I have written a new article about the changes in DSM-5, including a discussion of the changes to personality disorders under DSM-V (now known as DSM-5). You can view it at http://www.dsm-5diagnosis.com
I will also be summarizing here the evidence for a ”depressive type,” or how you would view these traits in a profile under the new personality trait/ facet system.
MEMO on the Inclusion of Depressive Personality Disorder in DSM-V (or DSM-5)
December 11, 2009
“Depressive personality disorder is one of the most familiar, frequent and fundamental disorders” (Vachon, David D.; Sellbom, Martin; Ryder, Andrew G.; Miller, Joshua D.; and Bagby, R. Michael, 2009).
The diagnoses of Depressive Personality Disorder and “depressive traits/features” can be conceptualized in a hybrid categorical and dimensional manner for DSM-V. The diagnosis itself is categorical, but the severity and underlying DSM-IV-TR criteria can be treated dimensionally. In addition, while the concept of depressive pd is directly related to a profile of Five-Factor Model (FFM) traits and facets, these more “normal” traits may be viewed as the low end of a depressive pd spectrum or dimension. Additionally the existence of a next step up on this dimension commonly referred to as “depressive traits” or “depressive features” is also supported by the research on constructs such as those considered to be maladaptive expressions of personality traits including cognitive vulnerabilities to depression. Some maladaptive schemas that are sometimes the focus of attention in empirically supported Cognitive Behavioral Therapy may also fit well within this spectrum. The Depressive Personality Disorder itself can be diagnosed when the DSM-V defined diagnostic threshold for a personality disorder is reached. Depressive pd has been shown to have a significant impact on multiple domains of functioning, and a focus on both symptom severity and functional severity is recommended. The DSM-IV criteria for depressive pd already reflect these underlying traits, and these criteria may be more likely to be a focus of empirically supported psychotherapy than are the symptoms of dysthymic disorder.
This dimensional view of depressive pd opens the door to a wealth of research not just on depressive pd, but on cognitive vulnerabilities to depression and other relatively stable factors that have been found to be independent of depression. These factors or maladaptive “depressive traits” are in many ways also quite similar to the diagnostic criteria for depressive pd, and depressive pd has also been found to be relatively stable and independent of depression. The depressive pd construct would be more useful than crafting a laundry list of maladaptive characteristics in individuals who would have otherwise qualified for a depressive pd diagnosis. It also focuses the attention of practitioners on more specific and independent traits which would be useful for practitioners of cognitive-behavioral therapy (to name just one), as opposed to more nebulous constructs such as neuroticism. Even the vulnerability facet of neuroticism tends to unnecessarily lump these relatively independent factors together without giving the clinician an alert to focus on each. Listing depressive pd criteria does give this alert, and additional considerations can also be expressed within the DSM-V narrative for depressive pd. We should keep in mind that personality traits are also abstract concepts without distinct physical findings at this point, and are not necessarily the only building blocks involved in the presentation of individuals with personality disorders. We also should not ignore an existing framework for incorporating depressive traits (such as cognitive and other vulnerabilities to depression) in to DSM-V. The concept of personality disorders currently offers this framework which can be used now for an immediate impact on the field.
Reasons for a proposed change
Depressive traits are well represented in clinical populations and contribute to the presentation of other Axis I and II disorders, however they are currently not well represented in the main text of the DSM-IV-TR. Including Depressive Personality Disorder in the main text of DSM-V would highlight psychiatric factors with a profound impact on prognosis and treatment success. In addition to creating distress and interpersonal problems in their extreme form, depressive pd is constructed of clinically useful concepts that suggest a risk for the onset of other problems, a longer course of distress and risk of recurrence of distress. The criteria of depressive pd taken together can be seen as an engine within and individual which generates pathology and keeps fueling that pathology once it has started. Meeting the criteria for an Axis I disorder at some points in their lives should be expected of someone with personality disorders, otherwise the individual may actually fall somewhat lower than the “disorder” point on the maladaptive personality dimension. Including depressive pd in DSM-V is supported and will urge clinicians to address factors which may lead to treatment resistance and treatment failure if left unaddressed. These factors are also sometimes addressed in psychotherapies which are described as empirically supported, and highlighting them may also highlight the need for the EST/EVT approach to address them.
Depressive pd has been shown to be generally consistent with or superior to the other personality disorders on multiple benchmarks, including diagnostic overlap (Finnerty, 2009). Depressive personality disorder has more clinical utility than concepts such as dysthymic disorder, and its inclusion would involve more positive benefits for patients. Dysthymic disorder actually has a greater risk of redundancy with DSM-V mood disorders than does depressive personality disorder. Including depressive pd in DSM-V will also increase attention to underlying maladaptive patterns of thinking and behavior which are sometimes a focus of empirically supported cognitive behavioral treatment. It would also increase research attention on the components involved in depressive personality disorder. Depressive Personality Disorder is ready for the next step and promoting it to a recognized diagnosis in DSM-V will have a beneficial impact on clinical practice and the mental health of patients.
