May, 2013. This issue of the Journal coincides with the May 2013 publication of the fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5). A team of experts and advisors worked hard for over a decade to re-evaluate the contents of DSM-IV-TR and to examine expert opinion and the published literature to consider what revisions would be appropriate for the new diagnostic manual. In addition, for the first time in the history of the DSM revision process, draft revisions were posted on a public website, and comments and suggestions were received from all over the world. Some areas generated much more interest than others, particularly those that were controversial, but in the end a tiered and thoughtful peer-review process led to final decisions about the content of DSM-5.
One of the more controversial areas was that of the personality disorders (PDs). Since being defined by criteria and coded on Axis II in DSM-III and subsequent editions of the DSM, the PDs have been the subject of extensive study, and great progress has been made in our understanding of the heritability, neurobiology, natural course, and treatment of these disorders. A broad consensus has evolved that the PDs might better be conceptualized dimensionally, as extremes on a continuum with non-pathological personality traits, rather than as discrete illnesses defined in the language of the medically familiar categorical disease model. As a member of the Personality and Personality Disorders Work Group, I participated in the challenging effort to study the literature, including the extensive factor-analytic personality trait literature usually focused on non-pathological populations, with the goal of, as much as possible, preserving continuity with the categorical system of DSM-IV-TR, while incorporating the dimensional nature of normal and pathological personality traits. In an iterative process, a model was developed and revised, and the final version of the model was proposed by the Work Group. Although strongly endorsed by the APA DSM-5 Task Force, the APA Board of Trustees designated the proposed model as an “Alternative DSM-5 Model for Personality Disorders” to be placed in Section III (“Emerging Measures and Models”) of DSM-5, allowing time for additional research and for clinicians to become familiar with this new diagnostic approach.
In this issue of the Journal, Morey and Skodol (a Work Group member and chair of the Work Group, respectively) present new data about an important aspect of this alternative model, explicating the systematic evidence-based method used to establish diagnostic thresholds for the PDs—an important criterion for making a DSM-defined PD diagnosis. With the publication of the Alternative Model in DSM-5, studies such as this one will continue to clarify how best to diagnose personality disorders.
In this issue, it is also my pleasure to introduce to our readers our new Contributing Editor, Hal S. Wortzel MD, who succeeds William Reid, MD, as the author of the column on Law and Psychiatry. Dr. Wortzel is an outstanding forensic psychiatrist at the University of Colorado, and we are fortunate to welcome him to the Journal. In his first column in this issue of the Journal, Dr. Wortzel focuses on DSM-5 viewed through a forensic psychiatric lens, quite an important and sometimes unique perspective.
John Oldham, MD