Journal of Personality Disorders, 25(2), 136–169, 2011
© 2011 The Guilford Press
From University of Arizona College of Medicine and Sunbelt Collaborative, Tucson, AZ (A. E. S.,
D. S. B.); Texas A&M University, College Station, TX (L. C. M.); University of Notre Dame,
South Bend, IN (L. A. C.); Menninger Clinic and Baylor College of Medicine, Houston, TX
(J. M. O.); Mayo Clinic College of Medicine, Rochester, MN (R. D. A.); University of Minnesota,
Minneapolis, MN (R. F. K.); University of Amsterdam, Amsterdam, NL (R. V.); University of
Illinois at Chicago, Chicago, IL (C. C. B.); and Mt. Sinai School of Medicine, New York, NY
(L. J. S.)
Address correspondence to Andrew E. Skodol, MD, Sunbelt Collaborative, 6340 N. Campbell
Ave., Suite 130, Tucson, AZ 85718; E-mail: firstname.lastname@example.org.
Personality DisorDer tyPes ProPoseD
Andrew E. Skodol, MD, Donna S. Bender, PhD,
Leslie C. Morey, PhD, Lee Anna Clark, PhD, John M. Oldham, MD,
Renato D. Alarcon, MD, Robert F. Krueger, PhD,
Roel Verheul, PhD, Carl C. Bell, MD, and Larry J. Siever, MD
The Personality and Personality Disorders Work Group has proposed
five specific personality disorder (PD) types for DSM-5, to be rated on a
dimension of fit: antisocial/psychopathic, avoidant, borderline, obses-
sive-compulsive, and schizotypal. Each type is identified by core im-
pairments in personality functioning, pathological personality traits,
and common symptomatic behaviors. The other DSM-IV-TR PDs and
the large residual category of personality disorder not otherwise speci-
fied (PDNOS) will be represented solely by the core impairments com-
bined with specification by individuals’ unique sets of personality traits.
This proposal has three main features: (1) a reduction in the number of
specified types from 10 to 5; (2) description of the types in a narrative
format that combines typical deficits in self and interpersonal function-
ing and particular configurations of traits and behaviors; and (3) a di-
mensional rating of the degree to which a patient matches each type.
An explanation of these modifications in approach to diagnosing PD
types and their justifications—including excessive co-morbidity among
DSM-IV-TR PDs, limited validity for some existing types, lack of speci-
ficity in the definition of PD, instability of current PD criteria sets, and
arbitrary diagnostic thresholds—are the subjects of this review.
The Personality and Personality Disorder Work Group has proposed five
specific personality disorder (PD) types for DSM-5, to be rated on a dimen-
sion of fit: antisocial/psychopathic, avoidant, borderline, obsessive-compul-
sive, and schizotypal. Each type is identified by core impairments in
personality functioning, pathological personality traits, and common
symptomatic behaviors. Each is derived from—though not identical to—
TYPES PROPOSED 137
the corresponding DSM-IV-TR PD. The other DSM-IV-TR PDs and the
large residual category of PDNOS will be represented solely by the core
impairments combined with specification by individuals’ unique sets of
personality traits, and a diagnosis of personality disorder trait-specified
(PDTS) will be given. See Table 1, DSM-5 Borderline Personality Disorder
Type with Matching Scale, for an example of a type description and the
rating scale. See Krueger et al. in this issue for a description and discus-
sion of the personality trait structure proposed for DSM-5.1
The proposal for the specified PD types in DSM-5 has three main fea-
tures: (1) a reduction in the number of specified types from 10 to 5; (2)
description of the types in a narrative format that combines typical defi-
cits in self and interpersonal functioning and particular configurations of
traits and behaviors; and (3) a dimensional rating of the degree to which a
patient matches each type. The justifications for these modifications in
approach to diagnosing PD types include excessive co-morbidity among
DSM-IV-TR PDs, limited validity for some existing types, lack of specificity
in the definition of PD, instability of current PD criteria sets, and arbitrary
Considerable research has shown excessive co-occurrence among PDs
diagnosed using the categorical system of the DSM (Clark, 2007; Oldham,
Skodol, Kellman, Hyler, & Rosnick, 1992; Zimmerman, Rothchild, & Chel-
minski, 2005). In fact, most patients diagnosed with PDs meet criteria for
more than one. Some DSM-IV-TR PDs that rarely occur in the absence of
other Axis I and II disorders also have little evidence of validity. The cur-
rent DSM-IV-TR general criteria for PD3 were not empirically based and
are not sufficiently specific, so they may apply equally well to other types
of mental disorders (e.g., schizophrenia). PD diagnoses have been shown
in longitudinal follow-along studies to be significantly less stable over time
than their definition in DSM-IV-TR implies (e.g., Grilo et al., 2004). Final-
ly, all of the PD categories have arbitrary diagnostic thresholds (i.e., the
number of criteria necessary for a diagnosis). A reduction in the number
of types is expected to reduce co-morbid PD diagnoses by eliminating less
valid types. The requirement of core impairments in self and interpersonal
functioning helps to distinguish personality pathology from other disor-
1. Since the posting of proposed changes by the Personality and Personality Disorders Work
Group on the APA’s DSM-5 Website (www.dsm5.org) in early 2010, revisions of the proposal
have been made. Most relevant to this article, the type descriptions have been edited to be
more concise and the type ratings have been separated from trait ratings, with the intention
of determining these relationships empirically in the DSM-5 Field Trials. Core impairments
in personality functioning represented by the Levels of Personality Functioning have been
simplified and the levels, type, and trait ratings have been incorporated into revised General
Criteria for Personality Disorder.
2. The authors of this article requested an opportunity to see and respond to the specific
comments and critiques made by other contributors to this special issue, to ensure that their
concerns were addressed. The editor of the journal and those of this special issue denied
3. Briefly, “An enduring pattern of inner experience and behavior manifested in two or more
of the following: cognition, affectivity, interpersonal functioning, and impulse control.”
138 SKODOL ET AL.
ders. The addition of specific traits to behavioral PD criteria is anticipated
to increase diagnostic stability. And, the use of a dimensional rating of the
types recognizes that personality psychopathology occurs on continua.
nUMBer anD sPeCifiCation of tyPes
Five specific PDs are being recommended for retention in DSM-5: anti-
social/psychopathic, borderline, schizotypal, avoidant, and obsessive-
compulsive. Space limitations preclude a complete justification for the five
PDs retained, but each DSM-IV-TR PD was the subject of a literature
review performed by Work Group members and advisors. Antisocial/
psychopathic, borderline, and schizotypal PDs have the most extensive
empirical evidence of validity and clinical utility (e.g., Chemerinski, Trieb-
wassen, Roussos, & Siever, under review; New, Triebwasser, & Charney,
2008; Patrick, Fowles, & Krueger, 2009; Skodol, Siever, et al., 2002;
Skodol, Gunderson, Pfohl, et al., 2002; Siever & Davis, 2004). In contrast,
there are almost no empirical studies focused explicitly on paranoid,
schizoid, or histrionic PDs.
The DSM-IV-TR PDs not represented by a specific type (paranoid, schiz-
taBle 1. Borderline Personality Disorder type with Matching scale
Individuals who resemble this personality disorder type have an impoverished and/or unstable
self-structure and difficulty maintaining enduring and fulfilling intimate relationships. Self-
concept is easily disrupted under stress, and often associated with the experience of a lack
of identity or chronic feelings of emptiness. Self-appraisal is filled with loathing, excessive
criticism, and despondency. There is sensitivity to perceived interpersonal slights, loss or
disappointments, linked with reactive, rapidly changing, intense, and unpredictable emotions.
Anxiety and depression are common. Anger is a typical reaction to feeling misunderstood,
mistreated, or victimized, which may lead to acts of aggression toward self and others. Intense
distress and characteristic impulsivity may also prompt other risky behaviors, including
substance misuse, reckless driving, binge eating, or dangerous sexual encounters.
Relationships are often based on excessive dependency, a fear of rejection and/or abandonment,
and urgent need for contact with significant others when upset. Behavior may sometimes be
highly submissive or subservient. At the same time, intimate involvement with another
person may induce fear of loss of identity as an individual—psychological and emotional
engulfment. Thus, interpersonal relationships are commonly unstable and alternate between
excessive dependency and flight from involvement. Empathy for others is significantly
compromised, or selectively accurate but biased toward negative elements or vulnerabilities.
Cognitive functioning may become impaired at times of interpersonal stress, leading to
concrete, black-and-white, all-or-nothing thinking, and sometimes to quasi-psychotic
reactions, including paranoia and dissociation.
Instructions: Rate the patient’s personality using the 5-point rating scale shown below. Circle
the number that best describes the patient’s personality.