Evidence for change
Depressive pd has repeatedly been found to be a valid diagnosis which can be differentiated from other disorders (Huprich, 2009). It has a degree of stability similar to other personality disorders and is present even when a mood disorder such as depression is not. The criteria which construct depressive pd can be viewed as consistent with cognitive vulnerabilities to depression, maladaptive schemas and other conceptualizations of maladaptive personality traits. These underlying cognitive vulnerability concepts have also been found to be distinct from depression (See the listed research by Hankin, for example). The view that some people are more susceptible to stress and other factors is a long-held one in psychiatry and psychology and has been receiving increased research attention (See articles from individuals such as Hankin and Belsky). This is a worldview consistent with emerging biological and psychological findings. It is an appropriate next step in the evolution of our diagnostic system as it can be a bridge to future findings and research in both psychology, neuroscience and other biological sciences which are proceeding in the direction of this worldview.
See also (Finnerty, 2009 a) for an extensive review of the recent literature and additional commentary on the inclusion of depressive pd in DSM-V. A Google books electronic version of the 1st edition is now available for free online and conveniently linked to from: www.depressivepersonality.com. The print copy is available from Amazon or from the author by request.
A need for the category
As was noted earlier, depressive traits are well represented in clinical populations and contribute to the presentation of other Axis I and II disorders, however they are currently not well represented in the main text of the DSM-IV-TR. The inclusion of depressive personality disorder will increase practitioner’s awareness of factors which create the potential for treatment resistance in a patient, and also creates risks for a longer course of treatment, greater chance of recurrence, and greater risk of other difficulties.
Psychology and Psychiatry have historically originated a number of overlapping abstract concepts. While not necessarily overlying embracing any one theory, the depressive personality disorder is well represented by constructs from multiple perspectives in Psychology & Psychiatry and can pull together multiple lines of research in one location for use by the clinician.
Relationship with other DSM-V diagnoses
Depressive Personality Disorder, as well as the personality disorders in general, have been criticized at times for their potential diagnostic overlap and the degree of co-occurrence with other disorders. In clinical reality, an individual would generally need to present with some distress, interpersonal difficulties or other problems which could be consistent with symptoms of an Axis I disorder just to qualify for a “full blown” Axis II disorder. This is the result of the very nature of the personality disorder criteria. Depressive personality disorder tends to be compared to dysthymic disorder, avoidant personality disorder and borderline personality disorder. It has been found to be separate and distinct from these constructs, however, and can be differentiated. In addition, the criteria for depressive personality disorder closely resembles various constructs sometimes referred to as cognitive vulnerabilities to depression which are seeing increased research attention. For example, the “is brooding and given to worry” may be seen as related to some forms of depressive rumination. Ryder, Andrew G.; McBride, Carolina & Bagby, R. Michael (2008) found depressive personality disorder to be related to all of the cognitive vulnerability concepts they addressed in their study. These cognitive vulnerabilities have also been found to be stable, trait-like factors independent of depression (See research by Hankin and others).
Researchers A. Ryder, R. M. Bagby and others were more critical of the depressive personality disorder construct in the past, particularly with the potential overlap with the concept of dysthymic disorder. However, some of depressive pd’s most published critics have become supporters. More recently they have noted that “depressive personality disorder is one of the most familiar, frequent and fundamental disorders.” They note that expert consensus on the depressive pd prototype suggested better agreement than the other personality disorders previously evaluated (Vachon, et. al.; 2009).
As noted, in the past, Ryder, Bagby and others (2002) had offered criticism of the DSM-IV depressive personality construct, though generally their concerns about DPD could be directed at personality disorders under DSM-IV in general. They criticized DPD in light of its potential overlap with dysthymic disorder and suggested viewing the construct dimensionally under a changed DSM-V system based on the Five-Factor Model of personality, yet in this more distant they also used a categorical view of dysthymic disorder as opposed to a dimensional view of mood disorders. It is not fully clear if dysthymic disorder would even be needed in DSM-V if a dimensional expression of mood disorders includes relevant course specifiers for depression and revisions to how severity and functioning are communicated. Dysthymic disorder is often a diagnosis made by what it is not. Major depressive disorder with a chronic specifier communicates the two year duration found in dysthymic disorder. This 2 year duration reflects a longer duration, but it is in general rather arbitrary and not related to any distinction that exists in the real world. A mildly severe major depressive disorder that is chronic under DSM-IV is not dysthymic disorder, though depending on how severity is communicated and in what way the categories may change dysthymic disorder may become redundant with a more dimensionally defined mood disorder diagnosis in DSM-V. This is particularly salient when considering a diagnosis of dysthymic disorder should not be made if there was a major depressive episode within the first 2 years of the dysthymic disorder and the disorder should not be “better accounted for” by “chronic Major Depressive Disorder” (p 380, American Psychiatric Association, 2000). Hirschfeld (1991) expressed the opinion that “Many clinicians and researchers believe that dysthymia is too similar to major depression in its emphasis on depressive symptomology (especially vegetative). They believe that it fails to consider characterological aspects, in particular cognition.” Dunner (2005) noted that there were significant similarities between the various subtypes of chronic depression, including dysthymia, and suggested collapsing them in to one category called “chronic depression.” If there is a move towards less categorical thinking and more dimensional approaches toward mood disorders, dysthymic disorder may become overly redundant with a chronic depressive disorder; whereas DPD would continue to offer additional, clinically useful information and can be differentiated from a “milder form” of chronic depression. Though it is not best classified as a mood disorder, depressive personality disorder like other personality disorders, should of course continue to be viewed as involving a mood component.
