The Alternative DSM-5 Model for Personality Disorders

Robert F. Krueger, PhD


June 20, 2014

The Diagnosis of Personality Disorders

Personality disorders (PDs) are common, debilitating psychiatric conditions that have enormous costs to patients and their family members, and more broadly, to society. Unfortunately, these conditions are also widely misunderstood and misdiagnosed. A major reason why PDs are misunderstood is that the model of PDs in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV has serious conceptual and empirical shortcomings, making it difficult -- if not impossible -- to use in the clinic. As a result, during the DSM-IV era, one often saw a diagnosis of "deferred" on axis II (the axis where PDs were recorded), or PD-not otherwise specified (PD-NOS), as opposed to a more descriptive label, such as a specific PD diagnosis, or a description of clinically salient personality features.[1] This was indeed unfortunate, because personality dysfunction provides an important window into psychopathology in general, and understanding the personalities of patients is critical to effective clinical care.[2]

Fortunately for patients and their families, DSM-5 includes an alternative model of PDs that seeks to rectify at least some of the shortcomings of the DSM-IV model. In this brief commentary, I will review some of the limitations of the DSM-IV PD model and how the DSM-5 alternative PD model addresses these problems. Readers are encouraged to consult the DSM-5 for details[3] as well as the rapidly expanding scientific literature on the DSM-5's alternative PD model.[4]

Comorbidity Among PDs

One notable problem with the DSM-IV PD model was comorbidity, or the tendency for patients to simultaneously meet criteria for numerous, putatively distinct disorders. As explained in the DSM-IV Sourcebook,[5] the modal number of PD diagnoses for a patient with at least one PD was a 3-4, using older DSM systems. This resulted in several problems with clinical case conceptualization, because if a patient has 4 diagnoses, which one do we start with and why? The DSM-5 alternative PD model solves this problem through the diagnosis of PD trait specified (PD-TS). If the patient is not a good match to a single and specific DSM-IV PD type (eg, antisocial PD), the clinician records PD-TS and details the patient's clinically important personality features in the chart. For example, a patient may have features of antisocial, narcissistic, histrionic, and borderline PD. Rather than recording all 4 diagnoses, the clinician can record PD-TS and note the mix of antagonistic, grandiose, attention-seeking, and emotionally dysregulated features that become the focus of intervention, tailoring the treatment plan accordingly.

For example, this hypothetical patient may have an inflated and grandiose sense of self that leads him to seek attention from others, with the aim of reinforcing his sense of superiority. Such efforts are probably often thwarted, given that most people don't enjoy the company of people who always want to be the center of attention and think themselves better than the rest of humanity. At these times, the patient may lash out antagonistically, in ways that violate the rights of other people (eg, through physical aggression). The patient then has difficulty managing the resulting emotional and interpersonal turmoil, inasmuch as he wants to connect with others but does not yet understand how his grandiose interpersonal style interferes with establishing meaningful connections. Working toward this understanding with the patient then becomes the focus of the treatment of this patient's PD-TS.


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