Multidimensional perfectionism and the DSM-5 personality traits

Encouraging further research on the dimensional assessment of personality disorders (PDs), Section III of the DSM-5 introduced a hybrid model for the assessment of six PDs employing self-reports on 25 maladaptive personality traits (“DSM-5 personality traits”). Following suggestions that multidimensional perfectionism is an important characteristic across various personality disorders (Ayearst, Flett, & Hewitt, 2012), the present study investigated how personal (self-oriented) and interpersonal (other-oriented and socially prescribed) forms of perfectionism predicted the DSM-5 personality traits in a sample of 311 university students. Multiple regressions (controlling for the overlap between the different forms of perfectionism) showed that socially prescribed perfectionism positively predicted the traits defining schizotypal, borderline, avoidant, and obsessive-compulsive PD; other-oriented perfectionism positively predicted the traits defining narcissistic PD; and both socially prescribed and other-oriented perfectionism positively predicted the traits defining antisocial PD. In contrast, self-oriented perfectionism positively predicted only one of the four traits defining obsessive-compulsive PD (rigid perfectionism). Showing that multidimensional perfectionism predicted all DSM-5 traits defining the personality disorders of Section III, the findings suggest that future DSM-5 updates may profit from including interpersonal aspects of perfectionism as a diagnostic criterion.     

Assessing personality in the DSM-5: the utility of bipolar constructs

All previous editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) have described and assessed personality solely in terms of pathological categories. Nonetheless, there is compelling evidence that normal-range personality traits also provide clinically useful information, emphasizing the importance of thoroughly assessing both adaptive and maladaptive aspects of personality within a clinical context. The proposed inclusion of a dimensional trait model in the upcoming DSM-5 represents an important shift in the understanding of personality pathology and provides an ideal opportunity to integrate the assessment of normal personality into clinical practice. Building on research conceptualizing personality disorders as maladaptive, extreme variants of general personality traits, it is proposed that both normal and abnormal personality can be assessed within the same dimensional model using bipolar constructs. The inclusion of bipolar traits, such as a continuum ranging from introversion to extraversion, would hold numerous advantages for a dimensional model. These benefits include a strong foundation of existing validity research, comprehensive coverage of personality pathology, and the ability to provide useful information about all individuals. Despite potential complexities, the adoption of bipolar constructs within DSM-5's dimensional model presents the greatest opportunity to maximize efficiency, validity, and clinical utility.     

The DSM-5 dimensional model of personality disorder: rationale and empirical support

Ideally, a dimensional model of normal and abnormal personality functioning within the forthcoming DSM-5 would represent a common ground among the existing alternative models and would be consistent with the substantial body of empirical research that has accumulated on such models. The DSM-5 Work Group had the opportunity to make an historic step toward the integration of the normal personality traits researched within psychology with the personality disorders of psychiatry. They chose instead to construct a cumbersome six-dimensional model of personality disorder that excludes normal personality traits, is inconsistent with the preponderance of the research, and is distinguished explicitly from the predominant dimensional model of general personality structure.     

DSM-5 personality traits and DSM-IV personality disorders

Two issues pertinent to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) proposal for personality pathology, the recovery of DSM-IV personality disorders (PDs) by proposed DSM-5 traits and the validity of the proposed DSM-5 hybrid model, which incorporates both personality pathology symptoms and maladaptive traits, were evaluated in a large undergraduate sample (N = 808). Proposed DSM-5 traits as assessed with the Personality Inventory for DSM-5 explained a substantial proportion of variance in DSM-IV PDs as assessed with the Personality Diagnostic Questionnaire-4+, and trait indicators of the 6 proposed DSM-5 PDs were mostly specific to those disorders with some exceptions. Regression analyses support the DSM-5 hybrid model in that pathological traits, and an indicator of general personality pathology severity provided incremental information about PDs. Findings are discussed in the context of broader issues around the proposed DSM-5 model of personality disorders.     