The exclusion criterion of not diagnosing depressive personality disorder if it is better accounted for by dysthymic disorder should be dropped for DSM-V. As was indicated, the dysthymic disorder category is an arbitrary one which may not fit in well with the new theoretical framework of DSM-V. The use of “better accounted for” is vague, particularly when considering DPD may better account for the patient’s presentation in situations where enduring personality characteristics significantly contribute to the presentation, and many “non-textbook” patients will likely meet DSM-IV-TR criteria for both disorders since both include chronic mood states. What guidelines could help clinicians evaluate whether dysthymic disorder “better” accounts for the DPD presentation, and exactly how did dysthymic disorder acquire primacy over Depressive PD? Many mood disorders, including dysthymic disorder, are categorized via broad lists of symptoms leading to heterogenous groups of individuals with diverse etiologies and presentations. Also impacting the “not better accounted for” criterion is the assumption that DPD is more mild than dysthymic disorder, however (Finnerty, 2009) refutes the flawed arguments that DPD represents only a mild form of mood disorder lower on the spectrum of mood disorders than dysthymic disorder. This argument is not supported by recent research in to DPD. The vague statement about it not being better accounted for by dysthymic disorder unnecessarily interferes with clinical judgment, introduces excessive subjectivity impacting standardization and should not be included in DSM-V. The authors of a multi-year follow up study on DPD noted that “The DSM-IV exclusion of depressive personality disorder that is ““better accounted for”” by dysthymic disorder was not employed, as it is unclear how this can be determined” (Laptook, et. al., 2006). This long term study (10 years) not using this criterion would offer support for choosing to also not use the criterion under DSM-V.
The potential overlap of depressive personality disorder with a construct which is essentially depressive symptoms for 2 or more years should not be concerning. As many have noted and the basic description of a personality disorder would suggest, personality disorders include distress and mood concerns. It is one of the things which distinguishes them from “normal” personality functioning. The inclusion of the Axis II factors assist in communicating highly relevant information to treatment, rather than simply communicating symptoms and a duration which can lead to a heterogenous group of patients which can lead to research difficulties on chronic depression treatment.
Potential harm
The actor/observer effect may certainly come in to play, and some patients may be diagnosed with a personality disorder when a normal response to situational stressors is more consistent with the evidence. However, these patients would still likely benefit form any treatment received. The greater harm would be in continuing to under-treat individuals for mild depression symptoms when there is a high risk for greater functional limitations than would be expected in someone with mild depression. If they are left unaddressed via CBT or another means, these underlying maladaptive patterns will continue to create distress and interpersonal concerns.
While some may argue that a personality disorder “pathologizes” or “overpathologizes” someone with depression or mood problems, this may be based on an assumption that personality disorders are not treatable. The inclusion of depressive pd in DSM-V may actually improve the treatment outcomes of this group of individuals. Depressive personality disorder will focus attention on those stable patterns or “depressive traits” involved in this personality disorder. Given this image that “personality” can not be changed, the greater political and stigmatizing risk may be in “pathologizing normal personality,” suggesting FFM or other “normal” personality traits were in a range which require a specific kind of treatment, as this may create even more of an illusion of hopelessness and lack of ability to benefit from treatment in patients.
Available treatments
Certainly the inclusion of depressive personality disorder in the main text of DSM-V will help to stimulate interest in, funding of and the actual publication of research on the treatment of depressive personality disorder.
However, many of the underlying concepts are cornerstone’s of Beck’s Cognitive Therapy or other similar theories related to depressive traits. It stands to reason that focusing on these criteria could also promote the use of such empirically supported treatments.
Meets criteria for a mental (psychiatric) diagnosis.
As noted, depressive personality disorder is not simply a variation of normal psychological functioning. It is however anchored in research on personality and can be viewed as an expected reaction when personality functioning moves in to the maladaptive range. Depressive Personality Disorder does have a strong relation to measures of personality, including those measuring traits and facets of the Five-Factor Model, which supports its location among the personality disorders.
In reviewing previous studies and in conducting their own, Vachon, et. al. (2009) provide a profile of FFM traits and facets common to individuals with depressive personality disorder. These are generally measured by the NEO-PI-R. They also noted they tended to score higher on certain MMPI-2 RC scales. Multiple inventories have been crafted including The Depressive Personality Disorder Inventory (see Huprich, 2009 for a general review and other references from ex: Huprich for more specifics on these inventories). As with most instances in assessment, the clinician must put together all of the information at their disposal from testing, collateral evidence and the clinical interview to make a useful diagnostic decision.
New empirical evidence has been generated since the publication of DSM-IV which supported the inclusion of Depressive PD in DSM-V. The research supports the validity of the diagnosis. Clinicians report depressive pd is useful and a simple google search supports that it is already being used. A “depressive personality” is used commonly in the public (try a google search and this is evident). It is also used under Personality Disorder NOS by clinicians. I have seen it diagnosed by other professionals when I review their records submitted for a Social Security Disability determination, and a google search reveals individuals on message boards and blogs searching for information about it as their Psychiatrist or other professional had diagnosed them with it.
