Future of Personality Disorders: ICD Revolutionary, DSM Craven

Uploaded 3/4/2021, approx. 23 minute read

A revolution is underway in the way that we perceive and understand personality disorders.

And I'm going to describe to you today the rudiments and processes involved in this revolution, which is going to culminate these very years within a year or two or three.

So my name is Sam Vaknin, I'm the author of Malignant Self-Love, Narcissism Revisited, and I'm a professor of psychology.

This particular video lecture is part of Unit 4. The next lecture about MBTI, the Myers-Briggs type inventory, is part of Unit 5.

So students in CIAPS and students in Southern Federal University, pay heed, pay attention, and pay note, or you will have me to contend with.

All right, all right, let's get to the point.

As some of you may know, the Diagnostic and Statistical Manual is the bible of the psychiatric profession essentially in North America, mainly in the United States, to some extent Canada. The rest of the world, with the exception of China and Russia, actually use another book. And that book is the International Statistical Classification of Diseases in Related Health Problems, also known for short as the ICD, or International Classification of Disorders. The 11th edition of the ICD has been released online, and those of you with a subscription can access the edition in the website of the World Health Organization, the World Health Organization, the same organization which deals with COVID, and can access the ICD-11 edition.

The ICD-11 is a gigantic book. It has 17,000 categories, 80,000 concepts, 120,000 terms, and well over 1.6 million clinical terms interpreted. It dwarfs the Diagnostic and Statistical Manual, and a part of the ICD is dedicated to personality disorders.

The ICD-11 is the most courageous attempt to revise, revolutionize, and reform the way we regard personality disorders.

The ICD-10-11 suggests to replace all personality disorder categories with a single general personality disorder severity rating, and a five-domain dimensional trait model.

Those of you who are interested in delving deeper, I recommend you read Tyrer, T-Y-R-E-R, Read, R-E-E-D, and Crawford in 2015.

Now, the five trait domains correspond very loosely to the five-factor model of personality.

So, in the ICD-11, there's a single personality disorder, and the personality disorder is rated according to severity, how severe it is, and to each diagnosis, there is an emphasis on trait domains.

The trait domains are negative affectivity, detachment, disinhibition, anancastia, anancastia is a very fancy name for compulsivity, how compulsive the person is, and dissocial or antagonistic trait.

The primary measure for the ICD maladaptive trait model is the personality inventory for ICD-11, which was elaborated upon by Ottmans and Widiger in 2018.

So, the DSM-5, as you will see a bit later in this lecture, also attempted to revolutionize the field, but it failed, and it had failed because of special interest groups, most notably insurance companies. Insurance companies and pharmaceutical companies exert undue influence on the deliberations of the DSM committee, and it's evident in the DSM-5.

Again, we will discuss it a bit later.

So, the DSM-5 is now behind the times when compared to the ICD-11. The ICD-11 is much more advanced and reflects the most recent current knowledge, cutting edge, bleeding edge knowledge.

The passage of the ICD-11 proposal was a paradigm shift in how personality disorders were conceptualized, because the ICD-11 completed the move away from categorical diagnosis to a dimensional trait model classification, something that everyone, myself included, have been advocating since the 1990s.

I had written an article in 1995 suggesting to unify all personality disorders and to move into a dimensional trait model, and that was in 1995, and I was not the first by any stretch of it.

So, the ICD-11s finally did what numerous advocates, especially in the United States, were pushing the DSM committee to do, and they didn't have the courage to resist commercial special interests.

I referred to articles by Kruger, K-R-U-G-E-R, 2016, and by the aforementioned tire, T-Y-R-E-R, 2014. There were objections, of course, a shift of such magnitude, such courageous defiance of commercial interests, insurance companies, pharmaceutical companies. Of course, there were objections, and there were objections also on clinical grounds.

I referred to the work by Bateman, 2011, Gunderson, and Zanarini, in 2011, and others. But these objections were overruled, again, bravely overruled.

There was a last-minute expression of strong opposition, Hiperz, others. And finally, everything settled down, the dust settled down, and it was a compromise struck.

And the compromise was that the severity rating was put much more in alliance with the DSM-5.

It's nowhere as complex as the DSM-5 severity ratings, but there is a lot of congruence and a lot of compatibility and congruence.

And the five-domain model, they added another domain, and they called it borderline, the borderline domain.

The borderline domain in the ICD-11 is the exact equivalent of borderline personality disorder.

