Personality Disorders and DSM-5 Texas Behavioral Health Institute Austin, TX July 20, 2012

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1 Personality Disorders and DSM-5 Texas Behavioral Health Institute July 20, 2012 John M. Oldham, M.D. Senior Vice President and Chief of Staff The Menninger Clinic; Professor and Executive Vice Chair Menninger Department of Psychiatry and Behavioral Sciences Baylor College of Medicine; Immediate Past President, American Psychiatric Association Personality Disorders and DSM-5: Outline 1. Brief Historical PD Review 2. Draft Meta-Structure for DSM-5 and ICD Proposed DSM-5 Model for Personality Disorders 4. Brief Review of Borderline Personality Disorder, including DSM-5 criteria Personality Disorders and DSM-5 1. Brief Historical PD Review 1

2 Eugen Bleuler Emil Kraepelin Ernst Kretschmer Kurt Schneider Personality Types or Temperaments (Bleuler, Kraepelin, Kretschmer) Precursors or less extreme forms of psychotic conditions e.g. Aesthenic Autistic Schizoid Cyclothymic Cycloid Psychopathic Personalities (Schneider) Separate disorders, co-occurring with other psychiatric disorders p y Similar to current DSM categorical model 2

3 DSM-I (1952) Personality Pattern Disturbances The most entrenched, unlikely to change, even with treatment Inadequate Schizoid Cyclothymic Paranoid DSM-I (continued) Personality Trait Disturbances Least pervasive and disabling Absent stress, function ok With stress, deterioration in functioning Variably motivated and amenable to treatment Emotionally unstable Passive-aggressive Compulsive DSM-I (continued) Sociopathic Personality Disturbances Types of social deviance A ti i l ti Antisocial reaction Dyssocial reaction Sexual deviation Addiction 3

4 DSM-II (1968) Earlier view that patients with PDs did not experience emotional distress was discarded DSM-I subcategories were discarded One new PD, Aesthenic PD, added DSM-III (1980) Introduced multiaxial system Axis I = episodic, biological disorders characterized by exacerbations and remissions Axis II = personality disorders + mental retardation MR = biological etiology PDs = psychological etiology DSM-III (continued) Inadequate PD and Aesthenic PD discontinued Explosive PD and Cyclothymic PD Axis I Schizoid PD Schizoid, Schizotypal, and Avoidant PDs Borderline PD and Narcissistic PD added 4

5 DSM-III-R (1987) Appendix = Proposed Diagnostic Categories Needing Further Study Included: Self-defeating PD Sadistic PD Dimensional cluster system introduced DSM-IV (1994) Dropped Self-defeating PD and Sadistic PD Moved Passive-aggressive PD to Appendix Added Depressive PD to Appendix DSM-IV-TR (2000) No changes from DSM-IV in diagnostic terms or criteria for Axis II Only minimal revisions in text material for Axis II 5

6 DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-IV (1994) Personality Pattern Axis I cyclothymic Axis I cyclothymic Disturbance disorder disorder Inadequate Inadequate Cluster A Cluster A Paranoid Paranoid Paranoid Paranoid Cyclothymic Cyclothymic Schizoid Schizoid Schizoid Schizoid Schizotypal Schizotypal Personality Trait Disturbance Cluster B Cluster B Emotionally unstable Hysterical Histrionic Histrionic Passive-aggressive Antisocial Antisocial dependent type Borderline Borderline aggressive type Passive-aggressive Narcissistic Narcissistic Cluster C Cluster C Compulsive Obsessive-compulsive Compulsive Obsessive-compulsive Avoidant Avoidant Dependent Dependent Passive-aggressive Sociopathic Personality Disturbance Asthenic Antisocial Antisocial Dyssocial Explosive Axis I intermittent Axis I intermittent explosive disorder explosive disorder DSM-III-R Appendix* Self-defeating Sadistic Figure 1. Ontogeny of Personality Disorder Classification DSM-IV Appendix Passive-aggressive Depressive indicates that category was discontinued. DSM-IV Definition of Personality Disorder A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture. This pattern is manifested in two (or more) of the following areas: 1. Cognition (i.e., ways of perceiving and interpreting self, other people, and events) 2. Affectivity (i.e., the range, intensity, ability, appropriateness of emotional response) 3. Interpersonal functioning 4. Impulse control DSM-IV Definition of Personality Disorder B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. 6

