Portions of these pages were updated on May 1st, 2012
Please find below a list of disorders in the diagnostic class Personality Disorders. The Personality and Personality Disorders Work Group has been responsible for addressing these disorders. You will find that the work group has recommended a significant reformulation of the approach to the assessment and diagnosis of personality psychopathology, including revised general criteria for personality disorder, the provision for clinicians to evaluate a limited set of personality disorder types according to criteria based on core impairments in personality functioning and pathological personality traits, and an overall measure of the severity of personality dysfunction. Accordingly, the structure of this section of the Web site is necessarily somewhat different from that of the other disorders. All of the rationales for each of the proposed disorders in this section have been recently updated.
Changes to the Reformulation of Personality Disorders for DSM-5 (Updated June 21, 2011)
A hybrid dimensional-categorical model for personality and personality disorder assessment and diagnosis has been proposed for DSM-5 field testing. Since its original posting on the APA’s DSM-5 Web site in February of 2010, all parts of the model have been simplified and streamlined in response to comments received and to critiques in the published literature. Diagnostic criteria for specific personality disorders and for Personality Disorder Trait Specified (PDTS) have replaced the originally proposed prototype model.
Six specific personality disorder types (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and, schizotypal) are defined by criteria based on typical impairments in personality functioning and pathological personality traits in one or more trait domains. The diagnosis of Personality Disorder Trait Specified (PDTS) is defined by significant impairment in personality functioning, as measured by the Levels of Personality Functioning scale, and one or more pathological personality trait domains or trait facets. PDTS replaces Personality Disorder Not Otherwise Specified in the proposed DSM-5 system. The levels of personality functioning are based on the severity of disturbances in self and interpersonal functioning. Impairments in self functioning are reflected in dimensions of identity and self-directedness. Interpersonal impairments consist of impairments in the capacities for empathy and intimacy. Five broad personality trait domains (negative affectivity, detachment, antagonism, disinhibition vs. compulsivity, and psychoticism) are defined, as well as component trait facets (for example, impulsivity and rigid perfectionism).
The personality domain in DSM-5 is intended to describe the personality characteristics of all patients, whether they have a personality disorder or not. The assessment can “telescope” the clinician’s attention from a global rating of the overall severity of impairment in personality functioning, through increasing degrees of detail and specificity in describing personality psychopathology that can be pursued depending on constraints of time and information and on expertise.
Clinical Application and Utility
The proposed system is designed for flexible use to maximize clinical utility. Thus, it allows for the diagnosis of specific clinically salient personality disorders, the diagnosis of a fully trait specified personality disorder for patients who do not meet one of the six specific types, the description of heterogeneity of both level of personality functioning and pathological traits within personality disorder types, and the description of the personality trait profile of all patients.
Guide to Implementation
A standard approach to the assessment of personality pathology using the DSM-5 model could be the following:
1. Is impairment in personality functioning (self and interpersonal) present or not?
2. If so, rate the level of impairment in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning on the Levels of Personality Functioning Scale.
3. Is one of the 6 defined types present?
4. If so, record the type and the severity of impairment.
5. If not, is PD-Trait Specified present?
6. If so, record PDTS, identify and list the trait domain(s) that are applicable, and record the severity of impairment.
7. If a PD is present and a detailed personality profile is desired and would be helpful in the case conceptualization, evaluate the trait facets.
8. If neither a specific PD type nor PDTS is present, evaluate the trait domains and/or the trait facets, if these are relevant and helpful in the case conceptualization.
Revised General Criteria for Personality Disorder
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:
A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
B. One or more pathological personality trait domains or trait facets.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
Examples
Here are four examples to illustrate the clinical utility and flexibility of the approach, as well as how it connects with DSM-IV, yet also extends the DSM-IV system to provide more concrete information in a wider variety of clinical scenarios.
Example 1: The patient is a 28-year-old single female, who works as a manager for a city government. She has struggled with an unstable self-image, chronic feelings of emptiness, and difficulties maintaining close romantic relationships for all of her adult life, but she has a few close female friends and is considered a good worker. She is extremely self-critical and attempts to boost her self-esteem by seeking the approval of others. She has been told that she is “needy and often seems desperate,” which leads to some difficulties in maintaining romantic and other close relationships, although she often does not understand what she does that makes this impression. She experiences fluctuating strong emotions, such as panic, fear, depression, and anger, in response to interpersonal disappointments. She has made several suicidal gestures by cutting herself in the past couple of years when stressed by the ending of a relationship. This patient would likely meet criteria in DSM-5 for BPD, but her level of personality functioning might be rated as less impaired than that of the more typical borderline patient, with enhanced prospects for successful treatment.
Example 2: The patient is an adult male in his 20s with a history of problems with substance use, serious trouble with the law, and numerous behaviors that would constitute grounds for arrest, as well as unusual and bizarre behaviors, such as pretending that he can control others with his mind, a tendency toward suspiciousness and withdrawal from social interaction, and a tendency toward fits of rage and “flying off the handle” easily when provoked. In DSM-IV, this presentation would likely be coded as Personality Disorder Not Otherwise Specified, because these features do not readily coalesce into a single and specific (e.g., schizotypal or antisocial) personality disorder. In the proposed DSM-5 system, this presentation can be coded as Personality Disorder Trait Specified, and the specific personality features noted by the clinician (e.g., impulsivity, unusual beliefs and experiences, suspiciousness, withdrawal, hostility) can be recorded in the chart, and can thereby serve as specific foci of clinical attention.
Example 3: The patient is a 14-year-old female with a history of maltreatment, who shows some prodromal signs and symptoms that may foretell a future diagnosis of borderline personality disorder (BPD), but the patient’s personality is not yet fully matured because of her young age. The patient exhibits signs and symptoms compatible with BPD, including emotional lability, physical self-harm, and intense, unstable interpersonal relationships, more so than would be typical for her age-matched peers. In the proposed DSM-5 system, this presentation could be recorded in the chart as a low level of personality functioning and the presence of specific personality traits (such as emotional lability). In this way, these potentially important clinical features are noted and can be followed as the patient matures, without requiring the potentially inappropriate use of a formal BPD diagnosis.
Example 4: The patient is an 50-year-old male with chronic and recurrent major depression, as well as comorbid type II diabetes. In addition to these major psychiatric and medical disorders, the patient tends to be difficult to work with and uncooperative with his caregivers, including being non-compliant with both psychiatric and medical treatment regimens. In the proposed DSM-5 system, these clinically important trait modifiers can be recorded by noting the presence of the trait domain of antagonism and impairment in interpersonal personality functioning in the patient’s chart.
For additional information, please see:
Rationale for the Proposed Changes to the Personality Disorders Classification in DSM-5 (Updated May 1, 2012)
DSM-IV and DSM-5 Criteria Comparison (Updated May 1, 2012)
Rationale for Criterion A and Levels of Personality Functioning (Updated June 21, 2011)
Rationale for Criterion B and the Proposed Trait System (Updated June 21, 2011)
Levels of Personality Functioning Scale
Personality Disorder Types
Clinicians’ Trait Rating Form