And of course, scholars like Judith Herman and others are pushing to reconceive of borderline personality disorder as a form of complex trauma.

I, humbly, am pushing to do the same for narcissistic personality disorder. I'm trying to reconceive of narcissistic personality disorder as a post-traumatic dissociative condition.

Borderline personality disorder is of substantial clinical interest, of course.

There's always been Otto Kernberg and long before, in the 70s.

Ghanderson wrote about it in 2010. Ghanderson and Zanarini in 2011, they summarized the state of affairs at that time.

And even then, borderline was a very prominent feature of the landscape, the scholarly landscape.

Today, narcissism is as prominent as borderline, but as Ghandberg notes, had noted and is still noting repeatedly, the distinction between borderline narcissism is not that clear cut, not that clear cut.

One could easily claim that narcissism is a form of borderline phenomenon, and that they are both on the verge of psychosis.

Anyhow, we're not going to it right now.

If you're interested to hear Kernberg's view, I recommend that you watch his lecture about borderline narcissism. I think it's on the YouTube channel, Borderline Notes, as far as I remember.

And so there were numerous national conferences, international conferences, and in all these conferences, there was this huge debate, how can you create a model of personality disorders with trade domains, which doesn't take into account BPD, borderline personality disorder?

First of all, borderline personality disorder is the most studied. It's the most analyzed. It has the hugest data sets. It's empirically substantiated and validated. The treatment protocols are validated.

Dialectic behavioral therapy, for example, is by far one of the most successful therapies, etc.

So clinicians were concerned that the ICD-11 would be an ICD-11 without reference to borderline would be, how to put it gently, lacking.

And so when borderline was included, everyone was extremely happy. It was an outpouring of scholarly support by Mulder, M-U-L-D-E-R, Kim, Crawford, many others.

Okay. Each member of the World Health Organization is obligated to use a nomenclature that closely conforms to or is in compliance or accordance with the ICD, and it's not fundamentally inconsistent.

I refer you to studies by first, Reed, Hyman, H-Y-M-A-N, and Saxena in 2015.

The conformity between the ICD and, for example, the Chinese DSM or the American DSM is a metaphor of great grave concern because these countries, being the narcissistic civilizations that they are, superpowers, you know, no one tells me what to do, it's my way or the highway, they refuse actually to conform to WHO ICD standards, which is a huge loss and a great pity.

The DSM, for example, Section 2, in addition, DSM Edition 5, Section 2, still uses personality disorder diagnostic categories like paranoid, schizoid, antisocial, histrionic, dependent, narcissistic, and so on and so forth, and that is fundamentally inconsistent with the ICD-11 and, frankly, with the practice of psychiatry throughout the rest of the world.

When I gave a lecture at McGill University, I was actually representing continental psychology, psychology in Europe and psychology in the Middle East and psychology in China. I mean, the rest of the world, the overwhelming vast majority of humanity, don't use any more categorical personality disorders, and I suggested it in my lecture at McGill, I suggested a model to unify personality disorders which in Europe would not have been considered as a major revolution, would have been considered as, well, okay, yet another model because everyone in this dog in Europe is coming with models of suggesting to unify personality disorders.

I was among the first in 95, but I'm not unique in any sense, but in Canada, where McGill University is situated, this was a bit of a shock, as you can see in the video, because in North America, the categorical model is very well entrenched. There's no unifying overall overarching theory of everything.

So let's now talk about North America, Diagnostic and Statistical Manual, Edition 5. When Diagnostic and Statistical Manual was first published in the 50s, it had 100 pages. Now it has close to 1,000. That's not a good sign. It means that we are medicalizing and pathologizing conditions that we should never have. And it means that we are not sure of what we're doing. And it means that the whole field is a huge mess.

As if you take cancer, for example, oncology, there's no textbook in oncology that went from 100 pages to 1,000 pages. No such thing.

And yet in psychology, we have this.

The major innovation in the DSM-3 was the inclusion of specific and explicit criterion sets to facilitate the obtainment of reliable diagnosis.

And at the time in 1980, there were articles by Spitzer, by Williams, by Schulz, extolling this idea.

But when the committee of the DSM-5 had met, the same Schulz in 2012, for example.

So there was a personality and personality disorders work group. So this is a group of scholars and they wanted to, they really wanted, they had the goodwill and the courage to suggest, to revise the DSM-5 and to go back to the DSM-2, which was published in 1968, in which clinicians matched the global perception of a patient to some paragraph description. DSM-2 was narrative. It was literary. It was like a piece of literature. It was holistic in the sense that the clinician was supposed, and I'm quoting, to consider the patient as a whole rather than counting individual symptoms.