5 Very Good Match: patient exemplifies this type
4 Good Match: patient significantly resembles this type
3 Moderate Match: patient has prominent features of this type
2 Slight Match: patient has minor features of this type
1 No Match: description does not apply
TYPES PROPOSED 139
oid, histrionic, narcissistic, and dependent), the Appendix PDs (depressive
and negativistic), and the residual category of PDNOS will be diagnosed as
PD trait-specified (PDTS) and will be represented by mild impairment or
greater on the Levels of Personality Functioning (Table 2) continuum
(Bender, Maeg, & Skodol, under review), combined with descriptive speci-
fication of patients’ personality trait profiles. In general, these PDs are in
contrast to the above proposed types, which are structurally more com-
plex and represent combinations of multiple traits from across different
higher order trait domains. Thus, the proposed types represent a consid-
eration of types as particularly salient configurations or interactions of
traits—in contrast to the remaining disorders, which can be largely mod-
eled using fewer traits, often from a single, specific trait domain.
In the following sections, we highlight literature relevant to the retention
vs. deletion of DSM-IV-TR PDs as specified types in DSM-5. Most DSM-IV-
TR PDs suffer from the problem of excessive co-occurrence with other PDs
(i.e., poor discriminative validity), but the relative weight of evidence of
clinical utility and external validity favors retention of some of these disor-
ders more than others. For most PDs, neurobiological and/or genetic data
taBle 2. levels of Personality functioning1
1. Identity: Experience of oneself as unique, with boundaries between self and others;
coherent sense of time and personal history; stability and accuracy of self-appraisal and
self-esteem; capacity for a range of emotional experience and its regulation
2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization
of constructive and prosocial internal standards of behavior; ability to productively self-
1. Empathy: Comprehension and appreciation of others’ experiences and motivations;
tolerance of differing perspectives; understanding of social causality
2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness;
mutuality of regard reflected in interpersonal behavior
In applying these dimensions, self and interpersonal difficulties should not be better
understood as a norm within an individual’s dominant cultural.
Self and Interpersonal Functioning Continuum
Please indicate the level that most closely characterizes the patient’s functioning in the self
and interpersonal realms:
_____ No Impairment
_____ Mild Impairment
_____ Moderate Impairment
_____ Serious Impairment
_____ Extreme Impairment
1The original full scale with definitions of terms and detailed definitions of scale points is
provided elsewhere (see Skodol, Bender, et al., 2011).
140 SKODOL ET AL.
are sparse and findings are nonspecific (as is also the case for most Axis I
The median prevalence of ASPD across 12 epidemiological studies is 1.1%,
roughly average for PDs in the community (Torgersen, 2009). Individuals
with ASPD in the community have been found to have significantly-
reduced quality of life, but not to the degree of individuals with avoidant
PD (AVPD) or several other PDs (Cramer, Torgersen, & Kringlen, 2006).
Individuals with ASPD have been found to have problems with status and
wealth and with successful intimate relationships (Ulrich, Farrington, &
Coid, 2007), but not with psychosexual dysfunction (Zimmerman & Cory-
ell, 1989). ASPD was also associated with poor quality of life in the NESARC
(Grant et al., 2004) and with moderate dysfunction on the GAFS (Crawford
et al., 2005). In two large clinical populations (combined N = 1975) diag-
nosed with semi-structured PD interviews, the prevalence of ASPD was
3.9%, making it one of the less-commonly found PDs in clinical settings
(Stuart et al., 1998; Zimmerman, Rothchild, & Chelminski, 2005).
ASPD is one of the most frequently studied PDs, however. The construct
of ASPD is widely accepted, although there are controversies about spe-
cific aspects of the disorder. In general, the core features include egocen-
trism, callousness, exploitation, immorality, aggressiveness, hostility,
impulsiveness, irresponsibility, criminality, sadism, risk behaviors, and
fearlessness. With respect to current models of psychopathy (Patrick et
al., 2009), the proposed prototype for antisocial/psychopathic PD includes
both traits related to a disinhibition component (i.e., traits corresponding
most directly to the adult features of DSM-IV-TR antisocial PD) and traits
related to the construct of meanness (i.e., traits related to callousness/
lack of remorse, conning/manipulativeness, and predatory aggression).
There is abundant evidence that the impulsive-antisocial (disinhibited-
externalizing) and affective-interpersonal (boldness-meanness) compo-
nents of psychopathy substantially co-occur, but differ in terms of their
neurobiological correlates and etiologic determinants (e.g., see Moffit,
2005; Patrick, 2006), which provides a strong foundation for formulating
and testing questions in relation to distinctive antisocial and psychopath-
ic PD trait profiles, both within ASPD and across other PDs and other
mental disorders (Edens, Marcus, Lilienfeld, & Poythress, 2006; Rutter,
Due to its history, well-established validity, obvious importance in fo-
rensic settings, and relationships to other types of psychopathology (e.g.,
alcohol and substance use disorders, see Compton, Conway, Stinson, Col-
liver, & Grant, 2005), and other problems (e.g., poor physical health, ob-
sesity, see Goldstein et al., 2008), a revised construct of ASPD that in-
cludes psychopathic personality features has been recommended for
retention in DSM-5.
TYPES PROPOSED 141
BPD has been found to occur in 1.6% of the general population, about av-
erage for PDs in the community (Torgersen, 2009). BPD has been found to
be associated with moderate reductions in quality of life in the community
(Cramer, Torgersen, & Kringlen, 2006). However, when examined in rela-
tionship to a broader concept of dysfunction that included reduced quality
of life, problems with other people, number of lifetime Axis I disorders, and
treatment-seeking, BPD was the most dysfunctional PD (Torgersen, 2009).
In the Collaborative Longitudinal Personality Disorders Study (CLPS), pa-
tients with BPD have been found to have significantly more impairment at
work, in social relationships, and at leisure than patients with either less
severe types, such as obsessive-compulsive PD, or with major depressive
disorder in the absence of PD (Skodol, Gunderson, McGlashan, et al., 2002)
and functional impairment in BPD was stable over two years of follow-up
(Skodol et al., 2005). Borderline personality disorder was associated with
poor functioning in the Ulrich and colleagues study (2007) and with psy-
chosexual dysfunction in the study by Zimmerman & Coryell (1989). Per-
sons in the community with BPD have also been found to have the poorest
functioning as measured by the GAFS (Crawford et al., 2005). In two large
clinical populations, the prevalence of BPD was 12.7%, making it one of the
three most common PDs in clinical settings (Stuart et al., 1998; Zimmer-
man et al., 2005). In several other, smaller clinical epidemiological studies
based on semi-structured interview assessments, BPD was always found
to be one of the two most common PDs (Zimmerman et al., 2005).
Borderline PD is also one of the most studied of the BPDs, second only
to ASPD with respect to number of publications in the DSM era. DSM-IV-
defined BPD has been shown to identify a cohesive class of subjects, in
spite of internal heterogeneity. Fossati et al. (1999) carried out a latent
structure analysis of DSM-IV BPD criteria, which supported the hypothe-
sis that BPD is a unidimensional construct and that patients with BPD
represent a distinct, cohesive disorder, yet one with dimensionally distrib-
uted temperamental characteristics. Johansen, Karterud, Pedersen, Gude,
and Falkum (2004) examined the prototype validity of the DSM-IV border-
line construct and concluded that the current criteria fit the prototype
model well, with unstable relationships representing the criterion with
highest diagnostic efficiency and chronic feelings of emptiness the lowest.
Ryder, Costa, and Bagby (2007) utilized the SCID II to evaluate 203 pa-
tients with DSM-IV-defined personality disorders, focusing on convergent
validity, divergent validity, relation to general personality traits, and as-
sociation with functional impairment, as measured by the GAFS. Of the
10 DSM-IV personality disorders, only BPD criteria were satisfactory on
all four evaluation standards, and the majority of BPD criteria were asso-
ciated with impairment. Grilo et al. (2001), using data from the CLPS,
studied four DSM-IV personality disorder criteria sets to evaluate internal
consistency, intercriterion overlap, and diagnostic efficiency. They found
142 SKODOL ET AL.
that criteria for the specific PDs studied (schizotypal, borderline, avoidant,
and obsessive-compulsive) correlated better with each other within each
set, than with criteria for other PDs. Also from the CLPS data, Sanislow et
al. (2002) carried out a confirmatory factor analysis of DSM-IV criteria for
BPD. They reported that the diagnostic criteria for BPD reflect a statistically
coherent construct, composed of three primary components—disturbed re-
latedness, behavioral dysregulation, and affective dysregulation.
