Among the numerous controversies regarding the upcoming revisions to the Diagnostic and Statistical Manual of Mental Disorders (DSM), a new paper opines that the proposed removal of five personality disorders could actually wind up harming patients.
The DSM is used by psychiatrists and other mental health workers to diagnose mental illnesses, and a number of fierce battles have erupted as those who use the manual have debated the draft changes put forth for the new version, the DSM-5.
Based on their study, researchers from Rhode Island Hospital believe the changes could result in false-negative diagnoses for patients. This means that individuals will not be diagnosed as having a personality disorder, when in fact they meet current criteria for the disorder.
The issue arose as the DSM-5 Personality and Personality Disorders work group made several recommendations to change the approach toward diagnosing personality disorders.
One of the recommendations included the deletion of five personality disorders as a way to reduce the level of comorbidity among the disorders. Comorbidity implies that a disorder with a similar although different disorder may occur simultaneously but independently of the other; or, comorbidity may be a condition that results from the original condition.
The Work Group initially recommended that paranoid personality disorder, schizoid personality disorder, histrionic personality disorder, narcissistic personality disorder and dependent personality disorder be eliminated as a diagnostic definition.
More recently, the Work Group recommended that narcissistic personality disorder be retained.
Lead author Mark Zimmerman, M.D., points out, however, that no data were cited describing the impact this deletion had, or might have, on the overall prevalence of personality disorders. Likewise, no research was cited for the Work Group’s reversal in deciding to retain narcissistic personality disorder.
“When it comes to revising the official diagnostic classification system, the guiding principle should be that criteria should not be changed in the absence of research demonstrating that the new approach is superior to the old in either validity or clinical utility, preferably both,” Zimmerman said.
“Despite assurances that only data-driven modification would be made, with each new edition of the DSM, we have witnessed repeated instances of changes being made in the absence of sufficient data demonstrating the new criteria is superior.”
To evaluate the proposed changes of deleting five personality disorders from the DSM-5, Zimmerman and his colleagues evaluated 2,150 psychiatric outpatients, more than one-quarter of whom were diagnosed with one of the 10 current DSM-IV personality disorders.
When removing the proposed deleted disorders, 59 patients who were diagnosed with a personality disorder according to the DSM-IV criteria would no longer be so diagnosed. Thus, the findings suggest that patients will have false-negative diagnoses based on the proposed revisions to the DSM-IV.
Zimmerman commented, “The findings of the present study highlight our concerns about adopting changes in the diagnostic manual without adequate empirical evaluation beforehand. To be sure, there are problems with the classification of personality disorders, however, the identification of a problem is only the first step of a process resulting in a change to diagnostic criteria.”
He said, “The classification of personality disorders would not be improved if the new criteria or diagnostic material were more clinically useful but less reliable and valid.”
The paper is published in the Journal of Clinical Psychiatry and is now available online in advance of print.