Personality and the DSM-5

Personality and the DSM-5 Robert F. Krueger PhD Hathaway Distinguished Professor and Director of Clinical Training Department of Psychology University of Minnesota MPA First Friday Forum 6 December 2013

Who am I? Why am I interested in mental disorders and their classification? Mental Disorders have enormous social costs Leading causes of disability adjusted life years worldwide Numerous years of life lost to mental disorders World Health Organization. (WHO 2011a). Global status report on non-communicable diseases 2010. Geneva: WHO; World Health Organization. (WHO 2008). The Global Burden of Disease:2004 Update What I am trying to do about these costs Director of Clinical Psychology PhD Program at University of Minnesota Editor of Journal of Personality Disorders Participant in Diagnostic and Statistical Manual of Mental Disorders-5 th edition (DSM-5) Personality and Personality Disorder Workgroup Today s presentation focuses on classification issues Doing something about mental disorder requires pursuing empirical classification research Need research on what mental disorder is and how to define it based on data

Disclaimers I was an active participant in the DSM-5 process, but my personal views are not the views of any specific organization (e.g., the American Psychiatric Association) My DSM-5 service ended in December 2012 The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is Copyright 2013 by the American Psychiatric Association. All rights reserved.

DSM History DSM-I (1952) DSM-II (1968) DSM-III (1980) DSM-III-R (1987) DSM-IV (1994) DSM-IV-TR (2000) DSM-5 (2013) DSM-5.1?

Traditional Categorical Perspective on Psychopathology (DSM-IV Approach) Mental Disorders are Polythetic Dichotomies created by committees of clinician-experts Polythetic = Many combinations of symptoms lead to the same categorical label Example : Any 5 of 9 symptoms required for a diagnosis All DSM-IV Personality Disorders (PDs) are polythetic A focus on Personality Disorders (PDs) makes sense because these are arguably the vanguard Vanguard = out ahead of the rest of the field Dichotomy = The patient either has the diagnosis or does not No grades of severity Example : If you have 5, 6, 7, 8, or 9 symptoms you have the PD If you have 0, 1, 2, 3, or 4 symptoms you do not have the PD

DSM-IV Personality Disorder (PD) model consists of 10 polythetic dichotomies plus PD-NOS Cluster A : Odd or Eccentric Schizoid, Schizotypal, Paranoid Cluster B : Dramatic or Erratic Borderline, Narcissistic, Antisocial, Histrionic Cluster C : Inhibited or Anxious Avoidant, Dependent, Obsessive-Compulsive Personality Disorder Not Otherwise Specified (NOS)

Key Features of the DSM-IV Personality Disorders Copyright 2009 John Wiley & Sons, NY

DSM-IV Borderline Personality Disorder (one of 297 DSM-IV categorical disorders) A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following nine criteria: 1. frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5. 2. a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. identity disturbance: markedly and persistently unstable self-image or sense of self. 4. impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5. 5. recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. chronic feelings of emptiness 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 9. transient, stress-related paranoid ideation or severe dissociative symptoms

Rates of DSM-IV Personality Disorders in the Community and in Treatment Settings Copyright 2009 John Wiley & Sons, NY

DSM-IV PD Model: Serious problems and little to no empirical support Comorbidity Typical patient who meets criteria for at least 1 PD meets criteria for other PDs Modal (typical) number of diagnoses in inpatient settings for patients with at least one is FOUR Arbitrary thresholds The threshold for a diagnosis is the presence of more than half of the criteria This has no basis in data, and no dividing line in nature has been found Prevalence estimates are essentially meaningless (unfortunately) Heterogeneity within categories Extensive diversity of presentation within what are supposed to be coherent groups No evidence for the three cluster (ABC) scheme

DSM-IV PD Model: Serious problems and little to no empirical support Not Otherwise Specified (PD NOS) is typically the correct diagnosis Because patients tend not to fit into one and only one type Yet: The DSM continues to command epistemic authority Claims authority over knowledge about mental disorder definition And: DSM-IV PDs describe behaviors with huge societal costs Borderline PD is a good example (e.g., self harm aspects) Numerous active societies devoted to study and treatment of BPD This situation needs to be thoughtfully reconciled with reform Aim to continue to help patients while fixing a broken system

