Skodol 2012 Personality Disorders in DSM 5

CP08CH13-Skodol ARI 6 March 2012 8:0
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Annu. Rev. Clin. Psychol. 2012.8:317-344. Downloaded from www.annualreviews.org
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email: askodol@gmail.com
Annu. Rev. Clin. Psychol. 2012. 8:317–44 Keywords

The Annual Review of Clinical Psychology is online diagnosis, classification, mental disorders, personality functioning,
at clinpsy.annualreviews.org
personality traits, dimensions, categories, diagnostic criteria
This article’s doi:
10.1146/annurev-clinpsy-032511-143131 Abstract
Copyright c 2012 by Annual Reviews. A substantive revision of the Diagnostic and Statistical Manual of Mental
All rights reserved
Disorders (DSM) last occurred in 1994; therefore, the mental health
1548-5943/12/0427-0317$20.00 field should anticipate significant changes to the classification of mental
disorders in the fifth edition. Since DSM-5 Work Groups have recently
proposed revisions for the major diagnostic classes of mental disorders,
an article on the current status of the personality disorders (PDs) is
timely. This article reviews scientific principles that have influenced the
development of proposed changes for the assessment and diagnosis of
personality psychopathology in DSM-5, presents the proposed model
as of the summer of 2011, summarizes rationales for the changes, and
discusses critiques of the model. Scientific principles were articulated
for DSM-5 more than a decade ago; their application to the process has
not been straightforward, however. Work Group members have labored
to improve the DSM-5 approach to personality and PDs to make the
classification more valid and more clinically useful. The current model
continues to be a work in progress.
317
INTRODUCTION
Contents A revised classification of mental disorders
INTRODUCTION . . . . . . . . . . . . . . . . . . 318 is scheduled for publication in 2013 by the
SCIENTIFIC ISSUES IN THE American Psychiatric Association (APA). The
REVISION OF PERSONALITY Diagnostic and Statistical Manual of Mental
DISORDERS FOR DSM-5 . . . . . . . . 319 Disorders, Fifth Edition (DSM-5) will be the
Definition of Disorder . . . . . . . . . . . . . 319 product of over 13 years of work on the part
Dimensional Versus of many mental health professionals. A sub-
Categorical Approaches . . . . . . . . . 321 stantive revision of the DSM has not occurred
Criteria for Change . . . . . . . . . . . . . . . . 324 since 1994; therefore, the mental health field
Validity Versus Clinical Utility . . . . . 325 should anticipate significant changes, which
Cultural Applicability . . . . . . . . . . . . . . 325 will impact patients, providers, families, and

DSM-5 and ICD-11 . . . . . . . . . . . . . . . 326 society at large and may influence future
Diagnosis in Specialty Versus research agendas. Since DSM-5 Work Groups

Primary Care Settings . . . . . . . . . . . 326 have recently proposed changes for each of the
PROPOSED DSM-5 PERSONALITY major diagnostic classes of mental disorders
DISORDER MODEL . . . . . . . . . . . . . 327 and have revised their proposals in anticipation
Levels of Personality Functioning . . . 327 of APA-sponsored and -conducted Field Trials
Personality Disorder Types. . . . . . . . . 327 now under way, an article on the current status
Pathological Personality Traits . . . . . 327 of the personality disorders (PDs) in DSM-5 is
General Criteria for timely. This article (a) reviews scientific prin-
Personality Disorder . . . . . . . . . . . . 327 ciples that have influenced the development
RATIONALES FOR of proposed changes for the assessment and
PROPOSED CHANGES . . . . . . . . . . 327 diagnosis of personality psychopathology for
Revised Levels of Personality DSM-5, (b) presents the proposed model as
Functioning . . . . . . . . . . . . . . . . . . . . 327 of the summer of 2011, (c) summarizes the
Revised Personality Disorder rationales for the proposed changes, and (d ) dis-
Types . . . . . . . . . . . . . . . . . . . . . . . . . . 329 cusses critiques of the model and their impact
New Criteria for Six Specific on its evolution.1 More complete summaries
Personality Disorders and of the Personality and Personality Disorders
Personality Disorder Trait Work Group’s progress and products to date
Specified . . . . . . . . . . . . . . . . . . . . . . . 331 can be found elsewhere (Bender et al. 2011;
Revised Pathological Personality Krueger & Eaton 2010; Krueger et al. 2011a,b;
Traits . . . . . . . . . . . . . . . . . . . . . . . . . . 332 Morey et al. 2011; Skodol 2011; Skodol &
Revised General Criteria for Bender 2009; Skodol et al. 2009, 2011a,b,c).
Personality Disorder . . . . . . . . . . . . 333 In September of 1999, an initial DSM-V2
CRITIQUES OF THE PROPOSED Research Planning Conference sponsored by
MODEL AND THEIR IMPACT the APA and the National Institute of Mental
ON MODEL EVOLUTION . . . . . . 333
Levels of Personality Functioning . . . 334
Personality Disorder Types. . . . . . . . . 334 1
The views expressed in this review are those of the author,
Personality Traits . . . . . . . . . . . . . . . . . . 336 who is the Chair of the DSM-5 Personality and Personality
Disorders Work Group and a member of the DSM-5 Task
General Criteria for Personality
Force. They do not necessarily reflect the views of the Work
Disorder . . . . . . . . . . . . . . . . . . . . . . . 338 Group members, in general.
CONCLUSIONS . . . . . . . . . . . . . . . . . . . . 338 2
The switch from the Roman numeral V to the Arabic num-
ber 5 was deliberate, as is explained below. In this review, the
acronym DSM-5 is used except when DSM-V appears in the
name of a book, article, or conference.
318 Skodol
Health (NIMH) was held to set research pri- (d ) the validation of diagnostic categories
orities for DSM-5. In the introduction to the and criteria, (e) reducing the gaps between
published white papers from this conference DSM-5 and ICD-11, ( f ) the applicability of
in A Research Agenda for DSM-V, Kupfer and criteria across cultures, and ( g) facilitating
colleagues (2002) argued that the categorical psychiatric diagnosis in nonpsychiatric settings
approach to the diagnosis of mental disorders, (Rounsaville et al. 2002). All of these issues have
including PDs, needed reexamination. Epi- influenced the deliberations of the Personality
demiological and clinical studies showed high and Personality Disorders (P&PD) Work
rates of within- and across-axis comorbidity Group in proposing revisions.
and short-term diagnostic instability. No lab-
oratory marker had been found to be specific
for any DSM-defined syndrome. And a lack of Definition of Disorder
treatment specificity for disorders was the rule A personality disorder in DSM-IV is defined
rather than the exception. as an enduring pattern of inner experience

Because the reliability of psychiatric diag- and behavior that deviates markedly from
nosis had improved over the previous 40 years the expectations of the individual’s culture
with the innovations of explicit diagnostic cri- and is manifested in cognition, affectivity,
teria and of semistructured and fully structured interpersonal functioning, and/or impulse
diagnostic interviews, the authors believed that control (two or more). The enduring pattern is
the classification in DSM-5 should emphasize inflexible and pervasive across a broad range of
or facilitate an understanding of the pathophys- personal and social situations; leads to clinically
iology and etiology of mental disorders. Thus, significant distress or impairment in social,
the validity of diagnoses would be enhanced, occupational, or other important areas of func-
and consequently, better preventative and tioning; is stable and of long duration, with
treatment interventions based on them could an onset in adolescence or early adulthood;
be developed. Kupfer and colleagues also is not better accounted for as a manifestation
stated that a “slavish” adherence to DSM- or consequence of another mental disorder;
defined syndromes might actually impede and is not due to the effects of a substance or
research and that a “paradigm shift” might be a general medical condition. Individuals who
necessary to uncover the underlying etiologies met the criteria for a PD in DSM-IV were
of DSM-defined syndromes (Kupfer et al. 2002, assumed to meet the general definition, but
p. xix). To encourage thinking that went beyond were not explicitly required to do so.
the DSM-IV framework, participants at the These general criteria for PD were intro-
first series of planning meetings were primarily duced into DSM-IV without an empirical basis,
not involved in the development of DSM-IV and they have been considered too nonspecific.
and were encouraged to consider broad per- Incorporation of personality trait dimensions
spectives on diagnostic classification, including into DSM-5 (see below) necessitates the use of
from the fields of neuroscience and genetics. general criteria for PD that supplement those
dimensions, because an extreme position on a
trait dimension is a necessary but not sufficient
SCIENTIFIC ISSUES IN THE condition to diagnose a PD (Wakefield 2008),
REVISION OF PERSONALITY and extreme traits may predispose to mental
DISORDERS FOR DSM-5 disorders other than PDs. Thus, the P&PD
Seven basic nomenclature issues were identified Work Group developed a new definition
for DSM-5: (a) the definition of mental disor- and set of general criteria for PD that would
ders, (b) dimensional approaches to diagnosis be more specific and empirical. In addition,
versus categorical approaches, (c) rationales consideration at the Task Force level of more
for changing existing categories or criteria, clearly demarcating boundaries between the
www.annualreviews.org • Personality Disorders in DSM-5 319

manifestations of psychopathology and its adaptive failure, which included the failure to
consequences (Narrow & Kuhl 2011) has led develop a coherent sense of self or identity and
to discussion of discriminating “disability”— chronic interpersonal dysfunction. Evaluation
the impairments in functioning that are the of self pathology was based on indexing
consequences of disorders—from “dysfunc- three major developmental dimensions in the
tion,” which describes core disturbances in emergence of a sense of self: differentiation
capacities that underlie different forms of of self-understanding or self-knowledge (in-
psychopathology, in keeping with Wakefield’s tegrity of self-concept), integration of this
(1992) definition of mental disorder. The need information into a coherent identity (identity
for this discrimination is particularly apt for integration), and the ability to set and attain
the PDs because impairment in “interpersonal satisfying and rewarding personal goals that
functioning” is inherent to them. give direction, meaning, and purpose to life
The Work Group began with a “tripartite (self-directedness). Interpersonal pathology

