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Journal of Psychiatric Practice:
doi: 10.1097/01.pra.0000396058.82398.1a
From the Editor

Absence of Evidence

Oldham, John MD

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From the Editor:

March, 2011. I recently returned from the Congress of the International Society for the Study of Personality Disorders, where researchers and clinicians from all over the world presented educational sessions and reports on new findings on personality and personality disorders (PDs). There is intense international interest in the draft diagnostic model for personality disorders being proposed by the Personality and Personality Disorders Work Group of the DSM-5 Task Force. As a member of that work group, I was particularly interested to participate in many lively discussions about the changes being proposed. A plenary session was presented by Andrew Skodol, chair of the work group, reviewing the model in detail, another by John Gunderson taking issue with some of the proposed changes for borderline PD, and another by Peter Tyrer, reviewing a proposal being developed by the World Health Organization for the International Classification of Diseases. There was considerable debate about the DSM-5 work group's recommendations to reconfigure the PDs from criteria-defined categories to narrative-described prototypes, and to decrease the number of specific types from ten to five.

A strategy utilized by the work group was to review the literature for each DSM-IV-TR PD and to consider each PD's “construct validity” based on the published evidence. Based on these reviews, five PDs were not included as specific prototypes; these would now be included in a new diagnosis called PD, Trait Specified, which would lead to an individualized trait profile for each patient. Among the fives PDs not included in the prototype list, the one that has generated the most controversy is narcissistic PD (NPD), and I share some concern about this decision, which I have conveyed to the work group. Here, we have the familiar conundrum that absence of evidence does not necessarily mean evidence of absence of validity of a condition. Patients are very different. Those with borderline PD experience tremendous distress and are treatment-seeking. Patients with NPD, in contrast, often do not accept that they have problems, and it is more common that they are “driven” to treatment by others because of crises at work or at home. In light of the nature of their pathology, it seems unlikely that they would volunteer to participate in research on a disorder that they deny having. In this issue of the Journal, Ronningstam presents a thoughtful clinical perspective on NPD, registering her concerns about not retaining NPD as a specified PD or prototype, particularly that such a change might result in unintended consequences such as diminishing efforts to study and to develop new treatments for this condition. The clinical relevance of the concept of narcissism is also illustrated in this issue of the Journal in the guest column by Ness and Groat.

Also in this issue, we are extremely pleased to include the winning paper of this year's Resident Paper Competition, by Benjamin and colleagues, presenting a most interesting study of an educational intervention in a residency training program on prescribing practices involving the use of generic medications. Prescribing practices are also a focus of the paper by Jayaram et al, presenting an adverse event reporting system developed in a broad campaign to increase a “culture of safety” in clinical work—a goal of paramount importance for all.

John Oldham MD

© 2011 Lippincott Williams & Wilkins, Inc.

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