This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course during Spring 2014. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on evidence-based treatments for those disorders and the other focused on a particular myth or misunderstanding about mental illness.
Personality Disorder Changes in the DSM-5 by Brooke Kuns
The first official Diagnostic and Statistical Manual of Mental Disorders was published in 1952 by the American Psychiatric Association. This manual has undergone numerous revisions and changes over the years. The DSM was developed as a tool for clinicians of all psychiatric backgrounds to utilize. The DSM allows for consistency in diagnosing within the profession by providing rules, criteria, and guidelines. These guidelines allow clinicians to observe and compare characteristics based on research before diagnosing. Furthermore, the DSM allows for clinicians to have a coding system in which some insurance companies will reimburse for services. This aspect opens the door for individuals to seek guidance even if they are unable to pay out pocket for services. The most recent version of the DSM, the DSM-5, was released in May of 2013. There have been numerous changes from the DSM-IV-TR to the DSM-5. The changes are intended to continue to introduce new diagnosis, update and revise old diagnosis, and continue to produce new evidence based research additions for disorders.
One section of disorders that underwent a number of changes was the Personality Disorders section. The first major change between the DSM-IV and the DSM-5 was the fact that the personality disorders were found in both Section II and Section III in the DSM-5 but not in the DSM-IV. Section II of the DSM includes the diagnostic criteria, characteristics, prevalence rates, gender and culture issues, and comorbidity rates for each disorder. However, in the DSM-5’s Section III there is a specific section entitled the Alternative DSM-5 Model for Personality Disorder. This new section is designed to address flaws in the current diagnostic system used when diagnosing Personality Disorders. The major flaw the DSM-5 discusses is the high level of similar presenting symptoms for personality disorders. Often, individuals will display characteristics of more than one specific personality disorder. In the new model suggested by the DSM-5, suggests that the diagnosis can be made based upon the assessment of the level of impairment in the personality functioning as well as the based upon evaluation of the pathological personality traits. This section did not appear at all in the DSM-IV, was originally slated to be the model in the DSM-5, but was ultimately rejected as the “official” criteria.
Another change that was made to the DSM-5 was the exclusion of the recording procedures section. Since the DSM-5 no longer utilizes the multiaxial system for coding purposes, this section was completely removed from the DSM-5. The layout of the diagnosing information has changed from the DSM-IV to the DSM-5 as well. The diagnosing criteria for all disorders have now been placed at the beginning of the sections as opposed to the end. This seems to make the criteria flow easier.
Specific changes that are seen in the Generalized Personality Disorder (GPD) section (that is, the basic criteria that constitute what a PD is and is not) from the DSM-IV to the DSM-5 begin with the subsections of each disorder. In the DSM-IV and 5, you see diagnostic features; however, you do not see recording procedures in the DSM-5. The next change within the GPD section is the arrangement of the culture, age, and gender features information. In the DSM-IV, culture, age, and gender are all grouped together within one explanation but when moving to the DSM-5, these sections are separated into culture related issue and gender related issues. Each topic has its own section.
The first diagnosis in the Cluster A disorders is Paranoid Personality Disorder. The first change for this disorder is the prevalence rate. In the DSM-IV gives a range of 0.5% – 2.5% in the general population, the DSM-5 gives a range of 2.3% – 4.4%. This could likely be because the disorder has been researched more or there have been more reported diagnosis of PPD from the DSM-IV to the DSM-5. The next change in the PPD section is Familial Pattern is now changed to Risk and Prognosis Factors. While both sections offer the same information, the title of the particular section has changed. The DSM-5 offers a new section entitled Development and Course as well which was not offered in the DSM-IV.
The second diagnosis in the Cluster A disorders is Schizoid Personality Disorder. The major change you see from the DSM-IV to the DSM-5 is found in the Prevalence Section. In the DSM-IV simply states this disorder is uncommon in clinical settings whereas with the DSM-5 they add the data from the National Comorbidity Survey which states that 4.9% rate and the National Epidemiological Survey on Alcohol and Substance Related conditions suggests a 3.1% rate. The major change found in the Schizotypal Personality Disorder, which is the last diagnosis of the Cluster A disorders, begins in the Prevalence section. The DSM-IV states that approximately 3% of the general population meets the criteria for diagnosis but in the DSM-5 4.6%. This increase could be attributed to more research or possibly more diagnosis over time. The next change seen is in the development and course section. The DSM-IV does not offer much information about how this disorder may have appeared in childhood whereas the DSM-5 states individuals with Schizotypal Personality Disorder may have been classified as the odd or eccentric children and may have experienced poor peer relationships, social anxiety and may have been underachievers in school.
Moving on to Cluster B disorders, the first disorder is Antisocial Personality Disorder. The first major change here is with the prevalence rates. The DSM-IV states that this disorder occurs in approximately 3% of males and 1% in females with an overall diagnosis of 3% to 30%. In the DSM-5 however, it gives the prevalence rate of 0.2% to 3.3% with the highest rates being in males who have alcohol use or substance abuse disorders. The DSM-IV does not discuss in detail any age, gender, or cultural issues whereas the DSM-5 does. Another change for the Antisocial Personality Disorder is the addition of the differential diagnosis category criminal behavior not associated with a personality disorder.
The second disorder in the Cluster B disorders is Borderline Personality Disorder. The change from the DSM-IV to the DSM-5 begins with the prevalence rate. In the DSM-IV, the prevalence rate of BPD is stated to be about 2% of the general population whereas in the DSM-5 it states that up to 5.9% of the general population could meet criteria for this diagnosis. Furthermore, the DSM-5 goes on to state that this diagnosis may decrease with age and this is not stated in the DSM-IV. The next disorder in the Cluster B disorders is Histrionic Personality Disorder. The prevalence rate in the DSM-IV actually shows a higher rate of 2%-3% whereas the DSM-5 shows a rate of 1.84%. There were no changes for Narcissistic Personality Disorder.
For the Cluster C disorders, they begin with Avoidant Personality Disorders; the only change was with the prevalence rate. It increased from the DSM-IV with a rate of 0.5% to 1.0% for the general population to the DSM-5 with a rate of 2.4% for the general population. The next diagnosis is the Dependent Personality Disorder. The prevalence rate is also one of the major changes for this disorder as well. In the DSM-IV a statistic is not given it is just simply stated that Dependent Personality Disorder is the most frequently reported disorder in mental health clinics. In the DSM-5 the percentage of 0.49% is assigned. The last Cluster C disorder is Obsessive Compulsive Personality Disorder. For the DSM-IV the prevalence rate is 3% to 10% and in the DSM-5 the rate is less with a percentage of 2.1% to 7.9%.
Finally, in the DSM-IV the last disorder to be applied was the Personality Disorder Not Otherwise Specified however in the DSM-5 there are three new categories which are Personality Change due to Another Medical Condition, Other Specific Personality Disorders, and Unspecified Personality Disorders. All of the changes made to the DSM-5 from the DSM-IV were meant to further clinician’s knowledge about Personality Disorders and their characteristics to provide the best possible care for their clients.