Personality Disorders in the DSM-5

When it comes to personality psychopathology , you can’t help but think of the decades-long debate that has divided experts in the field of diagnosis and classification.

If, on the one hand, many professionals support a classification model based on discrete categories that distinguish the pathological personality from the “normal” one in qualitative terms (categorical diagnosis), on the opposite side are the supporters of the dimensional model, where the personality is seen as a set of traits arranged along a continuum and the pathology presents quantitative differences with the “healthy” personality.

Although the categorical model has long been criticized for the lack of attention given to the subjective experience of the individual and the high number of co-diagnoses it implies (because it is based on the principle of the presence / absence of certain criteria), the dimensional approach it has never been a valid alternative that would allow mental health professionals to create a common language with which to connote certain pathological personality pictures (also due to the fact of considering the union of individual traits as equivalent to the whole).

When the APA task force found itself – during the drafting of the DSM-5  (2013) – to address the issue of the classification of personality disorders , the split between the two positions emerged again, generating many critical issues.

The result, after years of debates that also involved well-known names of psychiatry in our country, was to leave essentially unchanged the categorical classification of the previous version of the DSM (DSM-4-TR), which illustrated 10 personality disorders divided into 3 distinct clusters.

Alongside this framework, an alternative model for the diagnosis of personality disorders has been proposed in section III of the DSM-5 , according to a dimensional-categorical hybrid approach .

Personality disorders, in this new model, are characterized by two main elements: 1) impaired personality functioning and 2) pathological personality traits.

The proposed elements of personality functioning are:

  • IDENTITY: the experience of oneself as unique, with clear boundaries between oneself and others; stability of self-esteem and precision of self-assessment; capacity for emotional regulation.
  • SELF-DIRECTIONALITY: ability to pursue coherent and significant objectives both in the short and long term, use of constructive and prosocial internal standards of behavior; self-reflect capabilities that allow you to acquire a sense of your own abilities and even your own limits.
  • EMPATHY: understanding and appreciation of the experiences and motivations of others; tolerance of different perspectives; understanding the effects of one’s behavior on others.
  • INTIMACY: depth and duration of the positive relationship with others; desire and capacity for closeness; behavior based on mutual respect.

The functioning of the individual’s personality within the domain of the Self (composed of identity and self-directionality) and in the interpersonal domain (consisting of empathy and intimacy), is evaluated along a dimensional continuum that goes from a level 0, equivalent to an absence. of impairment, at a level 4 indicating extreme impairment (Scale for the level of personality functioning; LPFS).

The second criterion (this time of a categorical order!) Distinctive of a personality disorder within this new model is the presence of at least one pathological personality trait.

The 25 proposed trait facets , which were developed from a first review of trait models already existing in the literature and then through research on clinical subjects, are organized into 5 higher-order traits:

  • Negative Affectivity (vs. Emotional Stability): Experiencing negative emotions intensely and frequently.
  • Detachment (vs. Extroversion): Withdrawal from other people and social interactions.
  • Antagonism (vs. Availability): exhibiting behaviors that put you in conflict with other people.
  • Disinhibition (vs. Conscientiousness): engaging in impulsive behavior without reflecting on possible future consequences.
  • Psychoticism (vs. mental clarity): having unusual and bizarre experiences.

The DSM-5 also presents the diagnostic criteria , consistent with the proposed alternative model, for 6 specific personality disorders (antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, schizotypic) and for a specific personality disorder (when the disorder personality is present but the criteria for none of the above are not met).

In conclusion, the new approach, certainly interesting from a theoretical point of view, faces the possibility of really changing the language of us professionals or of remaining, even in the future, only an “alternative model”.

It is perhaps still too early to say whether it will be successful among mental health professionals or whether it will be able to completely settle the question of the classification of personality disorders ; however, what is desirable is that at least it can be a valid alternative that can be well spent in clinical practice and research.


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