Major Changes Ahead for DSM-5 Personality Disorder Criteria

Deborah Brauser

July 08, 2011

July 8, 2011 — With the goal of increasing relevancy for both clinicians and patients, the diagnostic criteria for personality disorders may undergo significant restructuring in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

"The change integrates disorder types with pathological personality traits and, most importantly, levels of impairment in what is known as 'personality functioning,'" according to a release from the American Psychiatric Association (APA).

In the current edition of the manual, the disorders "are presented as rigid behavioral categories." However, the DSM-5 Personality and Personality Disorders Work Group is recommending cutting down the current 10 categories to the following 6 personality disorder types:

  • Antisocial;

  • Avoidant;

  • Borderline;

  • Narcissistic;

  • Obsessive/compulsive; and

  • Schizotypal.

However, a diagnosis for 1 of these types would also require significant impairment in both areas of personality functioning: self (how a patient views self and identifies and pursues life goals) and interpersonal (understanding others' perspectives and forming close relationships).

In addition, pathological personality traits will need to be present in at least 1 of 5 broad domains:

  • Negative affectivity;

  • Detachment;

  • Antagonism;

  • Disinhibition vs compulsivity; or

  • Psychoticism.

 "Our proposed criteria get away from the idea that personality pathology is just a group of disorders. We're instead defining it as a much broader characteristic," said Robert Krueger, PhD, Work Group member and professor of psychology at the University of Minnesota in Minneapolis, in the release.

Behavior-Based Criteria Fall Short

The new recommendations are due in large part to substantial research showing that behavior-based criteria have several shortcomings.

"Because behavior can be intermittent and changeable over time, the [old] criteria can hinder an accurate diagnosis and even impede treatment," according to the release. On the other hand, personality functioning and trait impairments are usually stable and consistent.

"In the past, we viewed personality disorders as binary. You either had one or you didn't. But we now understand that personality pathology is a matter of degree," added chair of the Work Group, Andrew Skodol, MD, research professor of psychiatry at the University of Arizona College of Medicine in Phoenix.

As reported last October by Medscape Medical News, field trials are underway to evaluate new draft criteria for mental illnesses, including personality disorders, in real-world clinical settings.

Although public comment on the latest proposed revisions was originally scheduled to end June 15, it has now been extended by a month and will go through July 15. The latest criteria recommendations are available at the APA's Web site.

"The proposed system is designed for flexible use to maximize clinical utility," according to the Web site.

"Thus, it allows for the diagnosis of specific clinically salient personality disorders, the diagnosis of a fully trait specified personality disorder for patients who do not meet one of the six specific types, the description of heterogeneity of both level of personality functioning and pathological traits within personality disorder types, and the description of the personality trait profile of all patients."

The DSM-5 is scheduled to be published in time for the 2013 APA Annual Meeting in San Francisco, California, and will be available in both electronic and print editions.


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