model of mental disorders” (Skodol et al. was evaluated by indexing failure to develop the
2009) based on a model of patient assessment capacity for empathy, sustained intimacy and
commonly used in clinical practice (Skodol attachment (labeled intimacy in the proposal),
& Bender 2008, Westen et al. 2006a). The prosocial and cooperative behavior (labeled
tripartite model consists of three fundamental cooperativeness), and complex and integrated
assessment domains: functioning, personality, representations of others.
and psychopathology. Within the functional Since its original posting, the general criteria
domain, strengths and impairments are as- for PD have been simplified, streamlined, and
sessed in cognitive, self, emotional, behavioral, integrated with the Levels of Personality Func-
physical, interpersonal, occupational, and tioning (see below). In its current iteration, two
recreational (leisure) functioning. Functioning assessments combine to comprise the essential
constructs span adaptive to maladaptive func- criteria for a PD: impairments in personality
tioning, allowing integration of the assessment (self and interpersonal) functioning (criterion
of dysfunctions with the assessment of func- A) and the presence of pathological personality
tional strengths associated with mental health traits (criterion B). Criteria also require rela-
(Vaillant 2003) and the resilient personality tive stability across time and consistency across
(Skodol 2010). situations and exclude developmentally or cul-
Impairments in specific adaptive capacities turally normative personality features and those
in the functional domain map onto specific due to the direct physiological effects of a sub-
symptom disorders. For example, impairments stance or a general medical condition. By inte-
in cognitive functioning suggest mental re- grating the Levels of Personality Functioning
tardation, delirium, dementia, or psychotic into criterion A of the revised general criteria,
disorders. Impairment in the function of all PDs will meet the general criteria, the core
emotional regulation suggests mood or anxiety component of impaired personality functioning
disorders. Although most mental disorders have has an empirical basis (see below), and core im-
impairments in multiple domains, identifica- pairments can be represented in gradations of
tion of the primary impairments can be helpful severity.
in the process of differential diagnosis and in The focus on core impairments in person-
guiding treatment. Impairments in the self ality functioning in the proposed new general
and interpersonal domains are deemed by the criteria is expected to be more specific for
Work Group to be most characteristic of PDs. personality psychopathology than the current
The originally proposed general criteria for DSM-IV general criteria for PD. These
PD, as posted on the DSM-5 Website in early impairments will not be totally specific, how-
2010 (see table 4 in Skodol et al. 2011c) were ever, just as psychosis is not totally specific
based on Livesley’s (1998) theoretical model of for psychotic disorders, mood disturbance
320 Skodol
for mood disorders, or anxiety for anxiety minimum number (e.g., five) from a list of cri-
disorders. The assignment of disorder names teria (e.g., nine) is required, but no single one
and classes is a convention based on the most is necessary, results in extreme heterogeneity
prominent aspects of psychopathology, with among patients receiving the same diagnosis.
presumed treatment significance. Thus, the For example, there are 256 possible ways to
focus is on self and interpersonal dysfunction meet criteria for borderline personality disor-
in the definition of PDs, for which various der (BPD) in DSM-IV-TR ( Johansen et al.
forms of psychotherapy dealing with issues of 2004).3 Furthermore, all of the PD categories
sense of self and interpersonal relations are have arbitrary diagnostic thresholds, i.e., the
regarded as the treatments of choice. number of criteria necessary for a diagnosis.
Consideration was given to changing the Finally, despite having criteria for 10 different
name of the class of PDs to a name that would PD types, the DSM system may still not cover
be more meaningful and less pejorative. “Re- the domain of personality psychopathology
lational disorders” was considered because of adequately. In fact, the most frequently used
the prominence of disturbances in interper- PD diagnosis is personality disorder not other-
sonal relations found in people with self-other wise specified (PDNOS) (Verheul et al. 2007),
issues. However, relational disorders have a a residual category indicating that a patient is
very different meaning in the context of the considered to have a PD but does not meet
DSM, since they have been proposed for the full criteria for any one of the DSM-IV-TR
disturbed relationships between people, rather types, or is judged to have a PD not included
than the psychopathology of individuals (First in the official classification (e.g., depressive,
et al. 2002). The name “adaptational disorders” passive-aggressive, or self-defeating PDs).
(Svrakic et al. 2009) was also considered as a Dimensional models of personality psy-
parallel to adjustment disorders. “Adaptational” chopathology make the co-occurrence of PDs
moves away from the “adaptive failure” concept and their heterogeneity more rational because
originally included in the revised definition of they include multiple dimensions on all of
PD and is more consistent with the wealth of which people can vary. The configurations of
data from prospective longitudinal studies that dimensional ratings describe each person’s per-
indicates that PDs may improve with time (or sonality, so many different multidimensional
treatment) (Skodol 2008) and with models of configurations are possible. Trait dimensional
PDs as “maturational delays” (Cohen & Craw- models were developed to describe the full
ford 2009). At this time, however, the name range of personality traits, so it should be
“personality disorders” has been retained. possible to describe anyone.
Dimensional models, however, are un-
familiar to clinicians trained in the medical
Dimensional Versus model of diagnosis, in which a single diagnostic
Categorical Approaches concept is used to communicate a large amount
A debate about the relative merits of categor- of important clinical information about a
ical and dimensional approaches to the PDs patient’s problems, the treatment needed, and
arose almost immediately after the publication the likely prognosis (First 2005). Dimensional
of DSM-III in 1980 (Frances 1980, 1982). models are also more difficult to use: Even
Since then, considerable research has shown the recently revised and pared-down DSM-5
excessive co-occurrence among PDs diagnosed personality trait assessment (see below) still
using the categorical system of the DSM
(Oldham et al. 1992, Zimmerman et al. 2005): 3
Heterogeneity among patients with the same disorder is not
Most patients diagnosed with a PD meet limited to PDs but would be found for any disorder defined
by a polythetic criteria set. In fact, the revised criteria for
criteria for more than one. In addition, use substance use disorder proposed for DSM-5 (any two or more
of the polythetic criteria of DSM, in which a of 11 criteria) result in over 2,000 possibilities!

requires 25 trait facet dimensions to fully Models designed to integrate Axis II and
describe a person’s personality. Finally, there Axis I disorders based on shared spectra
is little empirical information on the treatment of psychopathology have been developed:
or other clinical implications of dimensional Siever & Davis’s (1991) model, for example,
scale elevations and, in particular, where to set which hypothesizes fundamental dimensions
cut-points on dimensional scales to maximize of cognitive/perceptual disturbance, affective
their clinical utility. Proponents of dimen- instability, impulsivity, and anxiety that link
sional models point out how extremes of some related disorders across the DSM axes. Thus,
continuous clinical phenomena in medicine, schizophrenia and schizotypal personality
such as blood pressure, lead to meaningful disorder (STPD) are on a spectrum of cog-
categorical diagnoses (i.e., hypertension) once nitive/perceptual disturbance, sharing some
cut-points with significance for morbidity and fundamental genetic and neurobiological
a need for treatment are established. processes (Siever & Davis 2004). Another
Widiger & Simonsen (2005) reviewed 18 al- integrative model hypothesizes only two
ternative proposals for dimensional models of fundamental dimensions: internalization and
PDs. The proposals included (a) dimensional externalization (Krueger 2005, Krueger et al.
representations of existing PD constructs, 2001). Internalizing disorders include mood
(b) dimensional reorganizations of diagnostic and anxiety disorders from Axis I and avoidant
criteria, (c) integration of Axes II and I via com- and dependent personality disorders from Axis
mon psychopathological spectra, and (d ) inte- II. Externalizing disorders include substance
gration of Axis II with dimensional models of use disorders, for example, from Axis I and
general personality structure. antisocial personality disorder from Axis II.
A proposal by Oldham & Skodol (2000) con- Finally, the fourth group of alternatives
verted each DSM-IV PD into a six-point scale hypothesizes that PDs are on a continuum
ranging from absent traits to prototypic dis- of general personality functioning, i.e., are
order. Significant personality traits and sub- extremes of normal personality traits. Three-
threshold disorders could be noted in addition Factor Models (Eysenck 1987, Tellegen &
to full diagnoses. Another person-centered di- Waller 1994) include neuroticism, extrover-
mensional system is the prototype matching ap- sion, and psychoticism (or disinhibition versus
proach described by Shedler & Westen (2004, constraint) as higher-order factors, and the
Westen et al. 2006b), by which a patient is com- Five-Factor Model (FFM) includes neuroti-
pared to a description of a prototypic patient cism, extroversion, agreeableness, openness,
with each disorder, and the degree of match is and conscientiousness (Costa & McCrae
rated on a five-point scale. 1992), with each of the FFM factors composed
A dimensional system in which criteria for of six trait facets. The Temperament and
PDs are arranged by trait dimensions instead Character Model (Cloninger 2000) consists
of by categories is the model of the Schedule of four dimensions of temperament (novelty
for Nonadaptive and Adaptive Personality seeking, harm avoidance, reward dependence,
(SNAP) (Clark 1993), with three higher-order and persistence) and three dimensions of
factors (negative temperament, positive tem- character (self-directedness, cooperation, and
perament, and disinhibition), in addition to 12 self-transcendence).
lower-order trait scales measuring traits such Trull (2005) has summarized descriptions of
as dependency, aggression, and impulsivity. PDs in terms of dimensional models. Accord-
Livesley’s (Livesley & Jackson 2000) Dimen- ing to the Five-Factor Model, PDs in general
sional Assessment of Personality Pathology has would be characterized by high neuroticism.
broad domains of emotional dysregulation, dis- A specific PD, such as BPD, would also be
social behavior, inhibition, and compulsivity, characterized by low agreeableness and low co-
plus 28 lower-order, primary traits. operativeness. According to the Temperament
322 Skodol
Character Model, PDs would be characterized require the presence of typical impairments in
by low self-directedness and low cooperative- personality functioning and particular patho-
ness. PDs in Cluster B would also show high logical personality traits, but these can each
novelty seeking; those in Cluster C, high harm vary in degree. The rationale for the types is
avoidance; and those in Cluster A, low reward described below and elsewhere (Skodol et al.
dependence. 2011a).
The various models have also been synthe- For the assessment of pathological person-
sized into an overarching dimensional model. ality traits, the Work Group now proposes
Widiger & Simonsen (2005) proposed an in- five broad, higher-order personality trait
tegration over four levels of specificity. First, domains—negative affectivity, detachment,
personality psychopathology was divided at antagonism, disinhibition versus compulsivity,
the highest level by the dimensions of in- and psychoticism—each composed of several
ternalization and externalization. Below these lower-order, more specific trait facets. The
were broad domains of personality: extrover- proposed trait model originally consisted of
sion versus introversion, antagonism versus six domains and 37 trait facets but was revised
compliance, impulsivity versus constraint, emo- on the basis of a three-wave community
tional dysregulation versus emotional stability, survey (Krueger et al. 2011b; RF Krueger, J
and unconventionality versus closed to experi- Derringer, KE Markon, D Watson, & AE
ence. Below these were a number (25–30) of Skodol, unpublished data). The model contin-
lower-order traits, each with behaviorally spe- ues to be under development and may change
cific diagnostic criteria. Despite this integra- further based on future data, so it should be
tion, questions remain about which approach— considered preliminary. The rationale for this
categorical or dimensional—has more validity specific pathological personality trait model
and clinical utility and which would be more is summarized briefly below and has been
accepted by clinicians. described in detail elsewhere (Krueger &
Thus, a new hybrid dimensional-categorical Eaton 2010; Krueger et al. 2011a,b). Individual
model for personality and PD assessment and traits were tailored and assigned to PD criteria
diagnosis has been proposed for DSM-5 field sets (the B criteria) based on empirical data and
testing. Hybrid models combining elements of the Work Group’s assessment of their ability
categories and dimensions have been suggested to represent characteristics of current disorder
by personality disorder experts since before constructs.
the publication of DSM-IV (Benjamin 1993, Ideally, despite their being based on prior
Blashfield 1993). In a recent survey of person- models and research, the alternative model
ality disorder experts (Bernstein et al. 2007), components would all be tested to determine
Bernstein and colleagues found that a (unspeci- whether they are, in fact, improvements to the
fied) mixed system of categories and dimensions DSM-IV categorical system. Specifically, in
was the most frequently endorsed alternative their chapter in A Research Agenda for DSM-V,
system for PDs. First and colleagues (2002) suggested that
Six specific PD types are being recom- the dimensional alternatives should (a) better
mended for retention in DSM-5: antisocial, account for existing behavioral, neurobiolog-
avoidant, borderline, narcissistic, obsessive- ical, genetic, and epidemiological data and
compulsive, and schizotypal. The DSM-IV-TR adequately represent all clinically important
PDs not represented by a specific type will be aspects of a PD; (b) be more reliable, specific,
diagnosed as PD trait specified (PDTS) and and clinically informative; (c) more effectively
will be represented by significant impairment guide treatment decisions; (d ) have adequate
in personality functioning combined with de- levels of temporal stability in clinical settings;
scriptions of patients’ unique personality trait (e) relate to motivational and cognitive systems
profiles. Criteria sets for each specific PD of the brain; ( f ) provide a better understanding

