DSM-5: Personality Disorders as they Relate to the Workplace and Arbitration National Academy of Arbitrators Annual Meeting Chicago, IL May 23, 2014
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1 DSM-5: Personality Disorders as they Relate to the Workplace and Arbitration National Academy of Arbitrators Annual Meeting Chicago, IL May 23, 2014 Moderator: James Oldham National Academy of Arbitrators Presenters: John M. Oldham, MD Menninger Clinic & Baylor College of Medicine Gregg Bloche, JD, MD Georgetown University
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4 DSM-5 Section II Personality Disorders Diagnostic criteria for 10 personality disorders in Section II Essential Elements: Diagnostic Criteria and Codes are unchanged from DSM-IV However, Axis II has been eliminated
5 DSM-IV-TR Personality Disorders (A dimensionally-flavored categorical system) A. Cluster A (odd/eccentric) 1. Paranoid 2. Schizoid 3. Schizotypal B. Cluster B (dramatic/emotional/impulsive) 1. Antisocial 2. Borderline 3. Histrionic 4. Narcissistic C. Cluster C (anxious/fearful) 1. Avoidant 2. Dependent 3. Obsessive-Compulsive D. Personality Disorder Not Otherwise Specified
6 DSM-5 Table of Contents Section III 1. Introduction 2. Conditions for Further Study 3. Alternative DSM-5 Model for Personality Disorders 4. DSM-5 Dimensional Measures 5. Other Conditions that May Be a Focus of Clinical Attention 6. Cultural Formulation 7. Technical Glossary 8. Highlights of Changes from DSM-IV Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.
7 DSM-5 General Criteria for Personality Disorder (GCPD) The essential features of Personality Disorder are: A. Moderate or greater impairment in personality (self / interpersonal) functioning AND B. Pathological personality traits Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.
8 Criterion A: (Level of Impairment in Personality Functioning) Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas: 1. Identity 2. Self-direction 3. Empathy 4. Intimacy Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.
9 Criterion B: (Patterns of Pathological Personality Traits) Trait Domains Negative Affectivity Detachment Antagonism Disinhibition Psychotism Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.
10 Personality Disorders Antisocial Avoidant Borderline Narcissistic Obsessive-Compulsive Schizotypal PD Trait Specified
11 Concepts of Borderline Disorders Borderline Schizophrenia (Kety) (Schizotypal PD - Rado, Meehl) Schizophrenia Affective Disorders Atypical Affective Disorders (D. Klein) Borderline Personality Organization (Kernberg) Borderline Personality Disorder Neuroses Borderline Syndrome (Grinker)
12 DSM-IV defined BPD Not on psychosis spectrum Is on the border of Mood disorders Impulse control disorders
13 Heritability of Psychiatric Disorders Heritability ~zero Psychiatric Disorders Other Important Familial Traits Language Religion 20-40% Anxiety disorders, Depression, Bulimia, Personality Disorders 40-60% Alcohol and drug dependence 60-80% Schizophrenia Bipolar Illness Myocardial Infarction, Normative Personality, Breast Cancer, Hip Fracture Blood Pressure, Asthma Plasma cholesterol, Prostate Cancer, Adult-onset diabetes Weight, Bone Mineral Density % Autism Height, Total Brain Volume Kendler, 2011
14 Theoretical Model of BPD Symptom Expression Heritable Risk Mistrust Emotional sensitivity Impulsivity Stimulus Social stress Interpersonal interactions Compensatory (?) Efforts to Control Distress Self-inflicted pain Dissociation Rejection of / distancing from others Suicide Highly Symptomatic State Emotional distress Paranoid thinking Suicidal ideation / behavior Impulsive behavior Oldham, 2013
15 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.
16 APA Treatment Recommendations for Patients with Borderline Personality Disorder Evidence-based Treatment Strategies for BPD Psychotherapy (core treatment) Pharmacotherapy (adjunctive, symptom-targeted)
17 European guidelines and algorithms British 2009 Dutch 2008 German 2009
18 Global guidelines and algorithms Australia 2013 Clinical Practice Guideline for the Management of Borderline Personality Disorder Australian Government National health and Medical Research Council
19 Types of Psychotherapy for BPD (published RCTs) 1. Mentalization-Based Therapy (MBT) 2. Dialectical Behavior Therapy (DBT) 3. Schema-Based Therapy (SBT) 4. Transference-Focused Therapy (TFT) 5. Generalized Psychiatric Management (GPM) 6. Cognitive Behavioral Therapy (CBT) 7. Systems Training for Emotional Predictability and Problem Solving (STEPPS)
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309.28 F43.22 Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder with disturbance of conduct
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