EDITORIAL
CURRENT
OPINION Personality disorders in Diagnostic and Statistical
Manual of Mental Disorders-5: back to the past or
back to the future?
Charles B. Pull
INTRODUCTION
At the time when preparations began to revise
DSM-IV-TR [1], the categorical model of personality
disorders that had been adopted in previous editions
of the Diagnostic and Statistical Manual of Mental
Disorders (DSM) was widely regarded as obsolete,
owing, in particular to the model’s poor inter-rater
reliability, poor stability over time, poor discrimi-
nate validity, and poor general coverage of person-
ality disorder [2,3].
In 2004, as part of a series of research planning
conferences for DSM-5 [4], a panel of international
experts met in Arlington to discuss the situation.
There was widespread agreement with regard to the
shortcomings of the categorical model and the need
to look for alternative ways for classifying disorder
related to personality. In particular, participants
discussed various dimensional models to replace
or complement the categorical diagnoses described
in the previous editions of the DSM. The outcome of
the conference was published in a monograph
edited by Widiger et al. [5].
In the years to follow, a Personality and Person-
ality Disorders Work Group chaired by Andrew E.
Skodol developed two alternative models that were
posted on the DSM-5 website. The first, a prototyp-
ical model was posted on the DSM-5 Website
(www.dsm5.org) on 10 February 2010. It was
updated on 21 January 2011, but later discarded
following extensive objections raised by clinicians
and researchers. The second, a hybrid, categorical-
dimensional model, was posted on the Website on
21 June 2011 and then updated on 1 May 2012. A
final version was slated to be posted on the Website
by the end of 2012, following the results of field
trials to be completed by that time. This model did
not, however, meet with the approval of the APA
Board of Trustees who decided ‘to preserve continu-
ity with current clinical practice’ and ‘to maintain
the current approach to personality disorders in the
Section II (i.e., the official Section) of DSM-5 and to
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include the new model in Section III’, labeled
‘Emerging Measures and Models’ containing ‘tools
and techniques to enhance the clinical decision-
making process, understand the cultural context
of mental disorders, and recognize emerging diag-
noses for further study’.
BACK TO THE PAST: AN UPDATE OF THE
OLD, CATEGORICAL MODEL
On the basis of feedback from a multilevel review of
proposed revisions, the American Association Board
of trustees ultimately decided to retain the DSM-IV-
TR categorical approach with regard to the classifi-
cation and diagnosis of personality disorders. In
fact, the general diagnostic criteria and algorithm
defining personality disorder as well as the individ-
ual diagnostic criteria and algorithms defining
each specific personality disorder are identical in
DSM-IV-TR and DSM-5.
All of the 10 specific personality disorders iden-
tified in DSM-IV-TR are retained in DSM-5, that is,
paranoid personality disorder, schizoid personality
disorder, schizotypal personality disorder, antisocial
personality disorder, borderline personality dis-
order, histrionic personality disorder, narcissistic
personality disorder, avoidant personality disorder,
dependent personality disorder, and obsessive com-
pulsive personality disorder, as well as a category of
‘other specified personality disorder and unspecified
personality disorder’.
Head of Department, Clinique des Troubles Emotionnels, Centre Hos-
pitalier de Luxembourg, Luxembourg city, Luxembourg
Correspondence to Charles B. Pull, Clinique des Troubles Emotionnels,
Centre Hospitalier de Luxembourg, 4, rue Barblé, L-1210 Luxembourg,
Luxembourg. E-mail: pull.charles@chl.lu
Curr Opin Psychiatry 2014, 27:84–86
DOI:10.1097/YCO.0000000000000016
Volume 27  Number 1  January 2014

DIAGNOSTIC AND STATISTICAL MANUAL
OF MENTAL DISORDERS-5 DEPARTS
FROM DSM-IV-TR ON A FEW POINTS
First, schizotypal disorder is included twice in
DSM-5: once in the chapter on personality disorders
and once in the chapter on schizophrenia spectrum
and other psychotic disorders.
Second, DSM-5 includes a new category for
identifying personality change due to another
medical condition, that is, a persistent personality
disturbance that is judged to be due to the direct
physiological effects of a medical condition such as a
frontal lobe lesion.
The other changes in DSM-5, with regard to
DSM-IV-TR, are limited to minor adaptations and
corrections in the text that accompanies the diag-
nostic criteria. In particular, the general outline of
the text has been adapted to be in line with the
general outline in DSM-5 and as such includes para-
graphs on diagnostic features, associated features
supporting diagnosis, prevalence, development
and course, culture-related diagnostic issues, gen-
der-related diagnostic issues, and differential diag-
nosis. In addition, the text has been revised to
account for new data, for example, data yielded
from the 2002–2002 National Epidemiologic Survey
on Alcohol and Related Conditions and/or the
National Comorbidity Survey Replication, concern-
ing the prevalence of individual personality dis-
orders.
