Inpatient Psychiatric Unit
C O M M E N T A R Y
Changes in the Conceptualization of Personality Disorder: The DSM-5 Debacle
Thomas A. Widiger
Published online: 6 October 2012
� Springer Science+Business Media New York 2012
Introduction
Lanier, Bollinger, and Krueger (2011) provide an overview
of proposed changes to the diagnosis and classification of
personality disorders to appear in the forthcoming fifth
edition of the American Psychiatric Association’s (APA)
Diagnostic and Statistical Manual of Mental Disorders
(DSM-5). They are correct that the proposed changes to the
personality disorders section are fundamental, and in some
respects may represent a true paradigm shift in how a
mental disorder is conceptualized and diagnosed. As
expressed by the Chair of the DSM-5 Personality and
Personality Disorders Work Group (PPDWG), ‘‘the work
group recommends a major reconceptualization of per-
sonality psychopathology’’ (Skodol 2010, ‘‘Reformulation
of personality disorders in DSM-5,’’ para. 1). I do not
myself disagree with some of the more radical proposals
that are being made, but a difficulty I do have is the sur-
prisingly liberal threshold that has been accepted for
making any such revisions (Frances 2009; Widiger 2011).
In addition, one point of strong agreement with Lanier et al.
is that the construction of DSM-5 is in a state of ‘‘flux,’’ to
the point that it is frankly difficult to predict or anticipate
what may in fact happen to the diagnosis of personality
disorders.
Lanier et al. state that the proposals for DSM-5 consist of
four major changes (see Table 1 of Lanier et al.): (1) a
change to the definition of personality disorder to require the
presence of a pathology of identity integration, integrity of
self-concept, and self-directedness in order for a diagnosis to
be made; (2) an assessment of level of self and interpersonal
dysfunction; (3) the deletion of five diagnoses; and (4) the
inclusion of a six domain (37 trait) dimensional trait model.
However, since this paper was written, there have been quite
a few significant changes to these (and other) proposals.
Prototype Matching
Missing from the Lanier et al. list of changes was a deci-
sion by the PPDWG to abandon diagnostic criterion sets
for prototype matching (Skodol 2010; Skodol et al. 2011).
One of the, if not the, major innovation of the third edition
of the APA diagnostic manual (i.e., DSM-III; APA 1980)
was a shift away from the unreliable prototype matching to
the requirement that a mental disorder diagnosis include a
systematic and comprehensive assessment of a specific and
explicit set of diagnostic criteria (Spitzer et al. 1980). The
criterion sets of DSM-III increased dramatically the ability
of researchers to conduct reliable, replicable, and valid
research. As expressed recently by Kendler et al. (2010),
‘‘the renewed interest in diagnostic reliability in the early
1970s-substantially influenced by the Feighner criteria-
proved to be a critical corrective and was instrumental in
the renaissance of psychiatric research witnessed in the
subsequent decades’’ (p. 141). One of the benefits of this
renaissance was the highly published Collaborative Lon-
gitudinal Studies of Personality Disorders (CLPS), which
used as its primary measure a semi-structured interview
that systematically assessed the DSM-IV personality dis-
orders’ specific and explicit criterion sets (Skodol et al.
2005).
Nevertheless, the PPDWG proposed to abandon diag-
nostic criterion sets for prototype matching, in which one
matches one’s perception of a patient with a 10–17
T. A. Widiger (&) Department of Psychology, University of Kentucky, Lexington,
KY 40506-0044, USA
e-mail: widiger@uky.edu
123
Clin Soc Work J (2013) 41:163–167
DOI 10.1007/s10615-012-0419-9
sentence paragraph description of a prototypic case
(Skodol 2010; Westen et al. 2006). ‘‘To make a diagnosis,
diagnosticians rate the overall similarity or ‘match’
between a patient and the prototype using a 5-point rating
scale, considering the prototype as a whole rather than
counting individual symptoms’’ (Westen et al. 2006,
p. 847). Rather than require a researcher or a clinician to
spend 2–4 h carefully assessing each diagnostic criterion,
with prototype matching ‘‘clinicians could make a com-
plete Axis II diagnosis in 1 or 2 min’’ (Westen et al. p. 855)
because one does not assess each individual sentence
within the narrative description. Instead, the clinician
matches their perception of the patient with the overall
gestalt. The diagnosis is reduced from a systematic
assessment of each of the nine diagnostic criteria for DSM-
IV-TR borderline personality disorder (or each of the 13
sentences within the DSM-5 narrative description of a
prototypic case) to simply a single judgment: whether the
patient’s personality appears to match the set of sentences,
considered together as a unified whole.
