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: [email protected]

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

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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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