This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course. 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.
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The Alternative Model of Personality Disorders by Danielle Kilhoffer Soltani
We would all like to think that mental health practitioners and administrators listen to researchers, especially those researchers who think outside the box and look for ways to improve the current diagnostic system. However, research doesn’t always make it into everyday practice. More importantly, the general public recognizes that the categorical way of deciding if someone has a disorder is subjective and flawed. This isn’t a surprise to anyone! But what if I told you that there’s a way of diagnosing personality disorders that doesn’t rely on just categories? And what if this diagnostic method has actually tested better than the current diagnostic system? I bet you wouldn’t be surprised to learn that this method didn’t replace the existing one, not because of a lack of research and evidence… but because of the grimy, “I’ll scratch your back if you scratch mine” political banter that often happens in any group that has any power shred of power whatsoever.
Psychological research is an ongoing process, so it makes sense that the diagnostic manual for psychologists and psychiatrists would need to be updated and reprinted every once in a while. The DSM-5 Personality and Personality Disorder Work Group did the research needed to tell whether or not the old manual needed updating in this area (and it did). The DSM-5 Task Force approved of the changes, especially since the Alternative Model (this is what the work group named their hybrid dimensional-categorical model) had outperformed the old model in both the DSM-5 Field Trials and in a survey that asked mental health practitioners to rate the Alternative Model vs. the old model. For the printing of the new DSM-5 in 2013, the Alternative model didn’t make it into Section II, “Diagnostic Criteria and Codes” even though it had been approved to be included there. Instead, the American Psychiatric Association’s Board of Trustees voted keep using the old criteria from the DSM-IV.
The Alternative Model for personality disorders measures along dimensional lines, not categorical ones. This means that clinicians who are answering the question, “Does this person have a personality disorder?” are rating whether or not certain traits are present on a scale of “this trait doesn’t describe my client at all” to “this trait described my client A LOT”. That’s a far cry from the yes/no questions of the past. The question “Does this person like being around people?” becomes a lot less problematic when the clinician can say “kind of” or “most of the time” instead of the over-simplified “yes” or “no”. Having middle-of-the-road answers available when answering those kinds of questions avoids misdiagnosing people who don’t actually have a personality disorder. After all, most disorders actually describe behaviors that most of us do, those behaviors are just exaggerated. The Alternative Model makes sure that people who are just under the diagnostic criteria (or clinical threshold) of a disorder are not categorized as having that disorder. This is helpful because it recognizes there’s a potential problem without giving the person the negative label associated with personality disorders. Also, this prevents a clinician from giving the client the full-blown treatment for something they don’t technically have. A total assessment via the Alternative Method measures all of the traits associated with personality disorders. At the end of the day, you would not know if you had a personality disorder, but how close you came to having a personality and the specific rankings of all the traits involved. This way of assessing personality disorders is obviously much more nuanced that what’s currently being used and can be extremely helpful in helping a person understand themselves, period.
So let’s say John Doe is being evaluated for a possible diagnosis of Schizotypal Personality Disorder. He would be asked if he had 5 or more of the following:
- Ideas of reference (ex: thinking the group you just walked by was laughing at you)
- Odd beliefs or magical thinking that influences behavior and is not consistent with cultural norms
- Unusual perceptual experiences
- Odd thinking and speech
- Suspiciousness or paranoid ideation
- Inappropriate or constricted affect
- Behavior or appearance that is odd, eccentric, or peculiar
- No close friends (maybe first-degree relatives)
- Excessive social anxiety that doesn’t go away with familiarity and tends to be associated with paranoid fears rather than negative judgment
To be diagnosed with Schizotypal Personality Disorder, John Doe would need to have at least 5 of the symptoms/behaviors/though patterns in this list. This way of diagnosing has attracted a lot of criticism because it’s a system that basically says, “You either have it or you don’t.” Also, some of the criteria are highly prone to subjective opinion. For example, #7 (“Behavior of appearance that is odd, eccentric, or peculiar) is very much open to the opinion of the clinician. Is blue hair odd? Are dread-locks and piercings on an Irish-American woman peculiar? It depends who you ask. Also, can blue hair be odder than dread-locks or piercings? What if a person has dread locks, blue hair, and piercings? Is that person extremely odd, then? No need to worry about that because there’s actually no way the current system can record what the clinician thinks is slightly odd versus extremely odd. Appearance or behavior is either odd, peculiar, or eccentric… or it’s not.
Now, if this same person were being assessed for this same diagnosis under the Alternative Model, two sets of criteria would be looked at:
Criterion A
- Identity
- Self-direction
- Empathy
- Intimacy
Criterion B
- Negative affectivity
- Detachment
- Antagonism
- Disinhibition
- Psychoticism
Criterion A looks at how impaired personality functioning is. For example, does John Doe constantly look to others to validate who he is? Does he find ways to motivate himself? Can he empathize with others’ suffering? Does he seek out and value personal relationships? Criterion A is measured on a scale from 0 – 5:
0 = little to no impairment
1 = some impairment
2 = moderate impairment
3 = severe impairment
4 = extreme impairment
Anything rated a 2 or above (moderate or greater impairment) counts towards the personality disorder. Each personality disorder requires impairment in specific areas, so all 4 areas do not have to be rated a 2 or above to qualify for a diagnosis. Criterion A has been praised because it addresses the whole personality. Criterion B looks at 5 ways that personality disorders usually manifest themselves. Each of the 5 ways has 3-6 “facets” that can be examined. For example, Criterion B, #3 has 6 facets: manipulativeness, deceitfulness, grandiosity, attention seeking, callousness, and hostility. Criterion B is measured by asking, “How well does this describe my client?” And the answers are “not at all”, “mildly”, “moderately”, and “extremely”. Any trait facet that moderately describes the client is then marked as present because it is then considered clinically important. The facets that are mildly present are still accounted for, giving a more comprehensive view of the client. The “mild” facets just don’t count towards the personality disorder. There are specific facets that describe each personality disorder, and the presence of those facets determines if John Doe has Schizotypal Personality Disorder.
It’s definitely true that the Alternative Model narrows personality disorders down from 10 to 6. Comorbidity (having more than one personality disorder) is a huge problem with personality disorder diagnosis, so this reduction isn’t as bad as it sounds. Chances are, people who are consistently diagnosed as having two separate disorders truly only have one. So, does this mean that fewer personality disorders exist? Well, in a way. The DSM-5 Personality and Personality Disorder Work Group couldn’t gather substantial evidence/research to justify keeping Paranoid Personality Disorder or Schizoid Personality Disorder, partly because of this comorbidity problem. But don’t worry! If the psychologist or psychiatrist finds a personality trait that is extremely exaggerated, then there’s always the Personality Disorder—Trait Specified diagnosis that mentions specifically what trait is blown out of proportion. No more of this Personality Disorder NOS (not otherwise specified) that provided zero information while still managing to get insurance companies to cough up money.
Long story short, the Alternative Model can be used. However, it hasn’t fully replaced the faulty model that the DSM-5 currently endorses, even though it outperformed the old model in the DSM-5 Field Trials. Apparently, politics and power still speak louder than research. Like the old saying goes… you can lead a horse to water, but you can’t make it drink… because the horse wants to do what it’s always been doing so it’ll get what it’s always got: an uncomprehensive personality disorder diagnostic system with high comorbidity
