Inpatient Psychiatric Unit

Clin Soc Work J (2013) 41:155–162

DOI 10.1007/s10615-011-0333-6

O R I G I N A L P A P E R

Advances in the Conceptualization of Personality Disorders: Issues Affecting Social Work Practice and Research

Paul Lanier • Sarah Bollinger •

Robert F. Krueger

Published online: 17 February 2011

© Springer Science+Business Media, LLC 2011

Abstract This article provides a review of the research

that has informed the proposed changes to the DSM-5

conceptualization of personality psychopathology with a

focus on implications for social work practice and research.

A paradigm shift to a dimensional model is likely to

replace the current categorical model of personality dis-

orders and will have profound implications for the pro-

fession. While establishing a diagnostic system that is

grounded in empirical knowledge is the primary benefit,

this tool will also be more consistent with social work’s

orienting theories and values. Social workers should gain

knowledge about the proposed changes and actively par-

ticipate in the review process.

Keywords Personality disorders · DSM-5 · Five-factor model · Clinical social work

Clinical social work is now the nation’s largest provider of

mental health services with over 250,000 social workers

certified, licensed, or receiving clinical supervision to

diagnose and treat mental disorders (Harkness 2010; Center

for Workforce Studies 2006). According to the federal

government’s Center for Mental Health Services, there

were over 70,000 social workers employed by mental

health organizations in 2000 compared to about 20,000

P. Lanier (&) · S. Bollinger George Warren Brown School of Social Work, Washington

University in St. Louis, One Brookings Drive, CB# 1196,

St. Louis, MO 63130, USA

e-mail: [email protected]

R. F. Krueger

Department of Psychology, University of Minnesota,

Minneapolis, MN, USA

psychiatrists and 20,000 psychologists (Mechanic 2008).

The Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV-TR) (American Psychiatric Association [APA]

2000) is currently being revised for a 2013 release of its 5th

edition. Given the primacy of this diagnostic instrument and

the leading role that social workers play in mental health

treatment, it is vital that the social work profession not only

becomes aware of the proposed changes, but also critically

examines these changes from a social work perspective.

The portion of the DSM-IV-TR that will arguably

experience the most significant change will be the per-

sonality disorders (PDs). The current DSM-IV-TR is based

on a discrete categorical approach with an assumption that

diagnoses have clear boundaries (Maser et al. 2009).

Informed by a substantial body of research, the conceptu-

alization of PDs has moved towards a continuous, dimen-

sional scheme within a hierarchical structure (Markon

2009; Krueger and Eaton 2010). This paradigm shift is

quite significant and will have dramatic implications for

both clinical practice and research. An overview of the

empirical literature supporting this shift and the clinical

implications will be discussed with emphasis on the impact

to the field of social work.

Historical and Current Conceptualization

of Personality Disorders

The general diagnostic criteria for PDs consists of a pattern

of inner experience and behavior that deviate from the

expectations of an individual’s culture manifested in cog-

nition, affectivity, interpersonal functioning, or impulse

control. The current DSM-IV-TR distinguishes ten subtypes

of PDs organized within three clusters: paranoid, schizoid,

schizotypal (Cluster A), antisocial, borderline, histrionic,

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narcissistic (Cluster B), and avoidant, dependent, and

obsessive–compulsive (Cluster C). Consistent with the

DSM-IV-TR, the World Health Organization’s Interna-

tional Statistical Classification of Diseases and Related

Health Problems (ICD-10) specifies PDs separate from

other clinical disorders as Disorders of Adult Personality

and Behavior (World Health Organization 1993). Estimates

of the prevalence of any PD in the general population have

ranged from 9.0 to 15.7% (Samuels et al. 2002; Crawford

et al. 2005; Lenzenweger et al. 2007). The most common

PDs found in the National Comorbidity Study Replication

(NCS-R) were avoidant (5.2%), schizoid (4.9%),

Table 1 Proposed Changes to DSM-5 Personality Disorders

schizotypal (3.3%), and obsessive–compulsive (2.4%),

with common co-occurrence of PDs and comorbidity with

other disorders (Lenzenweger et al. 2007).

