Dimensionality in the proposed DSM-V

[walkitout]

I decided to take a closer look at the revamp of Personality Disorders in DSM-V. I have a long-ish standing interest in Borderline Personality Disorder, because I've run across people (_not_ friends of mine, but friends-of-friends) with this diagnosis and they really stand out as Trouble. I've never been able to make much sense out of the diagnostic criteria in DSM-IV, and quite a lot of my shorthand understanding of who winds up with this diagnosis isn't even in the criteria (the shortest of my short forms is, "cutter = BPD" -- and yes, I'm not a pro and yes, I understand this is actually not entirely accurate).

DSM-V has made a really big change to the way Personality Disorders are handled. They've moved from a set of criteria (must have n/2 or more of n items on a list to get the diagnosis and if you are on the edge, you'll lose eligibility for the diagnosis if you lose a single item on the list even tho the diagnosis is supposedly life-long or at least chronic) to a hybrid model of traits and types. The idea is to capture elements of who-the-person-is (think five factor model of personality) to describe better how the personality disorder will manifest as well as what-in-particular-is-broken to capture pathological behaviors/approaches/thought-patterns/etc. For some of the PDs, they've done a detailed match-up of the traits and types, but quite a few PDs went away. The rationale is that a lot of people clearly had a PD but didn't qualify for one in particular -- and some people qualified for more than one, when that's not supposed to happen either. The new approach is, like everything else in DSM-V, supposed to lead to better consistency of diagnosis over time and practitioner AND to reduce dependency on X-NOS coding.

I had to puzzle over this for a while to understand what they were doing and why, and then my brain kinda farted and I went, hey, this is like my modules theory! Instead of coming up with One Name to describe what a person has or is, try an analytical description and then address the pieces that are problematic. So I think I wholeheartedly approve, altho I'm now curious to read more of the diagnostic descriptions to see what I think of the implementation.

I'm really impressed by what's happening with DSM-V. The people running this round are being extremely diligent and careful and professional. Nor does it hurt that the way they think about mental health appears to run along very similar ideas to the way I think about it. ;-)

What I really like, however, is their minimalist approach is driven by an effort to find the parts that disparate theories hold in common. This is where I would expect to find stable ground.

From the Rationale section for Borderline Personality Disorder:

"Impairment in self and interpersonal functioning is consistent with multiple theories of PD and their research bases, including cognitive/behavioral, interpersonal, psychodynamic, attachment, developmental, social cognitive, and evolutionary theories, and has been viewed as a key aspect of personality pathology in need of clinical attention (e.g., Clarkin & Huprich, 2011, Luyten & Blatt, 2011, Pincus, 2011)."

That is just fucking brilliant.

If you have the time, go explore the proposed revision.

http://www.dsm5.org/Pages/Default.aspx

Wikipedia will help you out with the jargon.

Comments

[ethelmay.livejournal.com]

That's really interesting. I haven't heard anyone else have a good word for DSM V. My friend Aimee Yermish (I swear she is not paranoid by nature) just posted on Facebook thus: "The DSM-IV is deeply flawed but kinda still usable. The proposals and process for the DSM-5 are a complete train wreck -- not fixing the problems, making them worse, and adding new ones. Why exactly are psychiatric researchers dictating to all clinicians that they know better than we do and that we have to dance to their tune? Can we get off this train and let the wreck go on without us?"

The best thing I've heard her say about it "Glad to hear that they're going to clarify things a bit in the anxiety and mood disorders department."

She thinks there's a lot of inappropriate pressure to redefine autism spectrum disorders so that many fewer people will be diagnosed with them: "You cannot medicate away ASD (and in fact, recent research is showing that you can't even particularly effectively medicate away the symptoms). If you can't diagnose those folks with ASD, then they get some other diagnoses that are much more attractive to Big Pharma. ... Kids will tend to be shunted into whatever the latest euphemism is they've put in for Kiddie Bipolar and given large doses of atypical antipsychotics ( = chemical restraint). Am I cynical? You bet."

The awful thing is that you could both be right. I've seen this happen in education a lot, where a good theory gets pushed by people who think very reasonably that it will work, but the reason they're getting the money to push that theory is from folks who want it to happen for some completely different reason, and who are not concerned about whether the end plan is actually consistent with the theory they're supposedly pushing, as long as they've got a way to make money off the process.

fears about diagnosis rates

[walkitout]

The people working on DSM V have been criticized for trying to reduce rates of ASD. This is almost funny. It would be funny if I were callous, cruel and had no personal stake in the issue. But I'm not, generally speaking, and I do, so, Not Funny.

The DSM V groups are on record, repeatedly, saying that diagnosis rates _were not_ part of what they were thinking about. Their goals are straightforward: stabilize diagnosis across time and practitioner. Swedo says some people who identify as Aspie are no longer going to have a spectrum diagnosis, because they'll be moved over to Social Communication Disorder -- which will also pick up some new people. But that's only going to be Aspies who have no sensory issues, no stereotypy and no "special interest" thing going on and honestly? Do you even know anyone like that who is already getting services? Anyone being medicated for that shouldn't be taking drugs for it anyway, imo (altho maybe for a related anxiety thing, but that's not going to be affected).

There are people who are trying to target ASD with drugs. I've run across them and run away as soon as I encountered them. Almost all of the cost to "society" associated with ASD is the requirement (often embedded in state law, but also through Federal Law) to provide services to people with autism diagnoses. Some state law mandates life long services, IIRC; Federal law applies through the FAPE mandate. There's no real gain or loss to Pharma to redefine ASD.

The current state of affairs just encourages denial ("At least it's not autism" "It's just PDD-NOS" "Asperger's isn't a spectrum disorder!", etc.) and turns a bunch of parents with kids on the spectrum against each other. And whichever disorder you have, the school district doesn't really give a shit. They're going to do their own assessment and decide whether to provide you with access to their speech person, their OT, and their resource room based on their assessment -- not what some psychologist or psychiatrist says. If you need an outside person to come in to convince your district to provide needed services, _this redefinition will not affect you_. If you could get the psychiatrist or psychologist to produce documentation to force services to be provided under DSM-IV, it'll only get easier under DSM-V.

I think the fear about atypical antipsychotics being passed out is probably justified ... if you're near the poverty line and you have a highly involved child. That's the only group that I've run across that gets loaded up with insane drugs that doesn't have the resources to fight back and demand services instead.

Re: fears about diagnosis rates

[ethelmay.livejournal.com]

Well, I hope you're right and it turns out easier on Aimee and other clinicians than they fear.