of the interaction between temperaments response/outcome, reliability, internal consis-

and environment that result in PD; and tency, and acceptance/adherence by clinicians.
( g) explicate the mechanisms by which mal- Finally, criteria for change were proposed by
adaptive and adaptive personality traits impact the Task Force to be applied across all cate-
physical disease and health. Although the gories, which focus mostly on traditional mea-
results of prior research on which the proposed sures of validity (antecedent, concurrent, and
revisions are based suggest affirmative answers predictive) for making changes. The motivation
to many of these questions, only extensive for DSM-5 was the lack of validity of existing
future research will answer them with certainty. categories of mental disorders according to tra-
ditional (e.g., Robins & Guze 1970) criteria, yet
new options for these disorders are intended to
Criteria for Change somehow meet these standards.
The beginning deliberations of the DSM-5 Furthermore, different validators (e.g.,

Task Force revolved around a paradigm-shift family history versus consistent longitudinal
that was needed to characterize DSM-5 because course) are known to support different defi-
of the shortcomings of the neo-Kraepelinian nitions of disorder, and which is prioritized
model. For the first year or so, everything was depends on the specific purpose of the di-
on the table, and Work Groups were encour- agnosis (e.g., to study heritability versus to
aged to think outside the box. Tinkering with predict prognosis). This exact issue has been
the diagnostic criteria for disorders was referred playing out over the placement of STPD in the
to as “vandalism” because even small changes in DSM-5 metastructure. Genetic and some neu-
criteria could result in large changes in preva- robiological findings in STPD would suggest
lence rates and in difficulties in learning the placement with the schizophrenic disorders in
revised criteria, applying current treatments, DSM-5 (as it is in ICD-10) rather than with
or translating existing research findings (First the other PDs. Other neurobiological findings
2005). that protect against the development of frank
Eventually, various Work Groups became psychosis, the absence of a deteriorating
anxious about the scope and nature of a clinical course in STPD, and considerations
paradigm-shift and wondered whether one was of differential diagnosis (i.e., STPD is not
justified. Thus, many Work Groups assumed a characterized by psychotic symptoms) would
traditional tinkering approach to revising their suggest the opposite placement.
criteria sets. The P&PD Work Group per- The guidelines for change in DSM-5 state
sisted in the pursuit of a dimensional model for that the magnitude of a suggested change
PDs, for which the PD field had long waited should be supported by a proportional amount
(e.g., Frances 1993) and was apparently eager and quality of evidence in support of the change.
(Bernstein et al. 2007, Clark 2007, Trull & In the PD field, literature reviews support the
Widiger 2008), and which the DSM-5 research validity of some PDs much better than oth-
agenda had embraced. Eventually, the Work ers, but the general problems with the existing
Group’s dimensional model became an out- 10-category system for diagnosing PDs appear
lier with respect to the other Work Groups’ so severe that a reduced threshold for change
criteria-based, categorical approaches, and the seems warranted. Whether this assumption will
revised hybrid model for PDs surfaced. pass the scrutiny of the Scientific Review Com-
For the first year or so of Work Group mittee appointed to review all recommended
meetings, there were no guidelines for change changes for DSM-5 remains to be seen.
for DSM-5. The P&PD Work Group devel- Furthermore, the relationship of empirical
oped our own set of priorities for change— findings and clinical utility is not entirely
including such goals as increased specificity clear. Should recommended changes in the
for treatment selection, prediction of treatment classification reflect and promote progress on
324 Skodol
understanding pathophysiology and etiology valid, because few “zones of rarity” (p. 4) in the
or should they assist clinicians in doing their manifestations of disorders have been found,
essential tasks? When these goals are in and few disorders have been identified to have
conflict, on what basis, by what process, and by specific mechanisms of pathophysiology or
whom—Work Group members with expertise etiology. According to Kendell & Jablensky
in their particular field, general Task Force (2003), however, a diagnosis possesses utility
members, the Scientific Review Committee, “if it provides nontrivial information about
or boards of governance of the APA—will prognosis and likely treatment outcomes. . . .
decisions be made? Diagnostic categories provide invaluable infor-
DSM-5, as a whole, is intended to be a mation about the likelihood of future recovery,
“living document,” with the potential for par- relapse, deterioration, and social handicap; they
tial revision in an ongoing process, as research guide decisions about treatment. . . .” (p. 9).
advances warrant (Regier et al. 2009). Thus, the Therefore, in addition to the structural validity
edition scheduled for publication in 2013 tech- of personality pathology, it is the belief of
nically should be called DSM-5.0, with future many of the clinician/researchers on the Work
revisions called 5.1, 5.2, etc. Whether a contin- Group that attention should be paid to the
uing process of revision will be acceptable and clinical utilities for which diagnoses are used.
can be implemented by the APA, or will be too
disruptive to practice and research, is a matter
for the future. Cultural Applicability
A DSM-5 Study Group has been reviewing is-
sues involving age, gender, and culture (Regier
Validity Versus Clinical Utility et al. 2009). Sensitivity to cultural differences
The question of the validity of a diagnostic sys- in what constitutes personality pathology and
tem versus its clinical utility has loomed large in how it is manifested is important. For example,
DSM-5 deliberations. Related, the constructs the proposed Levels of Personality Function-
of validity and of clinical utility have been de- ing continuum (see below) specifies impairment
bated. Within the PD area, some Work Group in self and interpersonal functioning—identity
members believe that research on personality and self-direction and empathy and intimacy,
pathology approached from the factor analyt- respectively—as the core disturbances in PDs
ical perspective fails to validate any current and incorporates these into criterion A of the
PD category, whereas clinicians on the Work revised general and specific criteria for the PDs.
Group see evidence of the health impact, treat- These concepts, especially those focused on in-
ment and prognostic significance, neurobiol- dividualism and self-reliance, may be most rel-
ogy, and genetics of certain PD categories or evant in Western cultures and societies, where
their components as compelling evidence of they are highly valued. In other cultures, in
their validity. which relationships to the family, the commu-
The DSM-5 Work Groups were charged nity, or the social group, and religion and spir-
with developing a more clinically useful system. ituality are highly valued, the balance between
However, discussions of clinical utility are often individual and collective resources and deficits
limited to the user friendliness, feasibility, and may shift significantly in determining person-
clinician acceptability of proposals rather than ality psychopathology. Similar considerations
their usefulness in communication between apply to the pathological significance of the B
clinicians or between clinicians and patients or criteria personality traits. The revised criteria
their ability to guide treatment decisions or es- for PDs now proposed for DSM-5 require that
timate prognosis (First et al. 2004). According the impairments (and traits) are “not better un-
to strict definitions of validity (e.g., Kendell & derstood as normative within the individual’s. . .
Jablensky 2003), few psychiatric diagnoses are socio-cultural environment.”