Contributions from personality- and psychodynamically oriented assessment to the development of the DSM-5 personality disorders

Advances in personality assessment over the past 20 years have notably influenced the proposed assessment and classification of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]). However, a considerable body of personality assessment and psychodynamically oriented assessment research has significant relevance to the way in which personality disorders are evaluated that appears to have gone unrecognized in the current proposals for DSM-5. In this article, I discuss the ways in which some of these 2 bodies of literature can and should inform the DSM-5 so that the diagnostic nomenclature can be more scientifically and comprehensively informed and consequently improve the clinical utility of a diagnostic system in need of considerable revision.     

Normative and Maladaptive Personality Trait Models of Mood,Psychotic, and Substance Use Disorders

The Personality Inventory for DSM-5 (PID-5) is a questionnaire developed to assess the five domains represented in the alternative model for personality disorders proposed in Section III of the DSM-5. This study examined the ability of the PID-5 to distinguish between different mental disorders compared to a questionnaire measure of the five-factor model (FFM) of normative personality. The study included the administration of the PID-5 and Revised NEO Personality Inventory (NEO PI-R), a measure of the FFM, to treatment-seeking individuals with Depressive, Bipolar, Psychotic, and Alcohol Use Disorders (AUD). Diagnostic groups were compared at the domain level of PID-5 and NEO PI-R, with sex and age as covariates. The main findings on the PID-5 included higher Detachment scores for Bipolar and Depressive Disorders than Psychotic and AUDs, lower Psychoticism/higher Disinhibition scores for the AUD group compared to all other groups, and lower Negative Affect for the Psychotic Disorders versus AUD group. On the NEO PI-R, the AUD diagnostic group was associated with lower Conscientiousness and Agreeableness scores compared to all other groups, and lower Neuroticism scores than the Bipolar and Depressive groups. Group pairwise comparisons did not appear to show many differences between the PID-5 and NEO PI-R. The results suggest that the alternative DSM-5 model for personality disorders may have clinical utility in distinguishing personality profiles between diagnostic groups. These findings emphasize the importance of additional research on the capacity of maladaptive personality to contribute to the assessment of differential diagnoses.     

Deriving an empirical structure of personality pathology for DSM-5

The DSM-IV model of personality disorders is composed of trait sets arranged into 10 theoretically distinct, polythetically assessed categories, with little regard for how the traits comprising these disorders are interrelated and structured. Research since the publication of DSM-III has shown that this model is untenable. The question is not whether this model needs revision; rather, the question is how to move from the existing DSM-IV framework to a model better connected with data. Empirically-based models of personality trait variation provide a starting point for DSM-5, and ongoing research will be used to delineate further the empirical structure of personality traits in the pathological range. The ultimate goal is to frame future DSMs in a way that is maximally useful for clinicians as well as researchers. It is also critical to understand that the DSM-5 is intended to be a living document that will facilitate novel inquiry and clinical applications, as opposed to a document designed to promote and perpetuate a fixed set of constructs. Thus, we view a proposed trait system as a first step on a path to a well-validated, clinically-useful structure.     

An interpersonal analysis of pathological personality traits in DSM-5

The proposed changes to the personality disorder section of the Diagnostic and statistical manual of mental disorders (5th ed.) places an increased focus on interpersonal impairment as one of the defining features of personality psychopathology. In addition, a proposed trait model has been offered to provide a means of capturing phenotypic variation on the expression of personality disorder. In this study, the authors subject the proposed DSM-5 traits to interpersonal analysis using the inventory of interpersonal problems-circumplex scales via the structural summary method for circumplex data. DSM-5 traits were consistently associated with generalized interpersonal dysfunction suggesting that they are maladaptive in nature, the majority of traits demonstrated discriminant validity with prototypical and differentiated interpersonal problem profiles, and conformed well to a priori hypothesized associations. These results are discussed in the context of the DSM-5 proposal and contemporary interpersonal theory, with a particular focus on potential areas for expansion of the DSM-5 trait model.     

