Personality disorders in the DSM-5 and beyond

Personality disorders (PDs) are considered chronic conditions that emerge in late adolescence, and typically carry pervasive implications for self- and/or interpersonal functioning (American Psychiatric Association [APA], 2013; Skodol, 2012). Epidemiological studies have found that prevalence rates of PDs in the criminal justice system are quite high (e.g., Fazel & Danesh, 2002); for instance, estimates of Antisocial PD alone typically range from 50 to 80% in male correctional settings (Hare et al., 1991). Furthermore, PDs tend to be associated with a range of maladaptive outcomes, including violence, substance abuse, and reoffending (e.g., Hare & Neumann, 2009; McMurran & Howard, 2009; Soloff et al., 1994).

The DSM-5 Personality and Personality Disorder (P&PD) workgroup were charged with the task of revising a severely flawed system of PDs featured in the DSM-IV, which included (but were not limited to) challenges associated with extremely high diagnostic co-occurrence rates, problematic within-disorder heterogeneity, insufficient coverage of personality disorder variance (most patients being diagnosed with PD NOS), polythetic criterion sets with arbitrary cut points, poor convergent and discriminant validity among different assessment measures, and poor scientific basis for many of the disorders (e.g., Clark, 2007; Widiger & Trull, 2007; Widiger & Mullins-Sweatt, 2010). The P&PD workgroup proposed a hybrid dimensional-categorical system that would at least begin to address many of the problems just listed. The primary foundation of this model is the reliance on dimensional personality traits coupled with impairment in self- and interpersonal functioning to characterize the PDs (APA, 2011). More specifically, a dimensional trait model consisting of five higher-order domains (Antagonism, Psychoticism, Disinhibition, Negative Affectivity, and Detachment), with three to seven trait facets each, was proposed.

A configuration of trait facets is then used to define one of six proposed PDs(Antisocial, Avoidant, Borderline, Narcissistic, Obsessive-Compulsive, and Schizotypal)(Skodol, 2012). For instance, for a diagnosis of Antisocial PD, elevations on trait facets from both the Antagonism (Callousness, Deceitfulness, Manipulativeness, and Hostility) and the Disinhibition (Impulsivity, Irresponsibility, and Risk Taking) domains are required in addition to impairment in both self- and interpersonal functioning. A seventh type, Personality Disorder: Trait Specified, indicate the presence of maladaptive personality traits and associated impairment, but no trait profile that specifically maps onto one of the six aforementioned types (Skodol, 2012).

In the final hour, the APA Board of Trustees decided to reject the P&PD’s proposal and relegate it to Section III, which includes “emerging models and measures” (APA, 2013). Instead, they decided to retain the DSM-IV PD system for DSM-5 Section II, which lists all formal clinical diagnoses. The main impetus behind this decision (which has never been made clear publicly) was presumably that the proposal was considered to have insufficient scientific merit (i.e., it was untested) and therefore not ready for “prime time.” This was a rather disappointing decision given the substantial time and financial commitment devoted to this process, and the fact that a potentially unfinished dimensional system might nonetheless be superior to its seriously flawed predecessor. This, of course, remains an empirical question.

These changes (or lack thereof) carry implications for psychologists in criminal justice settings. As the field progresses, it is imperative that we evaluate the optimal way of characterizing personality pathology in offenders as well as to determine the most clinically useful method of assigning diagnosis. As mentioned earlier, the criminal justice system is likely associated with the highest prevalence rates of personality pathology of any setting in which psychologists practice; as such, information derived from correctional and other offender populations should be at the forefront when the revisions to the currently flawed PD system is eventually implemented in either DSM 5.1 or beyond. More specifically, in the following I present some thoughts about particular issues that require evaluation.

Definition of disorders. In order to maintain continuity with the DSM-IV categorical disorders, a decision was made to essentially re-create those categories via the requirement of elevation on a series of trait facets were conceptually deemed most representative of the various PD criteria. One of the main arguments against the original PD system was the use of arbitrary polythetic criterion sets. Unfortunately, recent research has shown that if all trait facets used to define a particular disorder are required to be elevated, then the prevalence rates of such disorders would likely be extremely low and not representative of personality pathology in general (Samuel et al., 2013). As such, the P&PD workgroup decided to incorporate polythetic criterion sets using the trait facets (e.g., six of seven trait facets required to be elevated for an Antisocial PD diagnosis) for the proposed PDs in DSM-5 Section III. This decision certainly begs the question of whether the attempt to re-invent the problematic DSM-IV categories using trait facets is the optimal strategy.

