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Proposed Changes in Personality and Personality Disorder Assessment and Diagnosis for DSM-5 Part I: Description and Rationale

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Proposed Changes in Personality and Personality Disorder Assessment and Diagnosis for DSM-5 Part I: Description and Rationale Personality Disorders: Theory, Research, and Treatment © 2011 American Psychiatric Association 2011, Vol. 2, No. 1, 4–22 1949-2715/11/$12.00 DOI: 10.1037/a0021891 Proposed Changes in Personality and Personality Disorder Assessment and Diagnosis for DSM-5 Part I: Description and Rationale Andrew E. Skodol Lee Anna Clark University of Arizona College of Medicine University of Iowa Donna S. Bender Robert F. Krueger University of Arizona College of Medicine University of Minnesota Leslie C. Morey Roel Verheul Texas A&M University University of Amsterdam Renato D. Alarcon Carl C. Bell Mayo Clinic College of Medicine University of Illinois at Chicago Larry J. Siever John M. Oldham Mt. Sinai School of Medicine Baylor College of Medicine A major reconceptualization of personality psychopathology has been proposed for DSM-5 that identifies core impairments in personality functioning, pathological personality traits, and prominent pathological personality types. A comprehensive personality assessment consists of four components: levels of personality function- ing, personality disorder types, pathological personality trait domains and facets, and general criteria for personality disorder. This four-part assessment focuses attention on identifying personality psychopathology with increasing degrees of specificity, based on a clinician’s available time, information, and expertise. In Part I of this two-part article, we describe the components of the new model and present brief theoretical and empirical rationales for each. In Part II, we will illustrate the clinical application of the model with vignettes of patients with varying degrees of personality psychopathology, to show how assessments might be conducted and diagnoses reached. Keywords: personality disorders, personality, DSM-5, assessment, diagnosis To see further discussion of the Target Conceptual Articles, versity of Illinois at Chicago; Larry J. Siever, Department of Commentaries, and Author Response, as well as to contribute Psychiatry, Mt. Sinai School of Medicine; John M. Oldham, to the ongoing dialogue on this topic, please visit our Online Department of Psychiatry, Baylor College of Medicine. Forum at http://pdtrtonline.apa.org/display/PER/Home Lee Anna Clark is now with the Department of Psychol- ogy at the University of Notre Dame. Andrew E. Skodol, Department of Psychiatry, University Portions of this article appeared on the American Psychi- of Arizona College of Medicine; Lee Anna Clark, Depart- atric Association’s DSM-5 website: www.DSM5.org. This ment of Psychology, University of Iowa; Donna S. Bender, article is being copublished by Personality Disorders: The- Department of Psychiatry, University of Arizona College of ory, Research, and Treatment and the American Psychiatric Medicine; Robert F. Krueger, Department of Psychology, Association. Lee Anna Clark is the author of the Schedule University of Minnesota; Leslie C. Morey, Department of for Nonadaptive and Adaptive Personality, published by the Psychology, Texas A&M University; Roel Verheul, Center University of Minnesota Press. of Psychotherapy De Viersprong, University of Amsterdam, Correspondence concerning this article should be addressed the Netherlands; Renato D. Alarcon, Department of Psychi- to Andrew E. Skodol, M.D., Sunbelt Collaborative, 4031 E. atry, Mayo Clinic College of Medicine; Carl C. Bell, De- Sunrise Drive, Suite 101, Tucson, AZ 85718. E-mail: askodol@ partment of Psychiatry and School of Public Health, Uni- gmail.com 4 SPECIAL ISSUE: PROPOSED CHANGES IN PDS FOR DSM-5, PART I 5 Overview of Proposed Model of patients with varying degrees of personality psychopathology, to show how assessments A major reconceptualization of personality might be conducted and diagnoses reached. psychopathology has been proposed for DSM-5 that identifies core impairments in personality Levels of Personality Functioning functioning, pathological personality traits, and prominent pathological personality types. A The Personality and Personality Disorders comprehensive personality assessment consists (P&PD) Work Group has proposed a measure of four components: of severity of impairment in core capacities (a) Five identified severity levels of person- central to personality functioning. Impairment ality functioning based on degrees of impair- in personality functioning forms the basis of a ment in core self and interpersonal capacities; revised definition of PD and is used to rate (b) Five specific personality disorder (PD) criterion A of the general criteria. The severity types, each defined by impairments in core ca- of impairment captures variation both across