This proposal was made despite the fact that there is a
considerable body of research to document the poor reli-
ability and validity of prototype matching (Widiger 2011;
Zimmerman 2011), a considerable body of research to
support the reliability and validity of specific and explicit
criterion sets (Zimmerman 2003), and no research that has
compared directly the reliability or validity of indepen-
dently administered prototype matching with specific and
explicit criterion sets. Skodol (2010) cited in support of
prototype matching studies conducted using the Personality
Assessment Form (PAF). However, the authors of these
studies in fact acknowledged that they used prototype
matching only because at the time their study began semi-
structured interviews to assess the DSM-III criterion sets
were not yet available (Shea et al. 1987). Pilkonis et al.
(2011) have since indicated their significant concern that
prototype matching permits diagnosticians to ‘‘interpret
each prototype narrative in potentially different ways,
opening the door to a host of known problems with cog-
nitive heuristics, such as salience and availability biases’’
(p. 73).
The only empirical support beyond the early PAF
research was a validity study by Westen et al. (2006) and
an interrater reliability study by Westen et al. (2010), both
of which included fundamental methodological flaws. For
example, in the case of the validity study, the clinicians
who provided the prototype ratings also provided the cri-
terion diagnoses, the latter even provided prior to their
provision of the prototype ratings. Frankly, using this
methodology, it would be difficult to obtain weak results,
as the clinicians were simply confirming their own recently
made judgments. If this criterion contamination was not
problematic enough, the ratings were provided for patients
the clinicians already knew extremely well (in treatment on
average for 16 months), which is not the situation in which
diagnostic criterion sets are typically used. With respect to
the reliability study, these prototype ratings were obtained
in the course of a 4.5 h standardized interview, inconsistent
with the purported method of prototype matching. In
addition, there was a clear possibility that the assessments
were again not in fact blind to one another. The clinicians
who provided the ratings were graduate students working
together within a psychological clinic. It is not uncommon
in such a setting for student clinicians to discuss amongst
themselves their diagnostic impressions of new clients (and
in some cases initial clients are discussed together at formal
case meetings).
In response to the critiques of prototype matching
(Widiger 2011; Zimmerman 2011), the PPDWG was com-
pelled to abandon their proposal for prototype matching and
to include instead diagnostic criterion sets (Siever 2011). In
sum, it now appears that this major innovation for DSM-5 has
been rejected. However, rather than work from the diag-
nostic criterion sets that were developed for DSM-IV-TR and
have since been used in a substantial body of empirical
research (e.g., Skodol et al. 2005), the PPDWG has appar-
ently decided to construct brand new criterion sets by arbi-
trarily combining the self and interpersonal pathologies that
they think will be specific to each respective personality
disorder along with a list of traits they again think will likely
be diagnostic of each personality disorder.
Deletion of Diagnoses
The PPDWG also intends to delete half of the diagnoses;
more specifically, the dependent, narcissistic, paranoid,
schizoid, and histrionic personality disorders. The primary
reason for their deletion is to reduce diagnostic co-occur-
rence (Skodol 2010). Diagnostic co-occurrence has been a
significant problem for the categorical diagnoses (Widiger
and Trull 2007) but sacrificing fully half of them would
seem to be a rather draconian approach for addressing this
problem. In addition, it does not speak well for the credi-
bility of the field of personality disorder to be so willing to
sacrifice half of its coverage in order to address diagnostic
co-occurrence, as if half of what we have been diagnosing
and treating for the past 30 years was not worth the clinical
attention (Widiger 2011). Persons will still have dependent,
schizoid, paranoid, histrionic, and narcissistic personality
traits despite their diagnoses being deleted (if not, then it is
unclear why there is any need to include these traits within
the dimensional model). Lack of adequate coverage has
been a problem of comparable magnitude to diagnostic
co-occurrence (Verheul and Widiger 2004). This problem
will be magnified substantially in DSM-5.
164 Clin Soc Work J (2013) 41:163–167
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In addition, significant questions have been raised with
respect to the rationale for which diagnoses to delete. There
does appear to be as much, if not more, empirical support
for the narcissistic and dependent personality disorders
(two diagnoses to be deleted) as there is for the avoidant
and obsessive–compulsive personality disorders (Bornstein
2011; Ronningstam 2011). Zimmerman (in press) suggests
that it is no accident that four of the five diagnoses being
retained (i.e., avoidant, obsessive–compulsive, schizotypal,
and borderline) were the focus of the CLPS project,
spearheaded by the Chair of the PPDWG (Skodol et al.