Reconceptualizing personality pathology in DSM-5: limitations in evidence for eliminating dependent personality disorder and other DSM-IV syndromes

The DSM-5 Personality and Personality Disorders Workgroup proposed that five DSM-IV personality disorders be eliminated as formal diagnostic categories (paranoid, schizoid, histrionic, narcissistic, and dependent), because these syndromes purportedly have low clinical utility and minimal evidence for validity. Scrutiny of studies cited in support of this proposal reveals difficulties in three areas: (1) Inadequate information regarding parameters of the literature search; (2) Mixed empirical support for proposed changes; and (3) Selective attention to certain disorders and not others. Review of validity and clinical utility data related to dependent personality disorder indicates that evidence regarding this syndrome does not differ from that of syndromes proposed for retention in DSM-5. Limitations in the research base cited by the workgroup illuminates gaps in the personality disorder literature, and may serve as a starting point for systematic research on personality pathology so that adequate empirical data are available to decide which syndromes to retain, revise, or remove in future versions of the diagnostic manual.     

Personality in DSM-5: helping delineate personality disorder content and framing the metastructure

The transition from the Diagnostic and Statistical Model of Mental Disorders (4th ed., text revision [DSM-IV-TR]; American Psychiatric Association, 2000 ) to the fifth edition (DSM-5) represents an unprecedented opportunity to integrate dimensional personality trait models into the official nosology. Not surprisingly, a variety of issues have arisen in contemplating this challenging integration. In this article, we address how a dimensional personality trait model could be a helpful component of DSM-5, from the perspective of our roles as work group members and advisors involved in the creation of a trait model and corresponding assessment instrument. We focus in particular on two potential roles for a trait model in DSM-5 that are under official consideration. First, a dimensional personality trait model might be helpful in delineating the content of personality disorders. Second, a trait model might assist in organizing the "metastructure" of DSM-5 (i.e., the arrangement of chapters and other broader classificatory rubrics).     

Persönlichkeitsdiagnostik im DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in May 2013 and features (in Section III) a new model for the diagnosis of personality disorders. The aim of this paper is to introduce this model to a broader German-speaking readership. The article begins by explaining why a new model seems necessary. Secondly, the different components of the new DSM-5 model are presented, the theoretical and empirical background is explained and it is shown how the model works using a clinical case example. Thirdly, several advantages of the new model as compared to the DSM-IV diagnostic categories (which will be retained in DSM-5 Section II) are discussed. Finally, the article highlights some open questions and problems that require further conceptual and empirical research.     

Introduction to the special issue on personality assessment in the DSM-5

The DSM-5 is poised to dramatically reshape the way clinicians and researchers assess personality by reconfiguring the conceptualization of DSM-IV personality disorders. This special issue brings together leading scholars in personality pathology, including members of the DSM-5 Personality and Personality Pathology Work Group, as well as personality assessors operating from a variety of theoretical perspectives, to describe various facets of these changes and their potential impacts and in some cases to propose alternative solutions. As we describe in this brief introductory article, the articles in this special issue highlight several important and controversial issues in the transition to DSM-5 personality assessment.     

A framework for integrating dimensional and categorical classifications of personality disorder

Although empirical evidence strongly supports a dimensional representation of personality disorder, there is strong resistance to dimensional classification due in part to concerns about clinical utility. Acceptance of an evidence-based dimensional classification would be facilitated by information on how such a system would map onto existing diagnoses. With this objective in mind, an integrated framework is proposed that combines categorical and dimensional diagnoses. A two-component classification is adopted that distinguishes between the diagnosis of general personality disorder and the assessment of individual differences in the form the disorder takes. Then, the DSM definition of personality disorders is extended by defining individual disorders as categories of trait dimensions. This makes it possible to develop an integrated classification organized around a set of empirically derived primary traits. Assessments of these traits may then be combined to generate categorical and dimensional diagnoses. It is argued that this approach would introduce an etiological perspective into the classification of personality disorder and improve categorical classification by providing an explicit definition of each diagnosis. The clinical utility of incorporating a dimensional classification is discussed in terms of convenience and acceptability, value in predicting outcomes and treatment planning, and usefulness in organizing and selecting interventions.     

