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CLINICAL SYNTHESIS   |    
Alternative DSM-5 Model for Personality Disorders
FOCUS 2013;11:189-203. doi:10.1176/appi.focus.11.2.189
Abstract

The current approach to personality disorders appears in Section II of DSM-5, and an alternative model developed for DSM-5 is presented here in Section III. The inclusion of both models in DSM-5 reflects the decision of the APA Board of Trustees to preserve continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders. For example, the typical patient meeting criteria for a specific personality disorder frequently also meets criteria for other personality disorders. Similarly, other specified or unspecified personality disorder is often the correct (but mostly uninformative) diagnosis, in the sense that patients do not tend to present with patterns of symptoms that correspond with one and only one personality disorder. In the following alternative DSM-5 model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. This approach also includes a diagnosis of personality disorder—trait specified (PD-TS) that can be made when a personality disorder is considered present but the criteria for a specific disorder are not met.

(Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Washington, DC,APA, 2013. Copyright © 2013, American Psychiatric Association. Used with permission.) 

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General Criteria for Personality Disorder

The essential features of a personality disorder are

  • Moderate or greater impairment in personality (self/interpersonal) functioning.

  • One or more pathological personality traits.

  • The impairments in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.

  • The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.

  • The impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder.

  • The impairments in personality functioning and the individual’s personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).

  • The impairments in personality functioning and the individual’s personality trait expression are not better understood as normal for an individual’s developmental stage or sociocultural environment.

A diagnosis of a personality disorder requires two determinations: 1) an assessment of the level of impairment in personality functioning, which is needed for Criterion A, and 2) an evaluation of pathological personality traits, which is required for Criterion B. The impairments in personality functioning and personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations (Criterion C); relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood (Criterion D); not better explained by another mental disorder (Criterion E); not attributable to the effects of a substance or another medical condition (Criterion F); and not better understood as normal for an individual’s developmental stage or sociocultural environment (Criterion G). All Section III personality disorders described by criteria sets and PD-TS meet these general criteria, by definition.

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Criterion A: Level of Personality Functioning

Disturbances in self and interpersonal functioning constitute the core of personality psychopathology and in this alternative diagnostic model they are evaluated on a continuum. Self functioning involves identity and self-direction; interpersonal functioning involves empathy and intimacy (see Table 1). The Level of Personality Functioning Scale (LPFS; see Table 2) uses each of these elements to differentiate five levels of impairment, ranging from little or no impairment (i.e., healthy, adaptive functioning; Level 0) to some (Level 1), moderate (Level 2), severe (Level 3), and extreme (Level 4) impairment.

 
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Table 1.Elements of Personality Functioning
 
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Table 2.Level of Personality Functioning Scale

Impairment in personality functioning predicts the presence of a personality disorder, and the severity of impairment predicts whether an individual has more than one personality disorder or one of the more typically severe personality disorders. A moderate level of impairment in personality functioning is required for the diagnosis of a personality disorder; this threshold is based on empirical evidence that the moderate level of impairment maximizes the ability of clinicians to accurately and efficiently identify personality disorder pathology.

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Criterion B: Pathological Personality Traits

Pathological personality traits are organized into five broad domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Within the five broad trait domains are 25 specific trait facets that were developed initially from a review of existing trait models and subsequently through iterative research with samples of persons who sought mental health services. The full trait taxonomy is presented in Table 3. The B criteria for the specific personality disorders comprise subsets of the 25 trait facets, based on meta-analytic reviews and empirical data on the relationships of the traits to DSM-IV personality disorder diagnoses.

 
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Table 3.Definitions of DSM-5 Personality Disorder Trait Domains and Facets
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Criteria C and D: Pervasiveness and Stability

Impairments in personality functioning and pathological personality traits are relatively pervasive across a range of personal and social contexts, as personality is defined as a pattern of perceiving, relating to, and thinking about the environment and oneself. The term relatively reflects the fact that all except the most extremely pathological personalities show some degree of adaptability. The pattern in personality disorders is maladaptive and relatively inflexible, which leads to disabilities in social, occupational, or other important pursuits, as individuals are unable to modify their thinking or behavior, even in the face of evidence that their approach is not working. The impairments in functioning and personality traits are also relatively stable. Personality traits—the dispositions to behave or feel in certain ways—are more stable than the symptomatic expressions of these dispositions, but personality traits can also change. Impairments in personality functioning are more stable than symptoms.

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Criteria E, F, and G: Alternative Explanations for Personality Pathology (Differential Diagnosis)

On some occasions, what appears to be a personality disorder may be better explained by another mental disorder, the effects of a substance or another medical condition, or a normal developmental stage (e.g., adolescence, late life) or the individual’s sociocultural environment. When another mental disorder is present, the diagnosis of a personality disorder is not made, if the manifestations of the personality disorder clearly are an expression of the other mental disorder (e.g., if features of schizotypal personality disorder are present only in the context of schizophrenia). On the other hand, personality disorders can be accurately diagnosed in the presence of another mental disorder, such as major depressive disorder, and patients with other mental disorders should be assessed for comorbid personality disorders because personality disorders often impact the course of other mental disorders. Therefore, it is always appropriate to assess personality functioning and pathological personality traits to provide a context for other psychopathology.

