Prepared by W. John Livesley, M.D., Ph.D.
The proposed classification will retain the diagnosis of personality disorder but change diagnostic criteria because the DSM-IV criteria are poorly defined and not specific to personality disorder. Incorporation of dimensional classification into DSM-V necessitates the use of criteria for general personality disorder that are distinct from trait dimensions, because an extreme position on a trait dimension is a necessary but not sufficient condition to diagnose personality disorder (Wakefield, 1992; 2008). Literature reviews revealed a few systematic definitions that clearly differentiated personality disorder from trait extremity (Livesley, 2003; Livesley & Jang, 2005). A literature review indicated that personality disorder implies pervasive disorganization in personality structure and functioning that is manifested as a broad failure to develop important personality structures and capacities needed for adaptive functioning. These adaptive failures are manifested as: (1) the failure to develop coherent sense of self or identity; and (2) chronic interpersonal dysfunction (Livesley, 1998). Evaluation of self pathology will be based on criteria indexing three major developmental dimensions in the emergence of a sense of self: differentiation of self-understanding or self-knowledge (integrity of self-concept), integration of this information into a coherent identity (identity integration), and the ability to set and attain satisfying and rewarding personal goals that give direction, meaning, and purpose to life (self-directedness). These dimensions capture important aspects of self and identity problems described in the clinical literature (see Cloninger, 2000; Horowitz, 1979; Kernberg, 1984; Kohut, 1971) in a format that is consistent with cognitive approaches to personality. Interpersonal pathology is evaluated using criteria indexing failure to develop the capacity for empathy, sustained intimacy and attachment (labeled intimacy in the proposal), prosocial and cooperative behavior (labeled cooperativeness in the proposal) and complex and integrated representations of others. This component reflects a second emphasis in the clinical literature (see Rutter, 1987; Benjamin, 1996).
References for Definition and General Diagnostic Criteria
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Horowitz MJ: States of Mind. New York, Plenum Press, 1979
Kernberg OF: Severe Personality Disorders. New Haven, CT, Yale University Press, 1984
Kohut H: The Analysis of the Self. New York, International Universities Press, 1971
Livesley WJ: Suggestions for a framework for an empirically based classification of personality disorder. Can J Psychiatry 1998; 43:137-147
Livesley WJ: Diagnostic dilemmas in the classification of personality disorder. In Advancing DSM: Dilemmas in Psychiatric Diagnosis. Edited by Phillips K, First M, Pincus HA. Washington, DC, American Psychiatric Press, 2003, pp 153-189
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Wakefield JC: The perils of dimensionalization: challenges in distinguishing negative traits from personality disorders. Psychiatr Clin N Am 2008; 31:379-393