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DSM-5 and Personality Disorders: Where Did Axis II Go?

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DSM-5 and Personality Disorders: Where Did Axis II Go? SPECIAL SECTION DSM-5 and Personality Disorders: Where Did Axis II Go? Robert L. Trestman, PhD, MD The past decade has seen a period of extensive research into the etiology, pathophysiology, assessment, and treatment of personality disorders. Concomitantly, a group of experts in the field were brought together to form the Personality and Personality Disorder Work Group for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), charged with the responsibility of updating the diagnostic approach to personality disorders. This article is a review of some of the history of the American Psychiatry Association’s approach to the recognition and diagnosis of personality disorders over the past half century, the process of developing the recommendations for a DSM-5 personality disorder diagnosis and the elimination of the multiaxial system, and how DSM-5 has left us with essentially no changes of relevance to the practice of forensic psychiatry in the process for diagnosing personality disorders or in the specific diagnoses of personality disorder. J Am Acad Psychiatry Law 42:141–5, 2014 Many psychiatrists who practice at the interface with no meaningful changes in the clinical diagnosis of the law recognize that there is an apparent over- personality disorder in DSM-5. The story behind representation of people with personality disorders this outcome is enlightening, as it reflects the evolu- (PDs) in civil and criminal cases and in correctional tion of our understanding of personality disorders. settings. The data show them to be correct.1,2 Facets of functional impairment, associated with emotional The Evolution of the Personality Disorder regulation, interpersonal relationships, distrust of Diagnosis Over 60 Years others, a distorted sense of entitlement, and impulse Although personality and its dysfunction have management, which are each an aspect of the various been discussed for millennia, the modern era of per- personality disorders, relate directly to increased risk sonality disorders can be said to have begun in 1952 of legally problematic behavior. Codifying and diag- with the publication of the first DSM 5 by the Amer- nosing those personality disturbances have for over ican Psychiatric Association (APA). In this initial ver- half a century been the domain of the American Psy- sion, personality disorders had brief descriptions and chiatric Association’s Diagnostic and Statistical included a very broad diagnosis labeled sociopathic Manual of Mental Disorders (DSM). In this article, I personality disorder. This diagnosis included multi- review some of the history, its relevance to forensic ple subtypes: antisocial, sexual deviations, alcohol- psychiatric practice, and the implications of the ism, drug addiction, and dissocial reaction. It was changes in DSM-5.3 well over a decade later, in 1968, that DSM-II6 was Initially, a few key summary points are in order. published. It expanded coverage of personality disor- First, distinct from any specific functional impair- ders by devoting all of three pages (Ref. 6, pp 41–4) ments that may be present, PD diagnoses themselves to their description. One short paragraph descriptor are not accepted as a mitigating factor in criminal of each of 10 named personality disorders was pro- cases in the United States, but may enter into con- vided: paranoid, cyclothymic, schizoid, explosive, sideration in other jurisdictions.4 Second, there are obsessive compulsive, hysterical, asthenic, antisocial, passive-aggressive, and inadequate. It also included a Dr. Trestman is Professor of Medicine, Psychiatry and Nursing, Uni- variant labeled other personality disorders of speci- versity of Connecticut Health Center, Farmington, CT. Address cor- fied types. The introductory comments defined per- respondence to: Dr. Robert L. Trestman, PhD, MD, University of Connecticut Health Center, 263 Farmington Avenue, Farmington sonality disorders as “deeply ingrained maladaptive CT 06070. E-mail: [email protected]. patterns of behavior.... Generally, these are life- Disclosures of financial or other potential conflicts of interest: None. long patterns, often recognizable at the time of ado- Volume 42, Number 2, 2014 141 DSM-5 and Personality Disorders lescence or earlier” (Ref. 6, p 41). Neither the first tee charged by the APA with the responsibility for nor the second edition of DSM was supported by any formulating the new diagnostic nosology for person- research evidence, epidemiology, or discussion of the ality disorders. The work group, comprising 10 potential pathophysiology of personality disorder members plus a text coordinator, reviewed the liter- diagnoses. ature and research findings, conducted