The DSM-5 Personality Disorder Proposal and Future Directions in the Diagnostic Classification of Personality Disorder

Abstract

Background: The compilation of DSM-5 presented a substantial opportunity to develop a coherent, evidence-based classification of personality disorder. The irremediable problems with DSM-IV are widely recognized, the field seemed ready for change, and the data and methods for constructing a scientific classification are readily available. Rather than seize this opportunity, DSM-5 advanced an incoherent proposal lacking in evidential support and too poorly organized for clinical use. Methods: This article examines the problems with the proposal based on a consideration of the basic requirements of a satisfactory classification. It is suggested that an adequate system should have an explicit and coherent conceptual structure, be based on the best available scientific evidence, possess clinical utility, and be as parsimonious as possible. Results: The DSM-5 proposal fails to meet these criteria. Problems with the product and process suggest the need for a radical reconsideration of how personality disorders are classified and how classifications are compiled. Conclusions: The article proposes that greater emphasis be placed on developing a classification that provides the diagnostic information clinicians need to treat personality disorder and that future classifications should be constructed through an explicit process that is open to public scrutiny.

The Alternative Model of Personality Disorders (AMPD) from the Perspective of the Five-Factor Model

“…On the contrary, Clark and Krueger [7] explicitly distanced the DSM-5 trait model from the FFM, stating that compulsivity (which was included as a sixth domain) did not align with FFM conscientiousness and that schizotypy (which eventually became the psychoticism domain) did not align with FFM openness. For some, this gave the appearance that the model was created de nova (i.e., was not aligned with any existing trait model) and was not well grounded in the considerable body of prior FFM research [8, 9]. As expressed by Shedler et al [10] in their American Journal of Psychiatry editorial objecting to the trait model, “the resulting model no longer rests on decades of research, which had been the chief rationale for including it” (p. 1027).…”

“…In sum, the DSM-5 AMPD trait model can be understood as an instantiation of FFM PD [8]. There are, of course, other possible maladaptive trait models derived from the FFM.…”

What kind of science for psychiatry?

“…As a result, DSM-5 was a fairly conservative revision (Regier et al, 2013). Even in the area of personality disorders, where there was strong evidence from psychometric research for the value of a dimensional approach, the decision was ultimately to retain a categorical scheme similar to that of DSM-IV (Livesley, 2013). Much disappointment has been expressed with the outcome and there is a sense of deflation and skepticism about the whole enterprise (Paris and Phillips, 2013; Whooley, 2014).…”

Preliminary studies of the ICD-11 classification of personality disorder in practice

“…Unfortunately, it tried to cover every aspect of disorder within the revised classification and was rejected for DSM‐5 as being too complex, with more work being recommended before it could be used in practice. As Livesley () has commented, the classification failed because it did not have an ‘explicit and coherent conceptual structure, be based on the best available scientific evidence, possess clinical utility, and be as parsimonious as possible’.…”