On 12/11/09 a Google search from Columbus, OH produced the following number of hits for each personality disorder in quotes (minus the word disorder). As quotes were used in the search, each result is a specific occurrence of the phrase “X personality.”
626,000 “obsessive-compulsive personality”
531,000 “borderline personality”
460,000 “narcissistic personality”
430,000 “antisocial personality”
143,000 “paranoid personality”
120,000 “schizotypal personality”
115,000 “schizoid personality”
107,000 “avoidant personality”
99,700 “dependent personality”
84,100 “histrionic personality”
73,500 “depressive personality”
The number of search results for “Depressive personality” approach the other personality disorders despite it not being included in the main text of the DSM-IV, or being “officially recognized.” The concept of a “depressive personality” is clearly in use.
While the depressive pd criteria may sound similar to depression or anxiety symptoms, they are also relatively stable, maladaptive personality characteristics which create vulnerability to emotional problems. The depressive pd criteria reflect characteristics which can be assessed dimensionally and create impairment at more extreme levels. While at lower levels the depressive pd criteria may be seen as minor variations of normal personality characteristics, at higher levels they lead to significant difficulties. Coding features of depressive pd offers clinicians the ability to communicate the presence of stable depressive traits which have had increased research attention. For example, Hankin (2008) found cognitive vulnerabilities to depression to be fairly stable, enduring processes. A negative cognitive style, such as is seen in depressive pd, tended to be one of the most stable vulnerabilities studied. Ryder, at. al. (2008) found depressive pd to be related to all depression vulnerabilities assessed in their study. This would be an expected finding considering the depressive pd criteria generally look like these “vulnerabilities.” These cognitive vulnerabilities can be viewed as relatively stable depressive traits on a dimension with depressive personality disorder. These factors alone can create interpersonal problems and functional limitations and when they are present to a sufficient degree a depressive personality disorder diagnosis can be made.
Depressive pd is also correlated with neuroticism. Neuroticism is related mildly to many of these independent vulnerability constructs which make up the depressive pd criteria, but it is generally more associated with depression when factor analyses have been conducted. While neuroticism is sometimes treated as a cognitive vulnerability, it may be a nonspecific collection that includes these factors. Per Hankin, et. al.’s (2007) factor analyses, “cognitive vulnerability is not reducible to general trait neuroticism.” The many maladaptive expressions of depressive traits are not adequately covered by neuroticism alone but can be expressed through a depressive pd or depressive traits diagnosis. As DSM-V moves towards a more dimensional view of disorders, including depressive pd would increase attention on these underlying dimensional trait structures which should not be overlooked. It would also highlight factors with a profound impact on prognosis. In addition to creating distress and interpersonal problems in their extreme form, depressive pd is constructed of clinically useful concepts that suggest a risk for the onset of other problems, a longer course and risk of recurrence. As these vulnerabilities/maladaptive characteristics drift away from normal personality in to the maladaptive, they can be referred to as depressive traits (or features) and create depressive personality disorder in their most extreme form. It includes more information than the simple description of course in dysthymic disorder. It is also not surprising given it’s underlying constructs that depressive pd is functionally impairing in itself, creates interpersonal difficulties and should be considered a severe personality disorder that includes distress. It is not the same as a sub-threshold or minor depressive disorder, and should actually be looked on as more severe than these conditions (see Finnerty, 2009 for a more extensive review).
Depressive personality disorder should be included in the main text of DSM-V under the Personality Disorders section. However, as noted earlier it should be included without the exclusion criterion related to dysthymic disorder. A dimensional view of depressive pd is also supported.
© Todd Finnerty
A list of references related to depressive personality disorder: http://www.depressivepersonality.com/references.html
Just in time for the holidays you can read the entire book on Google books, much better than the clunky PDF file I had up:
Also, the Amazon price should be going down at least $10 as off sometime today, I changed the list price to $15.95 for the print copy just now as a Happy Holidays to all, and if you’d like go to http://www.dsm5.org and tell them you think Depressive Personality Disorder should be included in DSM-V.
If the price hasn’t updated on Amazon yet you can still get the print copy here for that price (its also fulfilled by Amazon from this site- its an Amazon owned company) https://www.createspace.com/3382024
Two new articles have recently been published related to Depressive Personality Disorder:
Vachon, David D.; Sellbom, Martin; Rider, Andrew G.; Miller, Joshua D.; and Bagby, R. Michael (2009). A Five-Factor Model Description of Depressive Personality Disorder. Journal of Personality Disorders, 23(5), 447-465.
and
Rudolph, Karen D. and Klein, Daniel N. (2009) Exploring Depressive Personality Traits in Youth: Origins, correlates, and developmental consequences. Development and Psychopathology, 21, 1155-1180.
(For a broad overview of recent research check out my book, or an article from earlier this year: Huprich, Steven K. (2009). What Should Become of Depressive Personality Disorder in DSM-V? Harvard Review of Psychiatry, 17:1,41-59).
What are the personalities of individuals with personality disorders like? Certain personality traits are prevalent in individuals with personality disorders, and a growing body of literature has been looking at both “normal” and “maladaptive” personality traits (and everything in between) in individuals with personality disorders.