While there is disagreement on seemingly basic issues,

such as where PDs should exist in the DSM, the work

groups charged with updating the DSM must attempt to

balance the myriad empirical studies with considerations of

clinical utility (First 2010). Although these revisions may

change, there has been a major reconceptualization of

personality psychology that has led to a proposed refor-

mulation of PDs in the DSM. These proposed revisions can

be found online (www.dsm5.org) and registered users are

(1) Definition PDs represent the

that are adaptive

failure to develop a sense of self-identity and the capacity for interpersonal functioning

in the context of the individual’s cultural norms and expectations.

(2) Levels of functioning Self Identity integration: Regulation of self-states; coherence of sense of

4 = Extreme impairment

3 = Serious impairment

2 = Moderate impairment

1 = Mild impairment

time and personal history; ability to experience a unique self and

to identify clear boundaries between self and others; capacity for self-reflection

Integrity of self-concept: Regulation of self-esteem and self-respect; sense

of autonomous agency; accuracy of self-appraisal; quality of

self-representation (e.g., degrees of complexity, differentiation, and integration)

0 = No impairment Self-directedness: Establishment of internal standards for one’s

behavior; coherence and meaningfulness of both short-term and life goals

Interpersonal Empathy: Ability to create an accurate model of another’s thoughts

and emotions; capacity for appreciating others’ experiences;

attention to range of others’ perspectives; understanding of social causality

Intimacy and cooperativeness: Depth and duration of connection with others;

tolerance and desire for closeness; reciprocity of regard and support

and its reflection in interpersonal/social behavior

Complexity and integration of representations of others: Cohesiveness,

complexity and integration of mental representations of others;

use of other-representations to regulate self

(3) Types Antisocial/ Antagonism and disinhibition

5 = Very good match psychopathic

4 = Good match Avoidant Negative emotionality, introversion, and compulsivity

3 = Moderate match

2 = Slight match Borderline Negative emotionality, antagonism, disinhibition, and schizotypy

1 = No match Obsessive– Compulsivity, negative emotionality, introversion, and antagonism

compulsive

Schizotypal Schizotypy, introversion, and negative emotionality

(4) Trait domains and facets

3 = Extremely descriptive

2 = Moderately

1 = Mildly

0 = Very little or not at all

descriptive

Negative

emotionality

Introversion

Antagonism

Emotional lability, anxiousness, submissiveness, separation insecurity,

pessimism, low self-esteem, guilt/shame, self-harm, depressivity, suspiciousness

Social withdrawal, social detachment, restricted affectivity, anhedonia,

intimacy avoidance

Callousness, manipulativeness, narcissism, histrionism, hostility,

aggression, oppositionality, deceitfulness

Disinhibition Impulsivity, distractibility, recklessness, irresponsibility

Compulsivity Perfectionism, perseveration, rigidity, orderliness, risk aversion

Schizotypy Unusual perceptions, unusual beliefs, eccentricity, cognitive dysregulation,

dissociation proneness

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asked to provide feedback and comments. The system on

the website is in flux and will be continually revised. The

four proposed changes (Table 1) are found in the general

definition of PDs, five severity levels of personality func-

tioning, five PD types, and six personality trait domains

and their corresponding facets.

As DSM-IV-TR diagnostic criteria are ‘‘poorly defined

and not specific to personality disorder’’ (Livesley 2010,

para. 1), the work group first recommends retaining the

diagnosis of PD, but suggests a new general definition.

Under the proposed definition, PDs ‘‘represent the failure

to develop a sense of self-identity and the capacity for

interpersonal functioning that are adaptive in the context of

the individual’s cultural norms and expectations’’ (APA

2010). ‘‘Adaptive failure’’ is manifested in either (or both)

an impaired sense of self-identity or a failure to develop

interpersonal functioning. Additionally, there must be an

extreme level of at least one personality trait, stability

across time, and evidence that the adaptive failure is not

just the consequence of another mental disorder, substance

use, or another medical condition (APA 2010).

