The politics of the DSM 5 personality disorders

Most science blog posts post a link to an academic article or two and discuss their merits or lack thereof. I am going to do something slightly different - I am linking to an entire special issue of a journal, with pdfs freely available online - and recommend that you do NOT waste any time reading any of it. All it really shows is a bunch of academics bickering over stuff that doesn't seem to make much of a difference.

I imagine the DSM 5 PD workgroup meetings look something like this:



South Korean politicians fighting



Anyway, on to the articles. Out of all the changes being considered for the DSM 5, the personality disorder (PD) work group has proposed some of the most sweeping ones such as dropping 5 of the current PDs entirely and adding a dimensional component that somehow involved asssessing 6 trait domains and 37 facets  for the remaining PDs. Not surprisingly, this has not gone over too well.

The Journal of Personality Disorders has recently published a special issue (see link here with pdfs) that has invited articles by the DSM PD workgroup members and other commentaries in response to it. I repeat - don't bother reading any of it. Most of these articles are filled with jargon (SNAP, DAPP, NEO, DIPSI, HEXACO, OMGWTFBBQ), are quite boring, appear to be selective in whatever literature they cite, with quite a few of the authors increasing their self-citation count, while sniping at each other. Here's a brief rundown.

In the first article, the workgroup (Andrew Skodol et al.) rehash their proposal, but note that "Feedback from the [DSM-5] website posting suggested that this system was too complicated, redundant with the full clinicians’ trait ratings, and unwieldy". Really? Nah! Say it ain't so! So their solution is to separate the 5 PD "types", from the "traits" and "facets" in the field trials, and somehow refine this system. How? It is not entirely clear.

In the next article (Krueger et al.), the authors repeatedly talk about the "empirical structure of personality". Curiously, while there is some overlap in authors with the first one, they are not all identical. I suspect this means some sort of division among the PD workgroup members. Anyway, as the authors themselves acknowledge, the bulk of the evidence for their proposal uses a statistical technique called factor analysis, which is essentially based on a whole lot of correlations. Why this makes the authors' proposal or review any more "empirical" is pretty unclear to me. The authors also take some effort to delineate why Thomas Widiger's (another big name in the personality world) preferred model of personality may not be as "empirical" as theirs.

The remaining articles are commentaries. Clarkin and Huprich's, and Zimmerman's, are worth skimming over, but don't really say anything that wasn't already known - i.e., the PD proposal is too complex to be clinically useful, and not really based on much evidence. Then, we have an article by the aforementioned Widiger, who hits back pretty hard at Lee Anna Clark and Robert Krueger (two other big names) for not using his preferred model of personality, and spends 13 pages or so picking apart the PD proposal and Clark and Krueger's work.

This is followed by a couple of articles by Robert Bornstein (an expert on Dependent PD) and Elsa Ronningstam (an expert on Narcissistic PD). These two PDs are slated to be dropped. So, no prizes for guessing what these commentaries are about. And lastly, Joel Paris has an article on the use of endophenotypes for diagnosing PDs - though as he clearly notes, we don't have any yet (which DSM disorder does anyway?). In other words, an academic exercise in what might be useful if we ever find it.

While I occasionally use some personality inventories in my work, most of my work doesn't involve the PDs, and as such, I have no strong ties to a 5-, 6-, or 18-factor model of personality. I picked up this special issue hoping for some sort of enlightenment on the PD proposal. Now, instead, I wish I could get back the hours I spent reading these articles.





Skodol AE, Bender DS, Morey LC, Clark LA, Oldham JM, Alarcon RD, Krueger RF, Verheul R, Bell CC, & Siever LJ (2011). Personality Disorder Types Proposed for DSM-5. Journal of personality disorders, 25 (2), 136-69 PMID: 21466247

Krueger RF, Eaton NR, Clark LA, Watson D, Markon KE, Derringer J, Skodol A, & Livesley WJ (2011). Deriving an Empirical Structure of Personality Pathology for DSM-5. Journal of personality disorders, 25 (2), 170-91 PMID: 21466248

Clarkin JF, & Huprich SK (2011). Do DSM-5 Personality Disorder Proposals Meet Criteria for Clinical Utility? Journal of personality disorders, 25 (2), 192-205 PMID: 21466249

Zimmerman M (2011). A Critique of the Proposed Prototype Rating System for Personality Disorders in DSM-5. Journal of personality disorders, 25 (2), 206-21 PMID: 21466250

Widiger TA (2011). The DSM-5 Dimensional Model of Personality Disorder: Rationale and Empirical Support. Journal of personality disorders, 25 (2), 222-34 PMID: 21466251

Bornstein RF (2011). Reconceptualizing Personality Pathology in DSM-5: Limitations in Evidence for Eliminating Dependent Personality Disorder and Other DSM-IV Syndromes. Journal of personality disorders, 25 (2), 235-47 PMID: 21466252

Ronningstam E (2011). Narcissistic Personality Disorder in DSM-V-In Support of Retaining a Significant Diagnosis. Journal of personality disorders, 25 (2), 248-59 PMID: 21466253

Paris J (2011). Endophenotypes and the diagnosis of personality disorders. Journal of personality disorders, 25 (2), 260-8 PMID: 21466254