Introduction
The notion that personality disorder is better represented dimensionally was discussed increasingly prior to and shortly after the publication of DSM-III (Walton & Presly, Reference Walton and Presly1973; Eysenck et al. Reference Eysenck, White and Eysenck1976; Wing, Reference Wing1976; Tyrer & Alexander, Reference Tyrer and Alexander1979; Frances, Reference Frances1982; Livesley et al. Reference Livesley, West and Tanney1985; Morey et al. Reference Morey, Waugh and Blashfield1985; Widiger & Frances, Reference Widiger and Frances1985). Consideration was given to introducing a dimensional model for personality disorder in DSM-IV, but there was no consensus on which dimensional model to select and the research literature was not conclusive (APA, 1994).
In the 15 years between the completion of DSM-IV and the establishment of the work group to revise personality disorders in DSM-5, many different dimensional options were developed (Costa & McCrae, Reference Costa and McCrae1990; Harkness et al. Reference Harkness, McNulty and Ben-Porath1995; Livesley, Reference Livesley and Strack2006; Clark, Reference Clark2007; Widiger & Trull, Reference Widiger and Trull2007). This resulted in a voluminous output of studies supporting the dimensional approach. At the beginning of the DSM-5 revision process, it was widely expected that the personality disorders would have a dimensional component. In the closing weeks of the revision process those with final authority decided that the categorical personality disorder model contained in DSM-IV would be reprinted in DSM-5 – with essentially no changes to the criteria. A hybrid model containing dimensions and categories that was intended to be the new DSM-5 model is printed in a section on ‘Emerging Measures and Models’.
Why this outcome? It is a story of shifting expectations, conflicting goals, and fractured alliances. The purpose of this article is to recount the key events that occurred from the beginning to the end of the process as it was experienced by those who lived through it. Doubtlessly it is a history that will be recounted many times, but there is an advantage to reconstructing it while memories are still fresh. If lessons can be learned, they should be.
With these goals in mind, between 12 February 2014 and 17 September 2014, the authors conducted phone interviews with many participants in the DSM-5 revision process (see Supplementary Appendix for details). Ninety-two percent of those contacted agreed to be interviewed. After the first draft of this article was written, all participants were sent a copy and asked for comments and all but one person replied.
Like other histories what we offer here is a partial reconstruction of events. It is based largely on these interviews. Information reported in more than one interview was given special emphasis. Both space limitations and narrative coherence required choices about what to include. Not everyone we spoke with agrees with our choices, but our hope is that we effectively convey why this revision became so complicated a process.
Preparing for DSM-5 (1999–2006)
A vision that would influence the development of the DSM-5 model of personality disorder was articulated in the initial planning phases. In A Research Agenda for DSM-V, Kupfer et al. (Reference Kupfer, First and Regier2002) proposed that ‘a slavish adoption of DSM-IV definitions may have hindered research in the etiology of mental disorders’ (p. xix). Success, they suggested, may require a paradigm shift. One possible form such a paradigm shift could take would be to better integrate categorical and dimensional approaches to diagnosis (Regeir et al. Reference Regeir, Narrow, Kuhl and Kupfer2009).
The most obvious place to initiate such a shift would be for personality disorder because that subfield had an extensive research literature on dimensional models. In the same book, Rounsaville et al. stated:
there is a clear need for dimensional models to be developed and for their utility to be compared with that of existing typologies in one or more limited fields, such as personality … If a dimensional system of personality performs well and is acceptable to clinicians, it might then be appropriate to explore dimensional approaches in other domains (e.g. psychotic or mood disorders) (p. 13).
