The practice of psychiatry, like the practice of all medicine, is an intellectual, emotional, moral, spiritual, and ethical vocation; it is a serious undertaking because people’s lives and well-being depend on the accuracy of the models, science, and art that determine outcomes. With this in mind, the American Psychiatric Association’s Board of Trustees appointed a work group to draft the section on personality disorders for the latest version of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5 , and I was a member of that work group.
Much research had been done on personality disorders since publication of the DSM-IV in 1994 . According to the DSM-IV, there were two ways to classify personality disorders—the categorical approach, which contends that personality disorders are distinct clinical syndromes—and the dimensional approach, which posits that personality disorders “are maladaptive variants of personality traits that merge imperceptibly into normality and into one another” . Since 1994, a wealth of research had been directed toward determining the value of a dimensional versus a categorical model for personality disorders, and, after lengthy discussions about the merits of each, the work group decided to strike a balance between the two approaches, developing a hybrid model with features of both.
The APA’s Board of Trustees decided that the work group’s model was too difficult for the field to use and put the product of our work in Section III of the personality disorder chapter, the section called “Emerging Measures and Models—Alternative DSM-5 Model for Personality Disorders.” Section II, “Diagnostic Criteria and Codes for Personality Disorder,” in the DSM-5remains the same as it was in the DSM-IV. Section III, containing the work group’s efforts, notes that personality disorders are characterized by impairments in personality functioning and pathological personality traits . With this conceptualization, the DSM-5 takes a decided turn to being psychodynamic as well as descriptive, where the DSM-IV was descriptive only.
In the Section III model, the functioning of personality is assessed in the domains of the self and interpersonal relations—decidedly psychodynamic concepts—and by personality traits—which are descriptive. The latter, the descriptive personality trait aspects that remain in Section II of the DSM-5, are unchanged from the DSM-IV. They describe Cluster A (paranoid, schizoid, and schizotypal) personality disorders; Cluster B (antisocial, borderline, histrionic, and narcissistic) personality disorders; and Cluster C (avoidant, dependent, and obsessive-compulsive) personality disorders .
Functioning of Personality in Domains of Self and Interpersonal Relations
The Section III addition outlines the characteristics of normal or healthy personality functioning in the domains of self and interpersonal relations. At the level of self-functioning, the healthy personality has two components:
- Identity: characterized by an “ongoing awareness of a unique self; maintenance of role-appropriate boundaries; consistent and self-regulated positive self-esteem, with accurate self-appraisal; and the capacity of experiencing, tolerating, and regulating a full range of emotions” , and
- Self-direction: exemplified in a person who “sets and aspires to reasonable goals based on realistic assessment of personal capacities; utilizes appropriate standards of behavior, attaining fulfillment in multiple realms, and can reflect on, and make constructive meaning of, interpersonal experience” .
Likewise, at the level of interpersonal functioning, a healthy personality is determined by the quality of two aspects of interpersonal relationships, empathy for others and intimacy with others.
- Empathy: a person has healthy empathy for others if he or she is: “capable of accurately understanding others’ experiences and motivations in most situations; comprehends and appreciates others’ perspectives, even if disagreeing, and is aware of the effect of [his or her]...actions on others” .
- Intimacy: intimate aspects of a personality are normal if the person is capable of: “maintaining multiple satisfying and enduring relationships in personal and community life; desiring and engaging in a number of caring, close, and reciprocal relationships; and striving for cooperation and mutual benefit and flexibly responds to a range of others’ ideas, emotions, and behaviors” .
This contribution provides a major breakthrough; by defining characteristics of a healthy personality, it establishes a normative reference point for interpersonal functioning in life that adds clarity to the assessment and diagnosis of the people we seek to serve and help.
As we begin to use the DSM-5, the ethical issues associated with the personality disorder descriptions will surface. For example, because carrying a diagnosis borderline or narcissistic personality disorder is quite damaging to patients, the DSM-IV categorical personality diagnostic approach perpetuates stigma, whereas a dimensional approach would break that stigma. Because the dimensional model has a more psychodynamic base, it is, for now, less stigmatizing, and has greater capacity for recognizing that personality traits are not everlasting and thus can be altered with early childhood social and emotional skills training . Regarding the impact on patients in the criminal justice system, although the DSM-5 has the customary “Cautionary Statement for Forensic Use” , a diagnosis of antisocial personality is associated with a dangerous, criminally prone person who is likely to be stuck in that mode for the rest of his or her life. Accordingly, using the dimensional personality model may mean that fewer people will be demonized by psychiatric personality diagnosis.
With electronic technology, the DSM-5 will be easier to revise than its predecessors, and, as more solid evidence accumulates, it is possible that the psychodynamic, hybrid personality disorder model of Section III will be integrated into the diagnostic criteria and codes section of the DSM-5before another 19 or 20 years elapses.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edition. Washington, DC: American Psychiatric Press, Inc.; 2013.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Press, Inc.; 1994.
American Psychiatric Association. A Research Agenda for DSM-V. Washington, DC: American Psychiatric Press, Inc.; 2002.
O’Connell ME, Boat T, Warner KE, eds. Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: National Academies Press; 2009. http://www.iom.edu/CMS/12552/45572/64120.aspx. Accessed August 9, 2013.