DSM-5 and ICD-11 self-report “review of systems” for major patho-

logical trait domains and is being tested in the
Attention is being paid to the harmonization
DSM-5 Field Trials. Patients who score above
of DSM-5 and ICD-11. The scheduled publi-
average (based on a community population
cation of DSM-5 is likely to precede the pub-
of persons who reported ever having sought
lication of ICD-11 by several years, based on
help for an emotional problem) will be flagged
current timelines. Compatibility between the
for more detailed personality assessment by
American and international classifications has
Field Trials clinicians. The inventory can also
always been a goal of DSM revisions, but this
provide a snapshot of the personality traits of
time the DSM-5 leadership has been more re-
all patients, whether they have a PD or not.
sponsive to proposals made by members of the
Other questions have been asked about the
ICD committees than before, in some cases fa-
proposed model, such as whether nonpsychi-
voring international proposals over ones made

atric medical practitioners will be able to un-
by the DSM-5 Work Groups, despite consid-
derstand the meaning of certain key terms, such

erable advantages in the amount of time and
as “identity” and “empathy,” despite the fact
resources being devoted to the DSM-5 efforts
that these terms have appeared in the DSM for
in comparison to those of the ICD-11.
the past 30 years, are represented in most the-
ories of personality, and can be readily found
in newspaper articles and in television scripts.
Diagnosis in Specialty Versus Primary Also, whether PDs can be diagnosed in 15 min-
Care Settings utes has been asked. It is interesting that simi-
Enhancing the use of DSM-5 in primary care lar questions are not asked about the meaning
settings has received considerable attention of less obvious diagnostic terms in other areas
in the DSM-5 development process. The so- of psychopathology (e.g., avolition or prosody
called Level 1/Level 2 crosscutting measures in schizophrenia), nor whether schizophrenia,
have been motivated by this objective. These attention-deficit disorder, posttraumatic stress
measures are meant to function as self-report disorder, or other complex mental disorders can
screening scales (Level 1) and diagnostic check- (or should be) diagnosed in 15 minutes.
lists (Level 2) to ensure that clinicians do The PD proposal is responsive to limitations
not miss important psychopathology in basic on clinicians. The model has been designed
assessments. Crosscutting dimensions of psy- to be flexible and to telescope a clinician’s at-
chopathology are also meant to reduce artificial tention onto personality psychopathology with
comorbidity of diagnoses in complex cases with increasing specificity, depending on limitations
mixed features and to describe heterogeneity on time, information, and expertise. The
within disorder categories (Regier et al. 2009). model is intended to facilitate identification of
Two Level 1 screening inquiries were recom- personality-related problems and their severity
mended to the Task Force to screen for core self (i.e., the Levels of Personality Functioning,
and interpersonal personality psychopathology see below) and then to characterize these
with high sensitivity based on secondary data problems according to clinically salient types
analysis: “Not knowing who you really are or and ultimately by patient-specific personality
what you want out of life” and “Not feeling trait profiles. The assessments of personality
close to other people or enjoying your relation- problems and of pathological personality traits
ships with them.” are relevant whether a patient has a PD or not.
In addition, a 25-item self-report Scale Nonetheless, many would argue that DSM-5
of Personality has been developed from a should be for specialists in psychiatry and that
community survey to tap into the five-domain a primary care version should be developed for
personality trait model now proposed by the primary care, rather than gearing the manual
Work Group. This scale is meant to serve as a toward the nonspecialist.
326 Skodol
PROPOSED DSM-5 PERSONALITY represented by significant impairment in

DISORDER MODEL personality functioning combined with specifi-
cation by pathological personality traits on the
The currently proposed DSM-5 model con-
basis of their most prominent descriptive fea-
sists of three interrelated parts: the Levels of
tures. (See http://www.dsm5.org for the rep-
Personality Functioning scale, diagnostic cri-
resentation of all DSM-IV-TR PDs by the cur-
teria for six specific PDs and for PDTS, and
rently proposed set of DSM-5 traits.) Scoring
a five-domain/25-facet pathological personal-
of the individual criteria and scoring algorithms
ity trait assessment.
for the specific disorders are currently under
development. (See http://www.dsm5.org for
Levels of Personality Functioning the diagnostic criteria for all DSM-5 PDs.)
Personality psychopathology emanates from

disturbances in thinking about self and others. Pathological Personality Traits
Because there are degrees of disturbance in the The Work Group has proposed five broad,
self and interpersonal domains, a continuum higher-order personality trait domains—
composed of levels of self and interpersonal negative affectivity, detachment, antago-
functioning was developed for assessing in- nism, disinhibition versus compulsivity, and
dividual patients. A review of the empirical psychoticism—each composed of from three
literature on dimensional models pertinent to nine lower-order, more specific trait facets.
to individuals’ mental representations of self Trait domains and facets are rated on a four-
and others (Bender et al. 2011) and subse- point dimensional scale of descriptiveness. (See
quent empirical analyses (Morey et al. 2011) http://www.dsm5.org for the definitions of
identified the components most central to a all DSM-5 trait domains and trait facets.)
personality functioning continuum: identity
and self-direction (self); empathy and intimacy
(interpersonal). The Levels of Personality General Criteria for
Functioning scale uses each of the components Personality Disorder
to differentiate five levels of impairment in self-
The revised general criteria for PD
interpersonal functioning, ranging from no
are described on the DSM-5 Web site
impairment, i.e., healthy functioning (level =
(http://www.dsm5.org). All PDs described by
0), to extreme impairment (level = 4). (See
criteria sets and PDTS will meet the general
http://www.dsm5.org for the complete scale.)
criteria.
Personality Disorder Types

The Work Group has proposed new di- RATIONALES FOR
agnostic criteria for six specific personality PROPOSED CHANGES
disorder types: antisocial, avoidant, border-
Revised Levels of
line, narcissistic, obsessive-compulsive, and
schizotypal. Each type is defined by typical
Personality Functioning
impairments in personality functioning (the Recent research suggests that generalized
A criteria) and pathological personality traits severity may be the most important single
(the B criteria). (See http://www.dsm5.org predictor of concurrent and prospective
for the new diagnostic criteria for BPD.) dysfunction in assessing personality psy-
The other DSM-IV PDs (paranoid, schizoid, chopathology and that PDs are optimally
histrionic, and dependent), the Appendix characterized by a generalized personality
PDs (depressive and negativistic), and the severity continuum with additional stylis-
large residual category of PDNOS will be tic elements, derived from PD symptom

constellations and personality traits (Hopwood To both validate the dimensional approach
et al. 2011). A number of experts (e.g., Parker of the proposed Levels of Personality Function-
et al. 2002, Tyrer 2005) concur that severity as- ing and to make the continuum more readily
sessment is essential to any dimensional system accessible and usable by clinicians of various
for personality psychopathology. Neither the disciplines, four subsequent steps were taken:
DSM-IV-TR general severity specifiers nor (a) a secondary data analysis, (b) a focus on only
its Axis V GAF Scale have sufficient specificity the most reliable constructs from the various
for personality psychopathology to be useful measures surveyed for the Levels development,
in measuring its severity. (c) a synthesis of 1 and 2 into a revised Levels
Literature reviewed by Bender et al. (2011) of Personality Functioning, and (d ) a further
demonstrated that PDs are associated with dis- simplification and reorganization of the Levels
torted thinking about self and others and that into a tabular format, with a five-point numer-
maladaptive patterns of mentally representing ical scale.

self and others serve as substrates for personal- To determine the validity of the core
ity psychopathology. A number of reliable and dimension of personality pathology based on
valid measures to assess personality functioning deficits in representations of self and others,
and psychopathology demonstrate that a self- Morey et al. (2011) used data from two samples:
other dimensional perspective has an empirical 424 patient participants from the Psychother-
basis and significant clinical utility. Reliable rat- apeutic Center De Viersprong and 2,730
ings can be made on a broad range of self-other participants from various treatment centers
constructs, such as identity and identity inte- and the general population in the Netherlands
gration, self-other differentiation, agency, self- (Verheul et al. 2008). The instruments measur-
control, sense of relatedness, capacity for emo- ing personality functioning were the Severity
tional investment in others, responsibility and Indices of Personality Problems (Verheul et al.
social concordance, maturity of relationships 2008) and the General Assessment of Per-
with others, and understanding social causality. sonality Disorder (WJ Livesley, unpublished
Numerous studies using these measures have manuscript). The instruments measuring
shown that a self-other approach is informative DSM-IV PD diagnoses were the Structured
in determining type and severity of personality Clinical Interview for DSM-IV Axis II Per-
psychopathology, in planning treatment inter- sonality Disorders (SCID-II; First et al. 1997)
ventions, and in anticipating treatment course and the Structured Interview for DSM-IV
and outcome. Because many of the constructs Personality (SIDP-IV; Pfohl et al. 1997).
measured by these instruments have significant First, specific items in the Severity Indices of
validity and utility for characterizing levels of Personality Problems and the General Assess-
personality psychopathology, they serve as the ment of Personality Disorder were identified
foundation for creating a new measure. as reliable and discriminating markers of the
To this end, the various concepts across dimensions identified above in the preliminary
self-other models were synthesized to form a Levels of Personality Functioning. Then, IRT
foundation for rating personality functioning analyses were conducted to identify items
on a continuum. A preliminary structure with characterizing the types of problems associated
three broad dimensions in each of the self with different levels of severity. In addition,
and interpersonal domains was proposed: Self discrimination parameters indicated the ability
(identity integration, integrity of self-concept, of a particular item to distinguish patients at a
self-directness) and Interpersonal (empathy, particular level from those at lower levels. The
intimacy, complexity and integration of results of these analyses demonstrated and de-
representations of others) (Skodol et al. lineated a coherent global dimension of severity
2011b,c). This was posted in February 2010 on of impairment in personality functioning that
the APA’s DSM-5 Website. was clearly related to the likelihood of receiving
328 Skodol
any PD diagnosis as well as to the likelihood of Impairment in self and interpersonal func-
receiving two or more PD diagnoses. Morey tioning is consistent with multiple theories
et al. (2011) concluded that, “indicators of this of PD and their research bases, including
dimension involve important functions related cognitive/behavioral, interpersonal, psycho-
to self (e.g., identity integration, integrity of dynamic, attachment, developmental, social
self-concept) and interpersonal relatedness cognitive, and evolutionary theories, and
(e.g., capacity for empathy and intimacy).” is a key aspect of personality pathology in
In response to suggestions from the DSM-5 need of clinical attention (Clarkin & Huprich
Website posting, a second step in refining the 2011, Luyten & Blatt 2011, Pincus 2011). A
model identified the most reliable dimensions factor analytic study of existing measures of
among those found in the measures considered psychosocial functioning found “self-mastery”
in the Bender et al. (2011) review. A threshold and “interpersonal and social relationships”
of 0.75 was established. Dimensions meeting to be two of four major factors measured (Ro
this criterion were retained. Other changes in- & Clark 2009). Furthermore, the Levels of
cluded combining identity integration and in- Personality Functioning constructs align well
tegrity of self-concept to form one facet called with the NIMH Research Domain Criterion
identity, because they were viewed as substan- of “social processes” (Sanislow et al. 2010).
tially overlapping concepts. Regulation of self- The interpersonal dimension of personality
states, sense of autonomous agency, and qual- pathology has been related to attachment and
ity of self-representation were eliminated based affiliative systems regulated by neuropeptides
on reliability or complexity considerations, and (Stanley & Siever 2010), and variation in the
the capacity for a range of emotional experience encoding of receptors for these neuropeptides
and its regulation was added to the identity do- may contribute to variation in complex human
main to capture an affect regulation component social behavior and social cognition, such
that was deemed important. For the interper- as trust, altruism, social bonding, and the
sonal domain, the complexity and integration ability to infer the emotional state of others
of representations of others facet and the term (Donaldson & Young 2008). Neural instantia-
mentalize were dropped. tions of the self and of empathy for others have
In summary, DSM-IV had no provision also been linked to the medial prefrontal cortex
for delineating severity of impairment specific and other cortical midline structures—the sites
to personality functioning. The Work Group of brain’s so-called default network (Fair et al.
demonstrated with a literature review that 2008, Northoff et al. 2006, Preston et al. 2007).
dimensional measures of personality psy-
chopathology based on representations of self
and interpersonal relations hold significant Revised Personality Disorder Types
clinical utility, particularly in identifying The original proposal for the specified PD
the presence and extent of personality psy- types in DSM-5 had three main features:
chopathology, for treatment planning, as (a) a reduction in the number of specified types
information for alliance building, and in study- from ten to five, (b) description of the types in a
ing treatment course and outcome. From these narrative format that combined typical deficits
measures, the Levels of Personality Function- in self and interpersonal functioning and par-
ing continuum has been derived for use in ticular configurations of traits and behaviors,
assessing personality functioning in DSM-5. and (c) a dimensional rating of the degree
Secondary data analyses have provided empir- to which a patient matched each type. Five
ical support for this continuum. The proposed specific PDs were recommended for retention:
severity dimension captures variability not antisocial/psychopathic, borderline, schizo-
only across but also within PD types. typal, avoidant, and obsessive-compulsive.