The second change, a dimensional measurement of

personality functioning, would be used to describe the

severity of the disorder on a zero to four scale ranging

from ‘‘no impairment’’ to ‘‘extreme impairment’’ for both

self and interpersonal functioning. Current DSM-IV-TR

severity indicators and the Axis V GAF lack adequate

specificity for determining the severity of personality

psychopathology (Bender 2010). Additionally, recent

research has found that in assessment of PDs, determina-

tion of severity is the most important predictor of current

dysfunction and prognosis (Hopwood et al. in press). The

constructs used to determine severity level are categorized

under self (identity integration, integrity of self-concept,

self-directedness) and interpersonal functioning (empathy,

intimacy and cooperativeness, complexity and integration

of representations of others). One argument supporting the

scale approach to impairment is that severity becomes

‘‘obvious with dimensions’’ and allows for continuity

between normal and maladaptive behaviors or cognitions

(Maser et al. 2009).

Third, there will be a reduction in the number of PD

types from 10 to 5. The retained types will be borderline,

antisocial/psychopathic, schizotypal, avoidant, and obses-

sive–compulsive. Dropped from the DSM list of types

would be paranoid, schizoid, histrionic, narcissistic,

dependent, depressive, and negativistic (the last two being

PDs described in the appendix of DSM-IV; Skodol 2010).

The proposed diagnostic rubric will include a description

of each PD type in a narrative format that includes a brief

overview of functional deficits and typical trait configura-

tion. There will be a dimensional rating of the match for

each type and for the personality traits associated with each

type. These changes are justified by ‘‘the excessive co-

morbidity among DSM-IV personality disorders, the lim-

ited validity for some existing types, arbitrary diagnostic

thresholds included in DSM-IV, and instability of current

DSM-IV PD criteria sets’’ (Skodol 2010, para. 1). The

dropped types from the DSM-IV-TR and the residual PD-

NOS diagnosis will be subsumed under a general PD

diagnosis with the descriptive trait profiles providing the

salient information regarding the disorder.

Lastly, there has been growing consensus that ‘‘normal

and abnormal personality variation can be treated within a

single, unified framework’’ (Markon et al. 2005, p. 139).

Therefore, it is recommended that individuals be rated on a

dimensional scale of six higher-order personality trait

domains. Within each domain, there are more specific

lower-order facets that comprise each domain. In addition

to being empirically validated, there are a number of rea-

sons why the use of traits as the essential diagnostic criteria

for PDs is beneficial. According to the work group (Clark

and Krueger 2010; Krueger and Eaton 2010), trait profiles

eliminate both comorbidity and PD-NOS, clarify within-

diagnosis heterogeneity, increase diagnostic stability, and

acknowledge the continuous nature of personality. Practi-

tioners will be more confident that their diagnosis is correct

and that it will be clearly distinguishable from other

diagnoses. The empirical work that undergirds the rationale

for a mixed categorical-dimensional system for diagnosis

will be described further (Maser et al. 2009).

Five-Factor Model and Diagnosis

Researchers have found overwhelming support for a ‘‘Big

Trait’’ model of personality structure that has been repli-

cated across cultures, languages, and ages using advanced

psychometric and analytic techniques (Marsh et al. in

press; Ashton et al. 2004; Ashton and Lee 2009; De Raad

et al. 2010). This development is viewed as ‘‘one of the

most important accomplishments of personality and

research’’ (Markon 2009, p. 1). There has been notable

consensus around a ‘‘Big Five’’ or Five Factor Model

(FFM) (McCrae and Costa 1985; Goldberg 1990; Saucier

2009). These factors are Neuroticism, Extraversion,

Agreeableness, Conscientiousness, and Openness.

There is considerable evidence that the structure of PDs

strongly relate to four of the five trait domains of the FFM.

