Psychiatry is failing those with personality disorders
A workable diagnostic system is needed, because sticking with the status quo is not an option
Psychiatry is failing those with personality disorders
05 December 2012
IF DOCTORS sent patients with angina home with nothing but a prescription for a painkiller to control chest pain, they would be sued for malpractice. Sadly, that is a fitting analogy for what happens all too often to people with personality disorders.
These conditions can wreck lives. Take borderline personality disorder, the most visible of the 10 such disorders currently recognised by the American Psychiatric Association (APA). Emotional instability can wreak havoc on the relationships of people with this condition.
All too often, there is no help at hand. The system for classifying these conditions in the APA’s Diagnostic and Statistical Manual of Mental Disordersis so confusing that many patients receive multiple diagnoses, while others receive none at all. Doctors may recognise and treat secondary symptoms such as anxiety or depression, but antidepressants don’t address the root of the problem. These patients need psychotherapy to help them interact with others.
This is why the APA’s failure to agree a new system of diagnosing personality disorders for the next edition of its handbook, DSM-5, is tragic (see “Personality disorder revamp ends in ‘horrible waste’“). It means that many patients will continue to be treated inadequately. What is now urgently needed is renewed determination to produce a workable diagnostic system, recognising that problems with personality operate on a scale of severity and abandoning the current constellation of disorders, which creates pigeonholes into which many patients don’t fit.
So it is critical that the APA makes good on its promise to make DSM-5 a “living document” that is updated between major rewrites. Personality disorders must be a priority for DSM-5.1.
The other hope is a system being developed for the next revision of the World Health Organization’s International Classification of Diseases, due out in 2015. It seems a step in the right direction, focusing on rating people’s difficulties in interacting with others on a four-point scale.
It will take time to convince doctors and patients that any alternative system is useful. But the only other option is to stick with the status quo – and that is not really an option at all.
Read the Article at newscientist
2 Comments
CP
Taken from wikipaedia on changes in the imminent new DSM-V Personality disorders-
Further information: Personality disorder
Major changes have been proposed in the assessment and diagnosis of personality disorders.[34] These include a revamped definition of personality disorder and a dimensional rather than a categorical approach based on the severity of dysfunctional personality trait domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy). In addition, patients would be assessed on how much they match each of six prototypic personality disorder types: antisocial/psychopathic, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal with their criteria being derived directly from the dimensional personality trait domains.
Borderline personality disorder controversy-
The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of borderline personality disorder in DSM-5.[59] The paper How Advocacy is Bringing BPD into the Light[60] reports that “the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma…”. Instead, it proposes the name “emotional regulation disorder” or “emotional dysregulation disorder”. There is also discussion about changing Borderline Personality Disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis.
The British Psychological Society in the United Kingdom stated in its June 2011 response that it had “more concerns than plaudits”.[65] It criticized proposed diagnoses as “clearly based largely on social norms, with ‘symptoms’ that all rely on subjective judgements… not value-free, but rather reflect[ing] current normative social expectations”, noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that “not otherwise specified” categories covered a “huge” 30% of all personality disorders.
It also expressed a major concern that “clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences… which demand helping responses, but which do not reflect illnesses so much as normal individual variation”.
The Society suggested as its primary specific recommendation, a change from using “diagnostic frameworks” to a description based on an individual’s specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality:
[We recommend] a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with ‘normal’ experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or ‘symptoms’ or ‘complaints’…… We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc)? These would be more helpful too in terms of epidemiology. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of ‘schizophrenia’ or ‘personality disorder’ may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person’s real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person’s problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives.
—British Psychological Society June 2011 response.
National Institute of Mental Health-
The head of the National Institute of Mental Health, Thomas Insel, withdrew support for the DSM-5 in his statement on April 29, 2013, stating, “the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.” Insel’s criticism was not specific to the new manual, but rather as a general criticism of the DSM as it has always existed, acknowledging that “the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published.”
“The goal,” he explained, “is to provide a common language for describing psychopathology. While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each.” While Insel acknowledges the strengths of the DSM in its reliability, ensuring that all members of the field use the same definitions, the biggest weakness has always been “its lack of validity”.
In their effort to resolve their issues with the new DSM, the NIMH launched the Research Domain Criteria Project (RDoC), based on four assumptions:
•A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
•Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
•Each level of analysis needs to be understood across a dimension of function,
•Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.
Insel stressed that the RDoC is not designed as diagnostic criteria to replace the DSM, but rather as a research framework, for future development.
Their argument is centered around the claim that, “symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.” As a result of this position, the NIMH is no longer using the DSM as the criteria upon which they will evaluate funding of future clinic trials.
The UK are withdrawing all funding for research and treatment for BPD.(Not that there was any in the first place.)This is just typical of our money-pinching government.If they can argue and pretend that PTSD and CPTSD,as well as serious personality disorders don’t exist, they don’t have to treat them.It’s tragic.
CP
(Quoted from today’s NHS Reforms Live Blog – Mental Health Special…..) – 8th May 2013.
“Mental health problems can be a stigma. The government’s health reforms will have huge implications for people suffering from mild bouts of depression right through to those who are self harming or suicidal.The future of long-term psychoanalytic therapy in the NHS depends upon the evidence for its effectiveness. There isn’t much evidence one way or another at present, although I think there is evidence that it isn’t very helpful for people with depression.
On the other hand, modifications of this type of therapy, for example mentalisation-based therapy (MBT), when used in the treatment of people with borderline personality disorder, shows it can be very effective. We need more trials of psychoanalytic therapy, preferably modified to fit particular groups of service users, and manualised/structured.
The health and social care bill, in our view, is likely to lead to three tiers of the NHS. The upper tier will be reserved for all those lucrative bits that can be marketised, such as hip ops, cataracts, interventional cardiology etc, the middle tier would comprise some cases that can be marketised but not others depending on comorbid illness such as uncomplicated gastric ulcers, kidney disease etc, and finally a lower tier for conditions that are chronic, complicated and require multiprofessional support such as mental illness, rehab medicine, A&E etc.
The bill marks the end of market incrementalism and a switch to US-style HMO (health maintenance organisation). Under these proposals, the NHS will be reduced to government payers funding the private sector to commission and provide care.
In England, GP consortia (many of so called pathfinders are run by private companies) are at the heart of the new deal, filling the role that insurance companies play in the US. Mental illness tends to have higher overall health costs, and the nature of care required is complex and unpredictable in chronic psychoses such as bipolar disorder and schizophrenia.When risk is devolved to GP consortia through a capitation fee or payment per head, they must seek to manage the risk.
In our view, the consortias will use three strategies to balance the books. They can reduce eligibility criteria for services or place time limits on care, they can cherry pick low-risk patients, or they can levy charges for services no longer offered by the NHS.
Most likely, they will use a combination of all three. Mental health commissioning, as has been proven time and time again, is ill understood, and so variable across England that any further bureaucracy will deprive these most vulnerable of society’s individuals from even the basic care. The health and social care bill, as proposed, incentivises GPs to manage enrolment to their patient list.
There is an inherent risk that the mentally ill, the elderly, those with long-term medical illnesses such as diabetes and chronic kidney disease, would struggle to find a primary care physician to register them because of the costs involved.
The proposed system predicates on driving efficiency through spending less, or not at all. Where would this group of patients find the GPs to take them on? Inevitably, relatives, charities and local authorities will fill the gap, and a system of inequitable care, determined by the wealth of local areas and individual ability to pay or ‘use the system’, will evolve.
All those who care about ensuring a universal, rational, fair, and effective system of mental health care have much to fear from a bill which has lacks the sophistication required in modern day medicine.”