A Research Agenda was jointly produced by the American Psychiatric Association (APA) and the National Institute of Mental Health (NIMH). The planning phase for DSM-5 involved 11 conferences. Attendance was by invitation only and the presentations were published in a book series entitled Refining the Research Agenda for DSM-V. Signaling its importance, the topic of the first conference, held in 2004, was on dimensional models of personality disorder (Widiger et al. Reference Widiger, Simonsen, Sirovatka and Reiger2007). A second conference on dimensional approaches to diagnostic classification occurred in 2006 (Helzer et al. Reference Helzer, Kraemer, Krueger, Wittchen, Sirovatka and Regier2008). It resulted in a proposal that was intended to be the starting point for a DSM-5 revision (Krueger et al. Reference Krueger, Skodol, Livesley, Shrout, Huang, Helzer, Kraemer, Krueger, Wittchen, Sirovatka and Regier2008). The primary elements of this proposal, similar to the approach of Livesley (Reference Livesley and Strack2006), were a list of 30 pathological personality traits, smaller menus of prominent traits associated with specific personality disorder types, and general criteria for personality disorder impairment. This structure is basically the same as the proposed DSM-5 model.
The initial work of the Personality & Personality Disorders Work Group (2007–2010)
In 2006, David Kupfer and Darrel Regier were named, respectively, chair and vice-chair of the DSM-5 Task Force. One of their first duties was to select the Task Force members who would lead the work groups responsible for the actual revisions.
After Andrew Skodol was named chair of the Personality Disorders Work Group in 2007, it was his task to select members – subject to the approval of the DSM leaders and the Board of Trustees. The approval process was complicated by conflict of interest guidelines. Skodol requested that several prominent personality disorder experts be named as work group members or advisors, but not all his requests were approved. In the final composition of the work group, six of 11 members held Ph.Ds. in psychology. The only returning member from the DSM-IV Personality Disorders Work Group was Larry Siever.
Members of the work group have various recollections of the early phase. They agreed that they had been charged by the leadership to move away from DSM-IV towards a more dimensional approach. Therefore, the name of the group was changed to the Personality and Personality Disorders Work Group (P&PDWG).
Members with degrees in psychology who were trained to test empirically based models of phenotypic structure might have been expected to be most committed advocates for dimensions, but it did not turn out to be that simple. Some of them did believe that the DSM-IV personality disorder categories were neither empirically supported nor clinically useful and should be eliminated from DSM-5. Others believed that a transitional model with bridges back to familiar categories would be better for practical reasons such as clinician acceptability. Also on the committee were those who held that whatever their scientific inadequacies, concepts such as borderline and antisocial personality disorder had enough grounding in clinical experience that they could not simply be ‘deleted’.
Work began with the common task of conducting literature reviews for each DSM-IV personality disorder. Once the reviews were completed, the members readily agreed on which disorders had the most empirical support. Subsequently, as various interviewees noted, vested interests began to show up. For example, should the DSM-5 personality disorder proposal be based on an existing proprietary model such as those measured by the NEO Personality Inventory (Costa & McCrae, Reference Costa and McCrae1992) or the Dimensional Assessment of Personality Pathology (Livesley & Jackson, Reference Livesley and Jackson2009) because it already had a supporting literature, or should it be a new but relatively untested model? If the trait constructs of the psychologists were to be mapped onto the personality disorder types, what counts as a ‘valid’ mapping?
Consensus did not emerge. The members did not agree on the value of clinical experience v. published research, what counts as clinical expertise, the strengths and weaknesses of the extant scientific findings, or how detailed the proposal should be. Depending on the issue, people aligned themselves in different subgroups based on divergent theoretical and clinical perspectives.
The first proposed model (2010)
After the initial phase of the work group, distinct subgroups began to take responsibility for different aspects of the emerging model. There were e-mail exchanges and monthly conference calls throughout the process.
A key event was Skodol's introduction of his first full proposal in autumn 2009. In this proposal personality disorder in general was defined by (a) deficits in self and interpersonal functioning and (b) the presence of pathological personality traits (Skodol et al. Reference Skodol, Clark, Bender, Krueger, Morey, Verheul, Alacron, Bell, Siever and Oldham2011). Self and interpersonal deficits were rated on a scale of 0–4. There were six broad personality disorder traits, each further decomposed into 4–9 specific traits. All traits were rated on a scale of 0–3. Five DSM-IV personality disorder categories were retained: borderline, antisocial, schizotypal, avoidant, and obsessive-compulsive. These were assessed using a prototype matching approach, i.e. a patient was matched to a narrative description of a personality type on a 1–5 scale. If a personality disorder was present, the degree to which a patient possessed the pathological traits associated with that type was rated from 0 to 3. The remaining five DSM-IV personality disorder categories – narcissistic, dependent, paranoid, histrionic, and schizoid, were replaced by a specification of core personality impairments and the patient's distinctive personality traits.
