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Personality and Personality Disorders

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 the proposal of a revised general category of personality disorder, and
the provision for clinicians to rate dimensions of personality traits, a limited set of personality types, and the
overall severity of personality dysfunction. Accordingly, the structure of this section of the Web site is necessarily
somewhat different from those of the other disorders.

Changes to the Reformulation of Personality Disorders for DSM-5 (Updated January 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, the model has been simplified and streamlined in response to comments received and to critiques in the
published literature.

In its current iteration, ratings from three assessments combine to comprise the essential criteria for a
personality disorder:

(1) A rating of mild impairment or greater on the Levels of Personality Functioning (criterion A),

(2) A rating of
(a) a “good match” or “very good match” to a Personality Disorder Type or
(b) “quite a bit” or “extremely” descriptive on one or more of six Personality Trait Domains (criterion B).

(3) Diagnosis also requires relative stability of (1) and (2) across time and situations, and excludes
culturally normative personality features and those due to the direct physiological effects of a substance
or a general medical condition.

The levels of personality functioning are based on the severity of disturbances in self and interpersonal
functioning. Disturbances in thinking about the self are reflected in dimensions of identity and self-directedness.
Interpersonal disturbances consist of impairments in empathy and intimacy. The five disorder types (e.g.,
borderline, obsessive compulsive) are combinations of core personality pathology, personality traits, and
behaviors. Six broad personality trait domains (e.g., disinhibition and compulsivity) are defined, as well as
component trait facets (e.g., impulsivity and perfectionism). Levels of personality functioning, the degree of
correspondence between a patient’s personality (disorder) and a type, and personality trait domains and facets
are all dimensional ratings.

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 “telescopes” 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.
Personality Disorder Types
The essential features of a personality disorder are impairments in identity and sense of self and in the
capacity for effective interpersonal functioning. To diagnose a personality disorder, the impairments must
meet all of the following criteria:

A. A rating of mild impairment or greater in self and interpersonal functioning on the Levels of Personality
Functioning.

B. Associated with a “good match” or “very good match” to a personality disorder type or with a rating of
“quite a bit like the trait” or “extremely like the trait” on one or more personality trait domains.

C. Relatively stable across time and consistent across situations.

D. Not better understood as a norm within an individual’s dominant culture.

E. 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).

Rationale for Definition and General Diagnostic Criteria for


Personality Disorder
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).

Levels of Personality Functioning


The Personality and Personality Disorders Work Group has simplified its measure of severity of impairment in
personality functioning in response to feedback from the original posting in February 2010.

Personality psychopathology fundamentally emanates from disturbances in thinking about self and others.
Because there are greater and lesser degrees of disturbance of the self and interpersonal domains, the following
continuum comprised of levels of self and interpersonal functioning is provided for assessing individual
patients.

Each level is characterized by typical functioning in the following areas:

Self
1. Identity: Experience of oneself as unique, with clear boundaries between self and others; coherent sense of
time and personal history; stability and accuracy of self-appraisal and self-esteem; capacity for a range of
emotional experience and its regulation

2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and
prosocial internal standards of behavior; ability to self-reflect productively

Interpersonal
1. Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing
perspectives; understanding of social causality

2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of
regard reflected in interpersonal behavior

In applying these dimensions, self and interpersonal difficulties should not be better understood as a norm within
an individual’s dominant culture.

Self and Interpersonal Functioning Continuum

Although the degree of disturbance of the self and interpersonal domains is continuously distributed, in practice it
is useful to consider levels of impairment in functioning for efficient clinical characterization and for treatment
planning and prognosis. Patients’ conceptualization of self and others affects the nature of interaction with
mental health professionals and can have a significant impact on treatment efficacy and outcome. The following
continuum uses each of the dimensions listed above to differentiate five levels of self-interpersonal functioning
impairment: No, Mild, Moderate, Serious, and Extreme.

