Personality Disorders DSM-IV to DSM-V
/Summary
In 2013, The American Psychiatric Association (APA) voted down proposed changes in the way Personality Disorders will be classified and diagnosed in the 5th edition of the Diagnostic and Statistical Manual (DSM-5 or DSM-V). As a result, the DSM-IV definitions of Personality Disorders have been retained in the DSM-V.
Background
The DSM is sometimes referred to as the "bible" of all mental illnesses and is used by clinicians, mental healthcare providers and insurance companies as a diagnosis guide.
Personality Disorders are broken into 10 separate diagnoses in the 4th edition - DSM-IV. However, the DSM-IV diagnoses are often criticized for being subjective and vague and there is so much overlap (known as comorbidity) between the definitions that many patients are diagnosed with more than one personality disorder while others are given the catch-all diagnosis Personality Disorder - Not Otherwise Specified (PD-NOS)
A working group developing new definitions for the DSM-V tried to resolve this by eliminating some diagnoses and developing a scale of traits. However the new system was criticized as being too complex for practical everyday use. The early decision to drop Narcissistic Personality Disorder (NPD) from the list of disorders led to so much criticism that NPD was later added back in. However, the controversy did not subside and the changes were dropped.
At issue is the problem that the neurological causes for personality disorders is not well understood. Rather than having an objective test, such as a blood test for HIV or an ECG for a heart condition, personality disorders are instead described by groups of symptoms - or behavioral traits - which are often viewed as subjective and vague. Some clues to the root causes for personality disorders have been seen by researchers using functional magnetic resonance imaging (fMRI) but this is not settled science or widely available today.
It is for this reason that Out of the FOG first published a combined list of personality disorder traits - our list of Top 100 Traits of Personality Disorders. There appears to be a great deal of overlap in personality disorders and no single set of traits that applies to everyone. There is also still a healthy debate on the nature vs nurture question - whether a person is born with biological propensity to develop a personality disorder in their DNA or whether a personality disorder develops during developmental years as a result of environmental stresses - such as child abuse.
However, the lack of a clear clinical definition of personality disorders in the DSM-V is clearly a setback for millions who suffer from these disorders and for families and loved ones. Clearly we have a lot of work left to do.
Proposed & Rejected DSM-V Personality Disorder Definitions
Here are the proposed personality disorder classifications which were rejected by the APA:
- Borderline Personality Disorder (BPD)
- Obsessive-Compulsive Personality Disorder (OCPD)
- Avoidant Personality Disorder (AVPD)
- Schizotypal Personality Disorder (STPD)
- Antisocial Personality Disorder (ASPD)
- Narcissistic Personality Disorder (NPD)
Other:
- General Criteria for a Personality Disorder
- Personality Disorder Trait Specified (PDTS)
Source: American Psychiatric Association DSM-V
Rejected mapping from the DSM-IV to the DSM-V
Here is a table showing the proposed (rejected) mapping from the DSM-IV-TR to the DSM-V.
Old DSM-IV-TR Personality Disorder |
New DSM-5 Personality Disorder Type |
Prominent Personality Traits/(Domains) |
Paranoid |
PD Trait Specified (PDTS) |
Suspiciousness (NA) Hostility (A) Unusual beliefs & experiences (P) Intimacy avoidance (DT) |
Schizoid |
PDTS |
Withdrawal (DT) Intimacy avoidance (DT) Restricted affectivity (DT) Anhedonia (DT) |
Schizotypal |
Schizotypal |
Eccentricity (P) Cognitive & perceptual dysregulation (P) Unusual beliefs & experiences (P) Restricted affectivity (DT) Withdrawal (DT) Suspiciousness (NA) |
Antisocial |
Antisocial |
Manipulativeness (A) Deceitfulness (A) Callousness (A) Hostility (A) Irresponsibility (DS) Impulsivity (DS) Risk taking (DS) |
Borderline |
Borderline |
Emotional lability (NA) Anxiousness (NA) Separation insecurity (NA) Depressivity (NA) Impulsivity (DS) Risk taking (DS) Hostility (A) |
Histrionic |
PDTS |
Emotional lability (NA) Manipulativeness (A) Attention seeking (A) |
Narcissistic |
Narcissistic |
Grandiosity (A) Attention seeking (A) |
Avoidant |
Avoidant |
Withdrawal (DT) Intimacy avoidance (DT) Anhedonia (DT) Anxiousness (NA) |
Dependent |
PDTS |
Submissiveness (NA) Anxiousness (NA) Separation insecurity (NA) |
Obsessive-Compulsive |
Obsessive-Compulsive |
Rigid perfectionism (C) Perseveration (NA) |
Depressive |
PDTS |
Depressivity (NA) Anxiousness (NA) Anhedonia (DT) |
Passive-Aggressive |
PDTS |
Hostility (A) Depressivity (NA) |
PD Not Otherwise Specified (PDNOS) |
PDTS |
Individual trait profile |
Notes:
- NA = Negative Affectivity
- DT = Detachment
- A = Antagonism
- DS vs. C = Disinhibition vs. Compulsivity
- P = Psychoticism
A recent empirical project reduced the number of facet traits from 37 to 25, reduced the number of domains from 6 to 5, and provided provisional mappings of traits onto domains. Please see the rationale for the B criteria for further information.