The prototype proposal was designed to correspond to how many practicing clinicians were thought to be making diagnoses (Westen et al. Reference Westen, Shedler and Bradley2006). In taking the lead, Skodol was attempting to exercise leadership and craft a proposal that was both progressive and clinically grounded. Its reception within the P&PDWG was mixed. Some members felt that their input and expertise had been minimized and that the full model was too complex to be used in clinical practice. More than one person was alienated by narrative prototypes.
This first model was posted for public comment on the DSM-5 website in early 2010. Over the next months the P&PDWG carefully considered all the comments received from the website. This was not an easy task as many conflicting views were articulated. The critics were in general agreement in opposing the proposed model, but in fact some groups opposed elements of the model (e.g. prototypes) that other groups strongly preferred and vice versa.
The establishment of oversight committees (2009–2010)
The Scientific Review Committee
The leaders of the Task Force did not want the work groups to treat the DSM categories as ‘inerrant Biblical scripture’ (p. 649). They encouraged them to consider adding more dimensional measures (Regeir et al. Reference Regeir, Narrow, Kuhl and Kupfer2009). By 2009 a small collection of work group chairs and other influential figures both within and outside of DSM-5 began to report quietly to the APA leadership their concerns about the absence of a structure for making and justifying decisions regarding proposed changes. They suggested that some oversight of the Task Force might be helpful. About this same time the chairs of two previous DSM revisions – Robert Spitzer and Allen Frances – began publically complaining about a lack of transparency in the development process (Spitzer, Reference Spitzer2008, Reference Spitzer2009; Frances, Reference Frances2009).
In their interactions with the APA leadership, Kupfer and Regier were consistently positive about the ongoing process – which roused concern given the evidence of internal discontent. When the APA leaders inquired further about the ongoing DSM-5 process, they were not satisfied with the answers. In summer 2009, therefore, they appointed an oversight committee chaired by Carolyn Rabinowitz. The committee's investigation reinforced earlier worries about a lack of structure and led to a recommendation that publication of the new manual be delayed.
By the autumn of 2010 the APA under the Presidency of Carol Bernstein remained concerned about DSM-5's development process. The perceived need for an additional layer of scientific advice between the Task Force and the Board of Trustees led to the establishment of the Scientific Review Committee (SRC). For the DSM-IV revision, the APA Council on Research fulfilled this role, so such a committee had precedent. The SRC was to be chaired by Kenneth Kendler with Robert Freedman as co-chair (Kendler, Reference Kendler2013). The SRC's charge was to provide an independent scientific review of all proposed changes to the DSM and report their findings to the President of the APA, and to Kupfer and Regier.
The SRC's work was to follow a structure outlined in a document entitled ‘Guidelines for making changes to DSM-V’ (Kendler et al. Reference Kendler, Kupfer, Narrow, Phillips and Fawcett2009) that had been formally adopted by the DSM-5, but its recommendations were far from uniformly followed. Several members of the P&PDWG anticipated the trouble that this approach might cause their evolving proposal. ‘The Kendler–Kupfer’ criteria were based on Robins & Guze's (Reference Robins and Guze1970) model for validating diagnostic categories like those used in DSM-IV. According to the SRC guidelines, large changes had to be supported by especially strong support from high-quality research. Still, at this point dealing with the SRC was an issue for the future as more pressing issues came to the fore.
The Yonkers–Nigg P&PDWG
When Skodol presented his first proposal to the Task Force, it was viewed as ambitious, but in conformity with the kind of changes envisioned by the leaders of the Task Force. There was concern about how the merits of these changes would be evaluated; what systematic criteria can be used to evaluate something so different?