In terms of a PD particularly relevant to the criminal justice system, Antisocial PD or psychopathy, the DSM-5 Section III trait model has implications for potentially shaping these diagnoses in future editions of DSM-5. Indeed, the requirement of six out of seven trait facets with a resulting broader representation of psychopathic personality traits (e.g., callousness, manipulativeness) provides for a more severe presentation of Antisocial PD that is more reflective of what has always been the target construct for this disorder (e.g., Hare, 1996). However, constraining the DSM-5 conceptualizations to pre-defined conceptual theories of psychopathy likely does not take full advantage of this emerging model in providing psychopathy-relevant trait information. Psychopathy scholars continue to debate a variety of important issues, including (but not limited to) optimal factor structures (e.g., Cooke et al., 2006; Hare & Neumann, 2008), whether antisocial/criminal behavior should be part of the construct (e.g., Skeem & Cooke, 2010; Hare & Neumann, 2010), and the role of fearless-dominance/boldness in psychopathy (e.g., Lilienfeld et al., 2012; Miller & Lynam, 2012). Moreover, scholars also continue to ponder which elements need to be present to constitute psychopathy (or “primary” psychopathy), including whether affective-interpersonal traits (e.g., callousness, deceitfulness, social potency) are sufficient in isolation (Lilienfeld, 1994; Poythress & Hall, 2011) in light of that not all individuals high on psychopathy are impulsive (cf. Hicks et al., 2004; Poythress & Hall, 2011). The DSM-5 Section III trait model, however, is not constrained by any such conceptualization and an emphasis on an individual’s actual trait constellation (and the associated description) rather than selecting a particular configuration of traits to indicate a pre-defined disorder, might prove more useful in clinical practice. For instance, the description derived from an individual high on callousness, hostility, manipulativeness, deceitfulness, and grandiosity (but low on impulsivity and irresponsibility) might not conform to the DSM-5 Section III profile of Antisocial PD or psychopathy, but nonetheless reflect a potential social predator with sufficient levels of conscientiousness to navigate society through exploitation and manipulation without perhaps being identified by the criminal justice system. Thus, a shift toward embracing descriptions based on trait constellations rather than fitting these traits onto potential fallacious criteria might allow for improved construct validity for the new model (cf. Cronbach & Meehl, 1955). I think it would serve psychologists in criminal justice settings well to consider and contribute to the evaluation of these issues, especially with respect to the PDs that are most frequently represented among offenders.

Clinical utility. A more purely dimensional system offers substantial benefits and improvements to arbitrarily defined categories based on the polythetical approach. Several scholars (e.g., Widiger & Trull, 2007) have suggested that a dimensional system for personality disorders might allow for differential cut-offs with respect to elevation on personality traits depending on specific opinions and decisions generated within the context of a forensic mental health evaluation tend to be subject to some of the most intense scrutiny (e.g., Melton et al., 2007), and a dimensional system might outperform a categorical one in terms of utility for addressing psycho-legal questions. Psychopathology is frequently relevant to addressing questions such as risk assessment, offender management, competency to stand trial, criminal responsibility, but the emphasis is typically on presenting symptoms and level of impairment rather than categorical diagnoses. For instance, psychologists in criminal justice settings need to consider a different level of clinical impairment when opining about mental status at the time of the offense relative to violence risk assessment. Thus, as DSM-5 Section III personality trait model is now available for use, empirical and practical scrutiny with respect to clinical utility can be determined in criminal justice settings.

In conclusion, personality disorder diagnosis is at a crossroads. The field is currently burdened by a model that most experts agree is fatally flawed. The solution is less clear, but most evidence suggests that incorporation of dimensional personality traits is consistent with most empirical evidence for conceptualizing and assessing personality psychopathology. It will behoove both academic and practicing psychologists to evaluate how these are best implemented in the future, which is now possible with the emergence of the DSM-5 Section III personality trait model. Indeed, the presence of both Section II and Section III in the DSM-5 to diagnose PDs provides for opportunities in terms of examining the optimal method to characterize these disorders, assessment, clinical utility, and most importantly, external validity. For instance, does the categorical or dimensional representations of Antisocial PD confer great risk for future violence? Or, should we rather rely on the elevation of specific personality traits (e.g., impulsivity, callousness, risk taking) rather than confining ourselves to pre-defined or bootstrapped disorders? Again, these are empirical and practical questions that I believe psychologists working in criminal justice settings might be optimally equipped to address.

References

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