Toward a multidimensional model of personality disorder diagnosis: implications for DSM-5

This article outlines a model of personality disorder (PD) diagnosis that combines clinically useful constructs from the Diagnostic and Statistical Manual of Mental Disorders (DSM) with assessment procedures that maximize reliability and clinical utility while minimizing problems associated with threshold-based PD classification. I begin by addressing limitations in the current DSM conceptualization of PDs: excessive comorbidity, use of arbitrary cutoffs to distinguish normal from pathological functioning, failure to capture variations in the adaptive value of PD symptoms, and inattention to situational influences that shape PD-related behaviors. The revisions proposed by the DSM-5 Personality and Personality Disorders Work Group help resolve some of these issues, but create new problems in other areas. A better solution would be to employ a multidimensional model of PD diagnosis in which clinicians (a) assign a single dimensional rating of overall level of personality dysfunction, (b) provide separate intensity and impairment ratings for each PD dimension, and (c) list those personality traits-including PD-related traits-that enhance adaptation and functioning. Preliminary evidence bearing on the multidimensional model is reviewed, and broader clinical and empirical implications of the model are discussed.     

The central domains of personality pathology in psychiatric patients

There is general agreement that the classification of personality disorders in DSM-IV is unsatisfactory. We systematically reviewed all studies that have analyzed patterns of personality disorder symptoms and signs in psychiatric patients; twenty-two papers were included in the final synthesis. There is reasonable consistency over the number and type of personality pathology traits reported despite differing samples, varying assessment methods, and different statistical manipulations. There are three or four high order traits; an externalizing factor incorporating borderline, narcissistic, histrionic, and antisocial traits (the latter is sometimes recorded as a separate trait); an internalizing factor incorporating avoidant and dependent traits; a schizoid factor; and often a compulsive factor. Using these domains of personality pathology would simplify classification, have higher clinical utility, and allow relatively easy translation of current research.     

Emergent Issues in Assessing Personality Pathology: Illustrations from Two Studies of Adolescent Personality and Related Pathology

As illustrated by two articles that each investigate personality pathology and its correlates in adolescents—Aelterman et al. (2010) on obsessive-compulsive personality disorder (OCPD) from a dimensional personality perspective, and Barry and Wallace (2010) on indicators of pathological and normative development of youth narcissism—this commentary discusses four important assessment issues that have become more salient as the field considers a shift, through proposed changes in the DSM, to an approach that incorporates trait dimensions as an important aspect of diagnosis: (1) the importance of using multiple information sources for valid personality/ PD assessment; (2) relations of personality traits to (mal)adaptivity in general and also with regard to (3) trait uni- versus bi-polarity; and (4) whether personality types have incremental predictive value beyond their component personality traits and related pathology. The article also discusses why research on childhood and adolescent personality/ PD is important in addressing these issues.     

Do DSM-5 personality disorder proposals meet criteria for clinical utility?

The Work Group for the DSM-5 personality disorders has submitted their proposal to the professional community. In this paper, we consider the proposal in light of its ability to meet criteria for clinical utility as proposed by First and colleagues (2004). While the Work Group's proposal has addressed some of these concerns, we conclude that there remain several unanswered problems with how the proposal will improve the clinical utility of personality disorders section of the DSM-5. Though these concerns can be addressed to some extent in the field trials, it is incumbent upon the Work Group and clinical researchers to attend carefully to these issues so that shortcomings of previous diagnostic manuals are not repeated in the future.