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 the underlying by the work group and included in Section III of pathophysiology of personality disorders; there is a DSM-5 is explicitly intended to support a research great deal of passion and commitment to strongly agenda (Ref. 3, p 645). This model might be useful if held attitudes about personality disorders and how it were the only initiative guiding advances in our best to approach diagnosis and treatment; and many understanding of the etiology, phenomenology, and psychiatrists find it easier and more consistent with treatment of personality disorders. However, even all other diagnoses to make categorical decisions. The that role is contested. final product of the work group was included as an The National Institute of Mental Health (NIMH) alternative model in Section III of DSM-5, “Emerg- has proposed a very divergent diagnostic approach to ing Measures and Models” (Ref. 3, pp 761–82). advancing psychiatric research, labeled the Research Another change of note is the elimination of the Domain Criteria (RDoC). This criteria set is in- multi-axial system. All development disorders, per- tended to be guided by data from genetics, cognitive sonality disorders, and general medical conditions science, and the search for potential biological mark- are now listed together, consistent with the approach ers.25 This approach has created a certain amount of used by the International Classification of 24 tension between the framers of DSM-5 and research- Diseases. ers at NIMH, as the former have maintained a phe- nomenological and descriptive nosology, whereas the The Final Product: Implications for latter argue for one based on a conceptualization of Practice in North America mental illnesses as disorders of brain function.25 This contentious environment may be quite fruitful for The Cautionary Statement the generation of novel ideas and research ap- The DSM-5 contains an expanded Cautionary proaches, but meanwhile, it is likely to limit the fo- Statement of explicit relevance to forensic psychiatry. rensic credibility of the current personality disorder It states in part that, “In most situations, the clinical diagnostic framework. diagnosis of a DSM-5 mental disorder . . . does not imply that an individual meets legal criteria for the Use of Personality Disorder Diagnoses in Expert presence of a mental disorder or a specified legal stan- Opinions and in Court dard....”Itgoes on to state that, “a diagnosis does Despite the political disagreements, the use of per- not carry any necessary implications regarding the sonality disorder diagnoses in expert opinion reports . . . individual’s degree of control over behaviors that is unlikely to be affected. Given the current state of may be associated with the disorder” (Ref. 3, p 25). our knowledge, the relevance of asserting a diagnosis For example, in regard to antisocial personality dis- of a personality disorder is not the disorder per se, but order (ASPD), DSM-5 does not address the often- rather its cognitive, affective, behavioral, and inter- troubling tautology about illegal behavior, in either personal manifestations.1 For example, the diagnosis civil or criminal matters. Specifically, four of seven of borderline personality disorder requires that an Criterion A diagnostic criteria for ASPD include il- individual satisfy at least five of nine specific criteria. legal behavior: “Failure to conform to social norms Two different individuals may therefore both carry a with respect to lawful behaviors, as indicated by re- diagnosis of borderline personality disorder, but peatedly performing acts that are grounds for arrest”; share in common only one of the nine criteria. In that “deceitfulness, as indicated by repeated lying, use of context, a matter of relevance to the court regarding aliases, or conning others for personal profit or plea- a child custody matter may not be a parent’s diagno- sure”; “irritability and aggressiveness, as indicated by sis of borderline personality disorder, but perhaps the repeated physical fights or assaults”; and “consistent parent’s severe emotional instability, impulsivity, irresponsibility, as indicated by repeated failure to and high risk for repeated suicide attempts. A judge . . . honor financial obligations” (Ref. 3, p 659). It may be swayed by the potential of exposing a child to may therefore prove challenging to offer in testimony parental instability and likely suicide, but not to a that ASPD should be considered a mitigating factor parent with only a diagnosed personality disorder. in the commission of a crime. Similar problems of functionality and behavior hold

