AMPD DSM-5

Alternative DSM-5 Model for Personality Disorders

  • This model serves as an alternative to the existing classification of personality disorders found in Section II of the DSM-5. The model is hybrid, combining dimensional and categorical approaches within Section III.

  • Personality disorder is defined by:

    • Impairments in personality functioning

    • Pathological personality traits

  • The inclusion of both models reflects the APA Board of Trustees' aim to maintain continuity with clinical practice while introducing a more comprehensive approach to personality disorders.

Limitations of Section II Model

  • The previous diagnostic categories often saw symptoms overlapping between different personality disorders.

  • Diagnoses such as other specified or unspecified personality disorder frequently resulted in vague and non-informative assessments since individuals usually do not present solely with the symptoms of one disorder.

Specific Personality Disorders

  • The disorders defined under this new model include:

    • Antisocial Personality Disorder

    • Avoidant Personality Disorder

    • Borderline Personality Disorder

    • Narcissistic Personality Disorder

    • Obsessive-Compulsive Personality Disorder

    • Schizotypal Personality Disorder

  • An additional diagnosis, Personality Disorder—Trait Specified (PD-TS), is included for individuals with personality disorder traits that do not meet the full criteria for a specific disorder.

General Criteria for Personality Disorder

  • Essential features include:

    • A. Moderate or greater impairment in self/interpersonal functioning.

    • B. Presence of one or more pathological personality traits.

    • C. Impairments are inflexible and pervasive across personal and social situations.

    • D. Such impairments are stable over time, dating from adolescence or early adulthood.

    • E. Impairments cannot be better explained by another mental disorder.

    • F. They are not solely due to physiological effects of substances or another medical condition.

    • G. Impairments are not typical for an individual’s developmental stage or sociocultural environment.

Determining Diagnosis

  • A diagnosis requires:

    • Determining the level of impairment in personality functioning (Criterion A).

    • Evaluating the presence of pathological personality traits (Criterion B).

Criterion A: Level of Personality Functioning

  • Disturbances in self and interpersonal functioning are core to personality psychopathology.

  • Evaluated on a continuum based on:

    • Self-functioning: Identity and self-direction.

    • Interpersonal functioning: Empathy and intimacy.

  • Level of Personality Functioning Scale (LPFS) defines five levels of impairment:

    • Level 0: Healthy functioning (little or no impairment).

    • Level 1: Some impairment.

    • Level 2: Moderate impairment.

    • Level 3: Severe impairment.

    • Level 4: Extreme impairment.

Criterion B: Pathological Personality Traits

  • Organized into five broad domains:

    • A. Negative Affectivity

    • B. Detachment

    • C. Antagonism

    • D. Disinhibition

    • E. Psychoticism

  • There are 25 specific trait facets within these domains developed from empirical evidence and clinical observations.

Criteria C and D: Stability and Pervasiveness

  • Impairments related to personality disorders exhibit:

    • Pervasiveness: Across various personal and social contexts.

    • Stability: Persisting over time, typically fixed during adulthood.

Table 1: Elements of Personality Functioning

  • Self:

    • Identity: Unique self-experience, boundary clarity, stable self-esteem, emotional regulation.

    • Self-direction: Coherent life goals, appropriate standards of behavior, productive self-reflection.

  • Interpersonal:

    • Empathy: Understanding others' feelings and motivations, tolerance of different perspectives.

    • Intimacy: Depth and duration of relationships, desire for closeness.

Criteria E, F, G: Alternative Explanations for Personality Pathology

  • Conditions resembling personality disorders may instead indicate:

    • Another mental disorder.

    • Physiological effects of substances.

    • Normal developmental stage characteristics.

    • Sociocultural context.

Specific Personality Disorders

  • Personality disorders are defined by:

    • Typical impairments in personality functioning (Criterion A).

    • Characteristic pathological traits (Criterion B).

  • Common personality disorders:

    • Antisocial Personality Disorder:

    • Features: Egocentrism, lack of concern for others, manipulative behaviors.

    • Avoidant Personality Disorder:

    • Features: Social avoidance, obsessive fears of criticism, feelings of inadequacy.

    • Borderline Personality Disorder:

    • Features: Instability in self-image and relationships, impulsivity, intense emotions.

    • Narcissistic Personality Disorder:

    • Features: Attention seeking, grandiosity, unstable self-esteem.

    • Obsessive-Compulsive Personality Disorder:

    • Features: Rigidity, perfectionism, emotional restriction.

    • Schizotypal Personality Disorder:

    • Features: Eccentric behavior, odd cognition, social anxiety.

Proposed Diagnostic Criteria for Specific Disorders

  • Each disorder presents specific impairment and trait requirements:

    • Antisocial Personality Disorder Criteria:

    • A. Moderate impairment in identity, self-direction, empathy, and intimacy.

    • B. Six traits including manipulativeness, callousness, deceitfulness, hostility, risk-taking, and impulsivity.

    • Avoidant Personality Disorder Criteria:

    • A. Moderate impairment in the same four domains.

    • B. Traits like anxiousness, withdrawal, anhedonia, and intimacy avoidance.

    • Others follow similar criterion structures.

Personality Disorder—Trait Specified (PD-TS)

  • Proposed Diagnostic Criteria:

    • A. Moderate or greater impairment in two domains.

    • B. Presence of traits across any of the five domains.

Level of Personality Functioning Scale

  • Levels of impairment detailed from little/no impairment to extreme impairment, with definitions provided.

Personality Traits

  • Defined as tendencies to feel, perceive, behave, and think consistently across situations.

  • Each trait is understood within a spectrum allowing for clinical assessment.

Assessment of Personality Disorders

  • Clinical assessments should utilize dimensional rating scales for comprehensive evaluation, potentially using tools like the Personality Inventory for DSM-5 (PID-5).

  • Clinicians assess all five domains of personality traits for personalized understanding and treatment planning.

Clinical Utility of the DSM-5 Trait Model

  • Provides insights into antecedent, concurrent, and predictive variables that influence treatment outcomes and patient management strategies.

Conclusion

  • Understanding the Level of Personality Functioning and pathological traits is crucial for identifying and diagnosing personality disorders effectively, impacting treatment plans and mental health prognosis.