A workable diagnostic system is needed, because sticking with the status quo is not an option

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 Disorders is 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.


The current constellation of disorders 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.