Time To Scrap the DSM-5 Personality Disorder Proposal


Humans have just these 2 ways of sorting things--giving them a name or a giving them a number. We have been naming things since the days of Adam.

Humans have just these 2 ways of sorting things -- giving them a name or a giving them a number. We have been naming things since the days of Adam. It is often quite an inaccurate approach, but one that is very familiar to us. Sorting by numbers is certainly much more precise, but it comes more naturally to computers than to us. The naming method is called sorting by categories, the numbering by dimensions.

In everyday day, we mostly use categories. Unless we are doing a physics experiment, we describe colors broadly as blue, or green, or red -- not more accurately by giving their exact wavelength. When describing ourselves we normally use adjectives not numbers, except only for those characteristics that are continuous in their distribution and readily rendered numerically (like height, weight, IQ).

The DSM-5 Personality Disorders Work Group meant well in its effort to substitute numbers for names. The categorical description of personality is awkward and inaccurate because the personality disorders have such unclear boundaries -- at its borders with normality, with each other, and with other psychiatric problems. Giving something a name carries an implicit assumption that it has reasonably well defined boundary. . .  and personality disorders often don't. Perhaps describing personality with numbers would be a better solution.

The Work Group's goal was reasonable, but its method was ludicrous. It developed a dimensional system so impossibly complicated and confusing that even experts in the field were befuddled and unable to figure it out. Clearly the proposal was the work of researchers trying to piece together their pet dimensions in a crazy quilt that was totally out of touch and had no relevance whatever to the realities of clinical practice. 

Predictably, the experts in personality disorder were appalled -- worried that the DSM-5 Work Group's muddled suggestions would result in a downgrade in both the clinical and the research work in personality disorder. In numerous journal articles, at meetings, and in a pained open letter to the Work Group, they detailed how completely unfeasible was the DSM-5 proposal and how lacking in empirical support. Finally, one of the Work Group members stood in open opposition to the Work Group and wrote a brilliantly reasoned paper detailing all the fatal flaws in the proposal.

The well meaning Work Group listened, went back to the drawing board, and returned some months ago with a proposal that was allegedly simpler and more user friendly. Simpler perhaps to its creators, but still an impossible mess to the rest of us. The Work Group was showered with continued cries of confusion and criticism. Agreeably enough, it went back to the drawing board yet again and its third proposal was recently posted on the DSM-5 web site.

I defy anyone to make sense of the jumble of this latest frankensteinish "solution." The DSM-5 Work Group has proven itself simply incapable of preparing a proposal that has any chance of ever being used by anyone in the world except its creators. Three strikes and you are out.
What to do now?  Clearly, it is long past time to give up-going back yet again to the drawing board makes no sense. It is also too late in the DSM-5 process to come up and to test alternative dimensional approaches that might have been sufficiently user-friendly for clinicians. There seems to be no choice. The existing section on personality disorders, with all its long admitted flaws and limitations, appears to be the only possible default position.

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