At the annual meeting of the APA in May 2010, conflict regarding the P&PDWG proposal was evident. In June, John Gunderson organized a letter signed by 29 prominent members of the research and clinical community addressed to the P&PDWG, the DSM-5 Task Force, and the APA Board of Trustees. The letter articulated why the proposed changes were too radical (Gunderson, Reference Gunderson2013). Later that autumn, the worry that the P&PDWG proposal was in trouble was further reinforced by a letter to the editor in American Journal of Psychiatry (Shedler et al. Reference Shedler, Beck, Fonagy, Gabbard, Gunderson, Kernberg, Michels and Westen2010). The letter was signed by eight prominent leaders in the personality disorder field, and argued that the trait part of the model was derived from studies of normal populations by academic psychologists and would not be useful in clinical practice. They did however, support the use of prototypes.
The criticisms moved the P&PDWG proposal to the top of the list of concerns for the Task Force. Not all agreed on the reasons for the discontent. From Skodol's perspective, the P&PDWG had been hampered by not being allowed to have a large group of advisors (as had been the case on DSM-IV). There was also a perception that the confidentiality agreements the members had signed pertaining to APA copyright of the DSM-5 prevented them from discussing group business outside the group – which was not in fact correct. This perception created animosity among some outside experts. From the DSM-5 leadership's perspective, the prototype proposal was leading to divisions rather than consensus.
In response, Kupfer and Regier established an advisory committee in which Kim Yonkers and Joel Nigg chaired telephone meetings of the P&PDWG. The goal was for these meetings was to get the proposal back to what was envisioned in the pre-DSM-5 ‘refining the research agenda’ conferences (Krueger et al. Reference Krueger, Skodol, Livesley, Shrout, Huang, Helzer, Kraemer, Krueger, Wittchen, Sirovatka and Regier2008) and to develop something that bridged the different perspectives in the work group. All P&PDWG members were invited to participate, but not all did on a regular basis. Regier joined every phone call and Kupfer several of them.
Skodol believed in and fought for prototypes due to their presumed clinical utility, but he was not successful. The outcome of the Yonkers–Nigg committee was a lengthy report introducing a hybrid model that abandoned prototypes in favor of diagnostic criteria, but not DSM-IV criteria. Instead, each of the retained personality disorder types would be defined by particular self and interpersonal deficits and small groups of dimensional personality traits. This new direction gained the support of the Task Force.
The attempt to validate the hybrid model (2011)
When the P&PDWG next met, the hybrid model concept was introduced. In addition the members were informed that narcissistic personality disorder was being re-inserted into the model. Oldham believed this change was an appropriate response to the concerns of many clinicians and scientists (Campbell & Miller, Reference Campbell and Miller2011; Ronningstam, Reference Ronningstam2011). Kupfer and Regier supported this as well. Others strongly believed that the original decision was correct (Alarcón & Sarabia, Reference Alarcón and Sarabia2012) and saw this as a purely political move taken to assuage external criticism.
In the life of the DSM-5 revision, spring 2011 was only 18 months away from the final December 2012 vote by the APA Board of Trustees. The need for a field trial to evaluate the new proposal was pressing. By the time the hybrid model was completed and posted to the DSM-5 website for further public comment, the official DSM-5 field trials had already begun. However, they were not assessing validity and thus would not provide the information the P&PDWG needed for their application to the SRC. The work group's own proposal for a field trial – as envisioned by Morey – was to assess systematically the clinical acceptability of the proposed hybrid model, and evaluate both its overlap and incremental validity relative to DSM-IV.