Section III includes diagnostic criteria for antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. Each personality disorder is defined by typical impairments in personality functioning (Criterion A) and characteristic pathological personality traits (Criterion B):

  • Typical features of antisocial personality disorder  are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking.

  • Typical features of avoidant personality disorder  are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment.

  • Typical features of borderline personality disorder  are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility.

  • Typical features of narcissistic personality disorder  are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity.

  • Typical features of obsessive-compulsive personality disorder  are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression.

  • Typical features of schizotypal personality disorder  are impairments in the capacity for social and close relationships, and eccentricities in cognition, perception, and behavior that are associated with distorted self-image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression.

The A and B criteria for the six specific personality disorders and for PD-TS follow. All personality disorders also meet criteria C through G of the General Criteria for Personality Disorder.

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Antisocial Personality Disorder

Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Antagonism and Disinhibition.

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Proposed Diagnostic Criteria

  • Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:

    • Identity:   Egocentrism; self-esteem derived from personal gain, power, or pleasure.

    • Self-direction:   Goal setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.

    • Empathy:   Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.

    • Intimacy:   Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.

  • Six or more of the following seven pathological personality traits:

    • Manipulativeness   (an aspect of Antagonism ): Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends.

    • Callousness   (an aspect of Antagonism ): Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.

    • Deceitfulness   (an aspect of Antagonism ): Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.

    • Hostility   (an aspect of Antagonism ): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.

    • Risk taking   (an aspect of Disinhibition ): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and denial of the reality of personal danger.

    • Impulsivity   (an aspect of Disinhibition ): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.

    • Irresponsibility   (an aspect of Disinhibition ): Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises.

Note. The individual is at least 18 years of age.

Specify if: With psychopathic features.

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Specifiers

A distinct variant often termed psychopathy (or “primary” psychopathy) is marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence). This psychopathic variant is characterized by low levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment domain) and high levels of attention seeking (Antagonism domain). High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/resilience) component.

In addition to psychopathic features, trait and personality functioning specifiers may be used to record other personality features that may be present in antisocial personality disorder but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g., anxiousness), are not diagnostic criteria for antisocial personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of antisocial personality disorder (Criterion A), the level of personality functioning can also be specified.

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Avoidant Personality Disorder

Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Negative Affectivity and Detachment.

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Proposed Diagnostic Criteria

  • Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:

    • Identity:   Low self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame.

    • Self-direction:   Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.

    • Empathy:   Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others’ perspectives as negative.

    • Intimacy:   Reluctance to get involved with people unless being certain of being liked; diminished mutuality within intimate relationships because of fear of being shamed or ridiculed.

  • Three or more of the following four pathological personality traits, one of which must be (1) Anxiousness:

    • Anxiousness   (an aspect of Negative Affectivity ): Intense feelings of nervousness, tenseness, or panic, often in reaction to social situations; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrassment.

    • Withdrawal   (an aspect of Detachment ): Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.

    • Anhedonia   (an aspect of Detachment ): Lack of enjoyment from, engagement in, or energy for life’s experiences; deficits in the capacity to feel pleasure or take interest in things.

    • Intimacy avoidance   (an aspect of Detachment ): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

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Specifiers

Considerable heterogeneity in the form of additional personality traits is found among individuals diagnosed with avoidant personality disorder. Trait and level of personality functioning specifiers can be used to record additional personality features that may be present in avoidant personality disorder. For example, other Negative Affectivity traits (e.g., depressivity, separation insecurity, submissiveness, suspiciousness, hostility) are not diagnostic criteria for avoidant personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of avoidant personality disorder (Criterion A), the level of personality functioning also can be specified.

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Borderline Personality Disorder

Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition.

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Proposed Diagnostic Criteria

  • Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:

    • Identity:   Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.

    • Self-direction:   Instability in goals, aspirations, values, or career plans.

    • Empathy:   Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.

    • Intimacy:   Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between overinvolvement and withdrawal.

  • Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:

    • Emotional lability   (an aspect of Negative Affectivity ): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

    • Anxiousness   (an aspect of Negative Affectivity ): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

    • Separation insecurity   (an aspect of Negative Affectivity ): Fears of rejection by—and/or separation from—significant others, associated with fears of excessive dependency and complete loss of autonomy.

    • Depressivity   (an aspect of Negative Affectivity ): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.

    • Impulsivity   (an aspect of Disinhibition ): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.

    • Risk taking   (an aspect of Disinhibition ): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.