Please indicate the level that most closely characterizes the patient’s functioning in the self and interpersonal
realms:

_____ 0 = No Impairment
_____ 1 = Mild Impairment
_____ 2 = Moderate Impairment
_____ 3 = Serious Impairment
_____ 4 = Extreme Impairment

Definitions of Levels:
0 = No Impairment:

Self:

Identity: Has ongoing awareness of a unique, volitional self, integrated into past and ongoing personal history.
Sense of individuality is not compromised in relationships. Able to recognize and maintain role-appropriate
boundaries. Relatively consistent and self-regulated level of positive self-esteem. Accurate or slightly positively
biased self-appraisal. Capable of experiencing, tolerating, and regulating a range of emotions.

Self-direction: Able to set and aspire to reasonable goals based on a realistic assessment of personal capacities.
Utilizes appropriate and effective standards of behavior, and is able to attain fulfillment in multiple realms. Can
reflect on, and make constructive meaning of, internal experience.

Interpersonal:

Empathy: Capable of accurately understanding the full range of others’ experiences in most situations.
Comprehends and appreciates others’ perspectives, even if disagreeing. Is aware of the effect of own actions on
others.

Intimacy: Desires and engages in multiple caring, close and reciprocal relationships in personal and community
life. Flexibly responds to a range of others’ ideas, emotions and behaviors, striving for cooperation and mutual
benefit.

1 = Mild Impairment:

Self:

Identity: Relatively intact sense of self that is unique and grounded in personal history, with some decrease in
effectiveness and clarity of interpersonal boundaries when strong emotions and mental conflict are experienced.
Self-esteem is somewhat well-regulated, although self-appraisal may be overly or insufficiently self-critical.
Emotional experience may be inhibited or restricted in range, and strong emotions may be distressing.

Self-direction: Goal-directed, but may be excessively or somewhat maladaptively so, somewhat goal-inhibited, or
conflicted. May have an unrealistic or socially inappropriate set of personal standards, limiting some aspects of
fulfillment. Able to reflect upon internal experiences, but may overemphasize a single (e.g., intellectual,
emotional) type of self-knowledge rather than integrate all types.

Interpersonal:

Empathy: Somewhat compromised in the ability to appreciate and understand others’ experiences and differing
perspectives. May tend to see others as having unreasonable expectations or a wish for control. Inconsist
awareness of the effect of own behavior on others.

Intimacy: Capacity and desire to form intimate and reciprocal relationships, but may be inhibited in meaningful
expression and sometimes constrained by any intense emotion or conflict. Ability to cooperate may be
constrained by unrealistic standards. Somewhat limited in the ability to respect or respond to the full range of
others’ ideas, emotions and behaviors.

2 = Moderate Impairment:
Self:

Identity: Excessive other-dependent identity definition, with somewhat compromised boundary delineation, a less
differentiated sense of uniqueness, and inconsistency in sense of personal history. Vulnerable self-esteem
controlled by exaggerated attunement to external evaluation, with a wish for approval and admiration from other
people. Sense of incompleteness or inferiority, with inflated or deflated self-appraisal. Emotional regulation is
predicated on the availability of others in specific ways and/or success in situations that bring external positive
appraisal. Threats to self-esteem may engender strong emotions such as rage and shame.

Self-direction: Goals are more often a means of gaining external approval than self-generated, and thus may
lack coherence and/or stability. Personal standards may be unreasonably high (e.g., a need to be special or
please others) or too low (e.g., not consonant with prevailing social values). Fulfillment is compromised by a
sense of lack of authenticity. Impaired capacity to reflect upon internal experience.

Interpersonal:

Empathy: Compromised ability to consider alternative perspectives; hyper-attuned to the experience of others,
but only with respect to perceived relevance to self. Generally unaware of or unconcerned about effect of own
behavior on others, or unrealistic appraisal of own effect.

Intimacy: Capacity and desire to form relationships, but connections may be superficial and limited to meeting
self-regulatory and self-esteem needs. Compromised in ability to respond appropriately to others; conversely has
unrealistic expectation of being magically and perfectly understood by others. Tends not to view relationships in
reciprocal terms, and cooperates predominantly for personal gain.

