Prepared by Andrew E. Skodol, M.D.
The proposal for specified PD types in DSM-V has four main features: 1) a reduction in the number of specified types from 10 to 5; 2) description of the types in a narrative format that combines typical deficits in self and interpersonal functioning and particular trait configurations; 3) a dimensional graded membership rating of the degree to which a patient matches each type; and 4) a rating of the personality traits most commonly associated each personality type. The justifications for these modifications in approach to diagnosing PD types include the excessive co-morbidity among DSM-IV personality disorders, the limited validity for some existing types, arbitrary diagnostic thresholds included in DSM-IV, and instability of current DSM-IV PD criteria sets.
Considerable research has shown excessive co-occurrence among personality disorders diagnosed using the categorical system of the DSM (Oldham et al., 1992; Zimmerman et al., 2005). In fact, most patients diagnosed with personality disorders meet criteria for more than one. In addition, all of the personality disorder categories have arbitrary diagnostic thresholds, i.e., the number of criteria necessary for a diagnosis. PD diagnoses have been shown in longitudinal follow-along studies to be significantly less stable over time than their definition in DSM-IV implies (e.g., Grilo et al., 2004). The reduction in the number of types is expected to reduce co-morbid PD diagnoses, the use of a dimensional rating of types recognizes that personality psychopathology occurs on continua, and the replacement of behavioral PD criteria with traits is anticipated to result in greater diagnostic stability.
Number and Specification of Types
Five specific PDs are being recommended for retention in DSM-V: borderline, antisocial/psychopathic (possibly with subtypes), schizotypal, avoidant, and obsessive-compulsive. Borderline, antisocial/psychopathic, and schizotypal PDs have the most extensive empirical evidence of validity and clinical utility (e.g., Skodol et al., 2002a; 2002b; Patrick et al., 2009; Siever & Davis, 2004). For example, severe PD types, such as schizotypal and borderline, have been found to have significantly more impairment at work, in social relationships, and at leisure than patients with less severe types, such as obsessive-compulsive disorder, or with major depressive disorder in the absence of personality disorder. Avoidant PD was in between. Even the less impaired patients with personality disorders (e.g., obsessive-compulsive), however, have moderate to severe impairment in at least one area of functioning (or a Global Assessment of Functioning rating of 60 or less) (Skodol et al. 2002). Patients with OCPD are also among the most common in community (Grant et al., 2004) and clinical (Stuart et al., 1998) populations, have increased levels of mental heath treatment utilization (Bender et al., 2001), and along with borderline PD, are associated with the highest total economic burden in terms of direct medical costs and productivity losses of all PDs (Soeteman et al., 2008).
With respect to current models of psychopathy (Patrick et al., 2009), the proposed trait-based prototype for antisocial/psychopathic PD would include both traits related to the disinhibition component (i.e., traits corresponding most directly to the adult features of DSM-IV ASPD) and traits related to the construct of meanness (i.e., traits related to callousness/lack of remorse, conning/manipulativeness, predatory aggression, and excitement seeking). There is abundant evidence that the impulsive-antisocial (disinhibited-externalizing) and affective-interpersonal (boldness-meanness) components of psychopathy differ in terms of their neurobiological correlates and etiologic determinants. This existing evidence base provides a strong foundation formulating and testing questions in relation possible antisocial and psychopathic PD subtypes.
The other DSM-IV PDs (paranoid, schizoid, histrionic, narcissistic, dependent, depressive, and negativistic), and the residual category of PDNOS will be represented by the use of general PD criteria combined with descriptive specification by personality trait profiles, based on most prominent descriptive features, since the literature lends more support for conceptualizing them as one or more dimensions of personality psychopathology than as types.
Dimensional Representation of Types
A “person-centered” dimensional approach to existing categories is the prototype matching approach originally described by Shea et al. (1987). Embedded in the Personality Assessment Form (PAF) are brief descriptive paragraphs emphasizing salient features of DSM-III personality disorders, with ratings of descriptiveness made for each disorder on a 6-point scale. In the context of the National Institute of Mental Health Treatment of Depression Collaborative Research Program, the factor structures of the clinician-rated PAF and an extensive self-report battery of personality traits were similar (Pilkonis & Frank, 1988) indicating construct validity. Patients with personality disorders according to the prototype matching had a significantly worse outcome in social functioning and were more likely to have residual symptoms of depression than were patients without personality disorders (Shea et al., 1990), similarly to results of longitudinal studies using standard DSM-IV diagnostic criteria assessed by semi-structured interview (Grilo et al., 2005; Skodol et al., 2005).