7 DSM-IV Definition of Personality Disorder C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM-IV Definition of Personality Disorder D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. DSM-IV Definition of Personality Disorder E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. 7

8 DSM-IV Definition of Personality Disorder F. The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma). 8

9 DSM5.org Web Site Open for public comment February-April 2010 More than 8,600 comments submitted All comments reviewed by work group members Comments considered in decision-making for field testing and later revisions to criteria in 2011 DSM-5.org Posting #2 (5/4 7/15/2011) 153,637 unique site visitors 219,483 unique site visits 1,063,895 pages viewed Visits came from 187 countries, with the largest number of visits coming from the US, Canada, Australia, the UK, and the Netherlands DSM-5.org Posting #3 (5/2 6/17/2012) 87,744 unique site visitors 114,324 unique site visits 448,957 pages viewed Visits came from 169 countries, with the largest number of visits coming from the US, Canada, Australia, and the UK 9

10 DSM-V Task Force David Kupfer, Chair, and Darrel Regier, Co-Chair ADHD and Disruptive Behavior Disorders (David Shaffer) Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders (Katherine Phillips) Eating Disorders (Timothy Walsh) Mood Disorders (Jan Fawcett) Neurocognitive Disorders (Daniel Blazer and Ronald Peterson) Neurodevelopmental Disorders (Susan Swedo) Personality and Personality Disorders (Andrew Skodol) Psychotic Disorders (William Carpenter) Sexual and Gender Identity Disorders (Kenneth Zucker) Sleep-Wake Disorders (Charles Reynolds) Somatic Symptom Disorders (Joel Dimsdale) Substance-Related Disorders (Charles O Brien) Personality Disorders and DSM-5 2. Draft Meta-Structure for DSM-5 and ICD-11 International Classification of Diseases Currently use ICD-9 in US since 1977 ICD-10 completed in 1990 and came into use by WHO Member States in 1994 APA developed an international version of DSM-IV with F-codes for ICD-10 However, though ICD-10-CM was prepared by the US National Center for Health Statistics in the early 1990s, US never adopted it (delays, insurance co. battles) At end of Bush administration, US Congress agreed that ICD-10-CM would go into effect on October 1, 2013 only 23 years after WHO approval! 10

11 International Classification of Diseases (continued) Meantime, WHO is now developing ICD-11 which will be published in 2015 (?) Negotiations in progress to harmonize DSM-5 with ICD-11 and to retro-fit these codes into ICD-10-CM CM ICD-10-CM codes were frozen on October 1, 2011, to allow insurance companies to reprogram and to train professionals to use new codes DSM-5 publication scheduled for 2013, but it needs to include ICD-10-CM F-codes in order to process all insurance claims beginning October 1, 2011 Implementation of ICD-10-CM opposed by AMA and now delayed by HHS Secretary Sibelius Stay tuned! DSM-5 Chapter Headings A. Neurodevelopmental Disorders B. Schizophrenia Spectrum and Other Psychotic Disorders C. Bipolar and Related Disorders D. Depressive Disorders E. Anxiety Disorders F. Obsessive-Compulsive and Related Disorders G. Trauma- and Stressor-Related Disorders H. Dissociative Disorders I. Somatic Symptom Disorders J. Feeding and Eating Disorders DSM-5 Chapter Headings K. Elimination Disorders L. Sleep-Wake Disorders M. Sexual Dysfunctions N. Gender Dysphoria O. Disruptive, Impulse Control, and Conduct Disorders P. Substance Use and Addictive Disorders Q. Neurocognitive Disorders R. Personality Disorders S. Paraphilias T. Other Disorders 11

12 RDoC Project ( a neuroscience-based approach to psychiatric classification ) Personality Disorders and DSM-5 3. Proposed DSM-5 Model for Personality Disorders Personality and Personality Disorders DSM-5 Work Group Andrew Skodol, MD, Chair Renato Alarcon, MD Carl Bell, MD Donna Bender, PhD Lee Anna Clark, PhD Robert Krueger, PhD Leslie Morey, PhD John Oldham, MD Larry Siever, MD 12