3 = Serious Impairment:

Self:

Identity: Sense of unique personal attributes is dysregulated, accompanied by confusion or lack of continuity in
personal history. Weak sense of autonomy/agency, and may experience a lack of identity, or emptiness.
Boundary definition is poor or rigid; may be over identification with others, overemphasis on independence from
others, or vacillation between these. Fragile self-concept, easily influenced by events and circumstances, and
lacking coherence. Self-appraisal is un-nuanced: self-loathing, self-aggrandizing, or an illogical, unrealistic
combination. Emotions may be rapidly shifting or a chronic, unwavering feeling of despair.

Self-direction: Difficulty establishing and/or achieving personal goals. Internal standards for behavior are unclear,
contradictory, and/or circumstantial. Life is experienced as meaningless or dangerous. Compromised ability to
reflect upon and understand one’s own mental processes.

Interpersonal:

Empathy: Ability to consider and understand the thoughts, feelings and behavior of other people is significantly
limited. May discern very specific aspects of others’ experience, particularly vulnerabilities and suffering, and
destructive motivations are often misattributed to others. Generally unable to consider alternative perspectives,
or threatened by a different perspective. Confusion or unawareness of social causality, including the impact of
one’s actions on others.

Intimacy: Relationships are based on a strong belief in the absolute need for the intimate other(s), and/or
expectations of instability, abandonment, and/or abuse. Feelings about intimate involvement with others are
unstable, alternating between fear/ rejection and desperate desire for connection. Little mutuality: others are
conceptualized primarily in terms of how they affect the self (negatively or positively); focused on what (negative
or positive) others have to offer. Cooperative efforts are often disrupted due to the perception of slights from
others.

4 = Extreme Impairment:

Self:

Identity: Experience of a unique self is virtually absent as is any sense of continuity of personal history. A sense
of agency/autonomy is virtually absent, or is organized around perceived external persecution. Boundaries with
others are confused or lacking. Diffuse self-concept, prone to significant distortions in self-appraisal. Personal
motivations may be unrecognized and/or experienced as external to self. Hatred and aggression may be
dominant affects, are disorganizing, and often disavowed and projected.

Self-direction: Poor differentiation of thoughts from actions, so goal-setting ability is severely compromised, goals
often are unrealistic, and goal-setting is incoherent. Internal standards for behavior are virtually lacking. Genuine
fulfillment is elusive and virtually inconceivable. Profound inability to constructively reflect upon one’s
experience.

Interpersonal:

Empathy: Pronounced inability to consider and understand others’ experience and motivation. Attention to
others' perspectives virtually absent (attention is hypervigilant, focused on need-fulfillment and harm avoidance).
Social interactions can be confusing and disorienting.

Intimacy: Desire for affiliation is limited because of profound disinterest or expectation of harm. Engagement with
others is detached, disorganized, or consistently negative. Relationships are conceptualized primarily as power
based, and considered in terms of their ability to provide comfort or inflict pain and suffering. Social/interpersonal
behavior is not reciprocal; rather, it represents fundamental approach (e.g., fulfillment of basic needs) and
avoidance (e.g., escape from pain) tendencies.
Personality Disorder Types

The Personality and Personality Disorders Work Group proposes five specific personality disorder types, to be
rated on a dimension of degree of fit. The five specific types are as follows:

Antisocial/Psychopathic Type
Avoidant Type
Borderline Type
Obsessive-Compulsive Type
Schizotypal Type

Each type is comprised of core personality pathology, personality traits, and behaviors. The other DSM-IV
Personality Disorders and the large residual category of Personality Disorder Not Otherwise Specified will be
represented solely by the core components combined with specification by personality traits, based on their most
prominent descriptive features. See DSM-IV Personality Disorder/DSM-5 Trait Cross-Walk for the representation
of all DSM-IV Personality Disorders by the currently proposed set of DSM-5 traits.

Rationale for Proposing Five Specific Personality Disorder Types


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.

301.7 Antisocial Personality Disorder


The work group is recommending that this disorder be reformulated as the Antisocial/Psychopathic Type.