However, the DSM leadership was not willing (or able) to expand the field trial beyond what was planned to meet the needs of one work group. The P&PDWG's next step was to write an NIMH grant to fund the trial. The proposal earned a high score in its initial NIMH review, but was not funded by the NIMH Advisory Council. Although considered highly meritorious, they decided that it was not the responsibility of the NIMH to fund the development of a classification system owned by the APA. So despite the early involvement of the NIMH in the push for dimensional models in the DSM, they withdrew their support at this crucial time. Indeed, the NIMH was working on a new approach to the conceptualization of psychiatric disorder called the ‘Research Domain Criteria’ or RDoC (Cuthbert & Insel, Reference Cuthbert and Insel2010; Insel et al. Reference Insel, Cuthbert, Garvey, Heinssen, Pine, Quinn, Sanislow and Wang2010).
The negative evaluations of the SRC and CPHC (spring–autumn 2012)
The next step was the reviews of the SRC and a second recently established oversight committee – the Clinical and Public Health Committee (CPHC). As it turned out, the first review was as negative as feared and the second even worse.
SRC evaluation
Skodol reported that many work group chairs had happily returned to seeking incremental improvements in DSM-IV rather than making large changes, but his group continued to pursue the original charge given to them by the leaders of the Task Force. Without the validity data sought by the P&PDWG, however, they were in a difficult position because the standards adopted by the SRC were not aligned with the efforts of the P&PDWG. The SRC had clear criteria for how to evaluate incremental improvements, but for larger changes they wanted extensive, high-quality research. Under this approach, it was not possible to make the argument that DSM-IV was so flawed that it should be replaced entirely, much less replaced with a fundamentally different model. In fact, Michael Rutter reported resigning from the SRC because of concerns that an incremental approach to DSM revision did not allow for nimble adaptation in situations where DSM-IV was lacking in evidentiary support.
The SRC had already reviewed 78 proposals when the personality disorder model came to them in spring 2012. There had also been conflict between the SRC and other work groups who also objected to review criteria which made DSM-IV criteria the default. As Kupfer noted, this type of conflict between work groups and the SRC was not unique to the personality disorders in DSM-5.
The reports submitted by the work groups to the SRC (up to 10 pages long) were named MOEC (Memo Outlining Evidence Change). These were summaries of the evidence for why any proposed change was an improvement on DSM-IV (Kendler, Reference Kendler2013). The P&PDWG's submission was 26 pages long plus an additional 19 pages of references. From the SRC's perspective, the bulk of the report's argument for validity relied on studies of normal, not clinical samples. Joel Yager also formed the impression that the work group members were pushing their own research and short-shrifting studies of other dimensional models in the literature. Others had made similar observations about the research literature cited in support of the proposed model (Blashfield & Reynolds, Reference Blashfield and Reynolds2012).
The SRC typically reviewed three or four proposals per phone meeting, but because of the importance and complexity of the personality disorders, it devoted an entire meeting to the hybrid model. Normally two members were assigned to conduct a careful review beforehand, but for this meeting four people were assigned to do reviews.
The proposal was broken down into six components each of which was rated separately. Similar to the expert consensus model used to evaluate grant proposals, every member of the committee submitted scores which were then averaged. The components were scored on a 1–6 scale with 1 being very good and 3 being the cut-off point for recommending acceptance. For the hybrid model, five of the components of the proposal were rated higher than 4 and one 3.5. That is, according to the SRC none of the components of the model had even modest support with respect to their criteria for evaluation.
Normally the SRC's reports back to the APA President and President-elect were 3–4 pages long. Their report on the hybrid model was 34 pages.
From both the perspective of the SRC and the P&PDWG, their committees were like two ships passing in the night. The charge to the P&PDWG, coming from the DSM-5 Task Force was to attempt something bolder than incremental improvements of DSM-IV personality disorders. The charge to the SRC from APA leadership was to evaluate the validating evidence in support of incremental changes to the categories – with the unstated assumption that if adequate validating data were not available, the DSM-IV criteria and categories should carry forth
CPHC evaluation
In addition to the SRC's focus on incremental improvements a different but still important question was to evaluate the clinical utility and public health consequences of all proposals. This task was assigned to the CPHC chaired by Jack McIntyre and co-chaired by Joel Yager.