There are a multitude of family, twin, adoption, genetic, neurobiological,
and imaging studies that have shed light on the distinctiveness of BPD
(e.g., see Goodman, New, Triebwasser, Collins, & Siever, 2010) and on
basic mechanisms underlying its core psychopathology. Originally, two
prominent features were singled out—affect dysregulation and impulsive
aggression (Coccaro & Siever, 2009). Neurocognitive studies have focused
on tasks related to symptoms seen in BPD, such as cognitive and behav-
ioral disinhibition, related to impulsivity and emotional processing and
have found deficits in behavioral control (e.g., Bazanis et al., 2002) and
abnormalities in emotional information processing (e.g., Donegan et al.,
2003). Published evidence suggests that there is an abnormality in seroto-
nergic function underlying the impulsive aggressive symptoms of BPD re-
lated to specific genetic risk factors, but the precise molecular nature of
this abnormality is not yet clear. Bender and Skodol (2007) posited that
BPD reflects fundamental disturbances in self and other representations,
a proposal conceptually akin to theory-based views of borderline intrapsy-
chic structure. Gunderson and Lyons-Ruth (2008) proposed a gene-envi-
ronment developmental model to support their view that interpersonal hy-
persensitivity represents a third core endophenotype, and a number of
research groups have identified the interpersonal realm as a key area of
disturbance in borderline patients. Leihener et al. (2003), for example, sug-
gested that there are two distinct subtypes of patients with BPD, autono-
mous and dependent, reflecting two different trait patterns of interpersonal
behavior. Stanley and Siever (2010) reviewed neurobiological studies of at-
tachment and affiliation and hypothesized that altered neuropeptide func-
tion may underlie the interpersonal domain of BPD. Livesley (2008), draw-
ing from empirical studies of the phenotypic structure and genetic
architecture of personality, described core self and interpersonal pathology
in patients with BPD, accompanied by a set of four types of traits: emo-
tional, interpersonal, cognitive, and self-harm.
The proposed BPD prototype includes characteristic core disturbances
in self and interpersonal functioning, coupled with manifestations of emo-
tional, behavioral, and cognitive dysregulation (See Tables 1 & 4). Treat-
ment and naturalistic studies of other mental disorders demonstrate the
negative prognostic impact of BPD co-occurrence and underscore the clin-
ical utility of the diagnosis (e.g., Grilo et al., 2005; Grilo et al., 2010). A
complete review of the literature on the validity of BPD is beyond the scope
of this paper, but a wealth of data have accumulated on this most clinical-
ly-salient PD being recommended for retention in DSM-5.
TYPES PROPOSED 143
Schizotypal PD (STPD) was added as a specific PD in DSM-III, to encom-
pass the attenuated schizophrenia-like symptoms observed in the relatives
of patients with schizophrenia (Spitzer, Endicott, & Gibbon, 1979). Without
inclusion of such nonpsychotic individuals in the original Danish Adoption
Studies of Schizophrenia, no genetic effects would have been found (Kety,
1983). STPD is one of the less-common PDs (median prevalence 0.9%)
found in general population studies (Torgersen, 2009), but one of the most
studied PDs. STPD is also one of the DSM-IV PDs most strongly associated
with reduced quality of life in the community (Cramer et al., 2006). Indi-
viduals in the community with STPD have also been found to have signifi-
cant problems in achievement and in interpersonal relationships by Ulrich
and collaegues (2007) and the 3rd lowest GAFS scores among the PDs by
Crawford et al. (2005). STPD is also rare in clinical populations (1.9%; Stu-
art et al., 1998; Zimmerman, Rothchild, & Chelminski, 2005). However,
patients with STPD have been found to have significantly more impairment
at work, in social relationships, and at leisure than patients with either
less-severe PD types, such OCPD, or with major depressive disorder in the
absence of PD (Skodol, Gunderson, McGlashan, et al., 2002).
The criteria of STPD reflect both positive psychotic-like manifestations
and negative deficit-like manifestations, and both have been validated by
numerous neurochemical, psychophysiological, neuropsychological, and
structural and functional imaging studies. For example, the psychotic-like
symptoms of STPD correlate with elevated levels of the dopamine (DA) me-
tabolite homovanillic acid (HVA), which are higher than in other PDs but
lower than in schizophrenia (Siever & Davis, 2004). Moreover, smaller vol-
umes of striatal structures (e.g., caudate and putamen) in STPD com-
pared to schizophrenia results in lower striatal DA release mediated by
amphetamine (Abi-Dargham, Mawlawi, & Lombardo, 2002; Siever et al.,
2002) or by physiological stressors in individuals with STPD (Mitropoulou
et al., 2004). Such findings have been hypothesized to result in signifi-
cantly lower vulnerability to frank psychosis in patients with STPD com-
pared to those with schizophrenia, and to account for the relatively low
rate of progression of STPD to schizophrenia. The negative manifestations
and cognitive deficits of STPD have also been related to external validators
(Holohan & O’Driscoll, 2005).
The study of STPD has increased knowledge about pathophysiological
factors that give rise to schiozophrenia, but also about differences that
result in more readily reversible cognitive and social deficits (Fossati,
Raine, Carretta, Leonardi, & Maffei, 2003; Mata, Mataix-Cols, & Peralta,
2005) and in decreased vulnerability to psychosis in STPD (Raine, 2006).
The clinical implications of these differences are recognized by research
groups who use individuals with STPD in studies assessing compensatory
processes that provide buffers against schizophrenia in vulnerable indi-
viduals. Despite its phenomenological similarities to schizophrenia, STPD
144 SKODOL ET AL.
is regarded by those who study it as a distinct disorder whose core fea-
tures more resemble the maladaptive patterns of a personality disorder
than the overt breaks from reality characteristic of psychotic disorders. It
is recommended that STPD be retained as a PD type, not a variant of
schizophrenia, in DSM-5.
The median prevalence of AVPD in 12 epidemiological studies was 1.7%,
making it one of the most prevalent PDs in the community (Torgersen,
2009). Avoidant personality disorder has also been found to be the PD most
strongly associated with reduced quality of life in the community, as mea-
sured by subjective well-being, self-realization, relation to friends, social
support, negative life events, relation to family of origin, and neighborhood
quality (Cramer, Torgersen, & Kringlen, 2006). AVPD has been found to be
associated with problems with status and wealth and with successful inti-
mate relationships (Ulrich et al., 2007) and with a high frequency of psycho-
sexual dysfunction (Zimmerman & Coryell, 1989). Grant et al. (2004) found
that individuals with AVPD had among the highest levels of impairment in
functioning in the NESARC. Crawford et al. (2005) found that persons in
the community with AVPD had the second lowest (to BPD) level of function-
ing as measured by the GAFS. In two large clinical samples, AVPD was the
single most frequently occurring PD (20.4%; Stuart et al., 1998; Zimmer-
man et al., 2005) and one of the two most common PDs (with BPD, see
above) in several other smaller clinical samples. AVPD was found to have
moderate levels of functional impairment in the CLPS, between that of the
severe PDs, such as STPD and BPD, and OCPD, and greater impairment
than for MDD without PD (Skodol, Gunderson, McGlashan, et al., 2002).
Much of the literature on AVPD is focused on its discrimination from
social phobia (SP), and specifically if it can simply be considered a severe
form of generalized social phobia (GSP). Although the conclusions drawn
from many studies and reviews suggest that AVPD and GSP differ only
quantitatively, but not qualitatively, a closer look at these studies indi-
cates a more complex picture. Alden, Laposa, Taylor, and Rider (2002)
noted that studies of social phobia/AVPD comorbidity typically examined
a sample of patients, all of whom were included because they had one of
these diagnoses, for overlap with the other. Such studies reliably find that
many—though far from all—patients with AVPD also have social phobia.
They reported an average comorbidity rate of 42% for SP in AVPD, with
somewhat higher rates for GSP, figures far lower than would be expected
if AVPD were simply a more severe form of SP. These studies do typically
find that, among patients with social phobia, those with comorbid AVPD
are more severe on a variety of indices.
Other studies (e.g., Jansen, Arntz, Merckelbach, & Mersch, 1994) exam-
ined the specificity of the AVPD/SP relationship by studying co-morbidity
of AVPD with other anxiety disorders and found modest rates of co-occur-
TYPES PROPOSED 145
rence and a relationship that was neither specific nor consistent with the
severity hypothesis. Shea et al. (2004) followed a large sample of patients
with at least one of four PDs, including AVPD and found that the course of
AVPD was linked with that of both SP and OCD, although slightly more
strongly to the former. Similarly, although the Harvard/Brown Anxiety
Research Project found that SP and AVPD had a stronger affinity to each
other than either disorder had to other diagnoses, again the relation was
neither strong nor specific enough to conclude they were simply the same
disorder (Dyck et al., 2001). Finally, Hummelen, Wilberg, Pedersen, and
Karterud (2007) reported a large-scale study examining 2,274 PD patients,
including 39% with AVPD and 30% with SP. Almost two-thirds (62.8%) of
SP patients also had AVPD—as expected, more than any other PD—but,
importantly, only 48% of those with AVPD had SP—just the reverse of ex-
pectations if AVPD were the more severe disorder on a shared continuum.
Further, odd ratios for elevated PD in SP patients were significant for four
other PDs, including antisocial, borderline, narcissistic, and PD not other-
wise specified (PDNOS), ranging from 5% to 25%. Thus, although SP typi-
cally is more comorbid with AVPD than with other PDs, and AVPD more
comorbid with SP than with other anxiety disorders, in neither case is the
relation at all exclusive, nor close enough to support a simple severity hy-
pothesis. In a large Norwegian twin study, Reichborn-Kjennerud et al.