Individuals who resemble this personality disorder type seek power over others and will manipulate, exploit,
deceive, con, or otherwise take advantage, in order to inflict harm or to achieve their goals. An arrogant, self-
centered, and entitled attitude is pervasive, along with callousness and little empathy for others’ needs or
feelings. Rights, property, or safety of others is disregarded, with little or no remorse or guilt if others are harmed.
Emotional expression is mostly limited to irritability, anger, and hostility; acknowledgement and articulation of
other emotions, such as love or anxiety, are rare. There is little insight into motivations and an impaired ability to
consider alternative interpretations of experience.

Temperamental aggression and a high threshold for pleasurable excitement are typically associated with this
type, linked to reckless sensation-seeking behaviors, impulsivity without regard for consequences, and a sense
of invulnerability. Unlawful or unethical behavior is often pursued, including substance abuse and physical
violence. Aggressive or sadistic acts are common in pursuit of personal agendas, and sometimes pleasure or
satisfaction is derived from humiliating, demeaning, dominating, or hurting others. Superficial charm and
ingratiation may be employed to achieve certain ends, and there is disregard for conventional moral principles.
General irresponsibility about work obligations or financial commitments is commonly present, as well as
problems with authority figures.

301.82 Avoidant Personality Disorder


The work group is recommending that this disorder be reformulated as the Avoidant Type.

Individuals who resemble this personality disorder type have a negative sense of self, associated with profound
feelings of inadequacy, and inhibition in establishing close interpersonal relationships. Anxiety, inferiority, social
ineptness, and a personal lack of appeal are often experienced, along with shame, embarrassment, and self-
criticism. Unrealistically high self-standards are held and there may exist a desire to be recognized by others as
special and unique. On the other hand, self-blame for bad things that happen is common, and often little or no
pleasure, satisfaction, or enjoyment in life’s activities is experienced. Emotions are inhibited or constricted, and
difficulty acknowledging or expressing wishes, emotions (positive and negative), and impulses is present.
Despite high standards, passivity may dominate, undermining pursuit of personal goals or achieving success.
This tendency sometimes leads to inappropriately low aspirations or achievements. Risk aversion is
characteristic. In social situations, behavior is shy or reserved, and sometimes social and occupational situations
are avoided altogether because of fear of embarrassment or humiliation. Sensitivity toward potential criticism or
rejection is high, with reluctance to disclose personal information. Basic interpersonal skills can appear to be
lacking, resulting in few close friendships. Intimate relationships are avoided because of a general fear of
attachments and intimacy, including sexual intimacy.

301.83 Borderline Personality Disorder


The work group is recommending that this disorder be reformulated as the Borderline Type.

Individuals who resemble this personality disorder type have an impoverished and/or unstable self-structure and
difficulty maintaining enduring and fulfilling intimate relationships. Self-concept is easily disrupted under stress,
and often associated with the experience of a lack of identity or chronic feelings of emptiness. Self-appraisal is
filled with loathing, excessive criticism, and despondency. There is sensitivity to perceived interpersonal slights,
loss or disappointments, linked with reactive, rapidly changing, intense, and unpredictable emotions. Anxiety and
depression are common. Anger is a typical reaction to feeling misunderstood, mistreated, or victimized, which
may lead to acts of aggression toward self and others. Intense distress and characteristic impulsivity may also
prompt other risky behaviors, including substance misuse, reckless driving, binge eating, or dangerous sexual
encounters.

Relationships are often based on excessive dependency, a fear of rejection and/or abandonment, and urgent
need for contact with significant others when upset. Behavior may sometimes be highly submissive or
subservient. At the same time, intimate involvement with another person may induce fear of loss of identity as an
individual – psychological and emotional engulfment. Thus, interpersonal relationships are commonly unstable
and alternate between excessive dependency and flight from involvement. Empathy for others is significantly
compromised, or selectively accurate but biased toward negative characteristics or vulnerabilities. Cognitive
functioning may become impaired at times of interpersonal stress, leading to concrete, black-and white, all-or-
nothing thinking, and sometimes to quasi-psychotic reactions, including paranoia and dissociation.

301.4 Obsessive-Compulsive Personality Disorder


The work group is recommending that this disorder be reformulated as the Obsessive-Compulsive Type.

