Main changes to personality disorders in DSM5

1. Personality disorders in
DSM5
Ahmed Eid Elaghoury
Arab & Egyptian Boards in Psychiatry
Psychiatry registrar
Armed Forces Center for Psychiatric Care,TAIF

2. Same criteria as DSM IV
Taif, Jun 2014 DSM5 changes series 2
DSM5 Task Force List

3. Taif, Jun 2014 DSM5 changes series 3

4. DSM 5 field trials
 In USA & Canada: 279 clinicians, 2246 pts, most
of them (86%) interviewed twice to test 23
disorders
 Borderline PD: good interrater reliability
 Obsessive compulsive PD & antisocial PD:
questionable reliability range
 Other PDs: too few pts to test reliability
(Kappa test)
Taif, Jun 2014 DSM5 changes series 4
Bret S. Stetka, MD, Christoph U. Correll, MD:A Guide to DSM-5. Medscape Psychiatry, May 21, 2013

5. DSM-5 field trials: diagnostic reliability in adults. Modified from: Freedman R, Lewis DA, Michels R,
et al. The initial field trials of DSM-5: new blooms and old thorns. Am J Psychiatry. 2013;170:1-5.
Taif, Jun 2014 DSM5 changes series 5

6. Multiaxial system
 Introduced with DSM III (1980): to complete
evaluation and not overlook any symptom
 Axis II: personality ds & specific
developmental ds
 Axes I & II: were mental ds
 Removed in DSM5 (2013):
◦ Axes I, II & III: as a list by principal diagnosis
◦ Axis IV  ICD10 Z codes
◦ AxisV  WHO disability assessment schedule
(WHODAS 2.0)
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7. Taif, Jun 2014 DSM5 changes series 7
DSM5: pg 21

8. We are back!! Keep skeptical
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DSM I, 1952: pg 46
DSM II, 1968: pg 2

9. New concept: Cross-cutting
symptom measures
 Modeled on general medicine’s review of
systems
 Reviewing psychopathological domains
 Level 1: brief survey:
◦ (13) domains for adult
◦ (12) domains for child & adolescent
 Level 2: more in-depth assessment
 Both: at initial interview and followup
Taif, Jun 2014 DSM5 changes series 9

10. Personality functioning
 Domain XII in level 1 cross-cutting symptom
measure
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11. Personality functioning
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DSM5

12. Taif, Jun 2014 DSM5 changes series 12
DSM5

13. Generic diagnostic criterion
in DSM5
DISABILITY
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DSM5: pg 21

14. Taif, Jun 2014 DSM5 changes series 14

15. Alternative DSM5 Model for
personality disorders
 In section III, so NOT official or for clinical use
 Still a research model
 Based on the “Big Five” Five Factor Model of
Personality “FFM” and the Personality
Psychopathology Five “PSY5” model.
 Trait approach: ie dimensional
 Categorical approach may be uninformative eg
other specified / unspecified PD
 Distinguishing traits, symptoms and specific
behaviors.
 Allow to describe a personality disorder – trait
specified (PD-TS)
Taif, Jun 2014 DSM5 changes series 15

16. Alternative DSM5 Model
 Main premise:
◦ Personality functioning: impaired (criterion A)
◦ Personality traits: pathological (criterion B)
◦ Pervasiveness & Stability (criteria C&D)
◦ Absence of alternative explanation (criteria E,
F & G)
Taif, Jun 2014 DSM5 changes series 16

17. Five personality disorder trait
domains
1. Negative Affectivity (vs emotional stability)
2. Detachment (vs Extraversion)
3. Antagonism (vs Agreeableness)
4. Disinhibition (vs Conscientiousness)
5. Psychoticism (vs Lucidity)
 Each domain has “facets” eg: anxiousness,
depressivity, etc inside Negative Affectivity
 All are 25 facets
 Only 6 specific PDs applied to this model:
antisocial, avoidant, borderline, narcissistic,
obsessive-compulsive & schizotypal
Taif, Jun 2014 DSM5 changes series 17

18. ICD-11 Beta Draft
 Personality disorder:
◦ Mild
◦ Moderate
◦ Severe
◦ Other
◦ Unspecified
 Allows “late onset” qualifier
 No specific subtypes of PDs.
Taif, Jun 2014 DSM5 changes series 18
http://apps.who.int/classifications/icd11/browse/f/en

19. Summary
 Multiaxial documentation is REMOVED from DSM5
 Only BORDERLINE PD is of good interrater reliability in
DSM5 field trials
 “PERSONALITY FUNCTIONING” & “CROSS-CUTTING
SYMPTOM MEASURES” are new DSM5 concepts
 “DISABILITY” is the generic diagnostic criterion in DSM5
 Personality functioning should be ASSESSED ROUTINELY as a
domain of level 1 cross-cutting symptom measure OR as a
domain of disability in WHODAS 2.0
 ALTERNATIVE DSM5 MODEL FOR PERSONALITY
DISORDERS is “five factor” dimensional (trait) model and still
under research, NOT for official use
 ICD 11 BETA CRITERIA for personality disorders are
dimensional and removing the specific subtyping till now
Taif, Jun 2014 DSM5 changes series 19