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Personality disorder criteria revised in new diagnosis manual

Draft criteria for identifying and diagnosing personality disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders simplifies the number of conditions and allows for a greater variety of impairment levels. The proposed recommendations follow the receipt of more than 8,000 public comments on the DSM-5 in 2010. The comments concerned all aspects of the DSM-5, not just personality disorders. Comments relevant to issues managed by the 11-member Personality and Personality Disorders Work Group led it to return narcissistic personality disorder to the list of disorder types after removing it in an earlier draft. The group also simplified and streamlined the process of assessing personality disorders. The goal of the new criteria is to maximize their utility to clinicians and benefit to patients, according to the American Psychiatric Assn. "Our proposed criteria get away from the idea that personality pathology is just a group of disorders," said Robert Krueger, PhD, a member of the Personality and Personality Disorders Work Group and a psychology professor at the University of Minnesota. "We're instead defining it as a much broader characteristic." Among the key changes for primary care physicians and specialists is reducing the 10 personality disorder categories in DSM-IV to six -- antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal. The removed categories were dependent, histrionic, paranoid and schizoid personality disorders. This change will eliminate overlapping conditions, which often lead to patients being diagnosed with more than one personality disorder, said Andrew Skodol, MD, chair of the Personality and Personality Disorders Work Group and research professor of psychiatry at the University of Arizona College of Medicine. Also significant is the elimination of Personality Disorder Not Otherwise Specified, which is in DSM-IV and does not offer doctors information about an individual's mental health, Dr. Skodol said. In its place, the work group proposes Personality Disorder Trait Specified for patients whose condition does not meet the full criteria for any specific disorder. To diagnose this condition, as well as the six specific personality disorder types, a patient must have significant impairment in the two areas of personality functioning, self and interpersonal, which are not part of DSM-IV. Self-functioning is defined as how patients view themselves and how they identify and pursue their goals. Interpersonal functioning is the ability of an individual to understand other people's perspectives and form close relationships. The work group proposes that patients also have at least one pathological personality trait, such as antagonism or detachment. "I think the fact that every patient will have clinically descriptive information is one of the main ways [the proposed criteria] will help clinicians," Dr. Skodol said. He added, "The importance of personality functioning and personality traits is the major innovation here. In the past, we viewed personality disorders as binary. You either had one or you didn't. But we now understand that personality pathology is a matter of degree." In fact, the work group is developing a scale to judge a patient's level of impairment that probably will extend from mild to extreme, Dr. Skodol said. He said the group also is working on a short questionnaire to help primary care doctors more easily identify patients with a personality disorder during their limited time for office visits. He said physicians then can refer such individuals to specialists for a detailed diagnosis and appropriate treatment. DSM-5 set for release in 2013 The draft diagnostic criteria are based on studies and other clinical research published as early as the 1990s. The data show that because patients' behavior can be intermittent and change over time, behavior-based criteria for diagnosing personality disorders, which is in DSM-IV, can hinder an accurate diagnosis and medical treatment. Impairments in personality functioning and pathological personality traits, however, tend to be more stable over time, according to the work group. About 9% of American adults have a personality disorder, according to the National Institute of Mental Health. Properly identifying and treating such patients is particularly important, because a personality disorder can be associated with other mental health conditions, including anxiety, depression and suicidal behavior. If an individual's personality disorder is not treated effectively, the patient's other mental health issues are less likely to improve, Dr. Skodol said. The draft criteria for personality disorders and other mental health conditions are being evaluated through field trials across the country, according to the American Psychiatric Assn. Clinicians are assessing the feasibility, clinical utility, reliability and, where possible, the validity of the recommended criteria and the dimensional measures proposed for DSM-5, which is scheduled for release in 2013. The full and original article can be found at: http://www.ama-assn.org/amednews/2011/07/25/hlsb0726.htm
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