Included in this focus is depressive personality disorder. Depressive pd can be conceptualized as a collection of these maladaptive expressions of traits which create problems in the various domains of an individual’s life and functioning. There is an argument to be made that if DPD were included in DSM-V that an increased focus could come to these factors which increase an individual’s risk for distressing symptoms, a longer course of depression, and a greater risk of recurring problems.
A number of studies have focused on depressive pd’s relationship to the Five-Factor Model of personality (FFM). While researchers Ryder and Bagby were once critical of DPD due to its potential overlap with the concept of dysthymic disorder, in more recent articles their opinion appears to have been changed and more recently they indicate with Vachon and others (2009) that “depressive personality disorder is one of the most familiar, frequent and fundamental disorders.” They note that expert consensus on the depressive pd prototype suggested better agreement that the other personality disorders previously evaluated. in reviewing previous studies and in conducting their own, they provide a profile of FFM traits and facets common to individuals with depressive personality disorder. These are generally measured by the NEO-PI-R. They also noted they tended to score higher on certain MMPI-2 RC scales. I will expand on these in an upcoming post devoted to the psychological assessment of depressive personality disorder (feel free to register your e-mail address at the bottom of the page for an e-mail update of new posts or follow @DrFinnerty on twitter).
Rudolph & Klein (2009) appear to have found similar patterns of depressive personality trait development as with research on related factors such as cognitive vulnerabilities to depression. Those interested in the developmental origins of depressive personality disorder and a developmental psychopathology perspective will be interested in this article.
A longer review of these articles in the context of related research is to follow. If you read them let me know what you’d think, I’d love to discuss them and other related issues. As the previous post noted, a recent discussion has started on the Amazon forum.
Its nice to report that someone has actually began using the discussion forum associated with my book to ask questions and begin a discussion, I’m happy to discuss the book and related topics here at the Amazon forum:
Amusing and sad, I don’t remember the last time I hada chance to work on the website http://www.depressivepersonality.com but the fact that I haven’t yet updated a notice I put on in August may speak volumes, strangely, an incorrectly named PHP file may have had it down for quite some time and I wasn’t even paying attention, sorry,now that the summer is over I’ll be trying to devote more time to writing. Within the next few days I’ll be posting a review of two new DPD-related articles here on the blog and perhaps some more book excerpts.
To the editor:
I commend Mark Moran for his fair reporting of the debate on DSM-V. It appears that the APA is now taking the first necessary steps in reforming the DSM-V process - i.e., , by creating an oversight committee, toning down ambitions, and endorsing caution - but these steps alone are not nearly enough. The closed method of doing DSM-V also needs a radical overhaul. The issue DSM-V secrecy is not remotely answered by assertions that there have been general presentations at scientific meetings and some papers written. All options and methods need to be posted now to allow a thorough review from the field and by the task force well before any field testing begins. Clearly, the publishing deadline must also be postponed to allow sufficient time to avoid what will otherwise be a sloppy and problematic DSM-V.
In regard to the proposed pre-psychotic diagnosis, the Carpenter/ McGlashan argument is that the benefits of identifying and treating true positives would outweigh the risks to false positives. Central to their claim is the notion that the pre-psychotic diagnosis will be used only in treatment seekers like the ones recruited in Dr. McGlashan’s studies. Even were this the case, the high false positive rate in Dr. McGlshan’s own very carefully conducted studies with highly screened patients would be unacceptable given the shortened life expectancy associated with the use of atypical antipsychotics (to say nothing about the considerable stigma, insurance, and forensic risks). But there is a much bigger problem of “patient” identification that is unrecognized by Carpenter and McGlashan. In the real world, the population of “patients” and clinicians will be very different than in their rarified research setting. Once the pre=psychotic diagnosis is made official and fanned by drug company marketing, it will almost certainly take on a life of its own and spread wildly beyond the confines envisioned by the experts who created it. The DSM-IV experience with much less radical changes in the ADHD and Autistic Disorders clearly demonstrates the risk of false epidemics.
Allen Frances MD
This, in a nutshell, illustrates our ongoing concerns about the inadequacies of DSM-V transparency. With less than two years left until the final DSM-V draft is approved by the APA Assembly and Board of Trustees, what continues to be missing-in-action is any presentation of precisely what the options for DSM-V will be. Notably, conspicuously absent from these articles in this issue was any reporting about the specifics of the field trials (including methods or timeline).
The purpose of field trials should be to collect primary data about the performance characteristics (i.e., reliability, validity, potential for false positives) of specific DSM-V proposals. This requires that the specific wording of the full range of the various options to be tested be fixed at the time of the field trials so that the Workgroups can use data collected in the field about these specific options in order to choose among them.
According to the article, Dr. Kupfer believes that the purpose of the field trials is to provide a” wider review” of the diagnostic criteria “before we make some final decisions.” In fact, a wide review requires that complete drafts of proposed options for all changes be made publicly available, as was done with the DSM-IV options book which appeared before the start of its field trials. For reasons that remain unclear, the DSM-V leadership has apparently decided to commence field trials without giving the field the opportunity to vet the criteria set wording, which could potential lead to serious problems down the line.
