Alternative Diagnostic Models For Personality Disorders Continued

We are discussing a proposed, alternative model for personality disorder diagnosis offered in DSM-5 in the chapter called Emerging Measures and Models. It is a type of dimensional model with two main dimensions: level of personality functioning and pathological personality traits. In the previous section we discussed the first dimension: personality functioning. In this section we discuss the second dimension: pathological personality traits.

Personality traits are a tendency or disposition to behave in a particular way. Traits are considered relatively stable across time and situations. Although traits are relatively immutable they can and do change throughout the lifespan. Traits are different from symptoms because symptoms can increase or decrease, come and go. Traits on the other hand have far less fluctuation.

Personality traits are generally considered along a continuum ranging from a healthy and adaptive side of the continuum, to its polar opposite side that is unhealthy and maladaptive. A trait is considered maladaptive to the extent it interferes with someone’s success and satisfaction with life. Of course a particular trait that is adaptive in one culture may be maladaptive in another. Nonetheless, the research has consistently validated and replicated five broad personality domains, sometimes called, “The Big Five” or the Five Factor Model of personality. On the pathological side of the continuum, these five are:

1. NEGATIVE AFFECT (polar opposite is emotional stability):

• Emotional lability
• Anxiousness
• Separation anxiety
• Submissiveness
• Hostility
• Perseveration

2. DETACHMENT (polar opposite is extroversion):

• Withdrawal
• Intimacy avoidance
• Anhedonia (lack of enjoyment)
• Depressivity
• Restricted affect (limited emotional range)
• suspiciousness

3. ANTAGONISM (polar opposite is agreeableness):

• Manipulativeness
• Deceitfulness
• Grandiosity
• Attention seeking
• Callousness
• Hostility

4. DISINHIBITION (polar opposite is conscientiousness):

• Irresponsibility
• Impulsivity
• Distractibility
• Risk taking
• Rigid perfectionism

5. PSYCHOTISM (polar opposite is lucidity):

• Unusual beliefs and experiences
• Eccentricity
• Cognitive and perceptual dysregulation

In the DSM-5 alternative model (Chapter III), only six specific personality disorders are included, versus the ten included in the official section of the DSM-5 (Chapter II). The six that are included are: Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-compulsive, and Schizotypal. So what happened to the other four disorders (Paranoid, Schizoid, Histrionic, and Dependent)? Well, this was one of the greater controversies of DSM-5. It can be inferred from the text, the authors did not find sufficient research data to support the four omitted personality disorders. This should not be taken to mean these disorders do not exist. It may simply reflect that persons with these disorders may not come to the attention of mental health professionals and/or do not volunteer for research. For instance, due to the nature of the paranoid personality disorder, someone with this disorder is unlikely to seek help or volunteer for research. Nonetheless, the authors of the DSM-5 alternative model can be applauded for their conscientious commitment to research.

Each of the six specified personality disorders in Chapter III require a moderate, severe, or extreme impairment rating of personality functioning, and a specified number of pathological personality traits. The number required, and the list of pathological traits, is unique to each personality disorder. For instance, the list for the Avoidant Personality Disorder requires at least three of the following: anxiousness (an aspect of Negative Affectivity); withdrawal (an aspect of Detachment); anhedonia (an aspect of Detachment); and intimacy avoidance (an aspect of Detachment). In contrast, the list for Narcissistic Personality has only two traits but both are required for diagnosis: grandiosity (an aspect of Antagonism); and attention seeking (an aspect of Antagonism).

In addition to the six specified personality disorders, clinicians can use a diagnosis called Personality Disorder- Trait Specified (PD-TS). This allows clinicians to note the presence of a personality disorder without requiring a specific name for it. This offers a great deal more flexibility and descriptive information than the current categorical approach. It has the advantage of eliminating the need for vague diagnoses such as Other Specified and Unspecified Personality Disorder.

It should be pointed out that the polar opposite side of each dimension does not necessarily reflect a healthy adaptive response. For instance, the opposite of disinhibition is conscientiousness. However, extreme conscientious equates to rigid perfectionism; a pathological trait listed for obsessive-compulsive personality disorder. Extreme agreeableness equates to gullibility and make one an easy target for manipulation and abuse. Therefore, as we have emphasized throughout, the key to healthy personality and adaptive functioning is flexibility. Responses are varied according to the demands of each situation.

Although this dimensional model is not the officially recognized diagnostic system of DSM-5, clinicians may use this method for greater specificity. It further provides a standard model for continued research so that we may further develop and expand our knowledge of this important area of mental health and human functioning.