5c
Joel Paris
I agree with Peter Tyrer that in classification systems, science should trump clinical utility. I am just not sure how solid the science is behind the ICD-11 system. The research literature remains thin, although it is sure to grow now that the revised system has been published. But DSM-5 Section III has, at this point, a larger literature, and its advocates are just as certain that their system is scientific. It may be more accurate to say that both of these systems are provisional, and that it will take many decades of research to improve on them.
I am pleased that, as announced in June 2018, ICD-11 will allow clinicians to diagnose borderline personality disorder as a “pattern” along with five trait domain descriptors. The views of a number of researchers, reflected in a paper by Herpertz et al. (2017), seem to have influenced the final outcome, allowing for this compromise with a strictly dimensional approach. However, I have some concerns about the reliability of the ICD-11 system in practice. Unlike DSM-5 Section III (American Psychiatric Association, 2013), the trait domains and how to rate these traits in diagnostic evaluations are not spelled out in detail.
I have long been an advocate for the construct of borderline personality disorder, which, as a large body of evidence shows (there are thousands of research papers), is as valid as schizophrenia, bipolarity, or depression. Of course, these disorders, even though they are central to psychiatry, set a low bar! In a field trial conducted by the developers of DSM-5, borderline personality disorder had a much higher reliability than major depression (Regier et al., 2013).
For now, my view is that whatever the problems are with the borderline category, we need to retain it, at least until there is something clearly better. And it is compatible with DSM-5 Section III, even if the pathway to making the diagnosis is more complex. I have my doubts about the idea that the diagnosis of borderline personality disorder will eventually drop off as people realize the advantages of the ICD-11 system. Finally, whatever his expertise is on the genome, I suspect that if James Watson had spent a few evenings in an emergency room observing the patients who came in, he would understand why many researchers are “obsessed” with borderline personality.
Scott Lilienfeld has cogently summarized some of crucial unanswered questions about personality and personality disorders. I would add another one. We just do not know enough about mind or brain to understand complex forms of psychopathology that affect emotion, thought, and behavior. This is an understandable problem, given that evolution has shaped a brain with at least 80 billion interacting neuronal components (one can double that if the glia are considered). I am not suggesting, as in the Research Domain Criteria (Cuthbert & Insel, 2013), that solving the puzzle depends largely on the connectivity of neuronal networks. Even if we understood brain wiring, we would still be a long way from explaining mental activity, not to speak of consciousness. Many decades of research lie ahead of us.
Dr. Lilienfeld may have misunderstood me on one point – the problem of misdiagnosis. I was not concerned about separating personality trait profiles, which do overlap greatly. I was referring to the treatment of patients with borderline personality disorder wherein the focus is on abnormal mood – either depression or mania (Paris, 2012). This is where misclassification, and missing personality disorders entirely, is not just an issue for professors, but hurts patients by giving them a treatment they don’t need while denying them therapy that they do need.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Cuthbert, B. N., & Insel, T. R. (2013). Toward the future of psychiatric diagnosis: The seven pillars of RDoC. BMC Medicine, 11, 126.
Herpertz, S. C., Huprich, S. K., Bohus, M., Chanen, A., Goodman, M., Mehlum, L., … Sharp, C. (2017). The challenge of transforming the diagnostic system of personality disorders. Journal of Personality Disorders, 31, 577–589.
Paris, J. (2012). The Bipolar Spectrum: Diagnosis or Fad? New York: Routledge.
Regier, D. A., Narrow, W. E., Clarke, D., Kraemer, H. C., Kuramoto, S. J., Kuhl, E. A., & Kupfer, D. J. (2013). DSM-5 field trials in the United States and Canada, Part II: Test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry, 170, 159–170.