2005).
Skodol et al. (2011) provides a review of the literature
which they suggest indicates support for the decision to
delete the dependent and narcissistic personality disorders in
favor of the avoidant, obsessive–compulsive, antisocial,
borderline, and schizotypal. However, even if one confines
the decision to the studies cited by Skodol et al. one does not
discover much support for the decision (Mullins-Sweatt et al.
in press). For example, one of the reasons given for a
weakness in the validity of dependent personality disorder
was a difficulty in discerning its prevalence because the
prevalence purportedly fluctuates widely from study to
study. However, in the seminal review of epidemiology by
Torgersen (2009), cited by Skodol et al. the fluctuation in
prevalence was actually worse for the schizotypal (ranging
from 0.0 to 3.2 across the studies that were considered),
antisocial (0.0–4.5), borderline (0.0–3.2), avoidant
(0.4–5.0), and obsessive–compulsive (0.0–9.3), the five to be
retained, than it was for the dependent (0.4–1.8). Dependent
personality disorder was also said to be associated with only
moderate to low impairment in functioning, but its level of
impairment has been consistently higher than has been
obtained for the obsessive–compulsive in the studies con-
sidered by Skodol et al. (Mullins-Sweatt et al. in press).
Finally, Skodol et al. indicated that dependent was one of the
two least common personality disorders in the community,
according to the review by Torgersen. However, this was not
in fact the case. According to Torgersen’s review, with
respect to the median rate across the studies he considered,
dependent had a higher prevalence rate than schizotypal (and
higher than three other personality disorders), and, when
considering the pooled rate across these studies, a higher
prevalence within the community than either schizotypal or
borderline.
In any case, the decision of what to retain and what to
delete might in fact be moot, as it now appears that there
may not in fact be a personality disorders section, or at
least if there is one, it could very well be reduced to a
skeleton of its former self that is unlikely to survive any
future harsh winter. Siever (2011) indicates that a repre-
sentative of the PPDWG agreed with representatives of the
schizophrenia disorders work group to move schizotypal
personality disorder out of the personality disorders section
into a new class of schizophrenia-spectrum disorders. Its
primary coding will be as a schizophrenia-spectrum dis-
order, not as a personality disorder (the latter will only be
noted parenthetically for historical purposes). A similar
proposal is being pushed heavily for a shift of antisocial/
psychopathic personality disorder into a new class of (child
and adult) disruptive behavior disorders, wherein it would
also receive its primary diagnostic coding and noted only
parenthetically that it used to be classified as a personality
disorder (Siever 2011). If these new proposals are enacted,
the personality disorders section will be left with just three
diagnoses (i.e., avoidant, obsessive–compulsive, and bor-
derline), and it is difficult to imagine that the section could
then survive (Widiger 2011).
Dimensional Trait Model
It is evident that the diagnosis and classification of person-
ality disorder is shifting toward a dimensional trait model
(Widiger and Simonsen 2005). It has in fact been suggested
that the primary contribution of DSM-5 will be a shift of the
entire diagnostic manual toward a dimensional model of
classification (Regier 2008). This will be most clearly evi-
dent with the personality disorders, which will include a 6 (or
5) dimensional model of maladaptive personality, including
37 (or 25) lower-order traits that can be used to provide an
independent description of each particular patient and/or be
part of the diagnostic criterion sets for each respective per-
sonality disorder. Lanier et al. (2011) describe well many of
the benefits and advantages of this shift.
Lanier et al. (2011) also document well how this proposal
is well aligned with the five-factor model (FFM) of general
personality structure. An integrative dimensional model of
normal and abnormal personality offers quite a few benefits
(Krueger and Eaton 2010; Widiger and Trull 2007). It
addresses the many fundamental limitations of the categor-
ical model (e.g., heterogeneity within diagnoses, inadequate
coverage, lack of consistent diagnostic thresholds, and
excessive diagnostic co-occurrence). It provides a more
comprehensive and individually specific description of each
patient’s normal and abnormal personality structure, thereby
facilitating more precise and informative research concern-
ing etiology and pathology, and more specific and distinct
treatment decisions (Widiger and Mullins-Sweatt 2009).