Whenever a patient’s impairments in personality functioning are sufficiently severe to warrant a PD diagnosis, but the combinations of impairments and pathological personality traits do not meet criteria for one or more of the six specific personality disorder types, a diagnosis of PD Trait Specified (PDTS) is made.
Source: American Psychiatric Association DSM-V
Rejected DSM-V General Criteria for a Personality Disorder
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:
A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
B. One or more pathological personality trait domains or trait facets.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are 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).
Rejected DSM-V Criteria for Antisocial Personality Disorder (ASPD)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose antisocial personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
b. 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.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
b. 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.
B. Pathological personality traits in the following domains:
1. Antagonism, characterized by:
a. Manipulativeness: Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one„s ends.
b. Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
c. Callousness: 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.
d. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
2. Disinhibition, characterized by:
a. Irresponsibility: 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.
b. Impulsivity: 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.
c. Risk taking: 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.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are 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).
F. The individual is at least age 18 years.
Rejected DSM-V Criteria for Avoidant Personality Disorder (AVPD)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose avoidant personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Low self-esteem associated with self-appraisal socially inept, personally unappealing, or inferior; excessive feelings of shame or inadequacy.
b. Self-direction: Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others‟ perspectives as negative.
b. 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.
B. Pathological personality traits in the following domains:
1. Detachment, characterized by:
a. Withdrawal: Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
b. Intimacy avoidance: Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.
c. Anhedonia: Lack of enjoyment from, engagement in, or energy for life‟s experiences; deficits in the capacity to feel pleasure or take interest in things.
2. Negative Affectivity, characterized by:
a. Anxiousness: 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.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are 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).
Rejected DSM-V Criteria for Borderline Personality Disorder (BPD)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
AND
2. Impairments in interpersonal functioning (a or b):
a. 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.
b. 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 over involvement and withdrawal.
B. Pathological personality traits in the following domains:
1. Negative Affectivity, characterized by:
a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
b. Anxiousness: 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.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.
2. Disinhibition, characterized by:
a. Impulsivity: 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.
b. Risk taking: 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.
3. Antagonism, characterized by:
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are 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).
Rejected DSM-V elimination of Dependent Personality Disorder (DPD)
The Work Group recommends that this disorder be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
Prominent Personality Traits: Submissiveness, Anxiousness, Separation Insecurity
Source: American Psychiatric Association DSM-V
Because of this, it is likely in the future that people who would have been diagnosed with DPD will be diagnosed with other personality disorders which share a common set of traits, including Borderline Personality Disorder, Avoidant Personality Disorder or the generic Personality Disorder Trait Specified.
Rejected DSM-V elimination of Histrionic Personality Disorder (HPD)
The Work Group recommends that this disorder be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
Prominent Personality Traits: Histrionism, Emotional lability
Source: American Psychiatric Association DSM-V
Because of this, it is likely in the future that people who would have been diagnosed with HPD will be diagnosed with other personality disorders which share a common set of traits, including Narcissistic Personality Disorder, Borderline Personality Disorder or the generic Personality Disorder Trait Specified.