13 Revised General Diagnostic Criteria for PD The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met: A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning B. One or more pathological personality trait domain(s) or trait facet(s) C. The impairments in personality functioning and the individual s personality trait expression are relatively stable across time and consistent across situations D. The impairments in personality functioning and the individual s personality trait expression are not better understood as normative for the individual s developmental stage or socio-cultural environment E. The impairments in personality functioning and the individual s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma) Revised Levels of Personality Functioning I Continuum comprising five levels of personality functioning addressing self and interpersonal elements: Self: Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of selfappraisal; capacity for, and ability to regulate, a range of emotional experience. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively. Revised Levels of Personality Functioning II Continuum comprising five levels of personality functioning addressing self and interpersonal elements: Interpersonal: Empathy: Comprehension and appreciation of others experiences and motivations; tolerance of differing perspectives; understanding of the effects of our behavior on others. Intimacy: Depth and duration of positive connections with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior. 13

14 Five Levels of Self and Interpersonal Functioning 0 = (Healthy Functioning) 1 = (Some Impairment) 2 = (Moderate Impairment) 3 = (Serious Impairment) 4 = (Extreme Impairment) Personality Disorder Types References to DSM-IV Personality Disorders in Scientific Literature Science Citatio on Index Google Sc cholar 14

15 Personality Disorder Types Version 2 (posted June, 2011) Antisocial Avoidant Borderline Narcissistic Obsessive-Compulsive Schizotypal PD Trait-Specified Revised Personality Trait Domains Negative Affectivity (7 trait facets) Detachment (5 trait facets) Antagonism (5 trait facets) Antagonism (5 trait facets) Disinhibition vs. Compulsivity (5 trait facets) Psychoticism (3 trait facets) = 25 trait facets winnowed by survey in general population Overall Personality Assessment Clinician Assessment Level of Impairment in Personality Functioning (self, interpersonal) PD Types PD Trait Domains Positive IF either is positive Meets All Other General PD Criteria PD Diagnosis Confirmed 15

16 DSM-5 Field Trials DSM-5 Field Trials Moving Towards DSM-5: The Field Trials Helena C. Kraemer, David J. Kupfer, William E. Narrow, Diana E. Clarke, Darrel A. Regier Am J Psychiatry 167(10): , 2010 Large, Academic-Medical Settings Routine Clinical Practice Settings (RCPs) DSM-5 Field Trials DSM-5: How Reliable is Reliable Enough? Helena C. Kraemer, David J. Kupfer, Diana E. Clarke, William E. Narrow, Darrel A. Regier Am J Psychiatry 169(1):14-15, 2012 Large, Academic-Medical Settings Routine Clinical Practice Settings (RCPs) 16

17 DSM-5 Field Trials: Large Academic Settings The reliability and clinical usefulness of the proposed revisions have been assessed: Among various patient groups By various types of clinicians Across the age span, from children to the elderly In different clinical settings (e.g., large medical clinics and smaller practices) DSM-5 Field Trials: Routine Clinical Practice (RCP) Settings The feasibility and clinical utility of the proposed diagnostic criteria and measures are being tested in real-world clinical settings RCP Field Trials are also examining whether the measures are informative to treatment planning Personality Disorders and DSM-5 4. Brief Review of Borderline Personality Disorder, including DSM-5 criteria 17

18 Borderline Personality Disorder (BPD) APA DSM-IV Criteria (At least 5 must be present) 1. Fear of abandonment 2. Difficult interpersonal relationships 3. Uncertainty about self-image or identity 4. Impulsive behavior 5. Self-injurious behavior 6. Emotional changeability or hyperactivity 7. Feelings of emptiness 8. Difficulty controlling intense anger 9. Transient suspiciousness or disconnectedness Heterogeneity of BPD DSM-IV - defined BPD is an extremely heterogeneous construct (Est. 256 varieties) Mix of unstable, stress-induced symptoms and stable personality characteristics (i.e., dimensional traits) Comorbidity 84.5% of BPD patients met criteria for Axis I disorder, mean = 3.2 Most common = Mood disorders Anxiety disorders Substance use disorders - Lenzenweger et al., Biol Psychiatry,

