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      The Challenge of Transforming the Diagnostic System of Personality Disorders

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          Abstract

          <p class="first" id="P1">While the <i>DSM-5</i> alternative model of personality disorder (PD) diagnosis allows the field to systematically compare categorical and dimensional classifications, the ICD-11 proposal suggests a radical change by restricting the classification of PDs to one category, deleting all specific types, basing clinical service provision exclusively upon a severity dimension, and restricting trait domains to secondary qualifiers without defining cutoff points. This article reflects broad international agreement about the state of PD diagnosis. It is argued that diagnosis according to the ICD-11 proposal is based on broad, potentially stigmatizing descriptions of impaired functioning and ignores much of the impressive body of research and treatment guidelines that have advanced the care of adults and adolescents with borderline and other PDs. Before radically changing classification, which highly impacts the provision of health care, head-to-head field trials coupled with the views of patients as well as thorough debate among scientists are urgently needed. </p>

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          Most cited references 44

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          Initial construction of a maladaptive personality trait model and inventory for DSM-5.

          DSM-IV-TR suggests that clinicians should assess clinically relevant personality traits that do not necessarily constitute a formal personality disorder (PD), and should note these traits on Axis II, but DSM-IV-TR does not provide a trait model to guide the clinician. Our goal was to provide a provisional trait model and a preliminary corresponding assessment instrument, in our roles as members of the DSM-5 Personality and Personality Disorders Workgroup and workgroup advisors. An initial list of specific traits and domains (broader groups of traits) was derived from DSM-5 literature reviews and workgroup deliberations, with a focus on capturing maladaptive personality characteristics deemed clinically salient, including those related to the criteria for DSM-IV-TR PDs. The model and instrument were then developed iteratively using data from community samples of treatment-seeking participants. The analytic approach relied on tools of modern psychometrics (e.g. item response theory models). A total of 25 reliably measured core elements of personality description emerged that, together, delineate five broad domains of maladaptive personality variation: negative affect, detachment, antagonism, disinhibition, and psychoticism. We developed a maladaptive personality trait model and corresponding instrument as a step on the path toward helping users of DSM-5 assess traits that may or may not constitute a formal PD. The inventory we developed is reprinted in its entirety in the Supplementary online material, with the goal of encouraging additional refinement and development by other investigators prior to the finalization of DSM-5. Continuing discussion should focus on various options for integrating personality traits into DSM-5.
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            Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders study.

            Borderline personality disorder (BPD) is traditionally considered chronic and intractable. To compare the course of BPD's psychopathology and social function with that of other personality disorders and with major depressive disorder (MDD) over 10 years. A collaborative study of treatment-seeking, 18- to 45-year-old patients followed up with standardized, reliable, and repeated measures of diagnostic remission and relapse and of both global social functioning and subtypes of social functioning. Nineteen clinical settings (hospital and outpatient) in 4 northeastern US cities. Three study groups, including 175 patients with BPD, 312 with cluster C personality disorders, and 95 with MDD but no personality disorder. The Diagnostic Interview for DSM-IV Personality Disorders and its follow-along version (the Diagnostic Interview for DSM-IV Personality Disorders-Follow-Along Version) were used to diagnose personality disorders and assess changes in them. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Longitudinal Interval Follow-up Evaluation were used to diagnose MDD and assess changes in MDD and in social function. Eighty-five percent of patients with BPD remitted. Remission of BPD was slower than for MDD (P < .001) and minimally slower than for other personality disorders (P < .03). Twelve percent of patients with BPD relapsed, a rate less frequent and slower than for patients with MDD (P < .001) and other personality disorders (P = .008). All BPD criteria declined at similar rates. Social function scores showed severe impairment with only modest albeit statistically significant improvement; patients with BPD remained persistently more dysfunctional than the other 2 groups (P < .001). Reductions in criteria predicted subsequent improvements in DSM-IV Axis V Global Assessment of Functioning scores (P < .001). The 10-year course of BPD is characterized by high rates of remission, low rates of relapse, and severe and persistent impairment in social functioning. These results inform expectations of patients, families, and clinicians and document the severe public health burden of this disorder.
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              Assessment and diagnosis of personality disorder: perennial issues and an emerging reconceptualization.

               B. L. Clark (2006)
              This chapter reviews recent (2000-2005) personality disorder (PD) research, focusing on three major domains: assessment, comorbidity, and stability. (a) Substantial evidence has accrued favoring dimensional over categorical conceptualization of PD, and the five-factor model of personality is prominent as an integrating framework. Future directions include assessing dysfunction separately from traits and learning to utilize collateral information. (b) To address the pervasiveness and extent of comorbidity, researchers have begun to move beyond studying overlapping pairs or small sets of disorders and are developing broader, more integrated common-factor models that cross the Axis I-Axis II boundary. (c) Studies of PD stability have converged on the finding that PD features include both more acute, dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable-similar to normal-range personality traits-with increasing stability until after 50 years of age. A new model for assessing PD-and perhaps all psychopathology-emerges from integrating these interrelated reconceptualizations.
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                Author and article information

                Journal
                Journal of Personality Disorders
                Journal of Personality Disorders
                Guilford Publications
                0885-579X
                October 2017
                October 2017
                : 31
                : 5
                : 577-589
                Affiliations
                [1 ] Department of General Psychiatry, University of Heidelberg, Germany.
                [2 ] Department of Psychology, University of Detroit Mercy, Michigan.
                [3 ] Institute of Psychiataric and Psychosomatic Psychotherapy, Central Institute of Mental Health, Mannheim, Germany.
                [4 ] Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia.
                [5 ] The Mount Sinai Hospital, Bronx, New York.
                [6 ] National Centre for Suicide Research and Prevention, Oslo, Norway.
                [7 ] Centre for Academic Mental Health, School of Social and Community Medicine, University of Bristol, United Kingdom.
                [8 ] University of Otago, Wellington, New Zealand.
                [9 ] University of Pittsburgh, Pennsylvania.
                [10 ] Department of Psychology, University of Houston, Texas.
                Article
                10.1521/pedi_2017_31_338
                5735999
                28910213
                © 2017

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