Each DSM-IV-TR PD was the subject of a tions. Ratings on these traits were intended to
literature review performed by Work Group be used to describe the particular trait profile
members and advisors. Antisocial, borderline, of each patient who matched a type and thus to
and schizotypal PDs have the most extensive document potentially useful information about
empirical evidence of validity and clinical util- within-type heterogeneity. Feedback from the
ity. In contrast, there are almost no empirical Website posting suggested that this system was
studies focused explicitly on paranoid, schizoid, too complicated, redundant with the full clini-
or histrionic PDs. cians’ trait ratings, and unwieldy. Furthermore,
There are no clinical or empirical justifica- the empirical basis for assigning trait facets to
tions for the number of criteria needed to make types was questioned. Therefore, the trait rat-
a PD diagnosis according to DSM-IV-TR. ings were completely separated from the type
Although some studies consider patients who ratings in the first revised assessment model
fall even one criterion below threshold to developed for field testing, with the goal of es-
no longer “have” the categorical diagnosis, tablishing relationships empirically. Now, how-
most clinicians and researchers know that this ever, traits have been reintroduced as the B cri-
convention is a fiction. Of the number of ways teria for the six new PD criteria sets.
to dimensionalize PD diagnoses, a person- The rationales for retaining six of the 10
centered dimensional approach was originally DSM-IV PDs are reviewed in detail elsewhere
adopted by the Work Group to represent (Skodol et al. 2011a). Briefly, the rationales
specific PD types. Using this system, a clini- were based on their prevalence (and the
cian compares a patient to paragraph-length consistency of prevalence estimates) in com-
narrative descriptions of the prototypic patient munity and clinical populations, psychosocial
with each disorder, and the match is rated on a impairment associated with individual PDs,
5-point scale, with 5 being a very good match and other evidence of the validity and clinical
to 1 representing little or no match. Prototype utility of the disorders. The evidence does not
matching ratings have been shown to have align completely, but on the whole, there are
good interrater reliability (Westen et al. 2010), stronger arguments for retaining certain PDs
to reduce comorbidity, to predict external than for others. For example, two PDs rec-
validators as well as DSM-IV PD diagnoses ommended for retention, avoidant personality
(Westen et al. 2006b), and to be rated higher disorder and obsessive-compulsive personality
by clinicians on measures of clinical utility than disorder (OCPD), are consistently among
categorical, criteria count, or trait dimensional the most common in both epidemiological
approaches (Spitzer et al. 2008). A recent study (Torgersen 2009) and clinical (Stuart et al.
also found that clinicians made fewer correct 1998, Zimmerman et al. 2005) samples.
diagnoses of PDs when given ratings of patients Avoidant personality disorder (perhaps sur-
on a list of traits of normal-range personality prisingly) is also one of the most impairing
than when given prototype PD descriptions of the PDs, according to empirical studies.
(Rottman et al. 2009). These findings were Although OCPD has less broadly associated
replicated in comparisons of DSM-IV to the impairment, it nonetheless predicts poor out-
FFM with raters who were experts in PD and comes, including suicide (Diaconu & Turecki
familiar with the FFM (Rottman et al. 2011). 2009), and has high levels of associated health
In the original DSM-5 Website posting, se- and productivity loss costs (Soeteman et al.
lected personality trait facets from relevant trait 2008). STPD has relatively low prevalence in
domains (see table 2 in Skodol et al. 2011c) were both populations, is highly impairing, and has
grouped with each of the five types to provide considerable research to support it. BPD has an
context for the trait ratings. The traits were average prevalence in community studies but is
selected on the basis of a careful mapping of one of the most common in the clinic, is asso-
the language of the types onto the trait defini- ciated with high levels of impairment and poor
330 Skodol
outcomes, and has a wealth of data to support sonality disorder requires a rating of significant
its validity and utility. Antisocial personality impairment in personality functioning com-
disorder is less common, and of average im- bined with the presence of pathological trait
pairment, but has also been extensively studied domains or facets and is intended to provide
and has considerable relevance in forensic a diagnosis to replace PDNOS. That is, when
settings. Narcissistic personality disorder was the presentation does not neatly resemble a
originally slated for deletion as a disorder, with specific PD type, the clinician has the option of
dimensional representation in DSM-5 by typ- diagnosing PDTS and tailoring the description
ical personality functioning impairment levels of the PD to fit the specific patient, using the
and traits. It is among the less common PDs, specific features encoded by pathological traits.
is moderately impairing, and has an average A number of recent studies support a
research base. Following the original Website hybrid model of personality psychopathology
posting, however, many comments were consisting of ratings of both disorder and
received bemoaning its deletion as a specific trait constructs. Morey & Zanarini (2000)
PD. It has been reintroduced in the criteria found that FFM domains captured substantial
sets for DSM-5 with significant conceptual variance in the borderline diagnosis with
revisions to capture both the overt, grandiose respect to its differentiation from nonbor-
presentation and the covert, deflated one. derline PDs but that residual variance not
In contrast, schizoid PD (recommended for explained by the FFM was significantly related
deletion as a type and representation by PDTS) to important clinical correlates of BPD, such
is consistently among the least common, espe- as childhood abuse history, family history of
cially in clinical samples, although it has been mood and substance use disorders, concurrent
found to be impairing. Two other PDs to be (especially impulsive) symptoms, and two-
recommended for deletion as types, histrionic and four-year outcomes. In the Collaborative
and dependent, have lower prevalence in the Longitudinal Personality Disorders Study,
community, widely variable (by factors of 10 to dimensionalized DSM-IV-TR PD diagnoses
20 times) prevalence estimates in clinical popu- predicted concurrent functional impairment,
lations, relatively low levels of impairment, and but this diminished over time (Morey et al.
little empirical study as distinct PDs. Paranoid 2007). In contrast, the FFM provided less
PD has been found to be common and impair- information about current behavior and
ing, but little research has been done to support functioning but was more stable over time
it as a disorder separate from others. and more predictive in the future. The SNAP
model performed the best, both at baseline
and prospectively, because it combines the
New Criteria for Six Specific strengths of a pathological disorder diagnosis
Personality Disorders and Personality and normal-range personality functioning. In
Disorder Trait Specified fact, a hybrid model combination of FFM and
In response to feedback from the DSM-5 Task DSM-IV-TR constructs performed much like
Force, new diagnostic criteria sets have been the SNAP. The results indicated that models
developed for the six specific PDs as well as of personality pathology that represent stable
the category of PD Trait Specified, which is trait dispositions and dynamic, maladaptive
intended to replace PD Not Otherwise Spec- manifestations are most clinically informative.
ified (PDNOS) in DSM-5. Descriptions of Hopwood & Zanarini (2010) found that FFM
typical levels of impairment in self (identity or extraversion and agreeableness were incre-
self-direction) and in interpersonal (empathy mentally predictive (over a BPD diagnosis)
or intimacy) are included in the A criteria of the of psychosocial functioning over a 10-year
newly proposed diagnostic criteria for the spe- period and that borderline cognitive and im-
cific PDs. The diagnosis of a trait-specified per- pulse action features incremented FFM traits.

