Report of the DSM-V Personality and Personality Disorders Work Group
April 2009
Andrew E. Skodol, M.D.
The Personality and Personality Disorders Work Group is completing 20 literature reviews relevant to possible revisions in DSM-V. Overarching topics include a Definition and Diagnostic Criteria for Personality Disorder, Levels of Severity of Personality Psychopathology, the Clinical Utility of an Empirically-Based Model of Personality Traits, the Conceptualization and Assessment of Functioning, a Tripartite Model of Mental Disorder, Criteria for Change in DSM-V, Gender and Personality Disorder, Personality Pathology Across the Lifespan, Dimensional Representations of Existing Personality Disorder Categories, and the Resilient Personality. In addition, reviews are being conducted on the Validity of each of the 10 DSM-IV Personality Disorder Categories.
The Work Group has proceeded with the development of an alternative model of personality and personality disorder assessment and classification. A personality domain could be used for the description of the personality characteristics of all patients, whether they receive a diagnosis of a personality disorder or not. The full assessment of the personality domain is currently being conceptualized as consisting of five parts: 1) an overall rating of personality (self and interpersonal) functioning ranging from normal to severely impaired; 2) prototype descriptions of major personality (disorder) types; 3) personality trait assessment, on which the prototypes are based, but which can also be used to describe major personality characteristics of patients who either do not have a personality disorder or have a personality disorder that does not conform to one of the prototypes; 4) generic criteria for personality disorder consisting of severe deficits in self differentiation and integration and in the capacity for interpersonal relatedness; and 5) measures of adaptive functioning. The assessment is designed to “telescope” the clinicians 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.
The levels of personality functioning and the generic criteria for personality disorder are based on deficits in self and interpersonal functioning. Deficits in the self are reflected in the dimensions of self-integration, integrity of self-concept, and self-directedness. Interpersonal deficits consist of impairments in empathy, intimacy, and complexity and integration of representations of others. Impairments in self and in interpersonal relatedness are described for different levels of severity of personality disorder psychopathology.
Personality traits will be chosen for their clinical utility. Examples of traits under consideration are “emotional lability” (prone to mood fluctuations, emotions that are easily aroused and intense, unstable emotional experiences and frequent mood changes, and incapacitation by extremity of emotions) and “impulsivity” (tendency to act on the spur of the moment to immediate stimulus, to act on a momentary basis without a plan or consideration of consequences, to have difficulty following established plans, and to be unable to learn from experience). Traits will be rated on 4-point scales of applicability to a given patient. Traits will be unipolar, with definitions indicating maladaptive functioning. A set of highly adaptive or resilient personality traits (e.g., optimism, empathy) is also under consideration.
Personality prototypes will be described by combinations of core personality pathology and personality traits. Prototypes will be described such that description of different levels of self and interpersonal functioning with personality types will be possible, ranging from no core personality disturbances, to mild personality impairments with some core personality pathology and a few clinically significant traits, to severe personality disorder, which will consist of a number of very clinically significant pathological personality traits and characteristic severe core personality disorder impairment. The degree of correspondence between a patient’s personality disorder and a prototype will also be rated dimensionally.
The next steps for the Work Group are to complete the literature reviews, perform secondary data re-analyses, and conduct field trials. These activities will refine the levels of personality functioning for patients with personality disorders at differing levels of severity; identify personality traits that most adequately describe and discriminate between revised personality disorder prototypes and have maximal clinical utility; and determine age, gender and ethnic effects on personality functioning, personality disorder criteria, personality traits, and personality prototypes.