    • Hostility   (an aspect of Antagonism ): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

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Specifiers

Trait and level of personality functioning specifiers may be used to record additional personality features that may be present in borderline personality disorder but are not required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and perceptual dysregulation) are not diagnostic criteria for borderline personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of borderline personality disorder (Criterion A), the level of personality functioning can also be specified.

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Narcissistic Personality Disorder

Typical features of narcissistic personality disorder are variable and vulnerable self--esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Antagonism.

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Proposed Diagnostic Criteria

  • Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:

    • Identity:   Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.

    • Self-direction:   Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.

    • Empathy:   Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.

    • Intimacy:   Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.

  • Both of the following pathological personality traits:

    • Grandiosity   (an aspect of Antagonism ): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.

    • Attention seeking   (an aspect of Antagonism ): Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

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Specifiers

Trait and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder but are not required for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, deceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see Criterion B) but can be specified when more pervasive antagonistic features (e.g., “malignant narcissism”) are present. Other traits of Negative Affectivity (e.g., depressivity, anxiousness) can be specified to record more “vulnerable” presentations. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of narcissistic personality disorder (Criterion A), the level of personality functioning can also be specified.

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Obsessive-Compulsive Personality Disorder

Typical features of obsessive-compulsive personality disorder are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Negative Affectivity and/or Detachment.

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Proposed Diagnostic Criteria

  • Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:

    • Identity:   Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.

    • Self-direction:   Difficulty completing tasks and realizing goals associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.

    • Empathy:   Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.

    • Intimacy:   Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.

  • Three or more of the following four pathological personality traits, one of which must be (1) Rigid perfectionism:

    • Rigid perfectionism   (an aspect of extreme Conscientiousness [the opposite pole of Detachment]): Rigid insistence on everything being flawless, perfect, and without errors or faults, including one’s own and others’ performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order.

    • Perseveration   (an aspect of Negative Affectivity ): Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.

    • Intimacy avoidance   (an aspect of Detachment ): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

    • Restricted affectivity   (an aspect of Detachment ): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.

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Specifiers

Trait and personality functioning specifiers may be used to record additional personality features that may be present in obsessive-compulsive personality disorder but are not required for the diagnosis. For example, other traits of Negative Affectivity (e.g., anxiousness) are not diagnostic criteria for obsessive-compulsive personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of obsessive-compulsive personality disorder (Criterion A), the level of personality functioning can also be specified.

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Schizotypal Personality Disorder

Typical features of schizotypal personality disorder are impairments in the capacity for social and close relationships and eccentricities in cognition, perception, and behavior that are associated with distorted self-image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, along with specific maladaptive traits in the domains of Psychoticism and Detachment.

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Proposed Diagnostic Criteria

  • Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:

    • Identity:   Confused boundaries between self and others; distorted self-concept; emotional expression often not congruent with context or internal experience.

    • Self-direction:   Unrealistic or incoherent goals; no clear set of internal standards.

    • Empathy:   Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others’ motivations and behaviors.

    • Intimacy:   Marked impairments in developing close relationships, associated with mistrust and anxiety.

  • Four or more of the following six pathological personality traits:

    • Cognitive and perceptual dysregulation   (an aspect of Psychoticism ): Odd or unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or stereotyped thought or speech; odd sensations in various sensory modalities.

    • Unusual beliefs and experiences   (an aspect of Psychoticism ): Thought content and views of reality that are viewed by others as bizarre or idiosyncratic; unusual experiences of reality.

    • Eccentricity   (an aspect of Psychoticism ): Odd, unusual, or bizarre behavior or appearance; saying unusual or inappropriate things.

    • Restricted affectivity   (an aspect of Detachment ): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.

    • Withdrawal   (an aspect of Detachment ): Preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.

    • Suspiciousness   (an aspect of Detachment ): Expectations of—and heightened sensitivity to—signs of interpersonal ill-intent or harm; doubts about loyalty and fidelity of others; feelings of persecution.

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Specifiers

Trait and personality functioning specifiers may be used to record additional personality features that may be present in schizotypal personality disorder but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g., depressivity, anxiousness) are not diagnostic criteria for schizotypal personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of schizotypal personality disorder (Criterion A), the level of personality functioning can also be specified.

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Personality Disorder—Trait Specified

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Proposed Diagnostic Criteria

  • Moderate or greater impairment in personality functioning, manifest by difficulties in two or more of the following four areas:

    • Identity.  

    • Self-direction.  

    • Empathy.  

    • Intimacy.  

  • One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains:

    • Negative Affectivity  (vs. Emotional Stability): Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger), and their behavioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations.

    • Detachment  (vs. Extraversion): Avoidance of socioemotional experience, including both withdrawal from interpersonal interactions, ranging from casual, daily interactions to friendships to intimate relationships, as well as restricted affective experience and expression, particularly limited hedonic capacity.

    • Antagonism  (vs. Agreeableness): Behaviors that put the individual at odds with other people, including an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self-enhancement.