They concluded that both BPD symptoms and diagnosis by sharing a small number of spe-
personality traits are important long-term indi- cific traits or behaviors, or even only one. A
cators of clinical functioning and supported the trait-based diagnostic system directly reflects
integration of traits and disorder in DSM-5. the degree of similarity or difference between
individuals. The general diagnostic category of
PD is designed to accommodate the naturally
Revised Pathological occurring heterogeneity of personality, but the
Personality Traits heterogeneity of personality features within
The original proposal for DSM-5 included a PD can be fully specified, rendering it
six broad, higher-order personality trait understandable rather than obfuscating.
domains—negative emotionality, detachment The discrepancy between personality disor-
(originally called introversion), antagonism, ders as enduring patterns and the empirical re-
disinhibition, compulsivity, and schizotypy— ality of short-term instability (Grilo et al. 2004,
each composed of from four to 10 (total = Shea et al. 2002) had been a puzzle until re-
37) lower-order, more specific trait facets (see cent data suggested that the DSM criteria were
Appendix B, DSM-5 Clinicians’ Trait Rating a mix of more stable trait-like criteria and less
Form, in Skodol et al. 2011b). The rationale stable state-like criteria (McGlashan et al. 2005,
for this pathological personality trait model Zanarini et al. 2005), rendering PD diagnoses
is described in detail elsewhere (Krueger & as a whole less stable than their trait compo-
Eaton 2010; Krueger et al. 2011a,b; Skodol nents. Basing PD diagnostic criteria on more
et al. 2011c). stable traits and considering the more state-
A trait-based diagnostic system helps to re- like features that occur in individuals with PD
solve excessive comorbidity, which plagues all to be associated symptoms would eliminate the
aspects of mental disorder classification, by ac- conceptual-empirical gap in PD with regard to
knowledging that individuals too easily meet temporal stability.
criteria for multiple PD diagnoses because the The continuity between normality and
personality traits that comprise PDs overlap pathology is not unique to personality. For ex-
across diagnoses. The particular trait combina- ample, subclinical anxiety and depression also
tions that are set forth in the DSM as a whole do have large literatures and repeatedly have been
not represent areas of density in the multivariate shown to be continuous with more severe
trait space that has been identified empirically. manifestations of these disorders. In the case of
In familiar words, the DSM PD diagnoses fail personality, this is especially well documented,
to “carve nature at her joints.” Traits can com- and recent reviews and meta-analyses have doc-
bine in virtually an infinite number of ways. A umented clearly that an integrative structure
PD diagnostic system that is trait based—that is, can encompass both normal-range and abnor-
using traits themselves as diagnostic criteria— mal personality (Markon et al. 2005; O’Connor
provides a means to describe the personality— 2002, 2005; Saulsman & Page 2004; Trull &
normal or abnormal—of every patient. This Durett 2005). Implementing a trait-based sys-
has the highly beneficial effect of addressing tem for PD diagnosis, therefore, provides the
not only the comorbidity problem but also the beneficial option of assessing any patient’s per-
high prevalence of PDNOS diagnoses. In a fully sonality (i.e., not just those with PD). Insofar as
trait-based system, all patients have a specified personality has been shown to be an important
personality profile, so it is impossible to have a modifier of a wide range of clinical phenom-
profile that is “not otherwise specified.” ena (Rapee 2002), incorporating a dimensional
Given the polythetic nature of current trait model will strengthen not only PD diag-
PD (and many other DSM-IV) diagnoses, nosis but also DSM-5 as a whole.
individuals with markedly different overall Considerable evidence relates current DSM
trait profiles can meet criteria for the same PDs to four broad, higher-order trait domains
332 Skodol
of the five-factor model of personality: neu- review of existing measures of normal and
roticism, extraversion, agreeableness, and con- abnormal personality as well as recommen-
scientiousness (O’Connor 2005, Saulsman & dations by experts in personality assessment.
Page 2004). As mentioned above, Widiger & In measurement-model development, it is
Simonsen (2005) reviewed the literature on per- recommended initially to be over- rather
sonality pathology and found 18 extant mod- than underinclusive because it is easier to
els. They then demonstrated that these models collapse dimensions and eliminate redundant
could be subsumed by the same common four- or irrelevant traits at a later stage than it is to
factor model. These four factors are included in add missing elements (Clark & Watson 1995).
the proposed PD trait model. Because the pro- Accordingly, we expected that a number of the
posed model for DSM-5 is a model of person- proposed facets might be highly correlated and
ality pathology, its focus is on the maladaptive so could be combined into a smaller number
end of each dimension and thus includes the of somewhat broader facets. It is also possible
four trait domains of negative affectivity, de- that some facets were misplaced and would be
tachment, antagonism, and disinhibition. Neg- moved to a different domain; others may be
ative affectivity corresponds to neuroticism, and proven unreliable or structurally anomalous
the latter three are the maladaptive ends of and be eliminated. The structural validity of the
extraversion, agreeableness, and conscientious- original trait model was tested in a three-wave
ness, respectively. community survey (Krueger et al. 2011b; RF
Meta-analyses indicate that FFM openness Krueger, J Derringer, KE Markon, D Watson,
is not strongly related to PD (Samuel & & AE Skodol, unpublished manuscript) and
Widiger 2008) and that FFM traits tap only the was subsequently revised to yield the five-
social and interpersonal deficits of STPD and domain/25-trait model on which the newly
not the cognitive or perceptual distortions and proposed diagnostic criteria for PDs are based.
eccentricities of behavior (O’Connor 2005,
Saulsman & Page 2004). Several studies have
been published demonstrating that the psy- Revised General Criteria for
choticism (formerly called schizotypy) domain Personality Disorder
forms an important additional factor in anal- The proposal to change the general criteria
yses of both normal and abnormal personality for PD was based on observations that the
(Chmielewski & Watson 2008, Harkness et al. DSM-IV-TR criteria were poorly defined, not
1995, Tackett et al. 2008, Watson et al. 2008). specific to PD, and were introduced in DSM-
Therefore, an alternative fifth factor was added IV without theoretical or empirical justifica-
to the model. Meta-analyses further revealed tion. The rationale for revised general criteria
that OCPD is not well covered by the FFM is described earlier in this article in the sections
(Saulsman & Page 2004) since compulsivity is on the Definition of Disorder, the rationale for
more than extreme conscientiousness (Nestadt the Revised Levels of Personality Functioning,
et al. 2008). Given the radically different nature and the rationale for the Revised Pathological
of the proposed system compared to that in Personality Traits.
DSM-IV-TR, it is important to maintain
continuity to the extent possible and thus to
provide coverage of all traits relevant to the CRITIQUES OF THE PROPOSED
DSM-IV-TR PDs. Therefore, a sixth domain MODEL AND THEIR IMPACT ON
of compulsivity was added to address this MODEL EVOLUTION
otherwise missing element. A number of articles by Work Group members
Finally, the proposed specific trait facets have been published on the proposed model
were selected provisionally as representative of at various stages of its development. Most
the six domains on the basis of a comprehensive of these articles have been accompanied by

commentaries or critiques written by promi- 2010). Five of the six specific PDs currently pro-
nent members of the PD research and clinical posed for retention in DSM-5 (i.e., antisocial,
communities. In the sections that follow, these avoidant, borderline, obsessive-compulsive,
critiques are summarized along with brief and schizotypal) will be represented in substan-
accounts of how the critiques have or have not tial numbers (e.g., N = 50) in this field trial
impacted the most recent version of the model so that the specificity of the Levels ratings for
as presented above. personality disorders as opposed to other types
of psychopathology and the calibration of the
Levels ratings against PDs with varying degrees
Levels of Personality Functioning of severity can be assessed. The feasibility and
Critiques of the original DSM-5 proposed perceived clinical utility of the Levels ratings
revision generally praised the Levels of will also be assessed at the large academic
Personality Functioning as an advance over sites as well as in a representative sample of

DSM-IV (e.g., Ronningstam 2011, Shedler U.S. psychiatrists and other volunteer mental
et al. 2010) and suggested that the presence of health clinicians in clinical practice field trials
PD and its severity are the primary distinctions supported by the APA (Kraemer et al. 2010).
of importance for clinicians (Pilkonis et al. Other types of validity research should also be
2011). Some suggested even broader and more conducted in other geographic, cultural, and
complex constructs for the Levels (Clarkin clinical settings and with other types of subjects
& Huprich 2011, Pilkonis et al. 2011) and (e.g., nontreatment seeking) in order to in-
separate ratings of all components (Pilkonis crease the generalizability of the Levels rating.
et al. 2011). The need for reliability testing was
suggested (Pincus 2011). Balancing the need
for parsimony for general clinical use against Personality Disorder Types
the potential added value of a more complex Critiques of the DSM-5 proposal have almost
and potentially redundant set of indicators, universally been against the deletion of any of
the Work Group has simplified rather than the DSM-IV PD types, arguing that existing
elaborated on the Levels. A single global rating types have clinical utility and treatment rele-
of self and interpersonal functioning has been vance (Gunderson 2010, Shedler et al. 2010)
retained, rather than separate ratings, because or have heuristic value (Costa & McCrae 2010,
of evidence of the close developmental and Pilkonis et al. 2011). The empirical basis for
empirical relationships of these components of retaining versus deleting types has been ques-
personality functioning (Luyten & Blatt 2011). tioned (Bornstein 2011, Clarkin & Huprich
However, further empirical work investi- 2011, Pincus 2011, Widiger 2011a), and it has
gating the validity, reliability, and utility of been suggested that a limited research base does
the new Levels of Personality Functioning, as not mean a lack of utility (Gunderson 2010) and
well as of the other elements of the proposed should not be a criterion for deletion (Shedler
personality disorder assessment, is needed. Of et al. 2010). Deletion of types is anticipated to
primary importance will be to test the reliability result in loss of coverage of personality pathol-
of the new Levels of Personality Functioning ogy (Widiger 2011a), make comparisons of spe-
Scale as administered by clinicians to patients cific types and trait-specified disorders difficult
during conventional diagnostic evaluations. A (Clarkin & Huprich 2011), and may lead to cod-
formal test-retest reliability study is under way ing problems (First 2010, Widiger 2011a). By
in Phase I of the official DSM-5 Field Trials in far the most support for a PD to be reintro-
11 large academic settings in the United States duced into the system (including from the com-
and Canada, where two independent clinicians ments posted on the Website) has been for nar-
are evaluating patients with and without PDs cissistic PD (e.g., Pincus 2011, Ronningstam
within a two-week timeframe (Kraemer et al. 2011), but dependent PD has also had advocates
334 Skodol
(Bornstein 2011), even though the evidence suggested that prototypes replace categories in
presented for the validity of both of these disor- DSM-5. Questions were raised about the reli-
ders has often been based on dimensional mea- ability of prototype ratings, however, and fur-
sures rather than on the diagnostic category. ther testing of their reliability and validity in
Proponents for narcissistic PD agree, however, field trials was recommended (Pilkonis et al.
that its current representation in DSM-IV is in- 2011, Widiger 2011a, Zimmerman 2011). In
adequate. Pilkonis et al. (2011) argued for the a related vein, since there were no criteria per
inclusion in DSM-5 of PD types that have ap- se for the PD types, their utility for research
peared in any DSM since DSM-III. was questioned (Widiger 2011a, Zimmerman
Work Group members have developed the 2011). The derivation of the type descriptions
strong, consensus opinion not to include all of and their relationships to DSM-IV PD crite-
the DSM-IV-TR PDs in the official DSM-5 ria sets have been questioned (Pilkonis et al.
classification. In fact, some members have 2011), as was the impact of a shift to proto-
persisted in wanting to replace all of the cur- types on prevalence and comorbidity of PDs
rent disorders with a dimensional, trait-based (Zimmerman 2011).
model. The majority of the members believe Most critics believe that the originally pro-
that there are certain types that have particular posed linking of traits to types was ambigu-
clinical salience and evidence of validity and ous and without an empirical basis and that
that other PDs with less evidence supporting traits should be rated separately from the types
them can be adequately represented by traits in (Costa & McCrae 2010, Pilkonis et al. 2011,
combination with impairments in personality Pincus 2011). Some believe that trait ratings
functioning, i.e., as PD Trait Specified. This should be the basis for rating the types (Costa
convention not only makes the question of & McCrae 2010); some believe that the traits
inadequate coverage or false negative PD needed better rule-based methods for trans-
diagnoses moot, but also adds potentially lating traits to types and that both types and
useful clinical information about the nature traits should be optional, finer-grained distinc-
of personality pathology to the prevalent tions (after PD presence and severity) (Pilkonis
diagnosis of PDNOS, which in DSM-IV-TR et al. 2011); some suggest they be an optional
was unspecified. As mentioned above, however, rating on a separate axis (Axis II) (First 2010,
a revised category of narcissistic PD has been Widiger 2011a); and some thought that they
reintroduced at the time of this writing, were not needed at all (First 2010, Gunderson
despite some ambiguity in the strength of the 2010, Shedler et al. 2010).
rationale for doing so. Criteria sets may be Pilkonis et al. (2011) questioned whether
developed for other DSM-IV-TR PDs, using the hybrid model (types and traits) was of
the core impairment/trait hybrid model, for limited value or, in fact, had the best potential
a DSM-5 appendix, in the hope that they for representing personality pathology (see also
will receive greater research attention in the Hallquist & Pilkonis 2010). Livesley (2011)
future. recently questioned whether the combination
Reaction to the originally proposed shift of categorical types and dimensional traits
from criterion-based to prototype-based diag- mixed incompatible approaches to classifica-
nosis was more mixed. A number of review- tion. Historically, others (e.g., Benjamin 1993)
ers supported the prototype approach because have not seen the inconsistency, and experts in
it is simple and more familiar (types as com- personality disorder have explicitly endorsed
pared with traits) (First 2010), conforms to such a model (Bernstein et al. 2007). PD types
“what clinicians do” (Clarkin & Huprich 2011), represent the confluence of clinically relevant
and is judged to be more clinically useful than personality characteristics—impairments in
criterion-based or trait-based diagnosis (First personality functioning and traits—that have
2010, Shedler et al. 2010); these reviewers have come to facilitate communication between

