The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has some changes related to personality disorders, which were coded on Axis II under the DSM-IV. This article outlines some of the major changes to these conditions.
According to the American Psychiatric Association (APA), the publisher of the DSM-5, the major change with personality disorders is that they are no longer coded on Axis II in the DSM-5, because DSM-5 has done away with the duplicative and confusing nature of “axes” for diagnostic coding.
Prior to the DSM-5, mental disorders and health concerns of a person were coded in five separate areas — or axes — in the DSM. According to the APA, this multiaxial system was “introduced in part to solve a problem that no longer exists: Certain disorders, like personality disorders, received inadequate clinical and research focus. As a consequence, these disorders were designated to Axis II to ensure they received greater attention.”
Since there really was no meaningful difference in the distinction between these two different types of mental disorders, they axis system became unnecessary in the DSM-5. The new system combines the first three axes outlined in past editions of DSM into one axis with all mental and other medical diagnoses. “Doing so removes artificial distinctions among conditions,” says the APA, “benefiting both clinical practice and research use.”
Personality Disorders in the DSM-5
The good news is that none of the criteria for personality disorders have changed in the DSM-5. While several proposed revisions were drafted that would have significantly changed the method by which individuals with these disorders are diagnosed, the American Psychiatric Association Board of Trustees ultimately decided to retain the DSM-IV categorical approach with the same 10 personality disorders.
A new hybrid personality model was introduced in the DSM-5’s Section III (disorders requiring further study) that included evaluation of impairments in personality functioning (how an individual typically experiences himself or herself as well as others) plus five broad areas of pathological personality traits. In the new proposed model, clinicians would assess personality and diagnose a personality disorder based on an individual’s particular difficulties in personality functioning and on specific patterns of those pathological traits.
The hybrid methodology retains six personality disorder types:
- Borderline Personality Disorder
- Obsessive-Compulsive Personality Disorder
- Avoidant Personality Disorder
- Schizotypal Personality Disorder
- Antisocial Personality Disorder
- Narcissistic Personality Disorder
According to the APA, each type is defined by a specific pattern of impairments and traits. This approach also includes a diagnosis of Personality Disorder—Trait Specified (PD-TS) that could be made when a Personality Disorder is considered present, but the criteria for a specific personality disorder are not fully met. For this diagnosis, the clinician would note the severity of impairment in personality functioning and the problematic personality trait(s).
This hybrid dimensional-categorical model and its components seek to address existing issues with the categorical approach to personality disorders. APA hopes that inclusion of the new methodology in Section III of DSM-5 will encourage research that might support this model in the diagnosis and care of patients, as well as contribute to greater understanding of the causes and treatments of personality disorders.
Furthermore, the APA notes:
For the general criteria for personality disorder presented in Section III, a revised personality functioning criterion (Criterion A) has been developed based on a literature review of reliable clinical measures of core impairments central to personality pathology. Furthermore, the moderate level of impairment in personality functioning required for a personality disorder diagnosis was set empirically to maximize the ability of clinicians to identify personality disorder pathology accurately and efficiently.
The diagnostic criteria for specific DSM-5 personality disorders in the alternative model are consistently defined across disorders by typical impairments in personality functioning and by characteristic pathological personality traits that have been empirically determined to be related to the personality disorders they represent.
Diagnostic thresholds for both Criterion A and Criterion B have been set empirically to minimize change in disorder prevalence and overlap with other personality disorders and to maximize relations with psychosocial impairment.
A diagnosis of personality disorder—trait specified — based on moderate or greater impairment in personality functioning and the presence of pathological personality traits — replaces personality disorder not otherwise specified and provides a much more informative diagnosis for patients who are not optimally described as having a specific personality disorder. A greater emphasis on personality functioning and trait-based criteria increases the stability and empirical bases of the disorders.
Personality functioning and personality traits also can be assessed whether or not an individual has a personality disorder, providing clinically useful information about all patients. The DSM-5 Section III approach provides a clear conceptual basis for all personality disorder pathology and an efficient assessment approach with considerable clinical utility.