A major reason for the establishment of the CPHC in 2011 under the Presidency of John Oldham was to provide another route into DSM-5 for proposals that had limited validating data but still merited inclusion for strong clinical or public health reasons (Yager & McIntyre, Reference Yager and McIntyre2014). As noted, several work groups did not agree with the SRC criteria, including the Substance-Related Disorders Work Group and the Neurodevelopmental Disorders Work Group. With the support of the CPHC some of their new proposals were accepted into the manual despite the objections of the SRC. As the CPHC review of the hybrid personality disorder model drew nearer, however, the sky on the P&PDWG's horizon began to darken.
In May 2012, the APA Assembly DSM-5 Review Committee, which represented practicing psychiatrists from district and state branches across the US, vigorously opposed dimensional models for personality disorder. In their view, dimensional models were too complicated for routine clinical use, regardless of the empirical evidence in their favor. Regier was alarmed because this group had a history of resisting change – and they would have to be part of the final decision process.
In June, John Livesley and Roel Verhuel resigned from the P&PDWG in protest (Frances, Reference Frances2011). Livesley, who stopped attending meetings after the hybrid model was introduced, published a spirited criticism of the DSM-5 process and the hybrid model (Livesley, Reference Livesley2012). Verheul (Reference Verheul2012), whose participation in the group was minimal, did so as well.
In July, Gunderson's group of researchers and clinicians sent another letter to the DSM and APA leadership. They claimed that the many of the problems with the prior proposal had not been fixed by the hybrid model and the process by which this revision was developed was especially problematic.
After the SRC review was submitted, word got out in the community of personality disorder researchers that the SRC had ‘rejected’ the model for inclusion in DSM-5. Many P&PDWG members felt that this wrongly undermined their cause prior to the CPHC review, especially because the SRC was not designed to be an approval committee.
The members of the CPHC knew that the personality disorder proposal needed additional attention. For this reason they recruited eight external reviewers to evaluate the proposal, plus two primary and two secondary reviewers from the committee itself. Instead of their usual procedure of considering one or two proposals in a meeting, they spent three meetings (about 6 h) on the P&PDWG proposal which with attachments was now over 400 pages long. Although two reviewers had positive reactions to parts of the proposal, the others were negative and no one supported it as a whole.
In autumn 2012 the CPHC opined that the hybrid model was attempting too much change too fast without demonstrating improved clinical utility and did not support making it the official DSM-5 model of personality disorder. The members of the P&PDWG were displeased, particularly because several CPHC evaluators claimed to know very little about personality disorders. They were also unhappy that a preliminary report on the perceived clinical utility of the hybrid model from a study that Morey ran based on the unfunded NIMH proposal was dismissed (Morey et al. Reference Morey, Skodol and Oldham2014).
The Summit Group and Board of Trustees (autumn 2012)
Once these decisions were communicated to the P&PDWG, Larry Siever saw clearly that the hybrid model would not be the official DSM-5 model. Regier, Oldham, and Skodol, however, were not willing to give up and buoyed the hopes of the other members.
As noted before, the hybrid model was only one of the controversial issues in the DSM-5 development process. Dillip Jeste assumed the Presidency of the APA in May 2012 and was worried about the final approval process. The DSM-5 development was fragmented into groups with divergent perspectives and strong convictions – a Task Force, work groups, and several oversight committees. The final phase for all proposals had to involve the APA Assembly. A key challenge was that the members of the Assembly (and of the Board of Trustees) were not necessarily experts in nosology and might be more persuaded by some of the criticisms in the media. Meanwhile the Task Force and the work groups had come to believe that since they were the experts, what they recommended should prevail.
For these reasons, prior to the final vote of the Board of Trustees, Jeste convened what he called the Summit Group – which served as a final oversight committee that included the Executive Committee of the Board of Trustees and the chairs of those groups that would be making final reports to the Board. The goal was to overcome fragmentation and develop a cohesive, harmonious set of recommendations. Inviting the APA Assembly to be part of process was also a key reason for convening this group.