(2007) found that AVPD/SP were best modeled with shared genetic but
unique environmental variance. That is, the factors underlying whether
either disorder would develop were under common genetic control, but
which of the two would develop was due to environmental factors. Impor-
tantly, diagnostic overlap in this study was not trivial, yet was quite far
from suggesting identity: 20–30%, varying by current versus lifetime diag-
noses and whether one examined AVPD patients with SP or vice versa.
Given the co-morbidity of AVPD with multiple anxiety disorders, with
schizophrenia and related psychotic disorders, and with other PDs and
familial cross-linkages (Clark, unpublished manuscript), the question
arises of whether AVPD should be retained as a specific type in DSM-5 or
represented by a patient-specific trait profile to describe the heterogeneity
of patients who might receive this diagnosis. At the domain level, AVPD
would be characterized by primarily high negative emotionality and high
detachment (low positive affect), but also possibly by schizotypy. In the
currently proposed model, as a compromise position, AVPD is retained a
clinically useful type due to its prevalence in epidemiological and clinical
samples and its significant associated functional impairment; heterogene-
ity within the type is captured by trait facet assessment.
OCPD is the most prevalent PD in the general population, with the highest
median prevalence (2.1%) across 12 epidemiological studies (Torgersen,
2009). It is also among the most common PDs in clinical populations
146 SKODOL ET AL.
(13.1%; Stuart et al., 1998; Zimmerman, 2005). OCPD was not found to be
significantly associated with reduced quality of life (Cramer et al., 2006),
achievement and intimacy problems (Ulrich et al., 2007), or low GAFS
scores (Crawford et al., 2005) in the community. However, in the CLPS,
even though patients with OCPD had less severe impairment than those
with other PDs (i.e., BPD and STPD), they had moderate to severe impair-
ment in at least one area of functioning (usually interpersonal) or a Global
Assessment of Functioning rating of 60 or less (Skodol, Gunderson, Mc-
Glashan, et al., 2002) and functional impairment in patients with OCPD
did not change over two years of follow-up (Skodol et al., 2005). OCPD has
been shown to increase relapse rates of major depressive disorder (Grilo et
al., 2010) and to be associated with increased risk of suicide attempts in
depressed patients (Diaconu & Turecki, 2009). Patients with OCPD have
increased levels of mental heath treatment (Bender et al., 2001) and pri-
mary care (Sansone, Hendricks, Gaither, & Reddington, 2004) utilization,
and along with BPD, OCPD is associated with the highest total economic
burden in terms of direct medical costs and productivity losses of all PDs
(Soeteman, Hakkart-van Roijen, Verheul, & Busschbach, 2008).
Rigidity and perfectionism emerge as core features of OCPD in clinical
observations and in empirical studies (Pinto, Eisen, Mancebo, & Rasmus-
sen, 2008). Rigidity reflects the central interpersonal control and re-
sistance to change aspects of OCPD, while perfectionism reflects key
cognitive or intrapersonal control aspects (Grilo, 2004). Rigidity and per-
fectionism emerge as two robust factors of OCPD in confirmatory factor
analyses (CFA) in a binge eating sample (Ansell, Pinto, Edelen, & Grilo,
2008) and rigidity, perfectionism, and miserliness in a CFA in a sample
with PDs (Pinto, Ansell, Grilo, & Shea, 2007). McGlashan et al. (2005)
found that rigidity, reluctance to delegate, perfectionism were the three
most prevalent and stable OCPD criteria over two years of follow-up in the
CLPS. Perfectionism has been found to be a significant vulnerability factor
for depression (Rice & Aldea, 2006). These core aspects of self and inter-
personal pathology are among the phenomena included in the OCPD type
proposed for DSM-5.
A specific OCPD type is being recommended for DSM-5 because of its
high prevalence in community and clinical populations and its impact on
the course and outcome of depression and anxiety disorders. The discon-
nect between the low levels of impairment in patients with OCPD in the
community and the more substantial clinical costs may be due to the in-
clusion of a larger number of less severe or even adaptive cases of OCPD
in a general population sample compared to the more severe and dysfunc-
tional cases who seek treatment.
Narcissistic PD (NPD) is the least-frequently occurring PD in the general
population, with a median prevalence across the 12 studies reviewed by
TYPES PROPOSED 147
Torgersen (2009) of 0.5%. Only the recent NESARC study (Wave 2 not in-
cluded in the above review) has found a high prevalence (6.2%, 2nd most
common). NPD has been found to be moderately common in clinical set-
tings (5.7%; Stuart et al., 1998; Zimmerman et al., 2005), but less com-
mon than the average PD (9.3%). NPD was associated with a lesser degree
of impairment in quality of life in the Cramer and colleagues’ (2006) study,
but had some impairment, and had moderate impairment on the GAFS
(Crawford et al., 2005). Ulrich and colleagues (2007) found no impairment
for NPD on either their indices of achievement or interpersonal relation-
In addition to questions about the actual prevalence of NPD and how
impairing it is, two additional significant questions can be raised about
DSM-IV-TR NPD: (1) are the current criteria, which include a pattern of
grandiosity, need for admiration, and lack of empathy, adequate to de-
scribe the personality psychopathology of narcissistic individuals; and (2)
are narcissistic difficulties better represented by a categorical PD or by a
dimension of psychopathology that cuts across multiple PDs and other
mental disorders? Clinical and empirical studies have suggested a two-
factor structure for narcissistic personality or two subtypes: one an overt
type characterized by arrogance, grandiosity, assertiveness, and aggres-
siveness (e.g., the DSM type), and the other a covert type, characterized by
shyness, vulnerability, insecurity, and shame (Dickenson & Pincus, 2003;
Fossati et al., 2005; Pincus et al., 2009; Russ, Shedler, Bradley, & Westen,
2008). It has also been observed that individuals may have combinations
of these traits or may fluctuate between types depending on life circum-
stances, both positive and negative (Rhodewalt & Morf, 1998; Ronnings-
tam, Gunderson, & Lyons, 1995). A third, malignant type of narcissism
shows strong resemblance to antisocial or psychopathic personalities and
is characterized by hostility, aggression, violence, cruelty, and sadism.
Grandiosity can also be found in other mental disorders, such as bipolar
mood disorders and paranoid disorders, need for admiration is a hallmark
of histrionic PD, and impaired empathic capacity can be seen in autism,
schizophrenia, ASPD, and psychopathy. A lack of symptom specificity is
more consistent with a cross-cutting dimension of narcissism in psycho-
pathology, than a specific diagnostic category.
In addition to the range of phenotypic expression and the relative lack of
symptom specificity, because functioning, self-concept, and capacity for
empathy are thought to fluctuate in NPD (Ronningstam, 2009), in the pro-
posed changes for PDs posted on the APA Website, pathological narcis-
sism is represented in Levels of Impairment in Personality Functioning
Scale, which is based on self (e.g., identity) and interpersonal (e.g., empa-
thy) functioning. Empathy has been conceptualized in social psychology
as a skill or ability to perceive and experience the emotions of others,
which is related to the regulation of ones own emotions (Klein & Hodge,
2001). The neuropsychological components of empathy and the relation-
ship of self-awareness and self-regulation to empathic functioning are
148 SKODOL ET AL.
currently under study (Decety & Jackson, 2004). Impairment in personal-
ity functioning varies across different PDs, but also within PDs; severity of
impairment can fluctuate over time and in response to treatment. Typical
narcissistic functioning is represented by Level 2 = Moderate Impairment.
There are also many individual facet traits in the proposed model (Skodol,
Bender, et al., 2011), primarily from the antagonism and negative emo-
tionality trait domains, that can be used to describe the heterogeneous
patterns of narcissistic personality pathology by patient-specific trait pro-
files, including grandiosity, histrionism, manipulativeness, callousness,
hostility, aggression, low-self-esteem, guilt/shame, submissiveness, pes-
simism, social withdrawal, and perfectionism.
The median prevalence of histrionic PD (HPD) across 12 epidemiological
studies was 1.5%, about average for the 10 DSM-IV-TR PDs (Torgersen,
2009). Among individuals in the community, those diagnosed with HPD
were among the few with PDs who did not have a significant reduction in
quality of life (Cramer, Torgersen, & Kringlen, 2006) and had only mod-
estly low GAFS scores (Crawford et al., 2005). In the study by Ulrich and
colleagues (2007), HPD was positively associated with status and wealth.
HPD was also not found to be significantly associated with functional im-
pairment in a clinical sample (Ryder, Costa, & Bagby, 2007). The frequen-
cy of HPD in the large clinical samples of Stuart et al. (1998) and Zimmer-
man et al. (2005) varies extremely widely, with a prevalence of 21.3% in
the former, DSM-III-R based study and 1.0% in the latter, DSM-IV study,
making its true prevalence in clinical settings difficult to estimate.