The prototype dimensional model has subsequently been empirically derived and elaborated by Schedler and Westen (Schedler & Westen, 2004; Westen et al., 2006). Twelve personality syndromes were identified from a large national sample of patients who were rated by clinicians using the Shedler-Westen Assessment Procedure-200 (SWAP-200) (Shedler & Westen, 2004; Westen & Schedler, 1999a, 1999b). Each syndrome was then represented by a paragraph-length prototype description. Using this system, a clinician compares a patient to the description of the prototypic patient with each disorder and the “match” is rated on a 5-point scale from 5= “very good match” to 1 = “little or no match.” Prototype ratings have been demonstrated to have good inter-rater reliability. Spitzer et al. (2008) conducted a study of the clinical relevance and utility of five dimensional systems for personality disorders that have been proposed for DSM-V: (1) a criteria counting model based on current DSM-IV diagnostic criteria, (2) a prototype matching model based on current DSM-IV diagnostic criteria, (3) a prototype matching model based on the SWAP, (4) the Five-Factor Model, and (5) Cloninger’s Psychobiological Model. A random national sample of psychiatrists and psychologists applied all five systems to a patient under their care and rated the clinical utility of each system. The two prototype matching models were judged most clinically useful and relevant. The authors concluded that prototype matching systems most faithfully capture personality syndromes seen in practice and allow for rich descriptions without a proportionate increase in time or effort.
Rottman et al. (2009) found that clinicians made fewer correct diagnoses of personality disorders and more incorrect diagnoses when given ratings of patients on a list of the 30 facet traits of the FFM than when given prototype descriptions based on either the SWAP or DSM-IV criteria. And, on most questions about clinical utility, including about treatment planning and prognosis, the prototype systems were rated as superior. According to the authors, these findings indicate that personality traits in the absence of clinical context are too ambiguous for clinicians to interpret: although it may be possible to describe personality disorders in terms of the FFM, mentally translating personality traits back into syndromes or disorders is cognitively challenging.
Hybrid Model of Personality Disorder Diagnosis
Given that multiple candidate models have been suggested for the assessment of personality pathology in DSM-V, Morey et al. (under review) compared the stability and long-term predictive validity of three such models, the five-factor model (FFM), the SNAP, and DSM-IV personality disorders. Participants from the Collaborative Longitudinal Personality Disorder Study were followed for 10 years. Test-retest correlations were computed for measures of each model to assess their stabilities. Baseline data were used to predict long-term outcomes including functioning, Axis I psychopathology, and medication use. Traits were found to be more stable than disorders, even after correcting for short-term assessment dependability. Each model significantly incremented the other models to predict important clinical outcomes. Overall, an approach integrating normative traits and personality disorders was most valid. Within this model, DSM-IV antisocial, borderline, and schizotypal disorders and FFM extraversion and agreeableness provided specific incremental validity over other constructs in these systems, while the other FFM traits and personality disorders appeared to capture overlapping predictive information. The results argue for a hybrid model combining specific PD types and personality traits.
