Should the demonstration of improved patient outcome be necessary to overhaul diagnostic approaches?: Comment on Bach and Tracy (2022).

I will argue in this commentary that it is premature to change the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition approach toward diagnosing personality disorders to the alternative model for personality disorders (AMPD) because such a change in determining personality pathology will be disruptive, and such a disruption is warranted only when it can be demonstrated that patient outcomes are better. I briefly review studies comparing unstructured clinical evaluations with semistructured interviews for symptom disorders, and these studies have found that there is a high rate of missed diagnoses and misdiagnosis by usual clinical assessment. Although on common sense grounds it seems reasonable to assume that greater diagnostic precision will improve outcome, semistructured interviews are not recommended as the standard of care because no studies of adults have yet demonstrated that patient outcomes are better when semistructured interviews are used instead of unstructured clinical interviews. This logic equally applies to overhauling a diagnostic system. In fact, upon considering an approach toward subtyping patients based on outcome in treatment, it is unlikely that a study randomly assigning patients to competing diagnostic or assessment approaches would demonstrate superiority of one method over the other. Finally, I raise concerns about reliance on self-report scales to assess personality and note an absence of studies comparing self-report and interviewer assessments of the AMPD that computed or discussed the positive predictive value of self-report measures of the AMPD system. (PsycInfo Database Record (c) 2022 APA, all rights reserved).