According to Moran, APA leadership charges that the DSM-V “work in progress bears almost no resemblance to the one described by the two critics.” Given that the little that we know about the DSM-V process comes from what is publicly available, if we have got it all wrong, that would seem to prove our claim that there is, indeed, a serious problem with DSM-V transparency.
The July/August, 2009 edition of the National Psychologist Vol. 18 No. 4 will be available soon so check it out. I just received a print copy and it includes stories like a licensing board being sued for not investigating torture charges, and an article from DSM-V Personality Disorders task force member Lee Anna Clark, Ph.D. “Progress continues toward DSM-V” (which happens to be right next to mine ”Depressive personality disorder can be conceptualized dimensionally for DSM-V.”
There were some editorial changes of course which made the article better than what I wrote, but the one thing that may confuse you is the personality disorder “NOS” (not otherwise specified) was changed to “numbers” which may be related to a misunderstanding about an abbreviation for #s, but from now on we’ll just pretend it means the numbers in a diagnostic code 
301.9 to be exact.
Here we have a story involving past heads of DSM task forces, including the head of the current version of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition: DSM-IV (*cough* paradigm, I guess) pitted against the people in charge of bringing in the next manual, the DSM-V.
Take a look at the DSM-IV-TR, the current “text revision” being used prior to the publication of DSM-V in May, 2012.
Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision)
You say you want a revolution? I’ve heard this interesting story before.
There has been a lot of talk about “paradigm shifts” lately, which has made me eager to dust off the Thomas Kuhn books on my book shelf, most notably The Structure of Scientific Revolutions
In fact, Maser and others (2009) wrote an article for the March, 2009 journal Clinical Psychology: Science and Practice titled specifically “Psychiatric Nosology Is Ready for a Paradigm Shift in DSM-V.” They called for a mixed/hybrid categorical-dimensional system, which would be a shift from the paradigm and assumptions that were ushered in in 1980. They join the call for including more dimensional features in DSM-V. Clinicians of course, must think on a continuum (or spectrum), and I do agree with their call for a mixed categorical-dimensional format for personality disorders, particularly since it appears to be how clinicians think and practice now in terms of using personality disorder nos either to note the traits or features (but not full criteria of) one or more personality disorders. It could be interesting to allow for other maladaptive traits to be placed on Axis II as well, but likely more useful if standardized prototypes or “categories” continue to be used (such as depressive pd
The term “paradigm” was also brought out this week by the MD who led the creation of DSM-IV and by the current “framers” of DSM-V.
On June 26, 2009; Allen Frances, MD, the head of the task force that developed the DSM-IV wrote an article for Psychiatric Times: A Warning Sign on the Road to DSM-V: Beware of its unintended consequences as well as a Q&A interview. He suggested “grave problems in the DSM-V goals, methods and products…” He noted “I believe that the work on DSM-V has displayed the most unhappy combination of soaring goals and weak methodology” and noted that “excessive ambition” has “encouraged an excessive tolerance for risk taking.” He noted that the “DSM-V goal to effect a paradigm shift in psychiatric diagnosis is absurdly premature” and “There can be no dramatic improvements in psychiatric diagnosis until we make a fundamental leap in our understanding of what causes mental disorders.”
There is talk about basing diagnoses on biological findings, yet the evidence is not yet there to support this. It is certainly important to focus on underlying and shared factors across disorders, though they may not all be biological. Interestingly, a reductionist trend might also be hidden within the notion of including dimensional personality traits and similar suggestions. One suggestion would be incorporating an assessment of traits and/or facets of the Five-Factor Model of Personality instead of or in addition to personality disorders, in effect attempting to reduce larger abstract concepts like personality disorders and other maladaptive expressions of personality in to other, theorized abstract concepts which are on a more “basic” level (though arguably more in line with current theories about “normal” personality).
Getting back to Dr. France’s article, he charges that “A further problem is that almost everyone responsible for revising the DSM-V has spent a career working in the atypical setting of university psychiatry,” suggetsing they lack more real world experience (my words there). The author worries that subthreshold diagnoses (and presumably the lower ends of dimensional ratings) may “flood the world with tens of millions of newly labeled false-positive “patients.” “ The rates of DSM-V mental disorders would “skyrocket” and there would be a “medicalization of normality” which… wait for it… would be a “bonanza for the pharmaceutical industry.” He compares his perception of the DSM-IV development process with that of DSM-V and suggested that “DSM-V is continuing to veer badly off course…” “What is needed now is a profound midterm correction toward greater openness, conservatism, and methodological rigor.” The first concern he lists in his conclusion is “their ambition to achieve a paradigm shift when there is no scientific basis for one.”
On July 1, 2009 “Setting the Record Straight: A Response to Frances Commentary on DSM-V” appeared, signed by all the essentials : Alan F. Schatzberg, MD, James H. Scully Jr, MD, David J. Kupfer, MD, Darrel A. Regier, MD, MPH( Dr Schatzberg is President of the American Psychiatric Association. Dr Scully is Medical Director, CEO, of the American Psychiatric Association. Dr Kupfer is Chair, DSM-V Task Force Dr Regier is Vice Chair, DSM-V Task Force).