    • Disinhibition  (vs. Conscientiousness): Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences.

    • Psychoticism  (vs. Lucidity): Exhibiting 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).

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Subtypes

Because personality features vary continuously along multiple trait dimensions, a comprehensive set of potential expressions of PD-TS can be represented by DSM-5’s dimensional model of maladaptive personality trait variants (see Table 3). Thus, subtypes are unnecessary for PD-TS, and instead, the descriptive elements that constitute personality are provided, arranged in an empirically based model. This arrangement allows clinicians to tailor the description of each individual’s personality disorder profile, considering all five broad domains of personality trait variation, and drawing on the descriptive features of these domains as needed to characterize the individual.

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Specifiers

The specific personality features of individuals are always recorded in evaluating Criterion B, so the combination of personality features characterizing an individual directly constitutes the specifiers in each case. For example, two individuals who are both characterized by emotional lability, hostility, and depressivity may differ such that the first individual is characterized additionally by callousness, whereas the second is not.

The requirement for any two of the four A criteria for each of the six personality disorders was based on maximizing the relationship of these criteria to their corresponding personality disorder. Diagnostic thresholds for the B criteria were also set empirically to minimize change in prevalence of the disorders from DSM-IV and overlap with other personality disorders, and to maximize relationships with functional impairment. The resulting diagnostic criteria sets represent clinically useful personality disorders with high fidelity, in terms of core impairments in personality functioning of varying degrees of severity and constellations of pathological personality traits.

Individuals who have a pattern of impairment in personality functioning and maladaptive traits that matches one of the six defined personality disorders should be diagnosed with that personality disorder. If an individual also has one or even several prominent traits that may have clinical relevance in addition to those required for the diagnosis (e.g., see narcissistic personality disorder), the option exists for these to be noted as specifiers. Individuals whose personality functioning or trait pattern is substantially different from that of any of the six specific personality disorders should be diagnosed with PD-TS. The individual may not meet the required number of A or B criteria and, thus, have a subthreshold presentation of a personality disorder. The individual may have a mix of features of personality disorder types or some features that are less characteristic of a type and more accurately considered a mixed or atypical presentation. The specific level of impairment in personality functioning and the pathological personality traits that characterize the individual’s personality can be specified for PD-TS, using the Level of Personality Functioning Scale (Table 2) and the pathological trait taxonomy (Table 3). The current diagnoses of paranoid, schizoid, histrionic, and dependent personality disorders are represented also by the diagnosis of PD-TS; these are defined by moderate or greater impairment in personality functioning and can be specified by the relevant pathological personality trait combinations.

Like most human tendencies, personality functioning is distributed on a continuum. Central to functioning and adaptation are individuals’ characteristic ways of thinking about and understanding themselves and their interactions with others. An optimally functioning individual has a complex, fully elaborated, and well-integrated psychological world that includes a mostly positive, volitional, and adaptive self-concept; a rich, broad, and appropriately regulated emotional life; and the capacity to behave as a productive member of society with reciprocal and fulfilling interpersonal relationships. At the opposite end of the continuum, an individual with severe personality pathology has an impoverished, disorganized, and/or conflicted psychological world that includes a weak, unclear, and maladaptive self-concept; a propensity to negative, dysregulated emotions; and a deficient capacity for adaptive interpersonal functioning and social behavior.

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Self- and Interpersonal Functioning Dimensional Definition

Generalized severity may be the most important single predictor of concurrent and prospective dysfunction in assessing personality psychopathology. Personality disorders are optimally characterized by a generalized personality severity continuum with additional specification of stylistic elements, derived from personality disorder symptom constellations and personality traits. At the same time, the core of personality psychopathology is impairment in ideas and feelings regarding self and interpersonal relationships; this notion is consistent with multiple theories of personality disorder and their research bases. The components of the Level of Personality Functioning Scale—identity, self-direction, empathy, and intimacy (see Table 1)—are particularly central in describing a personality functioning continuum.

Mental representations of the self and interpersonal relationships are reciprocally influential and inextricably tied, affect the nature of interaction with mental health professionals, and can have a significant impact on treatment efficacy and outcome, underscoring the importance of assessing an individuals’ characteristic self-concept as well as views of other people and relationships. Although the degree of disturbance in the self and interpersonal functioning is continuously distributed, it is useful to consider the level of impairment in functioning for clinical characterization and for treatment planning and prognosis.

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Rating Level of Personality Functioning

To use the Level of Personality Functioning Scale (LPFS), the clinician selects the level that most closely captures the individual’s current overall level of impairment in personality functioning. The rating is necessary for the diagnosis of a personality disorder (moderate or greater impairment) and can be used to specify the severity of impairment present for an individual with any personality disorder at a given point in time. The LPFS may also be used as a global indicator of personality functioning without specification of a personality disorder diagnosis, or in the event that personality impairment is subthreshold for a disorder diagnosis.