19 High Suicide Risk in Patients with BPD 8 10 % commit suicide % make suicide attempts Patients with BPD Have Severe Impairment in Functioning Common history of childhood trauma Mistrustful of others, yet cling to others for life support High internal levels of anxiety and distress Stormy interpersonal relationships High family stress Difficulty keeping jobs Overemotional and impulsive Self-injurious behavior BPD as a Personality Disorder Emerging from the Interaction of Underlying Genetically-Based Traits Impulsive aggression and affective e instability ty = heritable endophenotypes that would contribute significantly to development of BPD Siever et al.,

20 Sequential Theoretical Model of BPD Pathogenesis Insecure Attachment Endophenotypes Impulsive aggression Affect instability Unstable Interpersonal Relationships Excessive intensity Overvalued Expectations Unfounded Anxieties Cognitive-Perceptual Symptoms Oldham, AJP, 2009 Amygdala-Prefrontal Disconnection in BPD Normal: prefrontal cortex inhibitory control over amygdala BPD: Absence of normally tight coupling = disconnect between orbital frontal cortex and amygdala failure to downregulate amygdala in response to aversive stimuli - New et al., 2007 Normal Cortex (thought center) + - Amygdala (emotion center) 20

21 Borderline Cortex (thought center) + - Amygdala (emotion center) Heritability of BPD Twin study (Torgersen et al. 2000) Novelty seeking (Cloninger, 2005) Impulsivity (New and Siever, 2002) Dopamine transporter polymorphism (Joyce et al., 2006; Tadic et al., 2009) Serotonin transporter gene (Ni et al., 2006, 2009) MAO-A gene (Ni et al., 2007) BDNF polymorphism (Wagner et al., 2010) Norwegian Twin Registry (Kendler, 2011) Dysregulation of Endogenous Opioids in BPD BPD Controls Baseline µ-opioid receptors (reflection of baseline endogenous neurotransmitter tone) Endogenous opioid response to negative emotions Implicated in regulation of emotion, response to stress Prossin et al., AJP,

22 A Neuropeptide Model of BPD Oxytocin involved in affiliation and trust (Deficient in BPD?) Vasopressin correlated with aggression (Elevated levels in BPD?) - Stanley and Siever, AJP, 2010 Bartz et al., SCAN Herpertz, 2011 ISSPD Congress The Rupture and Repair of Cooperation in BPD BPD patients profound incapacity to maintain cooperation impaired ability to repair broken cooperation Altered activity of anterior insular cortex in BPD Norms used in perception of social gestures are pathologically perturbed or missing altogether in BPD - King-Casas et al., Science,

23 APA Practice Guidelines Work Group on Borderline Personality Disorder John Oldham, M.D. (Chair) Glen Gabbard, M.D. Marcia Goin, M.D., Ph.D. John Gunderson, M.D. Paul Soloff, M.D. David Spiegel, M.D. Michael Stone, M.D. Katherine Phillips, M.D. BPD Treatment Psychotherapy is the treatment of choice Many types of psychotherapy are effective Medications can help but should be adjunctive, symptom-targeted, and usually time-limited Types of Psychotherapy for BPD 1. Mentalization-Based Therapy (MBT) 2. Dialectical Behavior Therapy (DBT) 3. Schema-Based Therapy (SBT) 4. Transference-Focused Therapy (TFT) 5. General Psychiatric Management (GPM) 6. Cognitive Behavioral Therapy (CBT) 7. Systems Training for Emotional Predictability and Problem Solving (STEPPS) 23

24 U.K. National Institute for Health and Clinical Excellence (NICE) NICE Clinical Guideline #78 Borderline Personality Disorder January 2009 Draft Clinical Practice Guideline (CPG) for the Management of Borderline Personality Disorder National Health and Medical Research Council Australian Government (Open for comment until May 14, 2012) ( Australian BPD CPG 1. Psychotherapy There is a range of structural psychological therapies that are effective in the treatment of BPD, compared to treatment as usual: CBT DBT ERT (Emotive Regulation Training) MACT (Manual-Assisted Cognitive Therapy) MBT MOTR (Motive-Oriented Therapeutic Relationship) SFP STEPPS TFP 24