In a series of weekly conference calls beginning in June the members of the Summit Group began to develop recommendations about all DSM-5 proposals. Regier was an active participant. Kendler recalled him being a heartfelt, compelling advocate for the hybrid model, extolling the hard work and dedication that went into preparing it. Oldham was given time to plead the case of the P&PDWG and answer questions.
The leadership of both the SRC and CPHC spoke strongly against approving the hybrid model, consistent with their groups’ reports. A large majority of the Summit Group were against recommending approval for the hybrid model. Furthermore, worry was expressed about adopting a model that was still evolving due to ongoing negotiations between Skodol and Oldham and the leaders of the CPHC. People's memories of what revisions were proposed to the CPHC are fuzzy – although many remember that they agreed to re-insert all of the excluded DSM-IV personality disorder categories and develop dimensional criteria for them. Eventually a compromise position was articulated. This was to reprint the DSM-IV personality disorder model in the main text of DSM-5 and print the hybrid model – unrevised – in Section III.
Prior to the Board's final vote in December, there was a November meeting to which the members of the Summit Group were invited. Disagreement still existed. On the topic of personality disorder, the Task Force and the various oversight and approval committees were not in consensus. In the end, the Board voted to reject the hybrid model for inclusion in the main section of DSM-5.
There was, however, an important victory for the model's advocates that Regier organized. The hybrid model would be entitled ‘Alternative DSM-5 Model for Personality Disorders’ – intimating that people were free to choose this alternative if they preferred.
The road to the future
Many readers may be surprised at the intensity of the debate and conclude that the scientific issues were overshadowed by the participants’ emotional investments, but what happened here is characteristic of many controversies. Recent examples in scientifically oriented fields include a rancorous battle between the proponents of cladistic taxonomy, evolutionary taxonomy, and phenetic taxomomy (Hull, Reference Hull1988) and the acrimonious debate about the planetary status of Pluto (Zachar & Kendler, Reference Zachar and Kendler2012). Psychiatrists and psychologists do not have a special immunity to the same kinds of passionate quarrels that occur in other disciplines.
This is not to say that the outcome was inevitable. As of this writing, the next revision of the ICD is proposed to include a dimensional approach to personality disorder emphasizing levels of severity (Tyrer et al. Reference Tyrer, Crawford, Mulder, Blashfield, Farnam, Fossati, Kim, Koldobsky, Lecic-Tosevski, Ndetei, Swales, Clark and Reed2011). This proposal represents a more revolutionary change than the alternative DSM-5 model because personality disorder categories are being eliminated. Why might the WHO accept such a novel approach? The proposed ICD model is more parsimonious than the DSM-5 multi-level categorical-dimensional hybrid, and in that respect is simpler, and therefore described by Tyrer (Reference Tyrer2014) as more clinically useful. Furthermore, the ICD revision has so far been less public and not as complicated by oversight committees and outside interest groups with conflicting priorities. The ICD-11 workgroup also observed what occurred in DSM-5 and has stated a desire to avoid rancor, while still proposing a novel approach (Tyrer, Reference Tyrer2014; Tyrer et al. Reference Tyrer, Reed and Crawford2015).
The initial development of the matrix of constructs for the Research Domain Criteria project was also less public. Nor was it complicated by having immediate relevance beyond the world of academic researchers.
The DSM-5 leaders correctly anticipated that obtaining agreement about which dimensional model to implement would be difficult, but they did not anticipate that obtaining agreement from the broader field to implement a dimensional model of personality disorder itself would be so challenging. This can partly be attributed to a divergence of goals.
For instance, the P&PDWG had the following goals for their revision.
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• Implement an empirically based model of structure for the personality disorder domain that is coherent with the structure of personality in general.
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• Eliminate the arbitrary diagnostic thresholds that create the deceptive appearance of strict category boundaries.
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• Eliminate excessive use of personality disorder – not otherwise specified.
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• Reduce diagnostic co-occurrence among personality disorder types.
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• Reduce the heterogeneity of personality disorder constructs.