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Definition and Description

Criterion B in the alternative model involves assessments of personality traits that are grouped into five domains. A personality trait is a tendency to feel, perceive, behave, and think in relatively consistent ways across time and across situations in which the trait may manifest. For example, individuals with a high level of the personality trait of anxiousness would tend to feel anxious readily, including in circumstances in which most people would be calm and relaxed. Individuals high in trait anxiousness also would perceive situations to be anxiety-provoking more frequently than would individuals with lower levels of this trait, and those high in the trait would tend to behave so as to avoid situations that they think would make them anxious. They would thereby tend to think about the world as more anxiety provoking than other people.

Importantly, individuals high in trait anxiousness would not necessarily be anxious at all times and in all situations. Individuals’ trait levels also can and do change throughout life. Some changes are very general and reflect maturation (e.g., teenagers generally are higher on trait impulsivity than are older adults), whereas other changes reflect individuals’ life experiences.

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Dimensionality of personality traits

All individuals can be located on the spectrum of trait dimensions; that is, personality traits apply to everyone in different degrees rather than being present versus absent. Moreover, personality traits, including those identified specifically in the Section III model, exist on a spectrum with two opposing poles. For example, the opposite of the trait of callousness is the tendency to be empathic and kind-hearted, even in circumstances in which most persons would not feel that way. Hence, although in Section III this trait is labeled callousness, because that pole of the dimension is the primary focus, it could be described in full as callousness versus kind-heartedness. Moreover, its opposite pole can be recognized and may not be adaptive in all circumstances (e.g., individuals who, due to extreme kind-heartedness, repeatedly allow themselves to be taken advantage of by unscrupulous others).

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Hierarchical structure of personality

Some trait terms are quite specific (e.g., “talkative”) and describe a narrow range of behaviors, whereas others are quite broad (e.g., Detachment) and characterize a wide range of behavioral propensities. Broad trait dimensions are called domains, and specific trait dimensions are called facets. Personality trait domains comprise a spectrum of more specific personality facets that tend to occur together. For example, withdrawal and anhedonia are specific trait facets in the trait domain of Detachment. Despite some cross-cultural variation in personality trait facets, the broad domains they collectively comprise are relatively consistent across cultures.

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The Personality Trait Model

The Section III personality trait system includes five broad domains of personality trait variation—Negative Affectivity (vs. Emotional Stability), Detachment (vs. Extraversion), Antagonism (vs. Agreeableness), Disinhibition (vs. Conscientiousness), and Psychoticism (vs. Lucidity)—comprising 25 specific personality trait facets. Table 3 provides definitions of all personality domains and facets. These five broad domains are maladaptive variants of the five domains of the extensively validated and replicated personality model known as the “Big Five”, or Five Factor Model of personality (FFM), and are also similar to the domains of the Personality Psychopathology Five (PSY-5). The specific 25 facets represent a list of personality facets chosen for their clinical relevance.

Although the Trait Model focuses on personality traits associated with psychopathology, there are healthy, adaptive, and resilient personality traits identified as the polar opposites of these traits, as noted in the parentheses above (i.e., Emotional Stability, Extraversion, Agreeableness, Conscientiousness, and Lucidity). Their presence can greatly mitigate the effects of mental disorders and facilitate coping and recovery from traumatic injuries and other medical illness.

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Distinguishing Traits, Symptoms, and Specific Behaviors

Although traits are by no means immutable and do change throughout the life span, they show relative consistency compared with symptoms and specific behaviors. For example, a person may behave impulsively at a specific time for a specific reason (e.g., a person who is rarely impulsive suddenly decides to spend a great deal of money on a particular item because of an unusual opportunity to purchase something of unique value), but it is only when behaviors aggregate across time and circumstance, such that a pattern of behavior distinguishes between individuals, that they reflect traits. Nevertheless, it is important to recognize, for example, that even people who are impulsive are not acting impulsively all of the time. A trait is a tendency or disposition toward specific behaviors; a specific behavior is an instance or manifestation of a trait.

Similarly, traits are distinguished from most symptoms because symptoms tend to wax and wane, whereas traits are relatively more stable. For example, individuals with higher levels of depressivity have a greater likelihood of experiencing discrete episodes of a depressive disorder and of showing the symptoms of these disorders, such difficulty concentrating. However, even patients who have a trait propensity to depressivity typically cycle through distinguishable episodes of mood disturbance, and specific symptoms such as difficulty concentrating tend to wax and wane in concert with specific episodes, so they do not form part of the trait definition. Importantly, however, symptoms and traits are both amenable to intervention, and many interventions targeted at symptoms can affect the longer term patterns of personality functioning that are captured by personality traits.