The phenomena of histrionic PD (HPD) are not specific to any one diag-
nostic category or one PD; its characteristics (e.g., self-centeredness, at-
tention-seeking, excessive emotionality, immaturity, low frustration toler-
ance, etc.) may also be found in other personality types (particularly others
belonging to DSM-IV-TR’s Cluster B; Blagov & Westen, 2008; Marinangeli
et al., 2000) and in other psychiatric disorders (Pfohl, 1995). Other mental
disorders frequently co-occurring with HPD include bipolar mood disor-
ders; substance abuse; and schizoaffective, dissociative, and somatization
disorders (Feske, Tartar, Kirisci, & Pilkonis, 2006; Oldham et al., 1995).
Structural analysis in one sample demonstrated good internal consis-
tency and convergence, but poor discriminating validity between border-
line, histrionic, and narcissistic PDs (Warren & South, 2009). In a princi-
pal component analysis, measures of impulsivity, aggressiveness, and
novelty-seeking grouped together in all Cluster B PDs, though sensation-
seeking traits were more associated with HPD (Fossati et al., 2007). There
are many studies indicating unclear boundaries between HPD and BPD,
the latter appearing to be more clinically complex, valid, and with a more
stable clinical course (e.g., Blagov & Westen, 2008).
No specific familial aggregation and/or co-aggregation studies of HPD
TYPES PROPOSED 149
patients have been published. Heritability studies show common genetic
risk factors for personality pathology in general, for impulsivity/low agree-
ableness, and for introversion, but not for specific PDs or Clusters (Kend-
ler et al., 2008). In another twin study (Torgersen et al., 2008), common
genetic and environmental influences were found for Cluster B PDs, but
ASPD and BPD as more closely related to each other than to the other
Cluster B disorders (histrionic among them). No genetic effects were found
for HPD, but common environmental effects accounted for over 50% of the
variance. In a Chinese twin pairs study, genetic effects for HPD were much
smaller than for other PDs (Ji et al., 2006). Few biological studies have
been conducted with adequate samples of patients with HPD and findings
have been weak and nonspecific. Similarly, adequate treatment studies
are virtually nonexistent. Finally, lower levels of stability for HPD have
been found when compared to other Cluster B PD types.
The proposed trait facet of histrionism captures the attention-seeking
and self-dramatization of histrionic PD, which can be measured and stud-
ied in relationship to PD types, other traits, and other mental disorders.
Paranoid PD (PPD) is one of the most common PDs in the community, with
a median prevalence of 1.7% (Torgersen, 2009). PPD in the community is
one of the three most impairing PDs with respect to reduced quality of life
(Cramer et al., 2006; Grant et al., 2004) and is associated with moderately
poor functioning as measured by the GAFS (Crawford et al., 2005). In
clinical samples, PPD occurs at a rate about average for the individual
DSM PDs (9.7%; Stuart et al., 1998; Zimmerman et al., 2005), although
its prevalence varies considerably (13.9% to 4.2%).
Despite its apparent prevalence and associated morbidity, since the
publication of DSM-III, PPD has been among the least studied of the PDs,
with relatively few empirical investigations specifically devoted to it in the
published literature. Recent descriptive information about PPD is derived
largely from broad-based epidemiological studies of personality disorders
as a whole (e.g., Coid, Yang, Tyrer, Roberts, & Ulrich, 2006), plus exami-
nations of the cluster A personality disorders and their relationship to
schizophrenia (e.g., Kendler, Myers, Torgersen, Neale, & Reichborn-Kjen-
nerud, 2007), though this latter group of studies tends to focus on STPD
rather than PPD (e.g., Hazlett et al., 2008; Torgersen et al., 2002). There
are virtually no published neurobiological studies devoted exclusively—or
even primarily—to PPD, and there is almost no published somatic or psy-
chotherapeutic treatment research.
It may be that researchers have not examined PPD because of an under-
lying skepticism about the psychometric properties of the diagnosis itself,
particularly its discriminant validity: paranoia is a key feature of several
different disorders, including, most obviously, the psychotic disorders. In
particular, delusional disorder, which—like PPD—can encompass non-
150 SKODOL ET AL.
bizarre paranoia and need not be accompanied by a catastrophic global
decline in functioning, may capture much of the symptomatology that
might otherwise be ascribed to PPD. Moreover, the hypervigilance of post-
traumatic stress disorder (PTSD), along with the associated PTSD feature
of constantly feeling threatened, are highly similar to, and indeed can be
indistinguishable from, paranoia. Among the personality disorders, STPD
includes paranoia among its DSM-IV-TR criteria, and borderline PD’s
DSM-IV-TR criteria include transient, stress-related paranoid ideation. An
analysis of data from the Mt. Sinai/Bronx VA research group, which for
decades has studied a large sample of personality disordered individuals,
shows a fairly high frequency of PPD but almost no cases of PPD unac-
companied by at least one other diagnosis, most frequently STPD.
Since the diagnostic criteria for paranoid PD describe pervasive mistrust
or suspiciousness and concomitant behaviors, which occurs in a variety of
Axis I (e.g., delusional disorder, PTSD) and II (e.g., STPD and BPD) disor-
ders (Chemerinski, Triebwasser, Roussos, & Siever, under review), it is
believed to be better to represent PPD as dimensional traits, rather than a
specific disorder. Suspiciousness and hostility are traits in the Negative
Emotionality trait domain proposed for DSM-5, and social withdrawal is
in the Detachment domain.
The median prevalence of schizoid PD (SPD) in epidemiological studies of
0.9% makes it one of the less common DSM-IV PDs (Torgersen, 2009). It
was found by Ulrich and colleagues (2007), however, to have the lowest
functioning among the PDs with respect to achievement and interpersonal
relations and has been associated with considerable reduction in quality
of life (Cramer, Torgersen, & Kringlen, 2006; Grant et al., 2004). In clinical
populations, it is consistently one of the least commonly encountered PDs
(2.2%; Stuart et al., 1998; Zimmerman et al., 2005).
Since the publication of DSM-III, SPD has also been—along with para-
noid PD—among the least studied of the personality disorders, with virtu-
ally no empirical investigations specifically devoted to it in the published
literature. Similarly to PPD (see above), descriptive information about SPD
is also derived almost entirely from broad-based epidemiological studies of
personality disorder as a whole and examinations of the cluster A person-
ality disorders and their relationship to schizophrenia (see above). There
are virtually no published neurobiological studies devoted exclusively—or
even primarily—to SPD, and there is no published quantitative somatic or
psychotherapeutic treatment research.
Moreover, the current conceptualization of SPD has been challenged as
representing the uneasy union of two separate disorders, an STPD-like
affect-constricted disorder, and a seclusive disorder, similar to avoidant
personality disorder (AVPD; Kalus, Bernstein & Siever, 1995). On the oth-
er hand, it might be argued that SPD and AVPD are fundamentally differ-
TYPES PROPOSED 151
ent in that patients with AVPD crave social interaction, but are too anx-
ious—because of low self-esteem or rejection sensitivity—to pursue or
enjoy it, whereas patients with SPD are genuinely indifferent to the com-
pany of others. However, in practice it can be difficult to make this distinc-
tion, and family research has suggested that AVPD (like SPD) is, in fact,
part of the schizophrenia spectrum (Fogelson et al., 2007; Silberschmidt
& Sponheim, 2008). It may be, then, that the habitual reclusiveness cen-
tral to SPD can often better be attributed to other disorders, e.g., AVPD,
mood disorders, anxiety disorders, and disorders with prominent para-
noia or irritability, that cause affected individuals to isolate themselves.
Since social isolation and affective constriction of SPD are also often
seen in other mental disorders, it may be better represented by traits (e.g.,
social withdrawal, social detachment, intimacy avoidance, and restricted
affectivity) in the Detachment trait domain proposed for DSM-5 that elab-
orate on the personality characteristics present in patients with a variety
of other disorders, rather than by an independent PD diagnosis (Chemer-
inski, Triebwasser, Roussos, & Siever, under review).
Dependent PD (DPD) is one of the two least-common PDs (0.7%; along
with NPD) in the community, according to the review by Torgersen (2009).
It has been found to be associated generally with moderate- to low-impair-
ment in functioning (Crawford et al., 2005; Cramer et al., 2006; Ulrich,
Farrington, & Coid, 2007), relative to other PDs, although in the NESARC,
individuals with DPD were found to have the poorest quality of life (Grant
et al., 2004). The prevalence of DPD in clinical settings, similarly to HPD,
is difficult to discern because it fluctuates widely from study to study. In
the study by Stuart et al. (1998), DPD was the third most common PD,
with a prevalence of 18.0%; in the study by Zimmerman and colleagues
(2005), DPD was one of the least common, with a prevalence of 1.4%. In
other, smaller clinical samples evaluated with semi-structured interviews,
the prevalence also fluctuates—from a high of 22.9% to a low of 5% (Zim-
merman et al., 2005).