Volume 42, Number 2, 2014 143 DSM-5 and Personality Disorders in the context of disability evaluations or fitness-for- Conclusion duty examinations. In part because of the very different views of ex- Although some psychiatric illnesses may serve as perts in the field of personality disorders and the mitigating factors in the sentencing phase of a trial rapidly changing nature of our understanding of the (e.g., acute psychosis associated with schizophrenia), 4 etiology, pathophysiology, and treatment of these personality disorders are not among them. Given disorders, DSM-5 presents us with DSM-IV-TR the lack of substantive changes in personality disor- redux. For the practical purposes of forensic psychi- der diagnosis in DSM-5, this situation is unlikely to atry, DSM-5 requires that we change essentially change. nothing as it relates to assessing, diagnosing, and One consideration is whether a forensic psychia- treating individuals with personality disorders. Fur- trist might use aspects of the alternative model as part thermore, DSM-5 will have little immediate impact of an evaluation. The hybrid model includes a newly on opinion writing, depositions, or courtroom testi- developed assessment of five broad areas of patholog- mony as it relates to individuals given a diagnosis of ical personality traits: the Personality Inventory for 26 personality disorder. It may, however, open up fur- DSM-5 (PID-5). Consistent with any of the com- ther contentious debate over the value of the DSM-5 ponents of a forensic evaluation, the validity and re- personality disorder diagnoses, given the disagree- liability would have to be adequate to survive scru- 26 ments among the members of the DSM-5 Personal- tiny. Initial data support the validity of PID-5 and ity and Personality Disorder Work Group and the its convergence with existing measures of psychopa- 27,28 ultimate decision to relegate the work of the commit- thology. The degree to which these evolving data tee to the “Emerging Measures and Models” section. demonstrate enhanced value in the assessment of personality disorders will determine its ultimate References value in a forensic evaluation. 1. Reid WH: Borderline personality disorder and related traits in Another interesting potential situation is a chal- forensic psychiatry. J Psychiatr Pract 15:216–20, 2009 lenge to the overall credibility of the diagnostic 2. Trestman RL, Ford JD, Zhang W, et al: Current and lifetime schema of personality disorders. Such an assertion psychiatric illness among inmates not identified as acutely men- tally ill at intake in Connecticut’s jails. J Am Acad Psychiatry Law may reasonably be based on both the contentious 35:490–500, 2007 process that relegated the recommendation of the 3. American Psychiatric Association: Diagnostic and Statistical work group to alternative model status and the Manual of Mental Disorders, Fifth Edition. Arlington, VA: broader rejection of DSM-5 (at least for purposes of American Psychiatric Association, 2013 4. Sparr LF: Personality disorders and criminal law: an international research) by the NIMH. perspective. J Am Acad Psychiatry Law 37:168–81, 2009 5. American Psychiatric Association: Diagnostic and Statistical Clinical Management of Patients with Personality Disorder Manual, Mental Disorders, First Edition. Washington DC: Diagnoses American Psychiatric Association, 1952 6. American Psychiatric Association: Diagnostic and Statistical Finally, nothing in the DSM-5 criteria for person- Manual of Mental Disorders, Second Edition. Washington DC: ality disorders suggests changes in the approach to American Psychiatric Association, 1968 treatment of individuals with a diagnosed personality 7. American Psychiatric Association: Diagnostic and Statistical disorder. The field of personality disorder research is Manual of Mental Disorders, Third Edition. Washington DC: American Psychiatric Association, 1980 growing at a rapid rate, as reflected in the expanding 8. American Psychiatric Association: Diagnostic and Statistical clinical research portfolio. Outcome studies reflect Manual of Mental Disorders, Third Edition, Revised. Washing- that treatment, both