Individual difference science provides an empirically-based alternative Build quantitative models of data on observable signs and symptoms Inductive research as opposed to clinical authority Clinical Authority Experts are asked their clinical opinions Opinions are assembled into criteria sets for categories, through political processes This is the traditional DSM approach Inductive Research Data are gathered on actual patient signs and symptoms Scientific approaches are used to assemble signs and symptoms into concepts for use in the clinic This is what should be done instead of the traditional DSM approach

Individual difference science and PD: Some key and inspirational figures Lee Anna Clark and David Watson Models of temperament connect with PD features Big 3 : Detachment (from others), Negative affect (anxiety and depression), Externalizing emotions and impulses (acting out, e.g., aggression and drug use) Temperament as the glue for the way psychopathology is organized Tom Widiger and Paul Costa The Five Factor Model (FFM) of normal personality can also be used to model PD Openness, Conscientiousness Extraversion, Agreeableness, Neuroticism OCEAN Hans Eysenck Continuity of normal and abnormal personality Abnormality is different in degree (amount), not in kind (persons with abnormal personalities are not different types of persons)

DSM 5: structure and political process American Psychiatric Association (APA) Task force David Kupfer MD and Darrel Regier MD were co-chairs Members were nearly exclusively research psychiatrists who were workgroup chairs Overseen by APA Board of Trustees (political appointees) Work groups Generally organized by traditional DSM chapter headings Examples: Mood, Anxiety, Substance Generally balkanized and siloed Focused on specific parts of the bigger clinical picture Jealously protect their control over their specific domain Personality and Personality Disorder was one of these workgroups

DSM 5: structure and political process The DSM process is a political process Necessary to create a provisional diagnostic system needed for practical purposes But there are now serious concerns that DSM inhibits scientific progress National Institute of Mental Health (NIMH) is going a different direction NIMH is the major funding body for research in the United States NIMH is pursuing the Research Domain Criteria Project (RDoC) as an alternative to the DSM RDoC focuses on dimensions connected with neuroscience Aims to identify brain circuitry that may be relevant to mental illness

DSM-5 historical-political events pertinent to personality and PDs 2007-2011: First stage iterations Work group was very divided about the right directions for the field 2011: April Task Force meeting Task force directed workgroup to construct a hybrid model Hybrid of traditional DSM-IV PDs and new dimensional concepts 2012: November Task Force and Board of Trustees Decisions for DSM 5 Task force endorses the hybrid model Board of Trustees does not endorse the hybrid model, prefers DSM-IV Current Result: DSM IV PD criteria are reprinted verbatim in Section II of DSM-5 Entire DSM-5 hybrid model printed in Section III of DSM-5 Intermediate step on the road to DSM-5.1 PD is the vanguard

Explanatory Text Section III : Emerging Measures and Models The current approach to personality disorders appears in Section II of DSM-5, and an alternative model developed for DSM-5 is presented here in Section III. The inclusion of both models in DSM-5 reflects the decision of the APA Board of Trustees to preserve continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

PD diagnoses in DSM-5 Section III Criterion A. Self and interpersonal dysfunction Self : Does the patient have a coherent sense of who they are and where they are going in life? Interpersonal : Is the patient able to interact successfully with others? Self and interpersonal functioning enable people to pursue major life tasks Criterion B. Maladaptive personality traits Dimensions corresponding to specific kinds of personality problems Examples : Manipulativeness, Callousness, Suspiciousness PD Trait Specified Explicitly incorporates the understanding that personality is multidimensional Clinician records pertinent traits in the patient s chart Also recapitulation of DSM-IV PD diagnoses Provides transitional objects

Measuring Maladaptive Traits: The Personality Inventory for DSM-5 (PID-5) (Krueger, Derringer, Markon, Watson, Skodol, 2012, Psychological Medicine) The aim was to influence the political process with data Basic maladaptive symptoms of PD generated by workgroup and consultants Old approach : lobby for organizing these into categories based on clinical opinion New (PID-5) approach: Use data from patients to organize symptoms into trait dimensions Worked with national samples of treatment seeking participants Asked patients directly about what is troubling them Resulted in 25 basic (facet) traits Organized into 5 bigger trait domains

Personality Inventory Example: The Gosling Ten Item Personality Inventory (TIPI) I see myself as (from 1 = not at all like me to 10 = describes me perfectly): 1. Extraverted, enthusiastic. 2. Critical, quarrelsome. 3. Dependable, self-disciplined. 4. Anxious, easily upset. 5. Open to new experiences, complex. 6. Reserved, quiet. 7. Sympathetic, warm. 8. Disorganized, careless. 9. Calm, emotionally stable. 10. Conventional, uncreative.