The alternative model goes a long way toward achieving these goals. Such goals, however, were not weighted as highly by all concerned.
Recent revisions of nosologic systems have typically involved incremental changes to existing criteria and additions of new categories. The P&PDWG was striving toward something bolder: a first step toward ‘re-boot’ of an entire section of DSM. Their work in statistical modeling using techniques such as factor analysis had convinced them that the latent structure of the symptom space better fit a dimensional model than a categorical one (Eaton et al. Reference Eaton, Krueger, South, Simms and Clark2011). The perception – an oversimplification – that this controversy came down to a clash of scientific cultures between traditional syndromes v. factor analytic models led some to view these disagreements as a technical debate among academics.
On what basis should such a change in paradigm be evaluated? Should the empirical data be especially strong because the change is so large or is less data needed because the proposed conceptual framework is so superior to the ‘hodge-podge’ of the DSM-IV personality disorders?
For large and theoretically substantive changes to be accepted, alliances within the community must hold. In this narrative, the alliances among the opposition held together more than did alliances among the proponents because it was easier for them to agree that they opposed something than it was for the proponents to agree on which of several alternatives to select.
In addition, opposition to the alternative model from within the community of researchers and clinicians who also advocated for dimensional approaches reinforced a worry in the SRC that the alternative model did not reflect a consensus in the field. This worry conflicted with the SRC's goal to alter the culture of the DSM revision process by requiring the process to be data-driven, largely by evidence from validators of diagnostic categories. They wanted all changes to be based on high-quality research and evidence rather than the preferences and opinions of those who happened to be on the relevant work group. Ironically, this goal would be enthusiastically endorsed by the advocates for the alternative model, but they and the SRC had different views about what to label as ‘preferences and opinions’.
It is possible that had there been more time for negotiation between the work group and the relevant scientific and clinical oversight committees or the opportunity to collect sufficient data to support robustly the clinical utility of the new proposal, a different outcome would have occurred. Also, the process was so rushed at the end that there was not enough time for the P&PDWG to articulate how clinical expertise developed in one paradigm (DSM categories) can transfer smoothly to a different paradigm (dimensional profiles).
At the very least, having clear and agreed-upon rules for change that are aligned with the leadership's vision at the beginning of a nosologic revision process is important. Many of the difficulties the P&PDWG faced arose from a shifting set of expectations and conflicting criteria by which to evaluate proposals.
Having arrived at the end of the article we ask again – why this outcome? Despite careful preparation, the extensive evidence supporting dimensional models in the decades leading up to the DSM-5 revision had not been accepted by powerful segments of the psychiatric community. The research community itself had not fully coalesced around a single model, and some people had strong commitments to specific preferred models.
We should also note that most of the participants reported making peace with the outcome and expressed hope that it will support progress. By placing the ‘alternative’ model in Section III, some of the conflict has been reduced. Rather than continuing to oppose the model, early indications are that both advocates and opponents are working together to study it and continue to develop it (Maples et al. Reference Maples, Carter, Few, Crego, Gore, Samuel, Williamson, Lynam, Widiger, Markon, Krueger and Miller2015; Zachar & First, Reference Zachar and First2015). As an ‘official’ alternative, the hybrid model is a recognized competitor to the traditional categorical model. In addition the nosological landscape of the future will be different because it will include the ICD dimensional model (presumably) and RDoC. In tandem they could create a kind of selection pressure on the evolution of the DSM going forward.
As this project unfolded, the participants’ explications of what happened made the story increasingly more complicated, but also made the outcome more understandable. Our impression in conducting the interviews is that no single person knew all aspects of the story, and everyone learned something. There is more to be learned from this history and much left for others to say, and propose. Ideally, processes for helping DSM evolve in a principled way, even in an area as fraught as personality disorder, might be developed from continued reflection upon what – at times – must have felt to those involved like a perfect nosologic storm.
Supplementary material
For supplementary material accompanying this paper visit http://dx.doi.org/10.1017/S0033291715001543.
Declaration of Interest
None.