clinicians and have particular developmental, apply to many types (First 2010, Paris 2011),
treatment, and prognostic significance. (b) inherently ambiguous, static (as opposed
In the most recent revision of the model, to dynamic) representations of personality,
narrative prototypes have been replaced by di- difficult to incorporate into coding systems,
agnostic criteria sets, at the request of the DSM- and (c) of uncertain clinical utility (First 2010).
5 Task Force. The new criteria sets incorporate Limited clinical utility was also raised as a
trait ratings (with core impairments) based on problem by Shedler et al. (2010), who noted
empirical data linking traits to types (Samuel & that clinicians judged dimensional trait systems
Widiger 2008, Saulsman & Page 2004) and ra- as less useful than DSM-IV, and by Clarkin &
tional methods, which may delight some critics Huprich (2011), who believed that clinicians
while discouraging others. The narrative proto- do not assess traits and that traits would
types have been used in the DSM-5 Field Trials impede communication. Bornstein (2011)
(with about 1,000 patients out of 3,000 assessed also bemoaned the loss of useful shorthand
as of this writing). It should be noted that the diagnostic labels.

prototypes were replaced without the benefit of Ronningstam (2011) found the trait rep-
information from these 1,000 patients, since no resentation of narcissistic PD to be scattered
data have been analyzed. In addition, both the (across domains) in a way that interfered with
impairment criteria (A) and the trait criteria (B) the perception of an integrated, clinically
have been adopted for the criteria sets without meaningful concept, to be missing important
any information on the reliability of these rat- traits, and to include facet traits with defini-
ings in the Field Trials and without any new em- tions that were neither clinically meaningful
pirical information on their relationships to the nor empirically representative. Pincus (2011)
disorders. It remains possible that further revi- echoed that the traits provided for narcissistic
sions of the criteria sets will be indicated. Fur- PD were too narrow, believed that some trait
thermore, scoring rules for the new criteria and definitions were confounded with interper-
diagnostic algorithms for the disorders need to sonal elements, and noted that there was no
be developed and their impact on the preva- empirical basis for reconstructing deleted types
lence and reliability of the disorders assessed. from traits. Shedler et al. (2010) also believed
combinations of traits would not easily yield
omitted PD types. The recommendation from
Personality Traits First (2010) is that a variable-centered trait
Published critiques of the originally proposed approach should not replace categories in
trait system were predominantly negative. DSM-5 but could be on a separate axis (Axis
According to Gunderson (2010), the six- II). Costa & McCrae (2010) argued that the
factor/37-facet trait system would be unfamiliar notion of personality dimensions as adjuncts to
to clinicians and unlikely to be used because the PD types is supported and that traits should be
traits lacked an experiential or empirical basis assessed in all patients, not just those with PDs.
for clinical salience. Although it may represent Pilkonis et al. (2011) said that although the
a factor structure that is scientific, he believed emphasis on personality traits as a basis for
there was an insufficient research base regard- diagnosis was well founded, traits (and types)
ing cut-points for diagnosis, the relationship of were “finer” distinctions that should be sec-
the model to other trait models, the delineation ondary (domain level first, followed by relevant
of the facet-level traits, the mapping of the trait facets) to establishing the presence of a PD
traits onto PDs, a consensus on the optimal and its severity. They also found the new trait
number of traits and their definitions, and their system and the diagnosis of PD trait-specified
use for making clinical inferences (Gunderson to be “jarring.” They found the trait definitions
2010). The traits were also criticized for being complex and inferential and believe that an
(a) nonspecific in that the same trait may assessment tool would be needed. They argued
336 Skodol
for a detailed translation of traits to types and above. That there are differences between ex-
that PDs were not merely extreme traits. tant models (including the DSM-5 model) at
Widiger (2011a) found that the trait the facet level should come as no surprise since
definitions were cumbersome and suspected there is little consensus on the facet structure
that they would not have official coding. He of trait domains. Problems with the narcissistic
also argued that there was much redundancy trait representation have been addressed with
in some of the proposed trait facets whereas the new criteria, which combine core narcis-
other key traits were missing, and that the sistic impairments in identity, self-direction,
definitions of the traits were very inconsistent, empathy, and intimacy that include both in-
with some defined broadly and others narrowly flated and deflated expressions and a revised
(Widiger 2011b). Both Widiger (2011b) and trait of grandiosity that refers to either overt or
Shedler et al. (2010) found the trait system too covert manifestations. PDs are not represented
complex. Paris (2011) wrote that the traits do solely by extreme traits in the revised model,
not map onto biological systems and ignore since all of the disorder criteria, including those
the emergent properties of cognitive, affective, for PDTS, require impairments in personality
and behavioral systems in PDs. functioning as well as the presence of patholog-
The basic structure of the proposed trait ical personality traits.
system was questioned by several authors. A The scoring of traits and diagnostic criteria
number of commentators suggested that traits are open issues. Within the criteria, it is possi-
should be bipolar, not unipolar, because patho- ble that ratings of trait domains will supersede
logical personality characteristics exist at both rating of trait facets for diagnostic purposes and
ends of the domain spectra (Costa & McCrae that facet ratings will be for more fine-grained
2010; Pilkonis et al. 2011; Widiger 2011a,b). descriptions. In the Field Trials, raters are asked
The lack of bipolarity to the traits leads to the first to rate domains, and only when a domain is
omission of clinically relevant traits and mis- rated as relevant are the component facets rated.
placed (within domains) traits (Pilkonis et al. An assessment tool for rating DSM-5
2011; Widiger 2011a,b). Several authors argue personality traits by self-report has been de-
that the proposed trait structure does not corre- veloped: the Personality Inventory for DSM-5
spond to the consensus “big four” and that the (Krueger et al. 2011; RF Krueger, J Derringer,
domains of compulsivity and schizotypy are not KE Markon, D Watson, & AE Skodol, unpub-
needed (Pilkonis et al. 2011; Widiger 2011a,b). lished manuscript). This 220-item question-
Several authors also argue for the importance naire was developed in a three-wave community
of including both normal and abnormal traits in survey and is currently being tested by a num-
DSM-5 and believe that the FFM does a better ber of research groups across the country. It
job at representing important personality vari- remains to be seen, however, whether clinicians
ation than the proposed new model (Costa & can rate these traits (and the disorders based on
McCrae 2010; Widiger 2011a,b). Finally, limi- them) reliably and whether clinicians regard
tations and ambiguities in factor analytic meth- them as useful. Both of these questions are be-
ods to derive trait structures were mentioned ing addressed in the Field Trials. Undoubtedly,
by several authors (Clarkin & Huprich 2011, training and familiarity will improve reliability.
Hallquist & Pilkonis 2010). Finally, the clinical salience and utility of patho-
The overall structure of the revised five- logical personality traits continues to be a topic
domain/25-facet system does correspond to the of debate. Certainly, broad personality trait do-
“big four” domains characterizing other trait mains, such as neuroticism (negative affectivity
models, with compulsivity representing the opin the DSM-5 proposal) have strong rela-
posite pole of a bipolar domain of disinhibi- tionships to adverse physical health outcomes
tion. Evidence for a psychoticism (formerly (Lahey 2009), and neuroticism, (dis)agree-
called schizotypy) domain has been mentioned ableness (antagonism in DSM-5),