25 Australian BPD CPG 2. Pharmacotherapy Overall, pharmacotherapy did not appear to be effective in altering the nature and course of the disorder Evidence does not support the use of pharmacotherapy as a first-line or sole treatment for BPD Longitudinal course Collaborative Longitudinal Personality Disorders Study (CLPS) 5 Collaborative Sites Brown (Shea), Columbia (Skodol), Harvard (Gunderson), Yale (McGlashan), Texas A&M (Morey) 668 Patients Recruited Originally (+65) STPD (N= 86), BPD (N=175), AVPD (N= 158), OCPD (N= 154), MDD and no PD (N= 95) Followed Longitudinally for >14 Years To determine the stability of symptoms, diagnoses, dimensions, and functioning and to determine the predictors of clinical course 25

26 100 Diagnostic Remission (cumulative): Lifetest survival estimates % Re emitted Remission definition: BPD > 12 mo Years of Follow-up Gunderson et al. Functional Remission (GAF > 70 for 12 months): Lifetest survival estimates 10 tted % Remit BPD OPD MDD Years of Follow-up Gunderson et al., Arch Gen Psych, 2011 The Good News BPD is treatable Treatment works With good treatment, and enough time, patients get better 26

27 Development of DSM-5 PD Diagnostic Criteria Example: Borderline Personality Disorder Should the Name be Changed? Borderline personality disorder by any other name would still be as real, as disabling, and as necessary to treat, as other serious mental illnesses. - Thomas Insell, MD Director, National Institute of Mental Health Director s Post, April 19, 2010 Diagnostic Criteria for Borderline Personality Disorder I A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning 2. Impairments in interpersonal functioning B. Pathological personality traits in the following domains: 1. Negative Affectivity 2. Disinhibition 3. Antagonism 27

28 Borderline Personality Disorder Criterion A1 A. Significant impairments in personality functioning manifest by: 1. Impairments in self functioning: a. Identity: Markedly impoverished, poorly developed, or unstable self image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress. b. Self-direction: Instability in goals, aspirations, values, or career plans. Borderline Personality Disorder Criterion A2 A. Significant impairments in personality functioning manifest by: 2. Impairments in interpersonal functioning: a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities. b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal. Borderline Personality Disorder Criteria B1-3 B. Pathological personality traits in the following domains: 1. Negative affectivity, i characterized by: a. Emotional lability b. Anxiousness c. Separation insecurity d. Depressivity 2. Disinhibition, characterized by: a. Impulsivity b. Risk taking 3. Antagonism, characterized by: a. Hostility 28

29 Preliminary Field Trials Results BPD has one of the best test-retest reliabilities of any DSM-5 diagnoses Better than: Bipolar Disorder Generalized Anxiety Disorder Major Depressive Disorder Schizophrenia Boyce N: The First Flight of DSM-5 The Lancet 377(9780), , May 28, 2011 The formulation of new psychiatric disorders and the revision of existing ones are a ready source of controversy, and traditionally provide rich pickings for psychiatry s critics. The proposed changes in DSM-5 have caused mixed reactions. Boyce N: The First Flight of DSM-5 The Lancet 377(9780), , May 28, 2011 The proposed structure is broadly in line with the human life-cycle, a sort of psychiatric seven ages of man. It is, however, disappointing that the proposed structure breaks its own rules in placing personality disorders after neurocognitive disorders. Surely an aetiological, chronological approach should lead to their appearance at a far earlier stage in the text? 29

30 Boyce N: The First Flight of DSM-5 The Lancet 377(9780), , May 28, 2011 Anyone with a stake in mental health would be well advised to go to the APA s website and take part in the ongoing consultation about DSM-5 s structure. DSM-5 now looks like it might, despite a turbulent takeoff, achieve a safe landing at the APA s San Francisco meeting in DSM-5: A Work in Progress Thanks for your interest! 30