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Assessment of the DSM-5 Section III Personality Trait Model

The clinical utility of the Section III multidimensional personality trait model lies in its ability to focus attention on multiple relevant areas of personality variation in each individual patient. Rather than focusing attention on the identification of one and only one optimal diagnostic label, clinical application of the Section III personality trait model involves reviewing all five broad personality domains portrayed in Table 3. The clinical approach to personality is similar to the well-known review of systems in clinical medicine. For example, an individual’s presenting complaint may focus on a specific neurological symptom, yet during an initial evaluation clinicians still systematically review functioning in all relevant systems (e.g., cardiovascular, respiratory, gastrointestinal), lest an important area of diminished functioning and corresponding opportunity for effective intervention be missed.

Clinical use of the Section III personality trait model proceeds similarly. An initial inquiry reviews all five broad domains of personality. This systematic review is facilitated by the use of formal psychometric instruments designed to measure specific facets and domains of personality. For example, the personality trait model is operationalized in the Personality Inventory for DSM-5 (PID-5), which can be completed in its self-report form by patients and in its informant-report form by those who know the patient well (e.g., a spouse). A detailed clinical assessment would involve collection of both patient- and informant-report data on all 25 facets of the personality trait model. However, if this is not possible, due to time or other constraints, assessment focused at the five-domain level is an acceptable clinical option when only a general (vs. detailed) portrait of a patient’s personality is needed (see Criterion B of PD-TS). However, if personality-based problems are the focus of treatment, then it will be important to assess individuals’ trait facets as well as domains.

Because personality traits are continuously distributed in the population, an approach to making the judgment that a specific trait is elevated (and therefore is present for diagnostic purposes) could involve comparing individuals’ personality trait levels with population norms and/or clinical judgment. If a trait is elevated—that is, formal psychometric testing and/or interview data support the clinical judgment of elevation—then it is considered as contributing to meeting Criterion B of Section III personality disorders.

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Clinical Utility of the Multidimensional Personality Functioning and Trait Model

Disorder and trait constructs each add value to the other in predicting important antecedent (e.g., family history, history of child abuse), concurrent (e.g., functional impairment, medication use), and predictive (e.g., hospitalization, suicide attempts) variables. DSM-5 impairments in personality functioning and pathological personality traits each contribute independently to clinical decisions about degree of disability; risks for self-harm, violence, and criminality; recommended treatment type and intensity; and prognosis—all important aspects of the utility of psychiatric diagnoses. Notably, knowing the level of an individual’s personality functioning and his or her pathological trait profile also provides the clinician with a rich base of information and is valuable in treatment planning and in predicting the course and outcome of many mental disorders in addition to personality disorders. Therefore, assessment of personality functioning and pathological personality traits may be relevant whether an individual has a personality disorder or not.

Bender  DS;  Morey  LC;  Skodol  AE:  Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods.  J Pers Assess 93(4):332–346, 201122804672
[CrossRef]
 
Clark  LA:  Trait diagnosis of personality disorder: domains or facets? Master Lecture presented at the Annual Meeting of the Society for Personality Assessment,  Chicago, IL, March 2012
 
Clarkin  JF;  Huprich  SK:  Do DSM-5 personality disorder proposals meet criteria for clinical utility? J Pers Disord 25(2):192–205, 201121466249
[CrossRef]
 
Goldberg  LR:  The structure of phenotypic personality traits.  Am Psychol 48(1):26–34, 19938427480
 
Hasin  D;  Fenton  MC;  Skodol  A  et al:  Personality disorders and the 3-year course of alcohol, drug, and nicotine use disorders.  Arch Gen Psychiatry 68(11):1158–1167, 201122065531
[CrossRef]
 
Harkness  AR;  Finn  JA;  McNulty  JL;  Shields  SM:  The Personality Psychopathology-Five (PSY-S): recent constructive replication and assessment literature review.  Psychol Assess 24(2):432–443, 201221988184
[CrossRef]
 
Hopwood  CJ;  Zanarini  MC:  Borderline personality traits and disorder: predicting prospective patient functioning.  J Consult Clin Psychol 78(4):585–589, 201020658814
 
Hopwood  CJ;  Malone  JC;  Ansell  EB  et al:  Personality assessment in DSM-5: empirical support for rating severity, style, and traits.  J Pers Disord 25(3):305–320, 201121699393
[CrossRef]
 
Kendell  R;  Jablensky  A:  Distinguishing between the validity and utility of psychiatric diagnoses.  Am J Psychiatry 160(1):4–12, 200312505793
[CrossRef]
 
Krueger  RF;  Eaton  NR;  Clark  LA  et al:  Deriving an empirical structure of personality pathology for DSM-5.  J Pers Disord 25(2):170–191, 2011a21466248
[CrossRef]
 
Krueger  RF;  Eaton  NR;  Derringer  J  et al:  Personality in DSM-5: helping delineate personality disorder content and framing the metastructure.  J Pers Assess 93(4):325–331, 2011b22804671
[CrossRef]
 