However, the Openness factor has been found to be unre-

lated to PDs in meta-analyses (Clark and Krueger 2010;

O’Connor 2005; Saulsman and Page 2004). These same

studies found that the FFM did not provide adequate cov-

erage of specific traits found in Obsessive–Compulsive PD

and Schizotypal PD (Saulsman and Page 2004). As the

DSM is a tool to diagnose maladaptive functioning,

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appropriate emphasis on abnormal personality structure is a

requirement. Thus, domains of Compulsivity and Schizo-

typy were added to provide full coverage of both normal

and abnormal personality with a six domain model, pend-

ing further empirical examination on how these domains

relate to the other four domains. As shown in Table 1,

these six domains (Neuroticism, Extraversion, Agreeable-

ness, Conscientiousness, Compulsivity, and Schizotypy)

correspond to the six proposed trait domains for the DSM-5

(Negative Emotionality, Introversion, Antagonism, Disin-

hibition, Compulsivity, and Schizotypy) although there is

still debate over how the domains should be named (Costa

and McCrae 2010).

There is already some indication that the FFM will

provide an improvement in diagnostic and clinical utility.

One study found that clinicians preferred the FFM to the

DSM for describing case vignettes (Samuel and Widiger

2006). Perhaps most important, the interrater reliability

using the FFM exceeded categorical diagnosis for proto-

typic and non-prototypic cases. Thus the FFM not only

performs more reliably, it also provides the opportunity for

deeper assessment and diagnostic utility exceeding the

diagnosis-by-prototype approach of the DSM (Clark 2007).

There are currently several standardized instruments that

can be employed to assess PD dimensions, including the

Revised NEO Personality Inventory (Costa and McCrae

1992), the Structured Interview for the Five Factor Model

(Trull et al. 2001), and the Schedule for Nonadaptive and

Adaptive Personality (Clark 1993).

Hierarchical and Dimensional Conceptualizations

The FFM represents one of the many models of personality

structure that attempt to describe both normal and abnor-

mal personality within a single framework (Eysenck 1947;

Cloninger 1987) and more recently, under a single inte-

grative hierarchy of superordinate and subordinate traits

(Markon et al. 2005). The main question is whether PDs

are ‘‘discrete clinical conditions or arbitrary distinctions

along dimensions of general personality functioning’’

(Widiger et al. 2009, p. 243). Currently, two people may

receive the same diagnosis, but present with different

personality traits and meet different criteria of the disorder

(Trull and Durrett 2005; Widiger et al. 2009). The cate-

gorical versus dimensional debate has been all but resolved

in recent years in favor of the dimensional approach.

The question then becomes how to accomplish a shift to

a dimensional model and which system to use. Concerns

about clinical utility and communication have been

expressed (Clark 2007). Although a dimensional system

would be more complex, it is specifically the invalid sim-

plicity of the previous system that should be addressed in

order to provide a more informed process of diagnosis and

treatment (Verheul 2005). FFM measures exhibit excellent

psychometric properties, making them reliable and valid

instruments to assess PDs and distinguish traits (Clark

2007). Thus, a ‘‘hybrid model’’ combining types and traits

assessed using dimensional ratings (mixed categorical-

dimensional system) has received preliminary empirical

support and is presented as the proposed model for the

DSM-5 (Skodol 2010; Maser et al. 2009; Morey et al. under

review).

In evaluating the proposed changes to the DSM-5, it is

evident that advances in the conceptualization of PDs were

considered in developing the recommendations. Personality

traits will be measured using a standardized dimensional

measure to determine the underlying personality structure of

the client. With a dimensional view of the level of functional

impairment and types that exhibit divergent and convergent

validity, these changes represent a revolutionary shift in the

way in which PDs are diagnosed and treated.

Implications for Clinical Social Work

There is evidence that clinicians already think dimension-

ally when considering patient characterization and that the

DSM has sacrificed clinical utility to mimic medical cate-

gorization (Maser et al. 2009). In the field of social work

some have taken this point beyond the dimensional versus

categorical debate of diagnosis. There is a strong position

that the use of the DSM is incongruent with the history and

focus of the profession (Kirk and Kutchins 1992; Kirk

2005). Indeed two national surveys of clinical social

workers use of the DSM-III (Kutchins and Kirk 1988) and

the DSM-IV (Frazer et al. 2009) found that while it is being

commonly used as clinical tool, its primary purpose is for

management of insurance reimbursement. Only half of the

respondents in the DSM-IV study indicated that they would

use the reference if it was not required. Kirk and Kutchins

(1992) have organized a reasonable opinion that the labeling

and medicalization of psychosocial problems directly

inhibits the understanding of the individual client, a key

feature of clinical social work. Further, they suggest that

social workers should pause before accepting the pairing of

the DSM and the insurance billing system. Although these

concerns are legitimate, the release of the DSM-5 is inevi-

table and fast approaching. Given this fact, perhaps a more

tenable position for social workers would be to purposefully

join the DSM-5 conversation by supporting and adding to

those changes that encapsulate cardinal social work per-

spectives and values (Frazer et al. 2009).