They describe the DSM-V development process and note it to be open and inclusive (admittedly, I do like that comments could be submitted through the dsm5.org website. Interestingly, they also note that “Recognizing changes in technology and the need for continued updates and revisions of DSM-V, we are setting up a process that will allow the new DSM to change with new developments, rather than being reified for a decade or more. New publishing technologies, not even imagined in the early 1990s, will help make this possible.” This reminds me of the ICD-10 which has a between revisions “updating process” (and presumably the future ICD-11 will as well, and there has been talk of attempting to get the two to mesh a bit more closely together). Its not clear what business model might be used in terms of publications of updates to the DSM (i.e. free on a website?). The authors note that “Science has advanced, treatments have advanced, and clinical practice has advanced since Dr. France’s work on DSM-IV. The DSM will become irrelevant if it does not change tor reflect these advances.” However the author’s concluding argument is hardly a scientific one, the shot they fire is “Both Dr. Frances and Dr. Spitzer have more than a personal ““pride of authorship”” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.” Apparently, conflicts of interest charges are especially powerful in psychiatry righyt now, but this one was broadened away from the “pharmaceutical industry” at least. Perhaps what was worst was that they called him Frances.
Of course, Dr. Spitzer was called out so then we have the follow up commentary: “APA and DSM-V: Empty Promises” who of course couldn’t help but notice the “ugly turn” the DSM-V debate has taken. Dr. Spitzer takes issue with the description of the DSM-V process being open and inclusive, and notes that although field trials are expected to begin, a laundry list of questions about those trials remain unanswered. As an aside, I did submit my e-mail address as someone willing to help with any trials but I haven’t heard anything back (though that really isn’t too surprising ;). He suggests that they either know the answers and aren’t telling, or if they don’t know, then it is “inconceivable” that the May, 2012 “deadline could realistically be met.”
Maybe there’ll be no more fireworks over the July 4th holiday, but I’ll keep an eye on it as are quite a few others, check out all the tweets on twitter Follow @DrFinnerty and I’ll pass them along to you when I see them (send me what you find too).
The DSM hasn’t been revised that many times, and certainly there are countless ramifications (some intended and some “unintended”) which will come from any revisions as well as any status quo that is maintained. Its expected to be published in May, 2012, and the “battles” leading up to that time, if recent articles are any indication, will likely prove to be interesting for both the combatants and spectators alike. I hope they give it their all and keep us as entertained as they have this week. I’m just reminded of the revolutionary words from the movie Braveheart that go something like ‘…and dying in your beds many years from now, would you be willing to trade all the days from this day to then, to come back here, and tell our enemies, that you may take our lives, but you’ll never take- our freeedom!’ Sorry, perhaps I got a little carried away. Its been a little while since I’ve witnessed scientists with their faces painted up so much for battle. I guess we have Thomas Kuhn’s work acted out for us on display, the naked realities of scientific progress made plain before our very eyes. Its not always facts speaking for themselves, sometimes communities of scientists must decide how to organize the abstract concepts involved and as can be seen from an example like DSM-V, come together in committee (apparently sometimes behind closed doors).
Meanwhile, I need more popcorn ;)
You can “get the latest” in Psychiatric Time’s DSM-V Topic Center
Check out the primer for understanding why science (even psychiatry and psychology) may be sloppier and more entertaining than you thought:
The Structure of Scientific Revolutions
Take a look at the DSM-IV-TR, the current “text revision” being used prior to the publication of DSM-V in May, 2012.
Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR Fourth Edition (Text Revision)
RE: Conceptualizing “depressive traits” (and depressive personality disorder) for DSM-V
The diagnoses of Depressive Personality Disorder and “depressive traits/features” (to take liberties) can be conceptualized in a hybrid categorical and dimensional manner for DSM-V. The diagnosis itself is categorical, but the severity and underlying DSM-IV-TR criteria can be treated dimensionally. This opens the door to a wealth of research not just on depressive pd, but on cognitive vulnerabilities to depression and other relatively stable factors that have been found to be independent of depression. These factors or maladaptive “depressive traits” are in many ways also quite similar to the diagnostic criteria for depressive pd, and depressive pd has also been found to be relatively stable and independent of depression. The depressive pd construct would be more useful than crafting a laundry list of maladaptive characteristics in individuals who would have otherwise qualified for a depressive pd diagnosis. It also focuses the attention of practitioners on more specific and independent traits which would be useful for practitioners of cognitive-behavioral therapy (to name just one), as opposed to more nebulous constructs such as neuroticism. We should keep in mind that personality traits are also abstract concepts without distinct physical findings at this point, and are not necessarily the only building blocks involved in the presentation of individuals with personality disorders. We also should not ignore a proven framework for incorporating depressive traits (such as cognitive and other vulnerabilities to depression) in to DSM-V.
Depressive PD was included for further study in an appendix of the DSM-IV, but was also given as an example of a diagnosis which can be made under personality disorder nos. The criteria reflect a negativistic individual who tends to be critical towards themselves and judgmental towards others. They are pessimistic and tend to brood and worry in addition to feeling guilty and remorseful. Per DSM-IV their “usual mood is dominated by dejection, gloominess, cheerlessness, joylessness, unhappiness” (pg. 733). Depressive pd has repeatedly been found to be a valid diagnosis which can be differentiated from other disorders (Huprich, 2009). It has a degree of stability similar to other personality disorders and is present even when a mood disorder such as depression is not. The criteria which construct depressive pd can be viewed as consistent with cognitive vulnerabilities to depression, and these underlying vulnerability concepts have also been found to be distinct from depression.
