Sunday, March 21, 2010

Forensic fallout of revamping personality disorders

What is a personality disorder?

Your answer likely depends on whether you are a mental health professional, a layperson, or a member of the legal profession, where the term can have a highly scripted meaning with weighty implications.

In fact, the Supreme Court of Washington just ruled that the precise definition is so critical that a judge's refusal of a defense request to define it for a jury invalidated a civil detention order. That's because in Washington, a convicted sex offender cannot be civilly committed to a state hospital unless he has either a personality disorder or a "mental abnormality" that makes him more likely than not to commit sexually predatory acts in the future. The legal distinction between these two conditions derives from the DSM's axial system, under which most illnesses are listed on Axis I but personality disorders are categorized as "Axis II," because they are conceptualized (not always accurately) as more chronic and enduring than acute Axis I disorders.

At the trial of Curtis Pouncy, the prosecution-retained psychologist, Richard Packard, had testified that Curtis Pouncy had both conditions. The jury ultimately found Pouncy to be a Sexually Violent Predator (SVP), but it did not state whether this finding was on the basis of a personality disorder, a mental abnormality, or both. Explained the Supreme Court in overturning the commitment:

"The phrase 'personality disorder' is not one in common usage and is beyond the experience of the average juror. It is a term of art under the DSM that requires definition to ensure jurors are not 'forced to find a common denominator among each member's individual understanding' of the term…. We have no way of knowing from the verdict whether the jury found that Pouncy was an SVP because he suffered from a mental abnormality or a personality disorder. And, if the jury agreed Pouncy suffered from a personality disorder, we have no way of knowing what definition the jury used in reaching this conclusion…. We cannot say the failure to instruct on the definition of 'personality disorder' in no way affected the final outcome of the case; accordingly, it was not harmless. A new trial is required."
The government of Washington is so interested in the precise meaning of the term that in 2009 it actually codified the definition for purposes of SVP civil commitment. Tagging off of the definition in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), the Revised Code of Washington Section 71.09.020(9) now defines a personality disorder as:
"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time and leads to distress or impairment. Purported evidence of a personality disorder must be supported by testimony of a licensed forensic psychologist or psychiatrist."
As Constance Holden reports in the current edition of Science magazine, "Personality disorders are hard to pin down. They don't have a common defining mood or behavior, people don't get hospitalized for having one, and a drug won't cure one."

If that sounds tricky, wait until the American Psychiatric Association adds layer upon layer of new complexity, and in the process completely scraps the definition as reified by government entities such as the Washington state legislature. Under a draft proposal rolled out last month for the new DSM-5* (due out in 2013), the old personality disorders are barely recognizable and some have disappeared altogether.
  • First off, the overarching definition will be new. Now, personality disorders are defined more briefly as:
"the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual's cultural norms and expectations."
Both self-identity and interpersonal functioning are then further defined. For example, poor interpersonal functioning involves failure to develop empathy, intimacy, cooperativeness, or "complexity and integration of representations of others."
  • Next, one rates the person on a set of six traits (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy) to determine whether the general adaptive failure is "associated with extreme levels of one or more" of these.
  • Finally, there are the specific personality "types," whittled down from the current 10 to only five: Schizotypal, Borderline, Obsessive-Compulsive, Avoidant, and Antisocial/Psychopathic. Note that psychopathy will make its grand debut, while narcissistic exits stage left.
In his erudite competency opinion in the Brian David Mitchell case, Judge Dale Kimball leaned heavily on narcissistic personality disorder as an explanation for the defendant's presentation. If the Personality Disorders Work Group for the DSM-5 gets its way, that diagnosis will go the way of of hysteria and melancholia. Of course, as the judge wisely pointed out, DSM diagnoses are not directly applicable to ultimate legal issues:

"[I]t is not particularly necessary for the court to determine a specific diagnosis in determining competency.... [E]ither an Axis I or Axis II condition could potentially render a defendant incompetent. And, on the other hand, a defendant could have an Axis I and/or Axis II condition and still be competent."
So, what do you get when you combine five personality types with six crosscutting traits? "A camel -- a horse made by committee," psychologist Drew Westen of Emory University told Science magazine.

And in forensic contexts, how will terms such as "culturally adaptive," "empathy," "cooperativeness," "negative emotionality," and "antagonism" be operationalized? Based on research into how forensic evaluators decide about other value-laden constructs such as psychopathy and risk, dare I predict partisan allegiance will rear its ugly head?

Paul A. Siciliano at Basically Law has more on the Pouncy decision. Psychologist Simone Hoermann has commentary on the DSM-5 personality disorders revamp at her Personality Disorders blog.

*The current DSM and all previous editions are designated by Roman numerals, but the APA has decided to use Arabic numerals starting with the fifth edition.

Photo credits: (1) Vagamundos (Creative Commons license 2.0); (2) Kaptain Kobold (Creative Commons license 2.0)

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DSM-5 POSTSCRIPT: Following much brouhaha, the American Psychiatry Association ultimately did not adopt the more radical proposed changes to the personality disorders for the DSM-5, nor did it remove Narcissistic Personality Disorder (much beloved in some psychiatric quarters) as one of the types. However, the entire axial system (i.e., the distinction between Axis I mental disorders versus Axis II personality disorders) was eliminated. Meanwhile, contemporary research is suggesting that personality disorders -- for example Borderline and Antisocial disorders -- are not nearly as enduring or lifelong as the DSM definitions continue to suggest.

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