There was a DSM-2. So they said the DSM-3 was a mistake. It was a wrong turn in the road. We went, we got lost. We ended up with a list of lists and we ended up with comorbidity and we ended up with polythetic problems. We ended up with situations where two patients can be diagnosed with the same diagnosis and have nothing in common.

So it's a mess.

Let's go back to DSM-2. Let's describe the patient in a holistic manner, capture the patient with the tools of language and impression management and presenting signs, and then at the very end also symptoms of course.

So, Western psychiatrist Bradley in 2006 was strong advocates of this.

Gestalt matching to paragraph narratives is the way to go, they said. It is much easier and quicker than having to systematically assess each individual diagnostic criterion.

And there were articles by Spitzer, by First, by Scheduler, by Western, by Scodle, as late as 2008.

But immediately there was enormous resistance.

Pilkonis, Widiger himself, Zimmerman, they all kind of promised and they said that there was weak empirical support for the reliability and the validity of a holistic evaluation and assessment of a patient.

They said if you deal with symptoms, we have a lot of literature, we have many studies, the symptoms are validated, the valid constructs. There's a lot of empirical data to support symptoms.

But if you look at a patient generally, you're going to end up with literature, not with science.

And of course psychology is a want to be science, not to say I want to be pseudoscience.

So everyone wanted to be extremely scientific with white lab coats. They wanted to feel like, I don't know, medical doctors or physicists.

So they wanted to compose lists the same way physicists have lists of elementary particles.

They didn't realize that Dostoyevsky was the greatest psychologist to have ever lived, for example.

And so finally the resistance was such that the proposal was abandoned and the whole approach, which was essentially a dimensional descriptive narrative approach, was abandoned in favor of the lists and all the lists of symptoms in the DSM-IV had survived in the DSM-5.

Another proposal of the working group was to revise the definition and diagnostic criteria for each respective personality disorder.

They wanted to include or incorporate psychodynamic clinical theory regarding, for example, perception of the self and how it is sometimes impaired when identity and self-direction are problematic.

They are not self-efficacious.

Problems with interpersonal relatedness, empathy, intimacy, they wanted to include all this in the new diagnostic criteria.

It was a dimensional approach. There's a spectrum. Everyone is on a spectrum when it comes to empathy or to perception of self or to self-direction.

They thought it gets much closer to a human being than a list of symptoms.

And so they created what was called later alternative models.

But this provoked enormous fracas, enormous fights and skirmishes.


Because it was founded and derived from psychoanalytic theory regarding the pathology of the self.

It relied heavily on work by Lifeslee and by Kernberg, for example.

And psychoanalysis is a no-no. It's taboo.


Because it's not science. It doesn't use statistics.

My God, can anything in psychology be without statistics? Statistics, it's not scientific.

We are scientists. We are physicists. We are better than physicists. We are, you know, and all this nonsense.

So regrettably, the dimensional approach was buried in page 767 in the Diagnostic and Statistical Manual Edition 5.

Because of this, it's not scientific enough approach.

Luckily, we have an alternative diagnostic manual. It's known as the Psychodynamic Diagnostic Manual, or PDM, which I personally much prefer to the DSM, the PDM, Psychodynamic Diagnostic Manual.

Anyhow, so what they had done, they made something called Level of Personality Functioning Scale, LPFS. And it required an assessment of five levels of severity for each of the four self and interpersonal components.

But all these were relegated, thrown into a trash bin called alternative model.

Like, you know, and it's, you know, if you're lazy, intellectually lazy, or ignorant, or both, the vast majority of therapies and psychologists are, I'm sorry to say, you know, it's much easier to work with a bullet point of nine points, nine criteria to select five of them and diagnose the patient.

It takes five minutes, goodbye, give me three hundred dollars.

The alternative model is very complex. It's narrative. It contains nuances. It's nuanced.

It requires investment of think, of thought, of analysis. It's a lot of work.

So the LPFS, while it's much more, if you ask me, closer to reality, the reality of the patient is very unlikely to be used widely together with the alternative model.

And so, Bender, Morris, and Scodell in 2011 argued that there was insufficient empirical support for the alternative models and that it is too complex for clinicians to use reliably. Clark and Hopperich in 2011 had written an article describing how the poor clinicians would have to work so hard and it's so complex and they would have to invest so much time.