On the whole, the position of DSM-5 on person-
ality disorders is a return to the past, that is, to the
model that prevailed in DSM-IV-TR and, consider-
ing that the 2000 Text Revision had not introduced
any significant changes to the original classification,
to DSM-IV.
BACK TO THE FUTURE: AN
INTRODUCTION TO A NEW, HYBRID,
DIMENSIONAL-CATEGORICAL MODEL
In Section III, DSM-5 introduces a new model for
classifying and diagnosing personality disorders.
The new model is proposed with the aim to address
numerous shortcomings of the current, official
approach to personality disorder, including in
particular excessive comorbidity and poor dis-
criminant validity of individual personality dis-
orders.
The alternative DSM-5 approach is a hybrid
dimensional-categorical model. Use of the model
is based on the assessment of particular difficulties
in personality functioning and specific patterns of
pathological personality traits, leading to the diag-
nosis of six specific and one nonspecific personality
disorder.
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Personality disorders in DSM-5 Pull
LEVEL OF PERSONALITY FUNCTIONING
In the alternative model, the diagnosis of a person-
ality disorder is based on the assessment of impair-
ment in personality functioning, as evidenced
by the presence of impairment in self and inter-
personal functioning. Impairment in self-func-
tioning involves the presence of disturbances
concerning a person’s sense of identity and self-
direction. Impairment in interpersonal functioning
involves disturbances with regard to a person’s
capacity for empathy and intimacy. Impairment
in these elements is assessed using a Level of Person-
ality Functioning Scale (LPFS), which differentiates
five levels, ranging from 0 (no impairment) to
some (1), moderate (2), severe (3), and 4 (extreme).
For a diagnosis of personality disorder, the presence
of at least a moderate level of impairment is
required.
PATHOLOGICAL PERSONALITY DOMAINS
AND TRAITS
In addition to the presence of impairment in self
and interpersonal functioning, the model requires
the presence of pathological personality traits. It
defines 25 traits organized into five domains: nega-
tive affectivity, detachment, antagonism, disinhibi-
tion, and psychoticism. The five domains and 25
traits are considered maladaptive variants of the five
domains and facets of the ‘Big Five’ or ‘Five Factor
Model’ of personality. The maladaptive domains
and traits can be assessed using a formal psycho-
metric instrument such as the Personality Inventory
for DSM-5 (PID-5). The clinician will have to decide
whether a specific trait is sufficiently elevated to be
relevant for a diagnosis of personality disorder.
Section III includes diagnostic criteria for six
specific personality disorders, that is, antisocial,
avoidant, borderline, narcissistic, obsessive compul-
sive, and schizotypal personality disorders, each
defined by typical impairments in personality func-
tioning and characteristic pathological personality
traits. Individuals presenting with personality dis-
order but not meeting criteria for any of the six
specific personality disorders may be given an
unspecific diagnosis called ‘personality disorder-
trait specified’.
Four personality disorders included in DSM-IV-
TR, that is, paranoid, schizoid, histrionic, and
dependent personality disorders are not part of
the alternative DSM-5 model. Neither are depressive
and passive – aggressive (negativistic) personality
disorders – listed in Appendix B of DSM-IV-TR
among criteria sets and axes provided for further
studies. The decision not to include those disorders
in DSM-5 was taken with regard to the ‘Guidelines
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 Personality disorders
for making changes to DSM-V’ as proposed by
Kendler et al. [6] and posted on the DSM-5 Website
in 2009. The reactions to remove vs. to retain
specific personality disorders in DSM-5 have been
discussed at length in a review by Pull [7].
DISCUSSION AND CONCLUSION
A hybrid, dimensional-categorical model, now
included in Section III of DSM-5, had been devel-
oped with the intention to replace the old categori-
cal model that had been adopted in the previous
editions of the DSM. It figured prominently on the
DSM-5 Website up to the end of December 2012.
The new model met with significant criticism,
including from members of the Personality and
Personality Disorders Work Group itself, two of
which resigned from the Workgroup. According to
Livesley [8], the basic structure of the model is
seriously flawed, in particular because it is too com-
plex for routine clinical work. It incorporates two
separate classifications, one typal and the other
dimensional, replacing the disorders of DSM-IV by
two distinct sets of higher-order constructs, that is,
six types and five domains, and it is not clear how
clinicians are supposed to use such a system. Accord-
ing to Verheul [9], the new model is ‘a heroic and
innovative but nevertheless fundamentally flawed
attempt to improve DSM-IV.’ In particular, ‘it fails to
retain user acceptability, accuracy and reliability, it
lacks empirical support and is far too complex for
the average clinician and does not provide a coher-
ent framework for reliable diagnosis’.
86 www.co-psychiatry.com
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In the end, the new model was relegated
to Section III ‘for further study’ and to ‘prompt
continued research’. Meanwhile, the old categori-
cal model defining 10 personality disorders will
prevail.
Acknowledgements
None.
Conflicts of interest
The author has no conflicts of interest to declare.
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