Krueger  RF;  Derringer  J;  Markon  KE;  Watson  D;  Skodol  AE:  Initial construction of a maladaptive personality trait model and inventory for DSM-5.  Psychol Med 42(9):1879–1890, 201222153017
[CrossRef]
 
Luyten  P;  Blatt  SJ:  Integrating theory-driven and empirically-derived models of personality development and psychopathology: a proposal for DSM V.  Clin Psychol Rev 31(1):52–68, 201121130936
[CrossRef]
 
Markon  KE:  The development of an Informant-Report Form of the PID-5: rationale and initial results (paper), in The DSM-5 Personality Traits: Measurement, Structure and Association (Wright AGC, Chair). Symposium presented at the Annual Meeting of the Society for Personality Assessment,  Chicago, IL, 2012
 
McCrae  RR;  Costa  PT  Jr:  Personality trait structure as a human universal.  Am Psychol 52(5):509–516, 19979145021
[CrossRef]
 
Morey  LC;  Zanarini  MC:  Borderline personality: traits and disorder.  J Abnorm Psychol 109(4):733–737, 200011195998
[CrossRef]
 
Morey  LC;  Hopwood  CJ;  Gunderson  JG  et al:  Comparison of alternative models for personality disorders.  Psychol Med 37(7):983–994, 200717121690
[CrossRef]
 
Morey  LC;  Shea  MT;  Markowitz  JC  et al:  State effects of major depression on the assessment of personality and personality disorder.  Am J Psychiatry 167(5):528–535, 201020160004
[CrossRef]
 
Morey  LC;  Berghuis  H;  Bender  DS  et al:  Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology.  J Pers Assess 93(4):347–353, 201122804673
[CrossRef]
 
Morey  LC;  Hopwood  CJ;  Markowitz  JC  et al:  Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.  Psychol Med 42(8):1705–1713, 201222132840
[CrossRef]
 
Morey  LC;  Bender  DS;  Skodol  AE:  Validating a severity indicator for personality disorder for DSM-5. Submitted for publication, September 2012
 
Pincus  AL:  Some comments on nomology, diagnostic process, and narcissistic personality disorder in the DSM-5 proposal for personality and personality disorders.  Personal Disord 2(1):41–53, 201122448689
[CrossRef]
 
Roberts  BW;  Walton  KE;  Viechtbauer  W:  Patterns of mean-level change in personality traits across the life course: a meta-analysis of longitudinal studies.  Psychol Bull 132(1):1–25, 200616435954
 
Samuel  DB;  Widiger  TA:  A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: a facet level analysis.  Clin Psychol Rev 28(8):1326–1342, 200818708274
[CrossRef]
 
Saulsman  LM;  Page  AC:  The five-factor model and personality disorder empirical literature: a meta-analytic review.  Clin Psychol Rev 23(8):1055–1085, 200414729423
[CrossRef]
 
Skodol  AE;  Grilo  CM;  Keyes  KM  et al:  Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample.  Am J Psychiatry 168(3):257–264
 
Specht  J;  Egloff  B;  Schmukle  SC:  Stability and change of personality across the life course: the impact of age and major life events on mean-level and rank-order stability of the Big Five.  J Pers Soc Psychol 101(4):862–882, 201121859226
 
Tang  TZ;  DeRubeis  RJ;  Hollon  SD  et al:  Personality change during depression treatment: a placebo-controlled trial.  Arch Gen Psychiatry 66(12):1322–1330, 200919996037
[CrossRef]
 
Widiger  TA;  Simonsen  E:  Alternative dimensional models of personality disorder: finding a common ground.  J Pers Disord 19(2):110–130, 200515899712.
 
References Container
Anchor for Jump
Table 1.Elements of Personality Functioning
Anchor for Jump
Table 2.Level of Personality Functioning Scale
Anchor for Jump
Table 3.Definitions of DSM-5 Personality Disorder Trait Domains and Facets
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References

Bender  DS;  Morey  LC;  Skodol  AE:  Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods.  J Pers Assess 93(4):332–346, 201122804672
[CrossRef]
 
Clark  LA:  Trait diagnosis of personality disorder: domains or facets? Master Lecture presented at the Annual Meeting of the Society for Personality Assessment,  Chicago, IL, March 2012
 
Clarkin  JF;  Huprich  SK:  Do DSM-5 personality disorder proposals meet criteria for clinical utility? J Pers Disord 25(2):192–205, 201121466249
[CrossRef]
 
Goldberg  LR:  The structure of phenotypic personality traits.  Am Psychol 48(1):26–34, 19938427480
 
Hasin  D;  Fenton  MC;  Skodol  A  et al:  Personality disorders and the 3-year course of alcohol, drug, and nicotine use disorders.  Arch Gen Psychiatry 68(11):1158–1167, 201122065531
[CrossRef]
 
