can’t pin any of these 10 on you]:

  1. Paranoid Personality Disorder
  2. Schizoid Personality Disorder
  3. Schizotypal Personality Disorder
  4. Antisocial Personality Disorder
  5. Borderline Personality Disorder (this may perhaps be the best known illness of Axis II)
  6. Histrionic Personality Disorder
  7. Narcissistic Personality Disorder
  8. Avoidant Personality Disorder
  9. Dependent Personality Disorder
  10. Obsessive-Compulsive Personality Disorder

The plan is to do away with five completely, collapsing the above 10 into the following 5 categories:

  1. Antisocial/Psychopathic Type
  2. Avoidant Type
  3. Borderline Type
  4. Obsessive-Compulsive Type
  5. Schizotypal Type

Bye bye paranoid, schizoid, histrionic, narcissistic* and dependent personality disorders.

Wouldn’t it be lovely if that meant the end of these disorders at all? What a fantasy: If we don’t have a diagnosis for narcissists, perhaps that mean we can’t be tortured by them anymore. But it seems unlikely–they tend to be a persistent bunch.

So what is to become of the suspicious paranoid or the seductively attention-seeking histrionic? Belive me, your histrionic won’t go away quietly, just because her diagnosis has been stricken. And she’s unlikely to allow herself to be talked into developing schizotypal behaviors, merely because her diagnosis got booted.

I don’t know–can’t answer it. The plan seems utterly perplexing to me, and almost subconsciously prejudiced against certain diagnoses. I mean, what did the poor schizoid, unsociable and eccentric, hidden away in his apartment, too shy to talk to his neighbors, and cut off from his family, really ever do to anyone, to get kicked out of the realm of diagnosis and potential treatment?

A statement from the DSM-5 committee explains the chopping block plan:

The Work Group recommends that [these disorders] be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.

That appeared abstruse enough to please very few. Thus the response to the proposal has been–how to be tactful?–underwhelming.

Take Dr. John Gunderson, an expert in personality disorders who led the personality disorders committee for the current DSM. His negativity was in response to the proposed elimination of the narcissistic personality disorder, but it could have applied to the changes in general.

Quoted by Tara Parker-Pope in a New York Times editorial, Gunderson said that eliminating the diagnosis of the narcissist shows how “unenlightened” the personality disorders committee is. “They have little appreciation for the damage they could be doing.”

“Unenlightened,” huh? Them’s some fighting words. Only to be topped by what comes next.

On a roll, Gunderson continued, “It’s draconian, and the first of its kind, I think, that half of a group of disorders are eliminated by committee.”

Now it’s ‘draconian,’–did you ever think diagnostic and statistical manuals could draw out the claws like that?

A concern expressed by many regarding the change is that there’s simply no research supporting the effectiveness of doing away with the disorders.

Mark Zimmerman, M.D., director of outpatient psychiatry at Rhode Island Hospital and one of the authors of the first semi-structured interview to assess the personality disorders for the DSM-III, points out that no data at all were cited about the impact eliminating 5 personality disorders might have on the prevalence of personality disorders in society, accuracy of diagnosis, or the potential for false negatives.

So Zimmerman and associates did their own research on the topic. They assessed a large number of psychiatric outpatients, finding 614 subjects diagnosed with at least 1 of the 10 personality disorders. While comorbidity dropped slightly when the disorders were cut in half, there was another concerning occurrence.

59 patients who were diagnosed with a personality disorder according to the DSM-IV criteria would no longer be so diagnosed under the proposed changes. Thus, the findings suggest a signficant number of patients will have false-negatives, leaving vulnerable and struggling individuals without recourse to treatment, or even the nominative comfort of possessing a name for their distressing symptoms.

I feel I’d best let you go at that. It’s been a rough day–first thing you’re functioning on five axes, next thing you know a committee in charge of major mental health decisions is ‘draconian.’ It’s enough to almost make you just a little bit paranoid that people are out to make things hard–for you, for the mentally ill–but you’d be wasting your time with your paranoia; it’s passé.

You’re better off picking a disorder that still exists. Why don’t you feel antisocial/psychopathic instead? That’s still allowed–lucky for you.

*As of the latest information release, narcissistic personality disorder has found its way back in to the manual.

To look into:

  • Clarkin JF, Huprich SK. Do DSM-5 personality disorder proposals meet criteria for clinical utility? Journal of Personality Disorders 2011; 25(2):192-205. (Abstract at http://guilfordjournals.com/doi/abs/10.1521/pedi.2011.25.2.192.)
  • Skodol AE, et al. Personality disorder types proposed for DSM-5. Journal of Personality Disorders 2011; 24(2):136-69. (Abstract of explanations of proposed modifications at http://www.ncbi.nlm.nih.gov/pubmed/21466247.)
  • Zimmerman M, et al. Impact of deleting 5 DSM-IV personality disorders on prevalence, comorbidity, and the association between personality disorder pathology and psychosocial morbidity. Journal of Clinical Psychiatry 2012; 73(2):202-7. (Abstract at http://www.ncbi.nlm.nih.gov/pubmed/22313813.)

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