References for Types
Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham JM, Gunderson JG: Treatment utilization by patients with personality disorders. Am J Psychiatry 2001; 158:295-302
Grant BF, Hasin DS, Stinson FS, Dawson DA, Chou SP, Ruan WJ, Pickering RP: Prevalence, correlates, and disability of personality disorders in the United States: results from the national epidemiologic survey on alcohol and related conditions. J Clin Psychiatry 2004; 65:948-958
Grilo CM, Shea MT, Sanislow CA, Skodol AE, Gunderson JG, Stout RL, Pagano ME, Yen S, Morey LC, Zanarini MC, McGlashan TH: Two-year stability and change in schizotypal, borderline, avoidant and obsessive-compulsive personality disorders. J Consult Clin Psychol 2004; 72:767-775
Grilo CM, Sanislow CA, Shea MT, Skodol AE, Stout RL, Gunderson JG, Yen S, Bender DS, Pagano ME, Zanarini MC, Morey LC, McGlashan TH: Two-year prospective naturalistic study of remission from major depressive disorder as a function of personality disorder co-morbidity. J Consult Clin Psychol 2005; 73:78-85
Morey LC, Hopwood CJ, Markowitz JC, Gunderson JG, Grilo CM, McGlashan TH, Shea MT, Yen S, Sanislow CA, Skodol AE: Long term predictive validity of diagnostic models for personality disorder: Integrating trait and disorder concepts. Submitted to American Journal of Psychiatry
Oldham JM, Skodol AE, Kellman HD, Hyler SE, Rosnick L: (1992). Diagnosis of DSM-III-R personality disorders by two structured interviews: patterns of comorbidity. Am J Psychiatry 1992; 149:213-220
Patrick CJ, Fowles DC, Krueger RF: Triarchic conceptualization of psychopathy: developmental origins of disinhibition, boldness, and meanness. Development and Psychopathology 2009; 21: 913-938.
Rottman BM. Ahn WK. Sanislow CA. Kim NS. Can clinicians recognize DSM-IV personality disorders from five-factor model descriptions of patient cases? Am J Psychiatry 2009; 166:427-33
Shea MT, Glass DR, Pilkonis PA, Watkins J, Docherty JP: Frequency and implications of personality disorders in a sample of depressed inpatients. J Personal Disord 1987; 1:27-42
Shea MT, Pilkonis PA, Beckham E, Collins JF, Elkin I, Sotsky SM, Docherty JP: Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program. Am J Psychiatry 1990; 147: 711-718
Shedler J, Westen D: Refining personality disorder diagnosis: integrating science and practice. Am J Psychiatry 2004; 161:1350-1365
Siever L, Davis K: The pathophysiology of schizophrenia disorders: perspectives from the spectrum. American Journal of Psychiatry 2004; 161:398-413
Skodol AE, Gunderson JG, McGlashan TH, Dyck IR, Stout RL, Bender DS, Grilo CM, Shea MT, Zanarini MC, Morey LC, Sanislow CA, Oldham JM: Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry 2002; 159:276-283
Skodol AE, Gunderson JG, Pfohl B, Widiger TA, Livesley WJ, Siever LJ: The borderline diagnosis I: psychopathology, comorbidity, and personality structure. Biol Psychiatry 2002; 51:936-950
Skodol AE, Pagano ME, Bender DS, Shea MT, Gunderson JG, Yen S, Stout RL, Morey LC, Sanislow CA, Grilo CM, Zanarini MC, McGlashan TH: Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychol Med 2005; 35:443-451
Skodol AE, Siever LJ, Livesley WJ, Gunderson JG, Pfohl B, Widiger TA: The borderline diagnosis II: biology, genetics, and clinical course. Biol Psychiatry 2002; 51:951-963
Soeteman DI, Hakkaart-van Roijen L, Verheul R, & Busschbach JJ: The economic burden of personality disorders in mental health care. J Clin Psychiatry 2008; 69:259-265
Spitzer RL, First MB, Shedler J, Westen D, Skodol AE: Clinical utility of five dimensional systems for personality diagnosis: a “consumer preference” study. J Nerv Ment Dis 2008; 196:356-374.
Stuart S, Pfohl B, Battaglia M, Bellodi L, Grove W, Cadoret R: The cooccurrence of DSM-III-R personality disorders. J Personal Disord 1998; 12:302-315
Westen D, Shedler J: Revising and assessing Axis II, part I: developing a clinically and empirically valid assessment method. Am J Psychiatry 1999a; 156:258-272
Westen D, Shedler J: Revising and assessing Axis II, part II: toward an empirically-based and clinically useful classification of personality disorders. Am J Psychiatry 1999b; 156:273-285
Westen D, Shedler J, Bradley R: A prototype approach to personality disorder diagnosis. Am J Psychiatry 2006; 163:846-856
Zimmerman M, Rothchild L, Chelminski I: The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry 2005; 162, 1911-1918