By Donald W. Black, MD
Those of us in the mental health professions anxiously await the release of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Others may wonder what the fuss is about, and may even wonder what the DSM-5 is. In short, it is psychiatry’s diagnostic Bible. While some imbue it with the reverence given a religious tract, it is not inerrant and only reflects the collective wisdom of those entrusted with the charge of revising it. The current manual, DSM-IV, came out in 1994 with a text revision in 2000, so in some ways the march to DSM-5 has been a 19 year journey.
As a psychiatrist, I am interested in classification, but I am particularly interested in how antisocial personality disorder, or ASP, has been classified over time. Over the past 200 years, ASP has been consistently recognized as one of the most identifiable and important of the psychiatric disorders, whether called manie sans délire, moral insanity, or even psychopathic personality. These terms all describe, at their most fundamental, bad behavior unconnected to medical illness or psychosis. During the DSM-5 deliberations, I and others became concerned that the committee dedicated to discussing personality disorders (the Personality and Personality Disorders Work Group) might decide to ditch the current diagnostic criteria and replace them with a combination of new diagnostic criteria and a “dimensional,” rather than categorical, evaluation of various personality traits.
The DSM-5 deliberations, for the most part, took place quietly and behind closed doors by clinicians and researchers who devoted many hours to their deliberations. They were tasked with considering the literature, research advances, and the users and patients’ needs when recommending changes to a diagnosis. Having watched the process as an interested observer, I can say that it was — for the most part — open, transparent, and free of conflicts of interest, despite loud and strident complaints from some quarters. Yet the Personality and Personality Disorders Work Group still produced a plan deemed by many as unworkable and overly complicated. This new plan was rejected by the leadership of the American Psychiatric Association in December 2012. The Personality and Personality Disorders Work Group was the only committee involved with the DSM-5 revision process in which two members openly and publicly resigned. No other work group had its many years of work rebuked.
So what went wrong? My own belief is that the work group overreached. In response to researchers on the committee whose life’s work was to understand and test dimensional schemes for describing personality traits, the committee wed itself to developing a scheme to replace the existing criteria for personality disorders. They came up against considerable pushback. I believe they never fully grasped that psychiatrists and many other clinicians tend to think categorically (is trait ‘x’ present or not?), rather than dimensionally (how much of trait ‘x’ is present?), and are very concerned with insurance reimbursement (would an insurer pay for the care of someone with some, but not all, of these traits?). The scheme itself appeared overly time consuming to busy practitioners; instead of simply deciding on a diagnosis, they might have to rate up to 5 personality ‘domains’ and 25 trait ‘facets’. Many clinicians, too, were concerned that some of the personality disorders that are well-researched and whose criteria were known to be valid (antisocial and borderline personality disorders, for example) would be changed for no good reason. In my view, the committee members have only themselves to blame for what proved to be an embarrassing turn of events. To preserve comity, the American Psychiatric Association leadership agreed to place the new scheme in the appendix of DSM-5 so as to be available to researchers and clinicians.
So, to those who wonder what has happened with antisocial personality disorder in DSM-5: the answer is nothing. After all those hours of deliberation and discussion, the criteria set for ASP, and all the other personality disorders, in the DSM-5 is exactly the same as it was in DSM-IV.
Donald W. Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated Edition. He is a Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. A graduate of Stanford University and the University of Utah School of Medicine, he has received numerous awards for teaching, research, and patient care, and is listed in “Best Doctors in America.” He serves as a consultant to the Iowa Department of Corrections. He writes extensively for professional audiences and his work has been featured in television and print media worldwide. Read his previous blog posts.
The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Michael A. Taylor and Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter and “The classification of mental illness” by Daniel Freeman and Jason Freeman.