selected focus Some of these shortcomings were addressed in groups, and reviewed trials of diagnostic models. The DSM-III7 and its revision, DSM-IIIR.8 DSM-III work group attempted to select only the personality elaborated for the first time a criterion-based, osten- disorders with a solid research basis for inclusion in sibly atheoretical categorical diagnostic system con- DSM-5. The primary focus was ultimately the diag- sistent with contemporary medical diagnoses. It also nostic model: categorical or dimensional. Categori- incorporated a multiaxial model that placed person- cal, criterion-based diagnosis is the foundation of ality disorders in the newly created Axis II, thus sep- most medical models and is inherent in the preceding arating them from the major syndromes reflected in editions of the DSM. It is also the basis for the diag- Axis I. These personality disorders were delineated nosis of all other major syndromes in DSM-5. Clin- by 3 clusters totaling 11 PDs plus personality disor- ical practitioners have grown comfortable with it, der-not otherwise specified (PD-NOS). This model even though multiple studies have demonstrated that was created for at least two specific reasons. One was clinicians frequently diagnose by impression rather to focus clinicians on the potential presence of the than by criteria. Moreover, even when criteria are chronic, lifelong conditions that were less acute than used, the inter-rater reliability is inconsistent.13 the more dramatic major syndrome presentations of Dimensional approaches to personality disorder Axis I. A second explicit reason was to help generate diagnosis have long been advocated by many prom- more research, and more was clearly needed: a search inent researchers and clinical psychologists.11,14,15 of PubMed (accessed on July 15, 2013) yielded only With the use of several nosologies, dimensional ap- 257 clinical studies on personality disorders pub- proaches may capture far more information about lished before December 31, 1987. affective lability, impulse dyscontrol, degree of per- The focus on the need for personality disorder ceptual and conceptual distortions, interpersonal re- research yielded results. By the time DSM-IV9 was latedness, and stability of self-concept. This rich in- published in 1994, 489 new studies had been con- formation, however, does not easily boil down to ducted on personality disorders (PubMed search on single-phrase diagnoses.16 In the end, the work July 15, 2013). DSM-IV and DSM-IV-TR10 pro- group proposed a hybrid model incorporating ele- vided incremental changes from DSM-III, with 10 ments of both categorical diagnoses and dimensional personality disorders, as in DSM-III, plus personality characteristics. disorder-NOS; passive aggressive personality disor- Which personality disorder diagnoses to retain der was renamed negativistic personality disorder from DSM-IV-TR or to add in DSM-5 became an and moved to the Appendix. The basic criterion- issue of substantial process and debate.17–20 Origi- driven, categorical approach to diagnosis was left un- nally, only six diagnoses were proposed for inclusion changed, although many experts in the field ac- as personality disorders: antisocial, avoidant, border- knowledged that the categorical diagnostic method line, narcissistic, obsessive-compulsive and schizo- was less than satisfactory.11,12 typal personality disorders (Ref. 20; Ref. 3, pp 763– By the time DSM-5 was published, no fewer than 4). The process, which extended over more than five 2,338 additional studies about personality disorders years, was contentious enough to generate ongoing had been conducted (PubMed search on July 15, active and vociferous challenges to its implementa- 2013). Although this plethora of research yielded a tion,22 and two of the committee members resigned great deal of knowledge regarding phenotypic pre- in protest.23 The APA Board of Trustees ultimately sentations, prevalence estimates, treatment benefits, decided to keep all 10 personality disorders from lifetime trajectories, and so forth, it became clear that DSM-IV-TR unchanged (with only minor text up- there was no consensus on underlying neuropathol- dating). This decision was based on the perception ogy or the optimum approach to diagnosis. That lack that, “. the transition from a categorical diagnostic of consensus played out in the DSM-5 Personality system of individual disorders to one based on the and Personality Disorder Work Group, the commit- relative distribution of personality traits has not been 142 The Journal of the American Academy of Psychiatry and the Law Trestman widely accepted” (Ref. 3, p xliii). The debate and Intended Use of the Alternative Model dissent were, in this author’s opinion, caused by the The hybrid personality disorder model developed following factors: we do not know
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