In my consulting rooms, on the centre of one of my bookcases is a well thumbed edition of the Diagnostic and Statistical manual of Mental Disorders, fourth edition. Also known as DSM-IV, it is an essential reference for all of us therapists and especially hypnotherapists I’d say…

Exciting, eh?

The good folk at the American Psychiatric Association who write and publish this piece of essential reading that no downstairs toilet should be without, are currently in the middle of a historical revision to this manual which is considered more of a ‘Bible’ by many in related fields.

This book has power! It is wielded used by clinicians, insurance companies, and even the legal system to define and identify the types and thresholds of mental illness that become the focus of treatment and research.

Following a very secretive process of review and revision that has been marked by a bunch of criticism, the APA has created a website, and officially released its first draft of the new system to the public… Needless to say, I’ve been hanging out there a tad recently… And have awoken many times with an imprint of my desk on my chin in a pool of my own dribble… It is that exciting.

Joking and being facetious aside, I wanted to point out a couple of bits… Mainly the section on personality disorders (also known as “Axis II”), the section with perhaps the most considerable changes in the entire manual.

Diagnosing disorders in the current edition of the DSM-IV involves two aspects. The first is defining what a personality disorder is. Currently, a personality disorder is defined as a pervasive pattern of “inner experience and behavior” that is deviant from a person’s cultural norms. These may be deviations in thoughts, emotionality, interpersonal relatedness, and impulse control.

Deviations in any of the above aspects need to be pervasive, stable, present at least since adolescence, and not due to substances or another mental disorder. Importantly, these ways of thinking, feeling, or behaving need to be significantly distressful and problematic.

The second aspect is not massively important to a hypnotherapist because we do not diagnose, and though these types of client issues are not really our realm, I thought I’d mention anyway… It involves defining what type of personality disorder is present. DSM-IV currently lists ten: paranoid, schizoid, schizotypal, narcissistic, antisocial, borderline, histrionic, avoidant, dependent, obsessive-compulsive, with a catch-all “not otherwise specified category”.

Each personality disorder had a certain number of criteria, to which you must meet an artificial cut-off. So to be Borderline, for example, you need to have five symptoms out of nine possible symptoms such as: self-harming, unstable relationships, fear of real/imagined abandonment, impulsivity, identity disturbance, etc.

The problems with the existing system are many. First, the different personality types were poorly defined. They weren’t based on research-derived criteria, the individual symptoms were vague, and the idea of checking off abstract criteria such as “an exaggerated sense of self-importance” were difficult… Don’t we all, at SOME point or another, have an exaggerated sense of self-importance? Another problem is that the criteria overlapped heavily. A person meeting criteria for one personality disorder usually met critieria for 3 or 4 others, as well…. I mentioned this in previous posts here on this blog…

The proposed revision on the DSM-V website appears quite complicated and has three major facets.

First, the definition of what a personality disorder is, in general, has changed. The proposed revision suggests that instead of a pervasive pattern of thinking/emotionality/behaving, a personality disorder reflects “adaptive failure” involving: “Impaired sense of self-identity” or “Failure to develop effective interpersonal functioning”. My own worry is that when these notions tend to seep into the mass consciousness of therapists, hypnotherapists in particular being my field of interest, some will start moving goalposts as to what and who they think they can and should treat…

There are a couple of things I actually really like about this new definition. The first is the use of the term “adaptive failure”. Every one of us has a personality, it’s just a matter of how you use it. Your personality features only become a disorder when there is a pervasive failure to adapt who you are as a person to the demands of everyday life. The second is the newly detailed descriptions of failure to develop effective interpersonal functioning. These are fairly straightforward: problems with empathy, intimacy, cooperativeness with others, and inability to formulate a good working understanding or conceptualisation of who others are as people.

There are two drawbacks, it seems to me. “Impaired sense of self-identity” is not quite as easily understood as someone who has pervasive failure in their relationships. The proposed revision breaks down identity problems into: poorly integrated identity (e.g. shifting self-states), poor integrity of self-concept (e.g. difficulty identifying and describing parts of oneself), and low self-directedness. The last part is great, and can be easily understood and observed as someone having trouble setting and achieving goals in life, showing a lack of direction, and feeling little meaning or purpose in life. Identity integration and integrity seem a little more “jargony” and a bit more difficult to explain or quantify in the real world.

I know, today’s entire blog entry is far too hevaily punctuated with jargon… For some it may make a refreshing change though, no?  😉

Instead of the old ten personality types, DSM-V has simplified the system by cutting them down to just five: Antisocial/Psychopathic, Avoidant, Borderline, Obsessive-Compulsive, and Schizotypal types. Each type comes with a narrative paragraph description.

Antisocial/Psychopathic types have inflated grandiosity and a pervasive pattern of taking advantage of other people. Avoidant types are inhibited from forming and maintaining relationships out of fears of humiliation and rejection. Borderline types show intense emotionality, impulsivity, internal feelings of emptiness, and fears of rejection. Obsessive-compulsive types are hyperfocused on details and are excessively stubborn, rigid, and moralistic. Schizotypal types are characterized by odd thinking and appearances or confused states.

Clinicians simply read each paragraph length narrative description and rate on a 1-5 scale how much a patient matches each one (with 4 or 5 being a threshold for diagnosis). Research studies have found that clinicians tend to find this the most useful and comprehensive method for personality diagnosis, improving clinical description and treatment planning from the current system.

The third and final element of the proposed system is a series of six personality “trait domains”. These domains are based on the widely used five-factor model of personality. The six domains include: Negative Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity and Schizotypy. Clinicians would be asked to rate each of the six domains on a 0-3 scale depending on how descriptive each is of the patient.

To aid with this, each of the six domains comes with a subset of adjectives, or facets. Disinhibition, for example, encompasses: impulsivity, distractability, recklessness, irresponsibility. While there is a great deal of personality research on these factors, and they are useful for a variety of purposes, their greatest limitation is the sense of vagueness for clinical use.  To compare, it would be like rating someone’s level of usual sadness, as opposed to having a coherent syndrome of depression.

My concern for the field of hypnotherapy is that someone, somewhere starts to think that it alters what should and should not be treated in the field, just because their revised edition of DSM has moved their goalposts… I know for the vast majority of folk, this is not of massive interest, but heck, it interested me today…