As social workers conscientiously anticipate the changes

that will occur with the release of the DSM-5, it is imper-

ative to evaluate how these changes relate to the

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profession’s orienting theories. For example, Ecological

Systems Theory, derived from the person-in-environment

perspective, grounds social work practitioners and

researchers in an understanding that people and environ-

mental systems mutually influence one another (Hepworth

et al. 2010). Social workers are trained to look not only at

individual psychopathology, but also to evaluate disorder as

embedded in a deep social, cultural, and political fabric that

may obscure, complicate, or augment pieces of the indi-

vidual psyche. A dimensional approach to mental health

diagnoses encourages social workers to use this broader

lens in reaching the root of the problem rather than dealing

only with the surface level manifestations. For example, in

assessing the client’s trait profile, not only will issues of

functional impairment be incorporated, but social workers

will be able to expand their understanding of personality

structure while using their unique skills grounded in clinical

social work theory to integrate other factors that may con-

tribute to a complex personality structure. Social workers

are trained to look for factors beyond the individual diag-

nosis that will aid in helping the client, and this orienting

theory is critical to articulate as we conceptualize the

changes being made in the DSM-5.

Additionally, the core values of the profession center on

a strengths-based perspective, which will be better sup-

ported by the dimensional approach to diagnosing PDs.

Hepworth’s (Hepworth et al. 2010) seminal textbook on

clinical social work practice distinguishes several cardinal

values of the social work profession consistent with the

Code of Ethics of the National Association of Social

Workers (NASW 1999). Three of these that are directly

applicable in framing this discussion can be paraphrased as:

(1) respect for the inherent dignity and worth of the indi-

vidual, (2) respect for self-determination and independent

decision making, and (3) respect for unique characteristics

of diverse populations. In the current model, a PD diagnosis

implies that the client is inherently flawed and deviant. A

dimensional approach to understanding PDs could poten-

tially minimize the stigma associated with such a diagnosis.

With an integrated, dimensional model, ‘‘a personality

disorder no longer would be conceptualized as something

that is qualitatively distinct from normal personality func-

tioning. Personality disorders simply represent the presence

of maladaptive variants of personality traits that are evident

within all persons.’’ (Widiger et al. 2009, p. 246).

Although the dimensional approach will maintain the

term ‘‘personality disorder,’’ the definition of disorder

would center on adaptive failure manifested in either (or

both) an impaired sense of self-identity or interpersonal

functioning (APA 2010), as opposed to disorder indicating

deviance. While still correctly termed ‘‘disorder,’’ this

modification of the definition from deviant to maladaptive

is of vital importance in how we understand the concept.

The evaluation of a disorder is placed on a continuum of

normality rather than seen as a fundamental and patho-

logical abnormality. This is a profound shift in conceptu-

alizing mental illness that will be critical in aiding

clinicians’ work in empowering clients toward attaining

greater levels of health and self-sufficiency.

Approaches to Assessment, Diagnosis, and Treatment

In reflection of the inherent values and characteristics of

social work, the process of mental health treatment will

inevitably be impacted by these changes. One of the pri-

mary roles of the clinical social worker is to assess and

diagnose mental disorders. The clinical social worker is

trained to provide a differential diagnosis to determine the

presenting condition, determine a reasonable prognosis,

formulate a treatment plan, and make appropriate referrals.

Clinical social workers are trained to use the DSM-IV-TR in

conjunction with a thorough biopsychosocial assessment to

determine the course of action within a framework of

evidence-based practice.