psychotherapeutic and pharma- ton DC: American Psychiatric Association, 1987 9. American Psychiatric Association: Diagnostic and Statistical cologic, is beneficial, and there is growing optimism Manual of Mental Disorders, Fourth Edition. Washington DC: among clinical researchers and clinicians for func- American Psychiatric Association, 1994 tional improvement and enhanced quality of life in 10. American Psychiatric Association: Diagnostic and Statistical 29 Manual of Mental Disorders, Fourth Edition, Text Revision. this population. Targeted research may also assist Washington DC: American Psychiatric Association, 2000 in defining interventions that substantially reduce 11. Widiger TA, Simonsen E, Sirovatka PJ, et al: Dimensional Mod- many of the problematic behaviors of individuals els of Personality Disorders: Refining the Research Agenda for with personality disorders and ultimately in develop- DSM-V. Arlington, VA: American Psychiatric Association, 2006 12. Bernstein DP, Iscan C, Maser J: Opinions of personality disorder ing preventive interventions targeting at-risk experts regarding the DSM-IV personality disorders classification populations. system. J Personal Disord 21:536–51, 2007

144 The Journal of the American Academy of Psychiatry and the Law Trestman

13. Harford TC, Chen CM, Saha TD, et al: An item response theory 21. Skodol AE: Personality disorders in DSM-5. Annu Rev Clin Psy- analysis of DSM-IV diagnostic criteria for personality disorders: chol 8:317–44, 2012 findings from the national epidemiologic survey on alcohol and 22. Frances A: Two Who Resigned From DSM-5 Explain Why, Psy- related conditions. Personal Disord 4:43–54, 2013 chology Today, Blog: DSM-5 in Distress. July 11, 2012. Available 14. McRae RR, Costa PT: Personality in Adulthood: a Five-Factor at http://www.psychologytoday.com/blog/dsm5-in-distress/ Theory Perspective (ed 2). New York: The Guilford Press, 2003 201207/two-who-resigned-dsm-5-explain-why 15. Tyrer P: Diagnostic and Statistical Manual of Mental Disorders: a 23. Livesley WJ: Disorder in the proposed DSM-5 classification of classification of personality disorders that has had its day. Clin personality disorders. Clin Psychol Psychother 19:364–8, 2012 Psychol Psychother 19:372–4, 2012 24. World Health Organization: ICD-10 Classifications of Mental 16. Pilkonis PA, Hallquist MN, Morse JQ, et al: Striking the (Im) and Behavioral Disorder: Clinical Descriptions and Diagnostic proper balance between scientific advances and clinical utility: Guidelines. Geneva: World Health Organization, 1992 commentary on the DSM-5 proposal for personality disorders. 25. Insel T, Cuthbert B, Garvey M, et al: Research Domain Criteria Personal Disord 2:68–82, 2011 (RDoC): toward a new classification framework for research on 17. Kendler K, Kupfer D, Narrow W, et al: Guidelines for making mental disorders. Am J Psychiatry 167:748–51, 2010 changes to DSMV. Washington DC; APA, revised October 21, 26. Fossati A, Krueger RF, Markon KE, et al: Reliability and validity 2009. Available at http://www.dsm5.org/ProgressReports/ Documents/Guidelines-for-Making-Changes-to-DSM_1.pdf. of the Personality Inventory for DSM-5 (PID-5): predicting Accessed July 20, 2013 DSM-IV personality disorders and psychopathy in community- 18. Pull C: Too few or too many?—reactions to removing versus dwelling Italian adults. Assessment 20:689–708, 2013 retaining specific personality disorders in DSM-5. Curr Opin 27. Sellbom M, Anderson JL, Bagby RM: Assessing DSM-5 Section Psychiatry 26:73–8, 2013 III Personality Traits and Disorders with the MMPI-2-RF. As- 19. Zimmerman M, Chelminski I, Young D, et al: Which DSM-IV sessment 20:709–22, 2013 personality disorders are most strongly associated with indices of 28. Few LR, Miller JD, Rothbaum AO, et al: Examination of the psychosocial morbidity in psychiatric outpatients? Compr Psychi- Section III DSM-5 diagnostic system for personality disorders in atry 53:940–45, 2012 an outpatient clinical sample. J Abnorm Psychol 122:1057–69, 20. Bornstein RF: Reconceptualizing personality pathology in 2013 DSM-5: limitations in evidence for eliminating dependent per- 29. Oldham J: Guideline watch: practice guideline for the treatment sonality disorder and other DSM-IV syndromes. J Pers Disord of patients with borderline personality disorder. American Psychi- 25:235–47, 2011 atric Publishing, Inc., 2010

Volume 42, Number 2, 2014 145