DSM-IV characterizes dependent PD (DPD) as a “. . . a pervasive and
excessive need to be taken care of that leads to submissive and clinging
behavior and fears of separation” (American Psychiatric Association,
1994). This definition also reflects that of trait dependency, which at path-
ological levels is characterized by similar patterns of lack of confidence in
the self, and a compelling need for affiliative others (Bornstein, 1993).
Dependent PD is one of only a few among the DSM-IV-TR PD diagnoses
that is both conceptually-defined and empirically-represented by a single
trait, dependency, and its concomitant behaviors. In early analyses, both
Morey (1988) and Blais, Benedict, and Norman (1998) found DPD to be
among the more internally consistent of the DSM-III and DSM-III-R PDs,
and Blais and colleagues went on to state that DPD was one of only three
152 SKODOL ET AL.
DSM-III and DSM-III-R PDs (along with antisocial and borderline PDs) to
have sufficiently acceptable psychometric properties, including discrimi-
nant validity, to be considered measures of coherent dimensions that were
distinct from other PDs. On the other hand, other studies of DPD have
found extensive overlap with other DSM PDs (e.g., Skodol, Gallaher, &
Oldham, 1996), suggesting a pattern of maladaptive traits and behaviors
that cut across a range of personality psychopathology. More recently,
Nestadt et al. (2006) examined all the DSM-IV PD criteria using both ex-
ploratory and confirmatory factor analyses, and found that DPD was best
represented by a single, latent trait dimension in both types of analyses.
Thus, these results indicated that DSM-III, -III-R, and –IV DPD criteria
all essentially reflect the characteristics of a single dimension. Later anal-
yses of the DPD criteria alone, however, have indicated that this dimen-
sion can be subdivided into two, correlated factors (e.g., Gude, Hoffart,
Hedley, & Ro, 2004). These factors have been found by others as well, and
have been termed variously as (1) attachment/abandonment, emotional
neediness, active-emotional, and insecure attachment, and (2) dependen-
cy/incompetence, self-perceived incompetence, and passive-submissive
(Morgan & Clark, 2010). These two factors are assessed in the proposed
DSM-5 trait model by two facets of Negative Emotionality: separation inse-
curity and submissiveness.
Importantly, DPD as defined in the DSM, and trait dependency as de-
fined in the personality literature, bear more than definitional similarity.
Studies that use both DPD and trait dependency measures consistently
find similar results for these variables. In a meta-analytic review of rela-
tions between measures of personality disorder and the five-factor model
(FFM) of personality, Saulsman and Page (2004) reported comparable re-
sults for studies that used self-report and interview measures of DPD, as
well as trait dependency questionnaires. Bornstein and Cecero (2000) also
obtained these results, using primarily DPD measures in their meta-anal-
ysis of dependency in relation to the FFM. Further, Huprich, Clancy,
Bornstein, and Nelson-Grey (2004) reported that both trait dependency
and SCID-II DPD scores accounted for similar variance in depression in
an undergraduate sample.
Taken together, these data suggest that (1) DPD can be well-modeled as
a lower order trait dimension with two subfacets and (2) current measures
of DPD and trait dependency are virtually interchangeable.
DeriVation anD Content of tyPes
SEVERITY OF IMPAIRMENT IN PERSONALITY FUNCTIONING
A recent three-year follow-along study of patients in the CLPS demon-
strated that “generalized severity is the most important single predictor of
concurrent and prospective dysfunction” in assessing personality psycho-
pathology (Hopwood et al., in press). The authors concluded that PD is
TYPES PROPOSED 153
optimally characterized by a generalized personality severity continuum
with additional specification of stylistic elements, derived from PD symp-
tom patterns and personality traits. This recommendation is consistent
with Tyrer’s (2005) assertion that severity level is essential to any dimen-
sionally-specified system for assessing personality psychopathology. Nei-
ther the DSM-IV-TR general severity specifiers nor the Axis V GAF Scale
have sufficient specificity for personality psychopathology to be useful in
measuring its severity. And, although PD co-morbidity is often interpreted
by clinicians as a proxy for a severe PD, representation of severity by the
application of multiple PD diagnoses is awkward, not parsimonious, and
misleading with regards to the core features of personality pathology.
SELF AND INTERPERSONAL FUNCTIONING
An extensive literature reviewed by Bender, Morey, and Skodol (under re-
view) demonstrates that PDs are associated with distorted thinking about
self and others. For example, a number of studies have shown representa-
tions of self and others by patients with borderline pathology to be dis-
torted and biased toward hostile attributions, compared to those of other
types of patients (e.g., Blatt & Lerner, 1983; Donegan et al., 2003; Wagner
& Linehan, 1999; Westen, Ludolph, Lerner, Ruffins, & Wiss, 1990) and
patients with BPD show the most difficulty in creating a helpful mental
image of treatment providers and the treatment relationship, compared
with patients with other PDs or Axis I disorders only (Bender et al., 2003;
Zeeck, Hartmann, & Orlinsky, 2006). These studies support the notion
that maladaptive patterns of mentally representing self and others serve
as substrates for personality psychopathology.
A number of reliable and valid measures that assess personality func-
tioning and psychopathology demonstrate that a self-other dimensional
perspective has an empirical basis and significant clinical utility (Bender,
Moreg, & Skodol, under review). Reliable ratings can be made on a broad
range of self-other constructs, such as identity (Gamache et al., 2009) and
identity integration (Verheul et al., 2008), self-other differentiation and
integration (Blatt, Stayner, Auerbach, & Behrends, 1996), sense of agency
(Bers, Blatt, & Dolinsky, 2004), self-control (Verheul et al., 2008), sense of
relatedness (Bers et al., 2004), capacity for emotional investment in others
(Porcerelli, Cogan, & Hibbard, 1998), responsibility and social concor-
dance (Verheul et al., 2008), maturity of relationships with others (Piper,
Ogrodniczuk, & Joyce, 2004), and understanding social causality (Porcer-
elli et al., 1998).
Numerous studies using the measures designed to assess these and
other related self-other capacities have shown that a self-other approach
is informative in determining type and severity of personality psychopa-
thology, in planning treatment interventions, and in anticipating treat-
ment course and outcome. For example, maturity of relationships with
others has been shown to be inversely correlated with the presence and
154 SKODOL ET AL.
severity of a PD diagnosis (Loffler-Stastka, Ponocny-Seliger, Fischer-Kern,
& Leithner, 2005) and social cognition and object relations scores identi-
fied and differentiated among patients with different types of PDs (Hilsen-
roth, Hibbard, Nash, & Handler, 1993; Porcerelli, Hill, & Dauphin, 1995).
Also, reflective functioning (i.e., the ability to understand and interpret
one’s own and others’ mental states) has been shown to be lower in pa-
tients with BPD than in nonborderline patients (Fonagy et al., 1996) and
to be inversely related to the number of Axis II PDs diagnosed in a given
patient (Bouchard et al., 2008). Overall quality of object relations predict-
ed the development of a positive therapeutic alliance and improvement as
a result of treatment (Piper et al., 1991) and capacities for self-other dif-
ferentiation and interpersonal relatedness have been shown to be sensi-
tive to change in treatment (Diamond, Kaslow, Coonerty, & Blatt, 1990).
A continuum of impairment in self and interpersonal functioning was
developed based on theory and existing research (see Table 2, Levels of
Personality Functioning) and then validated using IRT analyses on two
large samples of persons evaluated for DSM-IV-TR PDs with semi-struc-
tured diagnostic interviews (Morey, Berghuis, et al., under review). Scores
indicating greater impairment in personality functioning predicted the
presence of a PD, of more severe PD diagnoses, and of PD comorbidity.
Typical impairments in personality functioning were incorporated into
the description of the personality disorder types for DSM-5. For example,
the antisocial/psychopathic type refers to an arrogant, self-centered, and
entitled self, limited emotional expression, disregard for conventional
moral principles, little insight into motivations, and an impaired ability to
consider alternative interpretations of experience. Interpersonally, such
individuals are callous, have little empathy for others’ needs or feelings,
seek power over others to take advantage of them, and rarely experience
or acknowledge emotions such as love. The avoidant type has a negative
sense of self associated with a profound sense of inadequacy and inferior-
ity. These individuals are passive to an extent that the pursuit of personal
goals or achieving success is undermined. They are shy or reserved in in-
terpersonal situations and intimate relationships are avoided because of
fear of attachment and intimacy. The borderline type describes a self-
concept that is fragile and easily disrupted by stress that results in a lack
of a coherent identity or chronic feelings of emptiness. Difficulty maintain-
ing enduring intimate relationships and impaired empathic capacity are
among the characteristic interpersonal features described. The obsessive-
compulsive type describes significant insecurity over real or perceived de-
ficiencies or failures, difficulty experiencing or expressing strong emotions,
and compromised appreciation of the ideas, emotions, and behaviors of
others. The schizotypal self is characterized by feelings of being an outsid-
er; interpersonally, there is discomfort and reduced capacity for interper-
sonal relations, anxiety and suspiciousness in social situations, detach-
ment or indifference to others’ reactions, and few intimate relationships.