Rejected DSM-V Criteria for Narcissistic Personality Disorder (NPD)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.
b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
AND
2. Impairments in interpersonal functioning (a or b):
a. 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.
b. 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.
B. Pathological personality traits in the following domain:
1. Antagonism, characterized by:
a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.
b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are 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).
Rejected DSM-V Criteria for Obsessive-Compulsive Personality Disorder (OCPD)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose obsessive-compulsive personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.
b. 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.
AND
2. Impairments in Interpersonal functioning (a or b):
a. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.
b. Intimacy: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.
B. Pathological personality traits in the following domains:
1. Compulsivity, characterized by:
a. Rigid perfectionism: Rigid insistence on everything being flawless, perfect, 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.
2. Negative Affectivity, characterized by:
a. Perseveration: Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are 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).
Rejected DSM-V Criteria for Personality Disorder - Trait Specified (PD-TS)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:
A. Significant impairments (i.e., mild impairment or greater) in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
B. One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains.
1. Negative Affectivity
2. Detachment
3. Antagonism
4. Disinhibition vs. Compulsivity
5. Psychoticism
NOTE: Trait domain or one or more trait facets MUST be rated as “mildly descriptive or greater. If trait domain is rated as “mildly descriptive” then one or more of the associated trait facets MUST be rated as “moderately descriptive” or greater.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are 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).
Rejected DSM-V elimination of Paranoid Personality Disorder (PPD)
The Work Group recommends that this disorder be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
Prominent Personality Traits:
Suspiciousness, Intimacy avoidance, Hostility, Unusual Beliefs
Source: American Psychiatric Association DSM-V
Because of this, it is likely in the future that people who would have been diagnosed with PPD will be diagnosed with other personality disorders which share a common set of traits.
Rejected DSM-V elimination of Schizoid Personality Disorder (SPD)
The Work Group recommends that this disorder be represented and diagnosed by a combination of core impairment in personality functioning and specific pathological personality traits, rather than as a specific type.
Prominent Personality Traits:
Social withdrawal, Social detachment, Intimacy avoidance, Restricted affectivity, Anhedonia
Source: American Psychiatric Association DSM-V
Because of this, it is likely in the future that people who would have been diagnosed with SPD will be diagnosed with other personality disorders which share a common set of traits, including Avoidant Personality Disorder or the generic Personality Disorder Trait Specified.
Rejected DSM-V Criteria for Schizotypal Personality Disorder (STPD)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose schizotypal personality disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning:
a. Identity: Confused boundaries between self and others; distorted self-concept; emotional expression often not congruent with context or internal experience.
b. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
2. Impairments in interpersonal functioning:
a. Empathy: Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others‟ motivations and behaviors.
b. Intimacy: Marked impairments in developing close relationships, associated with mistrust and anxiety.
B. Pathological personality traits in the following domains:
1. Psychoticism, characterized by:
a. Eccentricity: Odd, unusual, or bizarre behavior or appearance; saying unusual or inappropriate things.
b. Cognitive and perceptual dysregulation: Odd or unusual thought processes; vague, circumstantial, metaphorical, over-elaborate, or stereotyped thought or speech; odd sensations in various sensory modalities.
c. Unusual beliefs and experiences: Thought content and views of reality that are viewed by others as bizarre or idiosyncratic; unusual experiences of reality.
2. Detachment, characterized by:
a. Restricted affectivity: Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.
b. Withdrawal: Preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
3. Negative Affectivity, characterized by:
a. Suspiciousness: Expectations of – and heightened sensitivity to – signs of interpersonal ill-intent or harm; doubts about loyalty and fidelity of others; feelings of persecution.
C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are 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).
Rejected DSM-V Criteria for Personality Disorder Trait Specified (PDTS)
The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a trait specified personality disorder, the following criteria must be met:
A. Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
B. One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains:
1. Negative Affectivity
2. Detachment
3. Antagonism
4. Disinhibition vs. Compulsivity
5. Psychoticism
C. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
E. The impairments in personality functioning and the individual’s personality trait expression are 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).