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.     

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.     

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.     

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).     

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 assessment in DSM-5: empirical support for rating severity, style, and traits

Despite a general consensus that dimensional models are superior to the categorical representations of personality disorders in DSM-IV, proposals for how to depict personality pathology dimensions vary substantially. One important question involves how to separate clinical severity from the style of expression through which personality pathology manifests. This study empirically distinguished stylistic elements of personality pathology symptoms from the overall severity of personality disorder in a large, longitudinally assessed clinical sample (N = 605). Data suggest that generalized severity is the most important single predictor of current and prospective dysfunction, but that stylistic elements also indicate specific areas of difficulty. Normative personality traits tend to relate to the general propensity for personality pathology, but not stylistic elements of personality disorders. Overall, findings support a three-stage diagnostic strategy involving a global rating of personality disorder severity, ratings of parsimonious and discriminant valid stylistic elements of personality disorder, and ratings of normative personality traits.     

A dimensional model of personality disorder: incorporating DSM Cluster A characteristics

The authors articulate an expanded dimensional model of personality pathology to better account for symptoms of DSM-defined Cluster A personality disorders. Two hundred forty participants (98 first-degree relatives of probands with schizophrenia or schizoaffective disorder, 92 community control participants, and 50 first-degree relatives of probands with bipolar disorder) completed a dimensional personality pathology questionnaire, a measure of schizotypal characteristics, and Chapman measures of psychosis proneness. Scales from all questionnaires were subjected to an exploratory factor analysis with varimax rotation. A 5-factor structure of personality pathology emerged from the analyses, with Peculiarity forming an additional factor to the common 4-factor structure of personality pathology (consisting of Introversion, Emotional Dysregulation, Antagonism, and Compulsivity). These results support a 5-factor dimensional model of personality pathology that better accounts for phenomena encompassed by the Cluster A personality disorders in DSM-IV-TR (4th ed., text revised; American Psychiatric Association, 2000). This study has implications for the consideration of a dimensional model of personality disorder in DSM-V by offering a more comprehensive structural model that builds on previous work in this area.     

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.     

Plate tectonics in the classification of personality disorder: shifting to a dimensional model

The diagnostic categories of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders were developed in the spirit of a traditional medical model that considers mental disorders to be qualitatively distinct conditions (see, e.g., American Psychiatric Association, 2000). Work is now beginning on the fifth edition of this influential diagnostic manual. It is perhaps time to consider a fundamental shift in how psychopathology is conceptualized and diagnosed. More specifically, it may be time to consider a shift to a dimensional classification of personality disorder that would help address the failures of the existing diagnostic categories as well as contribute to an integration of the psychiatric diagnostic manual with psychology's research on general personality structure.     

HiTOP thought disorder,DSM-5 psychoticism,and five factor model openness

HiTOP internalizing, detachment, antagonistic externalizing, and disinhibited externalizing align comfortably with respective domains of the Five-Factor Model (FFM) of general personality. The alignment of HiTOP thought disorder and DSM-5 Section III psychoticism with FFM openness though has been disputed, with the existing research obtaining weak and/or inconsistent results. The purpose of the current paper is to discuss possible reasons for this problematic alignment. The strength of the relationship is hindered in part because it is an alignment of a largely adaptive domain of personality with an entirely maladaptive domain (whereas this is not the case for the other four HiTOP-FFM alignments). The strength of the relationship is also affected by how both openness and psychoticism have been conceptualized and/or assessed.     

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.     

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.     

Categorical versus dimensional status of borderline personality disorder

One of the many controversies concerning the borderline personality disorder (BPD) diagnosis is whether the construct refers to a categorical or dimensional variable. The current study used Meehl's (1973) maximum covariance analysis to investigate this issue. The charts of 409 psychiatric inpatients were systematically reviewed for the presence of BPD and dysthymic symptoms. Charts of 244 inpatients were also reviewed to assess the presence of indicators of male sex, a categorical variable. The results for BPD and dysthymia were consistent with a dimensional model, whereas those for male sex were consistent with a categorical model. A dimensional model of classification of BPD is recommended, and suggestions for future research are provided.     

The structure of DSM-5 posttraumatic stress disorder symptoms in war veterans

Background and Objectives: The present research examined the underlying factor structure of posttraumatic stress disorder (PTSD) as conceptualized in the recently published fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5). Design: Participants were 258 trauma-exposed Iraq/Afghanistan war veterans. Methods: A self-report measure of PTSD symptoms was administered to all participants and confirmatory factor analysis (CFA) was used to compare several different models of PTSD. Results: CFA revealed that the best-fitting model was a six-factor model in which symptoms loaded onto the factors of intrusion, avoidance, negative affect, anhedonia, dysphoric arousal, and anxious arousal. Conclusions: These findings have important implications for ongoing conceptualization of PTSD and suggest that additional modifications to the diagnostic criteria for PTSD may still be warranted to more accurately reflect the underlying structure of PTSD symptoms.     

Alternative dimensional models of personality disorder: finding a common ground

The recognition of the many limitations of the categorical model of personality disorder classification has led to the development of quite a number of alternative proposals for a dimensional classification. The purpose of this article is to suggest that future research work toward the integration of these alternative proposals within a common hierarchical structure. An illustration of a potential integration is provided using the constructs assessed within existing dimensional models. Suggestions for future research that will help lead toward a common, integrative dimensional model of personality disorder are provided.     

DSM-III-R personality disorders and the five-factor model of personality: an empirical comparison.

The relationship between the five-factor model (FFM) of personality and the Diagnostic and Statistical Manual of Mental Disorders (rev. 3rd ed.; DSM-III-R) personality disorders was examined in a sample of 54 psychiatric outpatients. Correlations between raw scores on the NEO-Personality Inventory (NEO-PI) and the number of DSM-III-R personality disorder symptoms rated present using a semistructured interview were computed. In addition, correlations between NEO-PI scores and scores on two self-report personality disorder inventories were also examined to determine which results replicated across instruments. Results indicated that the FFM personality dimensions of Neuroticism, Extraversion, and Agreeableness were most apparent in the DSM-III-R conceptualizations of the personality disorders.     

Judgment research and the dimensional model of personality

Comments on the original article "Plate tectonics in the classification of personality disorder: Shifting to a dimensional model," by T. A. Widiger and T. J. Trull. The purpose of this comment is to address (a) whether psychologists know how personality traits are currently assessed by clinicians and (b) the reliability and validity of those evaluations. Although Widiger and Trull argued that the shift to a dimensional model will improve the diagnosis of personality disorders, we can also expect that it will lead to improvements in evaluating personality traits.