Despite the raging controversy over the release of DSM-5, there is little changed from the previous DSM-IV iteration, and, actually, remarkably minor adjustments to the DSM-III version of almost 30 years ago. Indeed, one disappointment in the latest edition is the fact that the categorical, criteria-based definitions of mental disorders persist. It is ironic that some of the most prominent critics of DSM-5 were champions of DSM-IV, quibbling over relatively minor, though controversial, shifts in defining some disorders. The definitions of the most recognizable illnesses, including all of the personality disorders, are virtually unchanged.

One reason why there were not more radical changes in the latest DSM is the low level of rater agreement in field tests, in which various raters were asked to diagnose a patient. Interestingly, Borderline Personality Disorder was one of the more consistent diagnoses, and the only personality disorder diagnosis that exhibited a high degree of interrelater agreement. Although the categorical definitions of all ten personality disorders were retained almost exactly as described in DSM-IV, the new DSM does contain a special chapter outlining an alternative, approach to defining personality disorders.

In the special chapter, “Alternative DSM-5 Model for Personality Disorders,” a dimensional view of personality disorders is proposed. Personality traits are distinguished from disorders, which imply severe impairments in identity and interpersonal function. In this model only six of the ten personality disorders can be rigorously defined—schizoptypal, antisocial, borderline, narcissistic, avoidant, and obsessive-compulsive.

Five factors are identified to determine dysfunctional characteristics of personality:

1. negativity (anxiety, fearfulness, mood changes)

2. detachment (avoidance, poor relationships)

3. antagonism (manipulativeness, deceitfulness, hostility)

4. poor impulse control (self-defeating risk taking)

5. reality distortions (paranoia, bizarre behavior)

Levels of impairment associated with these characteristics are measured along a spectrum, from 0 (no impairment) to 4 (extreme impairment). Levels of impairment determine if character traits morph into a character disorder. Primary features of BPD include an unstable self-image, lack of goals, impaired relationships, severe mood changes, impulsivity, risk taking, and hostility.

Although these definitions help us better understand the constellation of symptoms that define an illness, medical labels do not define a human being. Only when we begin to understand the interplay of environmental stresses, genetic vulnerabilities, and molecular interactions will we start to appreciate how the individual deals with his world. And then psychiatric diagnoses will achieve the level of many other medical diagnoses in leading to specialized, targeted treatment.

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