Poor clinicians, they just charge a month's salary every week. So, they're not supposed to work. Talk about entitlement.

In addition, the American Psychiatric Association is now gradually becoming a medical association. They want to be like medicine. They want to be medical doctors. They don't want to be psychologists, which are frowned upon and mocked and derided wherever you go, or feared. They want to be more like medical doctors.

So now the APA is touting and promoting neurobiological models of psychopathology, whatever the heck that means, that neurobiological models are philosophically nonsensical because it's a god-awful contribution, confusion between causation and correlation, and because we don't know if there are third structures that create the two effects. And because of numerous other philosophical arguments, neurobiological models of psychopathology are both philosophically untenable and not rigorous and hubristic and arrogant. They're hubristic and arrogant because we know close to nothing about the brain. We know almost nothing about the brain as we are discovering year by year.

And so to pretend that we know everything there is to know about the brain and then to construct a whole psychopathology on this, that's seriously grandiose. I mean, these people should be diagonals. And I'm talking about Kupfer and Rijers, R-E-G-I-R-K-S, for example, and others.

And the minute these people heard psychoanalysis, what are we going back 100 years to this fake charlatan, Sigmund Freud, and his literary inventions that cannot be tested in a laboratory with a white coat and cannot be converted into statistics? What did this guy know about anything?

Well, in one of my future lectures, you will find out that actually Freud had predicted perfectly most of the developments in current neuroscience. That's how stupid he was. That's how much of a dilettante, a charlatan he was.

So this proposal was shelved or actually relegated to the annexes and appendixes and other ones.

Another proposal for the DSM-5 was to delete half of the diagnostic categories because there were diagnostic occurrences known as comorbidities. And so they said there are too many diagnoses. We need to get rid of a few of them. We get rid of a few of them. People will fit snugly and conveniently into one. We wouldn't have to diagnose them with four personality disorders, one mood disorder, one eating disorder, and one substance abuse disorder, and one stupidity disorder.

I mean, let's enlarge the categories, make them more inclusive so that we can assign one category per person. There was Sosnowski 2012.

And so initially they wanted to delete the gout narcissistic, dependent, paranoid, schizoid, and histrionic personality disorders.

First of all, the narcissistic personality disorder was saved. And it was saved because of critical reviews that documented huge empirical support for narcissism.

And I refer you to work by Pincus, Miller, Widiger, Campbell, The Campbell, the experimentalist, Ronningstone, many others.

Narcissism is extremely well documented and supported and validated empirically.

And so narcissism was instantly restored, but there were huge debates about the others.

Dependent personality disorder, also colloquially known as codependency. Does it exist? Is there empirical evidence for it? What about paranoid? What about schizoid? What about histrionic?

They were huge debates.

Mullins, Switz, S-W-A-T-T-B-R-I-N-G-O-D, Bernstein, Widiger himself, I mean, they were all debating, should we keep these or not?

And finally they decided, you know what, even the diagnosis that don't have a lot of empirical support, for example, schizoid personality disorder, we're going to keep them. We're going to retain them.

Each and every turn there was a lack of courage, intellectual integrity in the DSM committee.

The DSM-5 is a fudge. It's a mess. It's a mess. It's a cocktail, poisonous, toxic cocktail of the DSM-4 approach and a halfhearted whistle attempt to introduce some dimensionality.

So there are questions remaining about many of these personality disorders.

For example, there's not much empirical support for histrionic personality disorder. It's widely considered honestly as a culture bound syndrome. It means that histrionic personality disorder is a disorder invented by white, old men because they dislike, sexually liberated or even promiscuous women. Nevermind that histrionics are actually hypersexual. They are so-called frigid.

Okay, so Blashfield, Reynolds, Stennett had written extensively about the lack of empirical support for histrionic personality disorder.

Hopwood, Thomas wrote about the lack of empirical support for paranoid and schizoid personality disorder, etc.

Everyone was gunning out for his or her unfavorable personality disorder that he or she wanted deleted from the Diagnostic and Statistical Manual.

It was a hell of a mess. The chair and vice chair of the DSM-5 committee, they said that the primary contribution of the DSM-5 would be to shift towards a dimensional model of classification.

So you've had articles by Regier, mainly R-E-G-I-E-R, Narrow, Kuhl, and Kupfer. And they were sort of touting this shift to dimensionality.

There was another work group called the Nomeclature work group, and they had a planning conference, and they were supposed to address fundamental assumptions of the diagnostic system. And the conference concluded with a whimper, rather than a bang, but with a whimper.