One advantage of the proposed changes to the DSM will

be a more accurate and specified diagnosis. As indicated on

the APA’s website, ratings from three assessments will be

used jointly to diagnose a personality disorder, streamlin-

ing the diagnostic process for mental health professionals.

These three assessments include, ‘‘(1) A rating of mild

impairment or greater on the Levels of Personality Func-

tioning (criterion A), (2) A rating of (a) a ‘‘good match’’ or

‘‘very good match’’ to a Personality Disorder Type or

(b) ‘‘quite a bit’’ or ‘‘extremely’’ descriptive on one or more

of six Personality Trait Domains (criterion B), and (3)

Diagnosis also requires relative stability of (1) and (2)

across time and situations, and excludes culturally nor-

mative personality features and those due to the direct

physiological effects of a substance or a general medical

condition’’ (APA 2010) (see Table 1). There is evidence

that a dimensional model that does not rely on arbitrary

boundaries will provide improved clinical utility in clas-

sifying disorder mainly by providing greater uniformity

within diagnostic categories, less comorbidity with other

disorders, and by eliminating the need for the NOS cate-

gory (Widiger et al. 2009; Clark 2007). The practitioner’s

subjective judgment would still be a valuable tool in

diagnosis. However, it would be accurate more often and

based on empirically validated tools that fit with contem-

porary theoretical development.

For the individual, developing a treatment plan begins

with providing an accurate diagnosis. With a dimensional

approach to assessment, it would follow that treatment

options would be more adequately tailored to the individ-

ual. The dose, setting, or treatment approaches that would

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be available would likely represent the broader spectrum of

function and personality dimensions. The lack of a valid

organizational structure in the DSM-IV-TR has been one

reason why there have been so few empirical studies

or attempts to develop manualized treatments for PDs

(Widiger et al. 2009). With a diagnostic tool that better

describes the complex array of behaviors that are the focus of

treatment, the clincian would have a more specific starting

point for determining the appropriate treatment plan. Again,

this is consistent with the person-centered treatment

approach central to clinical social work. There is also often a

concern that the long-term goal of recovery or ‘‘cure’’ from a

mental illness is not only too abstract but unrealistic for

clinicians and clients to address. The real focus is on small,

but not insignificant functional improvements and progress

along a continuum. Focusing on incremental changes on a

spectrum could have a tremendous impact on treatment

planning, prognosis, and client motivation.

These changes would also have practical implications

for the training and licensure of clinical social workers.

While there will be challenges in incorporating new

material into existing coursework and in training practicing

social workers, this also represents an opportunity to

expose clinicians to an improved approach to diagnosis. By

incorporating the cutting-edge research in human person-

ality and diagnosis of PDs into coursework and profes-

sional development, social workers will be better trained to

treat clients with PDs.

Implications for Social Work Research

Mental health research is becoming increasingly transdis-

ciplinary. If the social work perspective is going to be

incorporated in lines of research exploring PDs, a firmer

grasp of DSM changes and the empirical evidence that led to

such changes is required. This is in line with the profession’s

value of utilizing evidence-based practices in treating cli-

ents. The primary model of evidence-based interventions

demonstrates a clear relationship between using strong

empirical evidence, incorporating clients’ preferences,

understanding the social context, and drawing on the clini-

cian’s expertise. As new interventions are developed to treat

PDs, dimensional measures of change would provide better

specificity in development and evaluation.

The current DSM system of diagnosis for PDs has been

characterized as arbitrary, unreliable, incomplete, inaccu-

rate, and wrong (Clark 2007; Widiger et al. 2009). With the

bar of scientific rigor continuing to rise, constructs that fail

to exhibit superior reliability and validity should not be

included in research plans or in statistical models. To

diagnose PDs within individuals, the DSM and ICD cate-

gorical systems are the only choice but are empirically

unjustified and atheoretical (Andrews et al. 2009). By

simply moving from a categorical to a dimensional system

of classification, our knowledge of risk factors and disease

progression will improve dramatically. Clinical experience

shows that disorders across the lifetime do not switch from

either being present or absent but often exhibit a florid

presentation of symptoms and dysfunction.

Implementation Challenges

There is some apprehension to a new system of diagnosis.