Despite the inclusion of characteristic self and interpersonal features in
TYPES PROPOSED 155
the type descriptions, it should be recognized that this proposed severity
dimension can capture variability, not only across, but also within PD
OTHER DESCRIPTIVE FEATURES
In writing the descriptions of the five personality disorder types, attempts
were made to be faithful to the major DSM-IV-TR criteria, while recogniz-
ing the limitations of strictly defined behavioral criteria. Although behav-
ioral manifestations increase reliability (Livesley, 1986), they have often
been criticized for reducing the richness and distinctiveness of clinical
descriptions, for compromising validity, and for instability (see below). Ta-
ble 3 shows an example of mapping DSM-IV-TR criteria for borderline PD
onto language of the description of the edited borderline type, as proposed
for DSM-5. As can be seen, all nine of the criteria are represented by spe-
cific language. Although five of the nine criteria were specified for a DSM-
IV-TR diagnosis of borderline PD, there was never a requirement to specify
which of the nine were met and extreme heterogeneity within this category
(Johansen, Karterud, Pedersen, Gude, & Falkum, 2004); and others has
been widely recognized.
The major additions to the DSM-IV-TR criteria represented in the type
descriptions are derived from the PD prototypes developed by Westen and
colleagues. Originally, twelve personality syndromes (including one repre-
senting psychological health) were identified from a large national sample of
clinicians, who rated actual patients and prototypical disorders using the
Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler,
1999a, 1999b). Items included in the SWAP-200 reflect both DSM diagnos-
tic criteria and other constructs derived from the literature to reflect impor-
tant elements of personality pathology believed to be missing from DSM PD
categories. Many of these additional items emphasize the mental life or in-
ner experience of patients with personality disorders, which do not conform
to the more behavior-oriented DSM criteria (Shedler & Westen, 2004). Many
of these items also correspond to the core impairments in self and interper-
sonal functioning described above. Ratings of patients by clinicians using
the SWAP Q-sort procedure have been shown to be reliable (Shedler & West-
en, 1998) and descriptions of both prototypical patients and actual patients
have been shown to have high internal consistency reliability (Shedler &
Westen, 2004; Westen & Muderrisoglu, 2003), and convergent and discrim-
inant validity (Westen & Muderrisoglu, 2006; Westen & Shedler, 1999b).
SWAP-derived personality factors, such as psychopathy and emotional dys-
regulation, have been shown to correlate significantly with external valida-
tors, such as arrest history and suicide attempts, respectively, and to have
high test-retest reliability (Westen & Shedler, 2007). Mapping of the content
of SWAP-200 items for borderline PD, both as a clinical diagnosis made on
actual patients and as an ideal prototype of the disorder (italicized content)
(Shedler & Westen, 2004) is also illustrated in Table 3.
156 SKODOL ET AL.
STABILITY OF PATHOLOGICAL TRAITS
AND SYMPTOMATIC BEHAVIORS
The discrepancy between personality disorders as “enduring patterns”
and the empirical reality of short-term retest kappas around .55 (Zimmer-
man, 1994; see also Grilo et al., 2004; Shea et al., 2002) was a conceptual
puzzle for the PD field, until recent data documented that the DSM criteria
were a mix of more stable trait-like criteria and less stable state-like crite-
ria (e.g., McGlashan et al., 2005; Morey et al., 2007; Zanarini et al., 2005),
rendering PD diagnoses as wholes less stable than their trait components.
Transforming PD diagnostic criteria into more stable trait versions, and
considering the more state-like features that occur in individuals with PD
taBle 3. Derivation of DsM-5 Borderline Personality Disorder type
DsM-iV CriteriasWaP items
1. abandonment rejected or abandoned
unable to comfort self
fear of . . . abandonment
urgent need for contact . . . when
interpersonal relationships are
excessive dependency; intense
fear of rejection
chaotic, rapidly changing
needy or dependent, requires
attached quickly, intensely
lacks stable image
acts impulsively, without
regard to consequences
3. identitylack of identity; loss of identity
loathing, excessive criticism
highly submissive or subservient
characteristic impulsivity may
prompt risky behaviors . . .
substance misuse, reckless
driving, binge eating,
dangerous sexual encounters
aggression towards self
repeated suicidal threats,
emotions spiral out of
irrational, strong emotions
emotions change rapidly,
empty or bored
intense, inappropriate anger
6. affective instabilityreactive, rapidly changing,
chronic feelings of emptiness7. emptiness
8. angeranger . . . a typical reaction
anger . . . may lead to aggression
toward self and others
self-appraisal filled with loathing
paranoia and dissociation
concrete, black-and-white, all-
9. paranoid, dissociation
tends to idealize others, see
others as all bad
Note. SWAP items in italics based only on Clinical (Ideal) Prototype descriptions.
TYPES PROPOSED 157
to be associated symptoms, reduces the conceptual-empirical contradic-
tion in PD with regard to temporal stability, and also focus clinicians on
the layered nature of psychopathology in these individuals. A synthetic
view is that PD is a combination of stable traits and more transient symp-
toms. Further research from genetic and other viewpoints is needed to
address the question of whether an exclusively trait-based approach or a
hybrid has greater validity. The DSM-5 most likely will reflect the hybrid
model, since it preserves more continuity with the current PD diagnostic
HYBRID MODEL OF PERSONALITY DISORDER DIAGNOSIS
A number of recent studies support a hybrid model of personality psycho-
pathology consisting of both disorder and trait constructs. Morey and
Zanarini (2000) found that five-factor model (FFM) domains captured sub-
stantial variance in the borderline diagnosis with respect to its differentia-
tion from nonborderline PDs, but that residual variance not explained by
the FFM was significantly related to abuse history, family history of mood
and substance use disorders, and 2- and 4-year outcomes. In the CLPS,
dimensionalized DSM-IV PD diagnoses predicted concurrent functional
impairment, but this diminished over time (Morey et al., 2007). In con-
trast, the FFM provided less information about current behavior and func-
tioning, but was more stable over time and more predictive in the future.
The Schedule for Nonadaptive and Adaptive Personality (SNAP) model per-
formed the best, both at baseline and prospectively, because it combines
the strengths of a pathological disorder diagnosis and normal range per-
sonality functioning. The results indicated that models of personality pa-
thology that represent stable trait dispositions and dynamic, maladaptive
manifestations are most clinically informative. Hopwood and Zanarini
(2010) found that FFM extraversion and agreeableness were incrementally
predictive (over a BPD diagnosis) of psychosocial functioning over a 10-
year period and that borderline cognitive and impulse action features in-
cremented FFM traits. They concluded that both BPD symptoms and per-
sonality traits are important long-term indicators of clinical functioning
and supported the integration of traits and disorder in DSM-5. Morey,
Hopwood, et al. (under review) have extended the CLPS results on the sta-
bility and long-term predictive validity of the FFM, the SNAP, and dimen-
sional representations of all 10 DSM-IV personality disorders from 4 to 10
years. Traits continued to be more stable than disorders, even after cor-
recting for short-term assessment dependability. DSM-IV antisocial, bor-
derline, and schizotypal disorders and FFM extraversion and agreeable-
ness provided specific incremental validity over other constructs in these
systems, while the other FFM traits and PDs appeared to capture overlap-
ping predictive information. Taken together, these results argue support
for a hybrid model combining specific PD types and personality traits.
158 SKODOL ET AL.
TRAIT ASSESSMENT TO ACCOUNT FOR HETEROGENEITY
In the DSM-5 Website posting, selected personality trait facets from rele-
vant trait domains (see Skodol, Clark, et al., 2011) were grouped with
each of the five types to provide context for the trait ratings. The traits
were selected on the basis of a careful mapping of the language of the
types onto the trait definitions. Ratings on these traits were intended to be
used to describe the particular trait profile of each patient who matched a
type, and thus, to document potentially useful information about within-
Feedback from the website posting suggested that this system was too
complicated, redundant with the full clinicians’ trait ratings, and un-
wieldy. Furthermore, the empirical basis for assigning trait facets to types
was questioned. Therefore, the trait ratings have been completely sepa-
rated from the type ratings in the revised assessment model being readied
for field testing. The relationships of the trait domains and facets to the
types will be determined empirically in the DSM-5 Field Trials. Trait rat-
ings are still being recommended, and can be used to describe heteroge-
neity at different levels, depending on the purpose of the assessment. For
an initial diagnosis, trait ratings can be made at the level of the broad trait
domains, whereas facet-level ratings may be more useful, for example, for
case formulation in connection with treatment. The article by Krueger et
al. in this issue explains the derivation of the personality trait structure of
the proposed new model in detail. Skodol, Bender, et al. (2011) illustrate
how the traits can be applied to clinical cases.