Individuals who resemble this personality disorder type are ruled by need for order, precision, perfection, and
control. There is an overdeveloped sense of duty and obligation, and significant insecurity, anxiety, guilt, or
shame over real or perceived deficiencies or failures may arise. At the same time, behavior or attitudes are
commonly controlling, competitive, and critical. There may be conflict about authority (e.g., pressure to submit to
it or rebel against it), a tendency toward power struggles (overtly or covertly), and a self-righteous or moralistic
attitude. Appreciation of the ideas, emotions, and behaviors of other people is compromised at times. For the
most part, strong emotions – both positive (e.g., love) and negative (e.g., anger) – are not consciously
experienced or expressed, although irritability over self or others falling short of expectations may be common.

Activities are often conducted in super-methodical and overly detailed ways, along with concerns with time,
punctuality, schedules, and rules. The need to try to do things perfectly may result in a paralysis of indecision, as
the pros and cons of alternatives are weighed, such that important tasks may not ever be completed. Tasks,
problems, and people are approached rigidly, and there is limited capacity to adapt to changing demands or
circumstances.
301.22 Schizotypal Personality Disorder
The work group is recommending that this disorder be reformulated as the Schizotypal Type.

Individuals who resemble this personality disorder type have social deficits, marked by discomfort with and
reduced capacity for interpersonal relationships; eccentricities of appearance and behavior, and cognitive and
perceptual distortions. Anxiety in social situations (even when familiar with the situation), feeling like an outcast,
difficulty in connecting with others, and suspiciousness of others’ motivations is typical. Despite any internal
distress at being “set apart”, there appears to be detachment or indifference to others’ reactions. Emotional
experience and expression is likely constricted. Appearance and manner can be eccentric or odd (e.g.,
grooming, hygiene, posture, and/or eye contact are strange or unusual), and speech may be vague,
circumstantial, metaphorical, over elaborate, concrete, or stereotyped. These characteristics are all linked to a
tendency to have few, if any, close friends and/or intimate relationships.

Behavior may be influenced by magical thinking, such as superstitions, or belief in clairvoyance or telepathy.
Perception of reality is sometimes impaired, and reasoning and perceptual processes may become odd and
idiosyncratic (e.g., seemingly arbitrary inferences, or seeing hidden messages or special meanings in ordinary
events), or quasi-psychotic, with symptoms such as pseudo-hallucinations, sensory illusions, over-valued ideas,
mild paranoid ideation, or transient psychotic episodes. There usually is the ability, however, to “reality test”
psychotic-like symptoms, along with intellectual acknowledgement of irrationality and false beliefs.

301.9 Personality Disorder Not Otherwise Specified


The work group is recommending that this disorder not be included in DSM-5. This disorder should be
represented and diagnosed by a combination of core impairments in personality functioning and patients' unique
pathological personality traits.

Prominent Personality Traits: Unique to each individual

Personality Traits
The Personality and Personality Disorders Work Group proposes six broad, higher order personality trait
domains – negative emotionality, detachment, antagonism, disinhibition, compulsivity, and schizotypy – each
comprised of several lower order, more specific trait facets. The broad trait domains are listed below in boldface
with the trait facets comprising each domain listed below the domain name. The proposed trait model is in the
process of empirical validation.

Negative Emotionality is characterized by frequent experiences of high levels of a wide range of negative
emotions (e.g., anxiety, depression, guilt/ shame, worry, anger, etc.), as well as the behavioral (e.g., self-harm)
and interpersonal (e.g., clinginess, mistrustfulness) manifestations of these emotions.

Trait facets: Emotional lability, anxiousness, submissiveness, separation insecurity, pessimism, low self-
esteem, guilt/shame, self-harm, depressivity, suspiciousness

Detachment is characterized by withdrawal from other people--ranging from withdrawal from intimate, friendly,
and social relationships to withdrawal from the world at large; by restricted affective experience and expression;
and by having limited hedonic capacity.

Trait facets: Social withdrawal, social detachment, intimacy avoidance, restricted affectivity, anhedonia

Antagonism is characterized by callous antipathy toward others (e.g., aggression, oppositionality, deceitfulness,
manipulativeness), and a correspondingly exaggerated sense of self-importance (e.g., narcissism).