(un)conscientiousness (disinhibition), and personality traits. All levels of personality

extraversion predict both negative and positive functioning are now represented in the A
psychosocial (Ozer & Benet-Martinez 2006, criterion of the general criteria for PD.
Roberts et al. 2007) outcomes. Studies of hy- Pilkonis and colleagues agreed that PDs
brid models of personality disorders (see above) should be defined by impairments in func-
also show that traits increment disorders (and tioning and adaptation (not by extreme traits)
vice versa) in predicting important antecedent, but thought that the originally proposed cri-
concurrent, and predictive variables. The teria were too esoteric, inferential, and nar-
clinical value of assessing specific trait facets is row (Pilkonis et al. 2011). They advocated
less established, though theoretically appealing for including constructs of agency, community,
(Verheul 2005). autonomy, achievement, self-definition (iden-
tity versus confusion), capacity for attachment
(intimacy versus isolation), generativity, and

General Criteria for
prosocial engagement. Their proposal for gen-

Personality Disorder eral criteria would reflect (a) failure to achieve
As indicated previously, feedback received autonomy and self-direction (with objective
on the initial Website posting indicated that markers) and inability to develop consistent and
these criteria were too complicated, without realistic representation of self, (b) failures in in-
a sufficiently empirical basis, set at too severe terpersonal relatedness manifest by inability to
a level of dysfunction, inconsistent with more develop and maintain close relationships and
recent views of personality pathology as devel- general social integration, and (c) failures in
opmental delays as opposed to failures, and not generativity manifest by inability to engage with
integrated with the other parts of the proposed purpose beyond self-interest and imposition of
model. Therefore, these general criteria were distress on others. All of the above would be
simplified, and empirically based assessments rated separately, and the clinician should be able
of impairment in personality functioning were to stop an assessment after establishing pres-
integrated with pathological personality traits ence and severity of PD. Clarkin & Huprich
into the new general and specific criteria sets. (2011) viewed the originally proposed general
For all PDs, severity in core impairments criteria as too onerous and lacking a coherent
can vary on the continuum of the Levels of theme, but they believed that a more elaborated
Personality Functioning Scale. For PDTS, rating of severity of impairment in functioning
significant impairment is required, and a combined with prototypes should be the core of
threshold on the Levels is being studied in the clinical assessment. As in the case of the Levels
Field Trials. of Personality Functioning, which now consti-
Integration of the general criteria for PD tute the core impairments central to the person-
into the diagnostic process has been viewed ality disorder definition and are represented by
as an advance, by distinguishing normality the A criteria in the new general and specific di-
and abnormality separately from describing agnostic criteria, the majority of critics favored
individual differences (Pincus 2011). The a simplified, rather than a more elaborated, def-
constructs embedded in the proposed general inition, and the empirical support for the four
criteria for DSM-5 are consistent with research core self and interpersonal elements selected for
and many theories of PD but will require the revised model has been described above.
training to be rated reliably. Costa & McCrae
(2010) believed that the originally proposed
definitions of impairment in self-identity, CONCLUSIONS
which emphasized the instability of borderline Scientific principles were articulated for guid-
functioning, contradicted data on the internal ing DSM-5 more than a decade ago. These
consistency and stability of self-reported principles have influenced the development of
338 Skodol
proposed changes for the assessment and di- bored in a systematic and diligent manner to im-
agnosis of personality psychopathology. Their prove the DSM-5 approach to personality and
application to the process has not been straight- personality disorders in order to make the clas-
forward, however. Principles were left ambigu- sification more valid and more clinically useful.
ous and became open to interpretation, debate, They have attempted to be responsive to the
and controversy among Work Group mem- array of diverse and sometimes contradictory
bers. In some instances, contradictory messages suggestions made by other members of the PD
were sent. Deliberations have been hampered research and clinical communities. The current
by unclear decision-making processes. model continues to be a work in progress. The
Although widespread dissatisfaction with next steps will include the review of data from
the current DSM-IV-TR categorical classifica- the Field Trials on the reliability, feasibility,
tion of PDs has long pervaded the field, little and acceptability of each element of the assess-
consensus exists on the preferred alternative. ment. Further changes are expected as a result
The P&PD Work Group members have la- of the process.
DISCLOSURE STATEMENT
The author is Chair of the DSM-5 Personality and Personality Disorder Work Group, an unpaid
position. The author is unaware of any other affiliation, funding, or financial holdings that might
be perceived as affecting the objectivity of this review.
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CP08-FrontMatter ARI 2 March 2012 11:20
Annual Review of
Clinical Psychology
Volume 8, 2012
Contents
On the History and Future Study of Personality and Its Disorders

Theodore Millon p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
A “SMART” Design for Building Individualized Treatment Sequences

H. Lei, I. Nahum-Shani, K. Lynch, D. Oslin, and S.A. Murphy p p p p p p p p p p p p p p p p p p p p p p p p p21
Default Mode Network Activity and Connectivity in Psychopathology
Susan Whitfield-Gabrieli and Judith M. Ford p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p49
Current Issues in the Diagnosis of Attention Deficit Hyperactivity
Disorder, Oppositional Defiant Disorder, and Conduct Disorder
Paul J. Frick and Joel T. Nigg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p77
Psychiatric Diagnosis: Lessons from the DSM-IV Past
and Cautions for the DSM-5 Future
Allen J. Frances and Thomas Widiger p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 109
American Indian and Alaska Native Mental Health:
Diverse Perspectives on Enduring Disparities
Joseph P. Gone and Joseph E. Trimble p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 131
Emotion Regulation and Psychopathology: The Role of Gender
Susan Nolen-Hoeksema p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 161
Cognitive Bias Modification Approaches to Anxiety
Colin MacLeod and Andrew Mathews p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 189
Diagnosis and Assessment of Hoarding Disorder
Randy O. Frost, Gail Steketee, and David F. Tolin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 219
The Behavioral Activation System and Mania
Sheri L. Johnson, Michael D. Edge, M. Kathleen Holmes,
and Charles S. Carver p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 243
Prediction and Prevention of Psychosis in Youth at Clinical High Risk
Jean Addington and Robert Heinssen p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 269
From Dysfunction to Adaptation: An Interactionist
Model of Dependency
Robert F. Bornstein p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 291
vi
CP08-FrontMatter ARI 2 March 2012 11:20
Personality Disorders in DSM-5

Andrew E. Skodol p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 317
Development, Evaluation, and Multinational Dissemination
of the Triple P-Positive Parenting Program
Matthew R. Sanders p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 345
Empirical Classification of Eating Disorders
Pamela K. Keel, Tiffany A. Brown, Lauren A. Holland, and Lindsay P. Bodell p p p p p p p p 381
Obesity and Public Policy
Ashley N. Gearhardt, Marie A. Bragg, Rebecca L. Pearl, Natasha A. Schvey,
Christina A. Roberto, and Kelly D. Brownell p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 405
Cognition in the Vegetative State

Martin M. Monti p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 431
Coping with Chronic Illness in Childhood and Adolescence
Bruce E. Compas, Sarah S. Jaser, Madeleine J. Dunn, and Erin M. Rodriguez p p p p p p p 455
Indexes
Cumulative Index of Contributing Authors, Volumes 1–8 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 481

Cumulative Index of Chapter Titles, Volumes 1–8 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 484
Errata
An online log of corrections to Annual Review of Clinical Psychology articles may be

found at http://clinpsy.annualreviews.org
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CP08CH13-Skodol ARI 6 March 2012 8:0

• Top cited articles Andrew E. Skodol

Annu. Rev. Clin. Psychol. 2012. 8:317–44 Keywords

Cultural Applicability . . . . . . . . . . . . . . 325 will impact patients, providers, families, and

Diagnosis in Specialty Versus research agendas. Since DSM-5 Work Groups

rather than the exception. as an enduring pattern of inner experience

www.annualreviews.org • Personality Disorders in DSM-5 319

The Work Group began with a “tripartite (self-directedness). Interpersonal pathology

www.annualreviews.org • Personality Disorders in DSM-5 321

www.annualreviews.org • Personality Disorders in DSM-5 323

of the interaction between temperaments response/outcome, reliability, internal consis-

The beginning deliberations of the DSM-5 Furthermore, different validators (e.g.,

www.annualreviews.org • Personality Disorders in DSM-5 325

DSM-5 and ICD-11 self-report “review of systems” for major patho-

voring international proposals over ones made

derstand the meaning of certain key terms, such

PROPOSED DSM-5 PERSONALITY represented by signiﬁcant impairment in

Personality psychopathology emanates from

Personality Disorder Types

www.annualreviews.org • Personality Disorders in DSM-5 327

maladaptive patterns of mentally representing ical scale.

www.annualreviews.org • Personality Disorders in DSM-5 329

www.annualreviews.org • Personality Disorders in DSM-5 331

www.annualreviews.org • Personality Disorders in DSM-5 333

Personality Functioning as an advance over sites as well as in a representative sample of

www.annualreviews.org • Personality Disorders in DSM-5 335

as of this writing). It should be noted that the diagnostic labels.

www.annualreviews.org • Personality Disorders in DSM-5 337

(un)conscientiousness (disinhibition), and personality traits. All levels of personality

(intimacy versus isolation), generativity, and

prosocial engagement. Their proposal for gen-

The P&PD Work Group members have la- of the process.

www.annualreviews.org • Personality Disorders in DSM-5 339

personality in DSM-5. Personal. Disord. Theory Res. Treat. 1:123–26

and psychopathology: a proposal for DSM V. Clin. Psychol. Rev. 31:52–68

www.annualreviews.org • Personality Disorders in DSM-5 341

nosis. J. Personal. Disord. 25:248–59

incorporating DSM Cluster A characteristics. J. Abnorm. Psychol. 117:454–459

www.annualreviews.org • Personality Disorders in DSM-5 343

On the History and Future Study of Personality and Its Disorders

A “SMART” Design for Building Individualized Treatment Sequences

Personality Disorders in DSM-5

Cognition in the Vegetative State

Cumulative Index of Contributing Authors, Volumes 1–8 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 481

An online log of corrections to Annual Review of Clinical Psychology articles may be

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