Like many other suggested changes to the DSM, the pro-

posed PD revisions have generated spirited debate among

experts in the scientific community. The elimination of

narcissistic personality disorder within the broader dis-

cussion of dimensional versus prototype-based diagnosis

was recently described as a ‘‘battle worth watching’’ in The

New York Times (Zanor 2010). In fact, Dr. Allen Frances,

chair of the DSM-IV Task Force has openly criticized the

goal of creating a paradigm shift in diagnosis as being

‘‘absurdly premature’’ (Frances 2009, p. 2). There is also

concern with the appropriateness of a dimensional model in

clinical diagnosis. While both sides agree that a dimen-

sional trait model is a useful research tool, some have

suggested that it ‘‘reflects mainly the methods and concepts

valued by academic researchers who do not interact with

patients’’ (Shedler et al. 2011, p. 98).

One of the immediate concerns is the feasibility of

incorporating these changes into existing practice. While

researchers may be able to perform lengthy interviews

assessing the entire personality trait structure, a practitioner

in a clinical setting typically does not have the time to

evaluate dozens of criteria to comprehensively cover Axis

II. While this could be viewed as problematic given the

complexity of administration and interpretation of the

proposed system, it could be viewed instead as providing

both deeper and wider diagnostic abilities to the practi-

tioner. The judgment of the practitioner, along with the

client’s needs, will dictate whether a general screening tool

or a scale that delineates distinctions of the individual

within a specific personality domain is warranted. As new

instruments are developed and tested, the options available

to the practitioner should be greatly increased, improving

the possibilities for treatment.

Administrative concerns about training and education

are not sufficient reasons to delay the move forward. A

growing area of mental health research is in the field of

implementation science. This field is concerned primarily

with addressing the gap between what is known about

effective care and what is provided to consumers of mental

health services (Proctor et al. 2009). Viewing changes to

the DSM as an innovation, experts in this area could

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provide a great deal of knowledge and guidance in best

practices for incorporating new methods of assessment and

treatment planning within the organizational context of

mental health services. As a form of an evidence-based

practice, the dissemination of the DSM-5 and the dimen-

sional scales for assessing personality traits could be

planned and evaluated.

Conclusion

Knowledge about human personality has increased signif-

icantly in recent years warranting an overhaul of the pri-

mary tool for diagnosis of PDs, the DSM. The empirical

literature suggests a movement towards a dimensional

conceptualization of traits and functioning to accurately

diagnose PDs. The proposed changes for the DSM-5 reflect

the suggestions implied by the mounting research litera-

ture. As a leading provider of mental health services that

include assessment, diagnosis, and treatment planning,

social workers should become informed about the basis for

these changes and the specific proposals. Additionally,

social workers should be vocal advocates for the profession

and for clients in this discussion of change.

While there will be many challenges associated with

reformulating the DSM, leaders in the clinical social work

arena should begin to address these issues. Social workers

are encouraged to visit the DSM-5 website and read the

rationales provided for the proposed changes. Schools of

social work could be instrumental in organizing groups to

discuss the changes and the impact on clients and the

profession. As change is inevitable, this paper serves as a

possible template for framing the ensuing discussion sur-

rounding changes to the DSM and the impact on the social

work discipline.

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Author Biographies

Paul Lanier is a doctoral student at the George Warren Brown School of Social Work at Washington University in St. Louis. He is

an NIMH pre-doctoral fellow (T32 MH019960) and a student affiliate

of the Center for Violence and Injury Prevention. He received his

MSW from UNC-Chapel Hill.

Sarah Bollinger is a doctoral student at the George Warren Brown School of Social Work at Washington University in St. Louis. She is

an NIMH pre-doctoral fellow (T32 MH019960) and a recipient of the

American Cancer Society’s doctoral training grant (DSW-10-093-01-

SW) in oncology social work. She received her MSW from New York

University.

Robert F. Krueger, Ph.D. is Hathaway Distinguished Professor at the University of Minnesota. He completed his undergraduate and

graduate work at the University of Wisconsin, Madison, and his

clinical internship at Brown University. He has received a number of

awards, including the American Psychological Association’s Award

for Early Career Contributions.

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