DiMensional rePresentations of tyPes
There are no clinical or empirical justifications for the number of criteria
needed to make a PD diagnosis according to DSM-IV-TR. In all cases,
more than half of the polythetic criteria set are required. Although some
studies consider patients who fall even one criterion below threshold to no
longer have the categorical diagnosis, most clinicians and researchers
know that this convention is a fiction. There are a number of ways to di-
mensionalize PD diagnoses (Widiger & Simonsen, 2005). Some focus on
variables, such as personality traits; others focus on people. A person-
centered dimensional approach to personality disorder diagnosis using
prototype matching was described by Shea and colleagues (Shea, Glass,
Pilkonis, Watkins, & Docherty, 1987). Embedded in their Personality As-
sessment Form (PAF) were brief descriptive paragraphs emphasizing the
salient features of each DSM-III PD, with ratings of descriptiveness made
on a 6-point scale. In the context of the National Institute of Mental Health
Treatment of Depression Collaborative Research Program, the factor
structures of the clinician-rated PAF and an extensive self-report battery
of personality traits were similar (Pilkonis & Frank, 1988), indicating con-
TYPES PROPOSED 159
struct validity. Patients with PDs, according to their prototype ratings,
had a significantly worse outcome in social functioning and were more
likely to have residual symptoms of depression than were patients without
PD (Shea et al., 1990), similarly to results of longitudinal studies using
standard DSM-IV diagnostic criteria assessed by semi-structured inter-
view (Grilo et al., 2005; Skodol et al., 2005).
Westen and colleagues’ (Westen, Shedler, & Bradley, 2006) SWAP pro-
files represented by paragraph-length narrative descriptions also used
matching. Using this system, a clinician compares a patient to the de-
scription of the prototypic patient with each disorder and the match is
rated on a 5-point scale from 5 = very good match to 1 = little or no match
(see Table 1). For the purpose of making a categorical diagnosis, a rating
of 4 = good match or better is proposed. This scale has been adopted for
the type matching proposed for DSM-5. Prototype matching ratings have
been demonstrated to have good interrater reliability, with a median r =
.72 in patients seeking outpatient treatment (Westen, Defife, Bradley, &
Hilsenroth, in press). In an effort to provide more detailed specification of
pathology, a deconstructed format for the type descriptions is being con-
sidered. Table 4 shows the language of the borderline PD type grouped
into five sub-groups of manifestations: self-structure, interpersonal relat-
edness, emotions, cognition, and behavior. Individual ratings of the sub-
group manifestations are possible, in addition to the global match.
taBle 4. Deconstructed Borderline Personality Disorder type
self structure: Individuals who resemble this personality disorder type have an impoverished
and/or unstable self-structure and a self-concept that is easily disrupted under stress, and
often associated with the experience of a lack of identity or chronic feelings of emptiness.
Self-appraisal is filled with loathing, excessive criticism, and despondency.
interpersonal relationships: Individuals who resemble this type have difficulty maintaining
enduring and fulfilling intimate relationships. Relationships are often based on excessive
dependency, a fear of rejection and/or abandonment, and urgent need for contact with
significant others when upset. Behavior may sometimes be highly submissive or subservient.
At the same time, intimate involvement with another person may induce fear of loss of
identity as an individual—psychological and emotional engulfment. Thus, interpersonal
relationships are commonly unstable and alternate between excessive dependency and flight
from involvement. Empathy for others is significantly compromised, or selectively accurate
but biased toward negative elements or vulnerabilities.
emotions: Self-appraisal is filled with loathing, excessive criticism, and despondency. There
is sensitivity to perceived interpersonal slights, loss or disappointments, linked with reactive,
rapidly changing, intense, and unpredictable emotions. Anxiety and depression are common.
Anger is a typical reaction to feeling misunderstood, mistreated, or victimized.
Cognitions: Cognitive functioning may become impaired at times of interpersonal stress,
leading to concrete, black-and-white, all-or-nothing thinking, and sometimes to quasi-
psychotic reactions, including paranoia and dissociation.
Behavior: Anger may lead to acts of aggression toward self and others. Intense distress and
characteristic impulsivity may also prompt other risky behaviors, including substance
misuse, reckless driving, binge eating, or dangerous sexual encounters.
160 SKODOL ET AL.
Westen, Shedler, and Bradley (2006) have reported that the prototype
matching method reduced comorbidity among Cluster B PDs, predicted
external validators (adaptive functioning, treatment response, and etio-
logical factors) as well as DSM-IV PD diagnoses, and was rated higher on
measures of clinical utility (e.g., ease of use, description, communication)
than the corresponding DSM-IV PDs. Spitzer and colleagues (Spitzer,
First, Shedler, Weston, & Skodol, 2008) also conducted a study of the
clinical relevance and utility of five dimensional systems for PDs that have
been proposed for DSM-5: (1) a criteria counting model based on current
DSM-IV-TR diagnostic criteria, (2) a prototype-matching model based on
current DSM-IV-TR diagnostic criteria, (3) a prototype matching model
based on the SWAP, (4) the Five-Factor Model (FFM), and (5) Cloninger’s
Psychobiological Model. A random national sample of psychiatrists and
psychologists applied all five systems to a patient under their care and
rated the clinical utility of each system. The two prototype matching mod-
els were judged most clinically useful and relevant. The authors conclud-
ed that prototype matching systems most faithfully capture personality
syndromes seen in practice and allow for rich descriptions without a pro-
portionate increase in time or effort. In addition, Heumann and Morey
(1990) found that dimensionalized DSM prototype ratings were made with
considerably greater reliability by clinicians than the corresponding cate-
Rottman and colleagues (Rottman, Ahn, Sanislow, & Kim, 2009) found
that clinicians made fewer correct diagnoses of PDs and more incorrect
diagnoses when given ratings of patients on a list of the 30 facet traits of
normal-range personality derived from the NEO-PI-R (Costa & McCrae,
1992) than when given prototype descriptions based on either the SWAP
or DSM-IV criteria. And, on most questions about clinical utility, includ-
ing about treatment planning and prognosis, the prototype systems were
rated as superior. According to the authors, these findings indicate that
personality traits in the absence of clinical context are too ambiguous for
clinicians to interpret: although it may be possible to describe PDs in
terms of the FFM, mentally translating personality traits back into syn-
dromes or disorders is cognitively challenging, at least when the trait pro-
files are based on extremes of normal-range traits. Samuel and Widiger
(2006) did find, however, greater clinical utility for the FFM compared to
the DSM-IV-TR categorical diagnostic system.
reViseD General Criteria for Personality DisorDer
In response to numerous requests to simplify the PD diagnostic model
proposed for DSM-5 received on the DSM-5 Website posting of proposed
changes, a new set of general diagnostic criteria for PD has been devel-
oped. As can be seen in Table 5, the revised general criteria now integrate
the ratings of level of personality functioning, personality disorder type,
and pathological personality traits into the diagnostic criteria. A rating of
TYPES PROPOSED 161
mild impairment or greater in self and interpersonal functioning is needed
to meet criterion A. Either a good or very good match to one of the five
specific PD types or a rating of extremely descriptive on one or more per-
sonality trait domains is needed to meet criterion B. Criterion C requires
relative stability over time to account for recent studies showing that PDs
are not as stable as their current DSM definition requires. No age at onset
is specified in order to allow for either adolescent or later-life onsets of
PDs. An individual’s dominant culture must be taken into account in rat-
ing impairment in personality functioning. Exclusions for a substance-
related or a general medical etiology are retained, but the exclusion for a
“manifestation or consequence of another mental disorder” has been elim-
inated, as it was judged to be impractical and inconsequential. All ele-
ments of these new general criteria will be tested in the DSM-5 Field Trials.
sUMMary anD ConClUsions
The Personality and Personality Disorder Work Group has proposed five
specific personality disorder (PD) types for DSM-5, to be rated on a dimen-
sion of fit. Each type is identified by core impairments in personality func-
tioning, pathological personality traits, and common symptomatic behav-
iors. The specific PD types recommended for retention in DSM-5 were
determined on the basis of literature reviews of their validity relative to
other PDs. The content of the types was derived from reliable, valid, and
clinically useful indicators of impairment in self and interpersonal func-
tioning, from existing DSM-IV-TR criteria, and from work on the develop-
ment of empirically-based PD prototypes. The graded matching approach
to diagnosis was adopted to reflect the dimensional nature of personality
psychopathology and to improve the clinical utility of PD diagnosis. All of
these recommendations are under consideration and none have been
made final. All will undergo scrutiny for reliability and utility in the DSM-5
Field Trials and further revisions are anticipated.
taBle 5. revised General Diagnostic Criteria for Personality Disorder
The essential features of a personality disorder are impairments in identity and sense of
self and in the capacity for effective interpersonal functioning. To diagnose a personality
disorder, the impairments must meet all of the following criteria:
A. A rating of mild impairment or greater in self and interpersonal functioning on the Levels
of Personality Functioning.
B. Associated with a “good match” or “very good match” to a personality disorder type or
with a rating of “extremely descriptive” on one or more personality trait domains.
C. Relatively stable across time and consistent across situations.
D. Not better understood as a norm within an individual’s dominant culture.
E. Not solely due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head trauma).
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