Personality Inventory for DSM-5 (PID-5) (Krueger, Derringer, Markon, Watson, Skodol, 2012, Psychological Medicine) Five Trait Domains: 1. Negative affect vs. Emotional Stability 2. Detachment vs. Extraversion 3. Antagonism vs. Agreeableness 4. Disinhibition vs. Conscientiousness 5. Psychoticism vs. Lucidity Further evidence that the Five Factor Model (FFM) is out there in nature and pertinent in the clinic But emphasizes more maladaptive variants within the FFM

Personality Inventory for DSM-5 (PID-5) (Krueger, Derringer, Markon, Watson, Skodol, 2012, Psychological Medicine) Various forms available free online from APA at DSM5.org 220 item full form (25 facets) 25 Item 5-domain-focused short form Informant Report Form (Markon et al., in press) Also deemed acceptable for children age 11-17 Translations into: Dutch, Danish, Spanish, Italian, Portuguese, French, German, Catalan, Turkish

Connections with NIMH RDoC NIMH Research Domain Criteria (RDoC) endeavor takes a related dimensional approach, focused more on cognitive neuroscience Genomic and neuroscience indicators can be interwoven with the empirically-derived structure of psychopathology Five broad RDoC domains 1. Negative valence, 2. Positive valence, 3. Cognition, 4. Social Processes, 5. Arousal/Regulation Five related clinical domains (cf. DSM-5 personality domains; Trull & Widiger, 2013) 1. Negative affect, 2. Detachment (Internalizing) 3. Psychosis 4. Antagonism, 5. Disinhibition (Externalizing) See special section of Journal of Abnormal Psychology August 2013 (Ed. MacDonald & Krueger)

Extended hierarchy of traits (Wright, Thomas, Hopwood, Markon, Pincus, Krueger, 2012, Journal of Abnormal Psychology) Examined hierarchical unfolding of domains Are there even broader groupings than the five factors? Number of participants = 2,461(relatively large) Also studied Reliability and Congruence Reliability is higher if these traits are coherent Coherent = specific items within a trait tend to go together Values closer to 1 are better Median =.86; range =.72-.96 Congruence is higher if the domains are similar to other studies Congruence analysis asks: Are these variables organized the same way as in the original study? Values closer to 1 are better.97 (NA),.96 (Dt),.98 (An),.93 (Dis), and.95 (Psy)

Hierarchical structure (Krueger, Derringer, Marko, Watson, Skodol, in press, Psychological Medicine)

Literature on DSM-5 personality traits Convergence with MMPI-2 PSY-5 (Anderson et al., 2013) Ability to capture various conceptions of narcissism (Miller et al., 2012; Wright et al., 2013) Convergence with NEO-FFM instruments (DeFruyt Ability to capture various conceptions of et al., 2013; Gore & Widiger, 2013; Thomas et psychopathy (Fossatti et al., in press; Patrick et al., al., 2013) 2013; Sellbom et al., in press) Convergence with Inventory of Interpersonal Problems (IIP; Wright et al., 2012) Ability to recover FFM from clinician reports (Morey et al., 2013) Convergence with HEXACO (Ashton et al., 2012) Outcomes predicted by CBCL dysregulation profile (De Caluwé et al., 2013) Convergence with PAI (Hopwood et al., 2013) Ability to capture DSM-IV PDs (Fossatti et al., in press; Hopwood et al., 2012; Samuel et al., 2013) Structure and validity in adolescence (De Clercq et al., 2013) Special June 2013 Issue of Assessment Krueger & Markon (in press) Annual Review of Clinical Psychology

Current Directions in the Field Empirical research on PD yields meaningful and useful concepts for the clinic Mental disorder is dimensional, not categorical Broader groupings than Five Factors are also recognizable Hierarchy is also an important feature Dimensions make sense of otherwise puzzling clinical phenomena Provides an understanding of comorbidity and a way of conceptualizing complex presentations More informative than NOS (Not Otherwise Specified) DSM-5 contains elements that move (or at least slouch) in this direction Personality Inventory for DSM-5 (PID-5)

krueg038@umn.edu