While the depressive pd criteria may sound similar to depression or anxiety symptoms, they are also relatively stable, maladaptive personality characteristics which create vulnerability to emotional problems. The depressive pd criteria reflect characteristics which can be assessed dimensionally and create impairment at more extreme levels. While at lower levels the depressive pd criteria may be seen as minor variations of normal personality characteristics, at higher levels they lead to significant difficulties. Coding features of depressive pd offers clinicians the ability to communicate the presence of stable depressive traits which have had increased research attention. For example, Hankin (2008) found cognitive vulnerabilities to depression to be fairly stable, enduring processes. A negative cognitive style, such as is seen in depressive pd, tended to be one of the most stable vulnerabilities studied. Ryder, at. al. (2008) found depressive pd to be related to all depression vulnerabilities assessed in their study. This would be an expected finding considering the depressive pd criteria generally look like these “vulnerabilities.” These cognitive vulnerabilities can be viewed as relatively stable depressive traits on a continuum with depressive personality disorder. These factors alone can create interpersonal problems and functional limitations and when they are present to a sufficient degree a depressive personality disorder diagnosis can be made.
Depressive pd is also correlated with neuroticism. Neuroticism is related mildly to many of these independent vulnerability constructs which make up the depressive pd criteria, but it is generally more associated with depression when factor analyses have been conducted. While neuroticism is sometimes treated as a cognitive vulnerability, it may be a nonspecific collection that includes these factors. Per Hankin, et. al.’s (2007) factor analyses, “cognitive vulnerability is not reducible to general trait neuroticism.” The many maladaptive expressions of depressive traits are not adequately covered by neuroticism alone but can be expressed through a depressive pd or depressive traits diagnosis. As DSM-V moves towards a more dimensional view of disorders, including depressive pd would increase attention on these underlying dimensional trait structures which should not be overlooked. It would also highlight factors with a profound impact on prognosis. In addition to creating distress and interpersonal problems in their extreme form, depressive pd is constructed of clinically useful concepts that suggest a risk for the onset of other problems, a longer course and risk of recurrence. As these vulnerabilities/maladaptive characteristics drift away from normal personality in to the maladaptive and the more vulnerabilities that are present, they become depressive traits and create depressive personality disorder in their most extreme form. It includes more information than the simple description of course in dysthymic disorder. It is also not surprising given it’s underlying constructs that depressive pd is functionally impairing in itself, creates interpersonal difficulties and should be considered a severe personality disorder that includes distress and possibly anxiety and affective complaints, and is not the same as a sub-threshold or minor depressive disorder. I invite you to read through the manuscript (in POD book form) that I have been working on related to depressive personality disorder and thank you for your time. I also would like to let you know that a briefer article on depressive pd similar to this letter will likely soon be published in a national print publication. It will generally convey the same opinion that including these stable “depressive traits” which are independent of depression via depressive personality disorder will have the most beneficial effect on practice and be the most useful approach for DSM-V.
A link to an electronic copy of the book is available online for free in PDF format at http://www.worldwidementalhealth.com or http://www.depressivepersonality.com
Or please feel free to contact me and I would be happy to send you a free print review copy of the manuscript (in POD book form) if you do not have one already.
Thank you,
Todd Finnerty, Psy.D.
References:
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental
Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Association.
Finnerty, Todd (2009). Depressive Personality Disorder: Understanding Current Trends
in Research and Practice.Columbus, OH: WorldWideMentalHealth.com
Hankin, Benjamin L. (2008). Stability of Cognitive Vulnerabilities to Depression: A
Short-Term Prospective Multiwave Study. Journal of Abnormal Psychology, 117(2), 324-333.
Hankin, Benjamin L.; Lakdawalla, Zia; Carter, Ingrid Latchis; Abela, John R. Z. &
Adams, Phillipe (2007). Are Neuroticism, Cognitive Vulnerabilities and Self-Esteem Overlapping or Distinct Risks for Depression? Evidence from Exploratory and Confirmatory Factor Analyses. Journal of Social and Clinical Psychology, 26(1), 29-63.
Huprich, Steven K. (2009). What Should Become of Depressive Personality Disorder in
DSM-V? Harvard Review of Psychiatry, 17(1), 41-59.
Ryder, Andrew G.; McBride, Carolina; Bagby, R. Michael (2008). The Association of
Affilliation and Achievement Personality Styles with DSM-IV Personality Disorders. Journal of Personality Disorders, 22(2), 208-216.
Todd Finnerty, Psy.D. is a Psychologist in Columbus, OH. He also maintains a website and blog at www.depressivepersonality.com
This letter is copyright Todd Finnerty ©2009, it has been adapted from a shorter article which will be published this summer in a national print publication. While many changes have been made for the purpose of this letter, please do not redistribute it widely without the author’s permission due to the impending publication and inclusion of some paragraphs from that article. Thank you for your understanding. Please let me know if you’re interested and I’d be happy to send you an actual copy of the printed story on depressive pd later this summer after publication. Thank you again for your time.