And they said that it's important that consideration be given to advantages and disadvantages of basing part or all of the DSM-5 dimensions rather than categories.

No kidding, that was a revolutionary statement about 40 years too late, and I'm referring to R-E-G-I-E-S-A-V-I-L-L-E, and others.

They suggested that a dimensional model should be developed in particular for personality disorders. I'm quoting, 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.

Wow. Talk about revolutionaries.

And then there was a subsequent research planning conference. The DSM committee was devoted to documenting the empirical support for dimensionality and personality disorders.

Simonson was involved with the jury. So this was followed by another research planning conference, which was devoted to the proposals to shift the entire manual to the dimensional model, including personality disorder.

And everyone was shouting, shroud, wonk, many scholars were involved. Everyone was shouting and screaming and opposing and deposing, and finally everything calmed down.

And the main working group for personality disorder suggested the five-domain, 25-maladaptive trait model that could be used to describe a patient, but was also part of a newly proposed diagnostic criterion sets for the traditional personality disorder categories.

And the five domains that they had come up with were very similar, actually, to the ICD-11. ICD-11, the first edition, the review edition of ICD-11 was published, if I remember correctly, in 2008 or 2009.

So they knew about it. And mysteriously, the five domains which were recommended for the next edition of the DSM-5, edition five, at the time in 2011 were very similar. And the five domains were negative affectivity, detachment, psychoticism, antagonism, and disinhibition.

And the primary measure was personality inventory for DSM-5. That's how you measured the maladaptive traits.

Okay. Then there was a task force. And then there was a scientific oversight committee. And then there was the APA board of trustees. And then everyone was fighting with everyone. And then everything was rejected. I'm kidding you're not. All this work, years in the making, was rejected. By that time, and I'm talking about 2013, 2012-13, there was overwhelming preponderance of empirical evidence in support of the dimensional trait proposal. Even the five-factor model essentially is dimensional. Every work in personality theory is essentially dimensional. But special interests criticized the literature review of the working group that it was confined largely to studies offered by members of the group. And they did not cite other additional research.

Gore wrote about it, Kring, it was important, said the supervising bodies, said it was important for the proposal to be acceptable to clinicians. Poor clinicians, they overworked. God forbid they would have to invest some effort and sweat in extracting money from their clients.

There have been a number of studies documenting empirically that clinicians prefer the dimensional trademark over the existing diagnostic categories, but they find it much more complex and too hard to implement.

In other words, the lazy.

Glover wrote about it. Loew, L-O-W-E, Widiger, Samuel, others wrote about it. So ultimately, the literature review as well had not been completed.

Now that we encounter the incompetence of Americans in coping with COVID-19, I am not surprised. I'm not surprised. Everything in the United States is a facade. It's a facade. There's nothing behind. Nothing works. Nothing functions. The whole thing is a show. Fake it till you don't make it. The whole thing is pretension to. America is a piece of fiction, utter piece of fiction.

And the genius who understood this, his name is Donald Trump. He understood that America is reality TV. And he got to the White House, of course. And later on, a bit later to the Capitol.

Okay. That was my political aside. And so the literature review was rejected. And again, there was a debate among clinicians.

Rotman, AHN, Sunny Slough, Kim, an inmate, Spitzer. And so there was opposition by well-known and well-regarded personality disorder clinicians like Gunderson and Schadler. And so finally they said, you know what, forget the whole thing. Let's forget the whole thing. Let's copy paste the DSM-IV. And at the very end, we will tack on a few pages documenting out the liberations in effect. And some of the ideas we have had, like 2% of the ideas we've had, the dimensional trade proposal is included within Section 3 of the DSM-5 for emerging models and measures.

The introduction to the DSM-5 explicitly acknowledges the failure of the categorical model. I'm going to read to you. It defies belief.

The introduction says the categorical model is wrong and it's a failure. And then the entire manual, except Section 3, is the categorical model.

Can you believe this? Here's what they say.

The once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders.

And further, it is asserted that dimensional approaches will supersede current categorical approaches in coming years.

Following this introduction, they proceed in the rest of the book, hefty, hefty book, 1,000 pages. They proceed with a defunct, inappropriate, inapplicable, wrong model that they are castigating and criticizing in their own introduction. Isn't this a case of multiple personality disorder, currently known under the DSM as dissociative identity disorder? Methinks it is.

Thank you for listening.

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