Trait facets: Callousness, manipulativeness, grandiose narcissism, histrionic style, hostility, aggression,
oppositionality, deceitfulness

Disinhibition is characterized by an orientation towards immediate gratification, with behavior driven by current
thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences.

Trait facets: Impulsivity, distractibility, recklessness, irresponsibility

Compulsivity is characterized by perseverative, perfectionistic thinking, and by acting according to a narrowly


defined and unchanging ideal, and by the rigid expectation that this ideal should be adhered to by everyone

Trait facets: Perfectionism, perseveration, rigidity, orderliness, risk aversion

Schizotypy is characterized by a wide range of culturally incongruent odd, eccentric, or unusual behaviors and
cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs).

Trait facets: Unusual perceptions, unusual beliefs, eccentricity, cognitive dysregulation, dissociation
proneness

Rationale for a Six-Domain Trait Dimensional Diagnostic System


for Personality Disorder
Prepared by Lee Anna Clark, Ph.D., and Robert F. Krueger, Ph.D.
I. For our terminological usage:

Dimension: The term dimension refers to any scaled continuum and thus must always be modified (e.g.,
personality trait dimension) for clarity.

Trait: Similarly, the term “trait” refers to any characteristic (e.g., curly hair is a trait), but we always use it to mean
“personality trait.”

Domain: The term domain is associated in the personality literature with “broad” or “higher order” trait
dimensions, and we have adopted that terminology for consistency with that literature. However, this term also
is used to refer to distinct areas of functioning (e.g., “interpersonal domain”), so we modify the term (i.e., trait
domain) when referring to higher order personality trait dimensions.

Facet: The term facet is associated in the personality literature with “specific” or “lower order” trait dimensions,
and we have adopted that terminology for consistency with that literature. Again, however, because the term
has other, generic meanings, we will use the term trait facets to refer to lower order personality trait dimensions.

II. For proposing traits per se as the PD diagnostic criteria. The use of trait profiles:

A. Eliminates comorbidity and all PD-NOS by providing a specific trait profile for every patient with PD (Clark,
2005, 2007; Krueger, Skodol, Livesley, Shrout, & Hunag, 2007; Trull & Durrett, 2005).
B. Clarifies within-diagnosis heterogeneity by providing a specific trait profile for every patient with PD (Clark,
2007; Trull & Durrett, 2005).
C. Increases diagnostic stability (traits are more stable than PD diagnoses; multiple references, see below).
D. Acknowledges the continuous nature of personality and personality disorder; provides the option of
generating a personality trait profile for any patient (i.e., not just those with a PD diagnosis) Trull & Durrett
(2005); O’Connor (2002, 2005); Saulsman & Page (2004).
E. Improves convergent and discriminant validity of PD assessment (Clark & Harrison, 2001; Clark, Livesley,
& Morey, 1997).

III. For the specifically proposed trait set:

Considerable evidence relates current DSM PDs to 4 broad, higher order trait domains of the five-factor model
(FFM) of personality: Neuroticism, Extraversion, Agreeableness, & Conscientiousness (e.g., O’Connor, 2005;
Saulsman & Page, 2004; Widiger & Simonsen, 2005), but meta-analyses also indicate that the 5th factor,
Openness, is not strongly related to PD (e.g., O’Connor, 2005; Saulsman & Page, 2004).

Conversely, meta-analyses indicate that Obsessive-Compulsive PD is not well-covered by the FFM (Saulsman &
Page, 2004) and that only the “social and interpersonal deficits” of Schizotypal PD, and not the “cognitive or
perceptual distortions and eccentricities of behavior” is tapped by FFM traits. Therefore, we added a domain of
compulsivity and of schizotypy to address these missing elements. The schizotypy domain also has been shown
to form an important 6th factor in analyses of both normal and abnormal personality (Tackett et al., 2008; Watson
et al., 2008).