Harkness  AR;  Finn  JA;  McNulty  JL;  Shields  SM:  The Personality Psychopathology-Five (PSY-S): recent constructive replication and assessment literature review.  Psychol Assess 24(2):432–443, 201221988184
[CrossRef]
 
Hopwood  CJ;  Zanarini  MC:  Borderline personality traits and disorder: predicting prospective patient functioning.  J Consult Clin Psychol 78(4):585–589, 201020658814
 
Hopwood  CJ;  Malone  JC;  Ansell  EB  et al:  Personality assessment in DSM-5: empirical support for rating severity, style, and traits.  J Pers Disord 25(3):305–320, 201121699393
[CrossRef]
 
Kendell  R;  Jablensky  A:  Distinguishing between the validity and utility of psychiatric diagnoses.  Am J Psychiatry 160(1):4–12, 200312505793
[CrossRef]
 
Krueger  RF;  Eaton  NR;  Clark  LA  et al:  Deriving an empirical structure of personality pathology for DSM-5.  J Pers Disord 25(2):170–191, 2011a21466248
[CrossRef]
 
Krueger  RF;  Eaton  NR;  Derringer  J  et al:  Personality in DSM-5: helping delineate personality disorder content and framing the metastructure.  J Pers Assess 93(4):325–331, 2011b22804671
[CrossRef]
 
Krueger  RF;  Derringer  J;  Markon  KE;  Watson  D;  Skodol  AE:  Initial construction of a maladaptive personality trait model and inventory for DSM-5.  Psychol Med 42(9):1879–1890, 201222153017
[CrossRef]
 
Luyten  P;  Blatt  SJ:  Integrating theory-driven and empirically-derived models of personality development and psychopathology: a proposal for DSM V.  Clin Psychol Rev 31(1):52–68, 201121130936
[CrossRef]
 
Markon  KE:  The development of an Informant-Report Form of the PID-5: rationale and initial results (paper), in The DSM-5 Personality Traits: Measurement, Structure and Association (Wright AGC, Chair). Symposium presented at the Annual Meeting of the Society for Personality Assessment,  Chicago, IL, 2012
 
McCrae  RR;  Costa  PT  Jr:  Personality trait structure as a human universal.  Am Psychol 52(5):509–516, 19979145021
[CrossRef]
 
Morey  LC;  Zanarini  MC:  Borderline personality: traits and disorder.  J Abnorm Psychol 109(4):733–737, 200011195998
[CrossRef]
 
Morey  LC;  Hopwood  CJ;  Gunderson  JG  et al:  Comparison of alternative models for personality disorders.  Psychol Med 37(7):983–994, 200717121690
[CrossRef]
 
Morey  LC;  Shea  MT;  Markowitz  JC  et al:  State effects of major depression on the assessment of personality and personality disorder.  Am J Psychiatry 167(5):528–535, 201020160004
[CrossRef]
 
Morey  LC;  Berghuis  H;  Bender  DS  et al:  Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology.  J Pers Assess 93(4):347–353, 201122804673
[CrossRef]
 
Morey  LC;  Hopwood  CJ;  Markowitz  JC  et al:  Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.  Psychol Med 42(8):1705–1713, 201222132840
[CrossRef]
 
Morey  LC;  Bender  DS;  Skodol  AE:  Validating a severity indicator for personality disorder for DSM-5. Submitted for publication, September 2012
 
Pincus  AL:  Some comments on nomology, diagnostic process, and narcissistic personality disorder in the DSM-5 proposal for personality and personality disorders.  Personal Disord 2(1):41–53, 201122448689
[CrossRef]
 
Roberts  BW;  Walton  KE;  Viechtbauer  W:  Patterns of mean-level change in personality traits across the life course: a meta-analysis of longitudinal studies.  Psychol Bull 132(1):1–25, 200616435954
 
Samuel  DB;  Widiger  TA:  A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: a facet level analysis.  Clin Psychol Rev 28(8):1326–1342, 200818708274
[CrossRef]
 
Saulsman  LM;  Page  AC:  The five-factor model and personality disorder empirical literature: a meta-analytic review.  Clin Psychol Rev 23(8):1055–1085, 200414729423
[CrossRef]
 
Skodol  AE;  Grilo  CM;  Keyes  KM  et al:  Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample.  Am J Psychiatry 168(3):257–264
 
Specht  J;  Egloff  B;  Schmukle  SC:  Stability and change of personality across the life course: the impact of age and major life events on mean-level and rank-order stability of the Big Five.  J Pers Soc Psychol 101(4):862–882, 201121859226
 
Tang  TZ;  DeRubeis  RJ;  Hollon  SD  et al:  Personality change during depression treatment: a placebo-controlled trial.  Arch Gen Psychiatry 66(12):1322–1330, 200919996037
[CrossRef]
 
Widiger  TA;  Simonsen  E:  Alternative dimensional models of personality disorder: finding a common ground.  J Pers Disord 19(2):110–130, 200515899712.
 
References Container
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