Finally, it transfers to the psychiatric nomenclature a wealth
of knowledge concerning the origins, childhood antecedents,
stability, and universality of the dispositions that underlie
personality disorder (Widiger and Trull 2007).
Lanier et al. also indicate, however, that the authors of the
DSM-5 dimensional trait model disavow some of the con-
nection with the FFM; more specifically, that compulsivity is
Clin Soc Work J (2013) 41:163–167 165
123
not a maladaptive variant of conscientiousness and oddity or
peculiarity is not a maladaptive of openness (Clark and
Krueger 2010; Krueger et al. 2011). The rationale for this
position is unclear, as there is a considerable body of
empirical research that supports the relationship of com-
pulsivity to conscientiousness and oddity to openness
(Widiger 2011). In addition, failing to acknowledge this
continuum results in a model that lacks coherence or
consistency, as if some dimensions of maladaptive per-
sonality are on a continuum with general personality
structure (i.e., emotional instability or dysregulation,
antagonism, detachment, and disinhibition) whereas others
(i.e., compulsivity and oddity), are for no apparent reason
qualitatively distinct from general personality structure.
This has not been the position held previously by the
proponents of dimensional models of personality disorder,
including the authors of the model for DSM-5 (e.g., Clark
2007; Markon et al. 2005).
There are, however, important ways in which the
dimensional trait model proposed for DSM-5 is different
from the FFM. First, it does not actually include any nor-
mal personality traits, thereby failing to provide a truly
integrative model. The DSM-5 proposal is confined to
maladaptive personality traits, and thereby will not be able
to identify the normal variants of the traits could in fact be
quite useful, if not important, for treatment planning, such
as openness that can suggest a responsivity to insight,
reflective, and dynamic therapies, agreeableness and
extraversion that can suggest a receptivity to group, mari-
tal, and other forms of interpersonal therapy, and consci-
entiousness that can suggest a willingness and ability to
withstand the rigors of dialectical behavior therapy
(Widiger and Mullins-Sweatt 2009). In addition, the model
is entirely unipolar, failing to recognize the bipolarity of
personality structure that has been empirically very well
supported (Markon et al. 2005; Widiger 2011). The
absence of this bipolarity contributes to the failure of the
proposed model to recognize a number of important mal-
adaptive personality traits, such as the glib charm and
fearlessness of psychopathy (low neuroticism), gullibility
and meekness of dependency (high agreeableness), and
closedness to feelings of alexithymia (low openness).
In fact, like almost everything else for DSM-5, the
dimensional model has apparently changed since the paper
by Lanier et al. was accepted for publication. The model
proposed at this current moment in time is a 5 domain
model (emotional dysregulation, detachment, antagonism,
disinhibition, and peculiarity), with 25 lower-order trait
scales. The basis for this shift appears to be due simply to a
recent factor analysis conducted by member(s) of the
DSM-5 PPDWG (Siever 2011), rather than being guided by
the considerable body of existing research. This may reflect
the wider tendency of the DSM-5 process (Frances 2009) to
allow work group members to rely on their own prefer-
ences and their own studies rather than seeking a more
consistent historical continuity guided by a wider scientific
literature.
Conclusions
In sum, Lanier et al. are indeed correct that DSM-5 per-
sonality disorders are likely to be much different than the
DSM-IV-TR personality disorders. Some of these signifi-
cant changes could reflect major improvements in how
disorders of personality are conceptualized and diagnosed.
However, the proposals vary considerably in the extent to
which they have compelling empirical support. Even a
member of the DSM-5 PPDWG has opined that ‘‘the DSM-
5 proposal is a disappointing and confusing mixture of
innovation and preservation of the status quo that is
inconsistent, lacks coherence, is impractical, and, in places,
is incompatible with empirical facts’’ (Livesley 2010,
p. 304), characterizing the overall effort as an expression of
‘‘incoherence and confusion’’ (p. 304). The major accom-
plishment of the fourth edition of the APA’s diagnostic
manual was not in the development of surprising new
content but rather in the careful, cautious, and systematic
method with which it was constructed. The authors of the
forthcoming fifth edition may have turned this priority on
its head, emphasizing instead radical changes without first
conducting careful, systematic, thorough, or objective
reviews of the scientific literature.
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Author Biography
Thomas A. Widiger is the T. Marshall Hahn Professor of Psychology at the University of Kentucky. He was the Research Coordinator for
DSM-IV and the 2010 recipient of the Distinguished Scientist Award
by the Society for a Science of Clinical Psychology.
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