pacities and a set of pathological personality and within personality disorder types. traits, and one trait-specified type; Personality psychopathology fundamentally (c) Six broad, higher order personality trait emanates from disturbances in thinking about domains, with 4–10 lower order, more specific oneself and others. Because there are greater trait facets within each domain, for a total of 37 and lesser degrees of disturbance in the self and specific trait facets; interpersonal domains, a continuum of five lev- (d) New general criteria for PD based on els of self and interpersonal functioning is pro- severe or extreme deficits in core capacities of vided for assessing individual patients. Table 1 personality functioning and extreme levels of 1 depicts a summary of the levels of personality pathological personality traits. functioning scale. Scale anchor points for im- This four-part conceptualization and assess- pairment in self and in interpersonal functioning ment focuses attention on identifying personal- at each level of the scale have been written for ity psychopathology with increasing degrees of inclusion in DSM-5 (see part II, Appendix A). specificity, based on a clinician’s available We are currently scaling these anchor points, time, information, and expertise. The assess- using Item Response Theory (IRT) methods to ment model is intended to facilitate identifica- examine existing data sets and refine this char- tion of personality-related problems and their acterization of the severity dimension before severity and to characterize these problems ac- finalizing it for DSM-5. cording to broad, clinically salient types, in association with patient-specific personality trait profiles. Both of these assessments are rel- Rationale for Developing a Model for evant whether a patient has a PD or not. The Assessing Level of Personality Functioning assessment of the general criteria for a PD in- sures that inclusion and exclusion criteria for a A recent study (Hopwood et al., in press) of diagnosable disorder are met. patients with PDs participating in the Collabor- These new assessment components replace ative Longitudinal Personality Disorders Study the PD assessment in DSM–IV–TR, which con- (CLPS; Gunderson et al., 2000), demonstrated sisted of general PD diagnostic criteria and10 that, in assessing personality psychopathology, individual PDs (plus two additional PDs in the “generalized severity is the most important sin- Appendix), each identified by a specific poly- gle predictor of concurrent and prospective dys- thetic criteria set. Severity and course specifiers function.” The authors concluded that PD is were provided for all DSM–IV–TR disorders, but were not specific to personality psychopa- 1 At the time these papers were submitted, the four parts thology and were seldom applied to PDs. In Part of the model were undergoing revisions, based on public I of this two-part article, we will describe the comments received in response to the posting of proposed components of the proposed new model and changes on the American Psychiatric Association’s DSM-5 website (www.DSM5.org), secondary data analyses, and a present brief theoretical and empirical ratio- national survey. For the most part, the model presented here nales for them. In Part II, we will illustrate the is the one posted, except as noted. The revised versions of clinical application of the model with vignettes the four parts will be tested in field trials. 6 SKODOL ET AL. Table 1 influence how individuals typically view them- Levels of Personality Functioninga selves and others. Bowlby (1969), a pioneer in Personality psychopathology fundamentally emanates the area of development and attachment theory, from disturbances in thinking about self and others. posited that individuals develop “working mod- Because there are greater and lesser degrees of els” to help them deal with the external world, disturbance of the self and interpersonal domains, the particularly interactions with other people. following continuum comprised of levels of self and interpersonal functioning is provided for assessing Working from a social–cognitive perspective, individual patients. Anderson and Cole (1990) explored the idea Each level is characterized by typical functioning in the that individuals form social categories based on following areas: representations of significant others. They dem- Self: Identity integration, integrity of self-concept, onstrated that nonclinical individuals exhibited and self-directedness Interpersonal: Empathy, intimacy and pronounced false-positive errors in assessing cooperativeness, and complexity and integration new figures; that is, if the figure was assimilated of representations of others into a significant-other category, subjects were As with the general diagnostic criteria for personality quick to apply preconceived notions that were, disorder, in applying these dimensions diagnostically,
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