Finally, the proposed specific trait facets were selected as representative based on existing measures of normal
and abnormal personality, as well as recommendations by experts in personality assessment. Nonetheless, the
proposed trait set is provisional, and currently is being tested for its structural validity before finalizing the DSM-V
proposal.
DSM-5 Type and Trait Cross-Walk
DSM-IV-TR Personality Disorder to DSM-5 Type and Trait Cross-Walk

DSM-IV-TR Personality DSM-5 Personality Disorder Prominent Personality Traits/


Disorder Type (Domains)1
Paranoid PD Trait Specified(PDTS)2 Suspiciousness (NE)
Hostility (A)
Unusual beliefs (S)
Intimacy avoidance (DT)
Schizoid PDTS Social withdrawal (DT)
Social detachment (DT)
Intimacy avoidance (DT)
Restricted affectivity (DT)
Anhedonia (DT)
Schizotypal Schizotypal Eccentricity (S)
(Match level 4 or 5)3 Cognitive dysregulation (S)
Unusual perceptions (S)
Unusual beliefs (S)
Social withdrawal (DT)
Restricted affectivity (DT)
Intimacy avoidance (DT)
Suspiciousness (NE)
Anxiousness (NE)
Antisocial Antisocial/Psychopathic Callousness (A)
(Match level 4 or 5)3 Aggression (A)
Manipulativeness (A)
Hostility (A)
Deceitfulness (A)
Grandiose narcissism (A)
Oppositionality (A)
Irresponsibility (DS)
Recklessness (DS)
Impulsivity (DS)
Borderline Borderline Emotional lability (NE)
(Match level 4 or 5)3 Self-harm (NE)
Separation insecurity (NE)
Submissiveness (NE)
Anxiousness (NE)
Low self-esteem (NE)
Depressivity (NE)
Suspiciousness (NE)
Hostility (A)
Aggression (A)
Impulsivity (DS)
Recklessness (DS)
Dissociation proneness (S)
Cognitive dysregulation (S)
Histrionic PDTS Emotional lability (NE)
Manipulativeness (A)
Histrionic style (A)
Narcissistic PDTS Grandiose narcissism (A)
Manipulativeness (A)
Histrionic style (A)
Callousness (A)
Avoidant Avoidant Anxiousness (NE)
(Match level 4 or 5)3 Separation insecurity (NE)
Pessimism (NE)
Low self-esteem (NE)
Guilt/shame (NE)
Intimacy avoidance (DT)
Social withdrawal (DT)
Restricted affectivity (DT)
Anhedonia (DT)
Social detachment (DT)
Risk aversion (DS)
Perfectionism (DS)
Dependent PDTS Submissiveness (NE)
Anxiousness (NE)
Separation insecurity (NE)
Obsessive-Compulsive Obsessive-Compulsive Perfectionism (C)
(Match level 4 or 5)3 Rigidity (C)
Orderliness (C)
Perseveration (C)
Anxiousness (NE)
Pessimism (NE)
Guilt/shame (NE)
Low self-esteem (NE)
Restricted affectivity (DT)
Oppositionality (A)
Manipulativeness (A)
Depressive PDTS Pessimism (NE)
Anxiousness (NE)
Depressivity (NE)
Low self-esteem (NE)
Guilt/shame (NE)
Anhedonia (DT)
Passive-Aggressive PDTS Oppositionality (A)
Hostility (A)
Guilt/shame (NE)
PD Not Otherwise Specified PDTS Individual trait profile
(PDNOS)

Note: NE = Negative Emotionality, DT = Detachment, A = Antagonism, DS = Disinhibition, C = Compulsivity, S =


Schizotypy

1
Several additional traits (compared to the original proposal posted in February 2010) have been listed for
selected disorders, based on an analysis of the content of the personality disorder type descriptions. A further
revision of the list will be based on the results of field trials. The list of traits includes those that map to the DSM-
IV PD, the DSM-5 type, or both.

2
Whenever a patient’s impairment in personality functioning is sufficiently severe to warrant a PD diagnosis, but
the patterns of impairments and associated traits do not match one of the five types, a diagnosis of PD Trait
Specified (PDTS) is made.
3
This PD type is diagnosed by matching a patient’s personality psychopathology to a narrative description. In
the revised proposal, the rating of traits is independent of the rating of the type, but also may be clinically useful.
The relationship of traits to types will be studied in the DSM-5 Field Trials.