Alternative DSM-5 model for personality disorders
The Alternative DSM-5 Model for Personality Disorders, introduced in Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is a dimensional–categorical hybrid model of personality disorders, meaning that it integrates a dimensional model of personality disorders with a categorical one. This is achieved through mapping of individual, categorical personality disorders to specific combinations of impairment in personality functioning and pathological personality traits.
The alternative model features the following specific personality disorders: antisocial, avoidant, borderline, narcissistic, obsessive–compulsive, and schizotypal, constituting a reduction of entities, as the standard model contains the diagnoses of dependent, histrionic, paranoid, and schizoid personality disorders in addition to those in the AMPD. It also contains a trait specified diagnosis for manifestations of personality disorder not covered by the specific diagnoses, such as the four omitted categories.
Designed to address limitations of the categorical classification of personality disorders – such as heterogeneous PD categories, excessive comorbidity, arbitrary thresholds and insufficient diagnostic precision – the AMPD has generally been found to hold validity; however, it remains subject to ongoing debate and research in regards to aspects such as the relationship between traits and functioning level.
Background
The categorical model of personality disorders in the DSM was originally introduced in the DSM-III, released in 1980, replacing the previously used narrative-based diagnoses with diagnoses based on clearly defined criteria. This categorical model persisted in subsequent editions – such as the DSM-III-R and DSM-IV – of the DSM. In the 2000's, when the upcoming DSM-5 was being planned and developed, there was a consensus that the categorical model was insufficient due to personality disorders being better understood as dimensional, while the categorical approach was understood to have had a negative impact on the development of conceptual and clinical aspects of personality disorders. Shifting the paradigm in psychiatric diagnosis in the direction of a dimensional approach was a significant intention behind the proposal to create a new DSM edition.Early undertakings
The Personality and Personality Disorders Work Group was responsible for the development of the chapter on PDs for the DSM-5. Originally named the Personality Disorders Work Group, it was headed by chair Andrew E. Skodol beginning in 2007; the renaming occurred due to the understanding that the group was to shift to a dimensional approach. The paradigm shift had come to be manifested in the exclusion of the majority of individuals who worked on the DSM-IV from the early stages of development of the DSM-5, including from the work groups, with Larry Siever being the only one of the eleven members of the PPDWG who had been part of the DSM-IV PDWG.During their initial work, there was disagreement among the members of the PPDWG in regards to several aspects of the establishment of a new system for PDs for the upcoming DSM. While initially opting for a broad approach towards the selection of a conceptual model for PDs, agreement in favor of a dimensional approach emerged; however, disagreements continued regarding which specific model should be used. For example, there was tension between the use of one of several established models and the creation of a new one with lesser basis in research. Another matter of debate was whether all, or merely some, of the categorical PD diagnoses should remain, with consideration given to their validity and utility – as well as to these in relation to their entrenchment in practice and to the thus possible benefits of retention of continuity with the extant categorical model.
Emergence and rejection
The PPDWG iteratively developed what became a dimensional–categorical hybrid model of personality disorders which was to replace the previously used categorical model. In 2009, Skodol made the first proposal of a model, consisting of ratings of impairment in functioning, as well as of six trait domains consisting of specific traits – with both impairment and traits rated numerically. The five herein included personality disorders – namely: antisocial, avoidant, borderline, obsessive–compulsive, and schizotypal – were described through narratives, the correspondence of a subject with which was to be rated along with a rating of the elevation of the traits associated with the PD.During the evolution of the model, it was redesigned as a hybrid model anchored in impairment in areas of personality functioning and dimensional traits. Initially absent, narcissistic personality disorder was brought into the model following feedback from clinicians and researchers. The model also faced scrutiny against strict standards for evidence and utility. The Work Group and the DSM-5 Task Force recommended the transition to the model in its final form; however, in 2012, the American Psychiatric Association Board of Trustees voted against it, resulting in the new model being included in section III of the DSM-5 as the Alternative DSM-5 Model for Personality Disorders, with the DSM-IV categorical model being retained as the standard model in section II.
Core features
The alternative model contains seven general criteria for what constitutes a personality disorder, as well as criteria for specific and trait specified personality disorders. Of the general criteria, criterion A, i.e., an assessment of personality functioning level; and criterion B, i.e., an assessment of pathological personality traits; are the most prominent, both in clinical practice and as subjects of research.Further requirements are embodied in the additional general criteria, necessitating that a subject's manifestation of criteria A and B impacts them broadly, having remained temporally stable since youth ; while criteria E and F account for differential diagnosis in regards to other mental disorders and effects of medical conditions or substances; and criterion G excludes what is normal for the individual's social environment or developmental stage. These additional criteria align with traditional PD requirements.
The general criteria apply to any diagnosis of a PD, and as such, to any specified personality disorder, as well as to Personality Disorder - Trait Specified.
Criterion A: Level of personality functioning
Supposed to capture fundamental problems specific and common to personality disorders, the level of personalty functioning is assessed in accordance with a scale provided with the AMPD called the Level of Personality Functioning Scale. It ranges from 0 to 4, thus making the model truly dimensional and inclusive of the entire spectrum of personality functioning.In the LPFS, personality functioning is conceptualized as consisting of self functioning, comprising identity and self-direction; and interpersonal functioning, comprising empathy and intimacy. Each element consists of three subdomains, such as "comprehension and appreciation of others’ experiences, tolerance of differing perspectives, and understanding the effects of one’s own behavior on others" for the empathy element. However, the severity is conceptualized as being unidimensional.
A diagnosis of a personality disorder requires that the overall impairment is moderate or greater, stemming from this having been found to be the best threshold value for alignment with the population receiving DSM-IV PD diagnoses. The manner in which the overall level of functioning is determined is not universally defined; instruments of measure vary from reliance on clinical judgement to the average impairment across the twelve subdomains.
Criterion B: Pathological personality traits
The pathological traits of criterion B serve to describe the characteristics of any personality disorder, with identification of traits providing an explanation to specific reasons for impairment in personality functioning. Twenty-five pathological personality traits, known as trait facets, are grouped into the following domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. Each domain is indexed by three specific facets; the other ten facets can be used for further characterization of individuals’ personality traits. For example, the core facets of Antagonism are Manipulativeness, Deceitfulness, and Grandiosity, whereas Attention Seeking, Callousness, and Hostility may additionally characterize some individuals who manifest pathological-range Antagonism.Predominantly, these traits are assessed using the Personality Inventory for DSM-5. There is also the Structured Clinical Interview for Personality Traits, which is Module II of the SCID-5-AMPD.
The trait domains in the AMPD align with the more broadly used Five Factor Model of personality, but with focus on the mal-adaptive ends of each of these personality factor spectra. The relationship between the Five Factor Model's openness and the AMPD's psychoticism has been subject to dispute. Studies on the topic have utilized different measures and definitions of the two concepts and have given mixed results, with some studies showing little to no connection while other studies report a weak correlation. Conceptualizations of openness differ from each other, with some focusing on traits such as self-actualization and open-mindedness, whereas others align more closely with schizotypal tendencies, the latter resulting in higher correlations with psychoticism.