DSM-5 Alternative Model for Personality Disorders

The process of change can be complicated, as the Work Group on Personality and Personality Disorders (PDWG) for DSM-5 experienced firsthand, said John Oldham, M.D., M.S., senior vice president and chief of staff of the Menninger Clinic and Baylor Professor of Psychiatry, as well as past president of APA, at an interactive session with psychiatry residents today. The session was co-led by Andrew Skodol, M.D., research professor at the University of Arizona and recent chair of the PDWG.

But perhaps even more challenging, as Oldham and Skodol explained, has been the effort to differentiate highly variable but “normal” personalities from what we have termed “personality disorders.” Traditionally, DSM-IV has utilized a familiar medical model, a system of criteria-defined descriptive diagnostic categories that are intended to reflect discrete illnesses. This strategy has in many ways served the field well, and classifying the PDs on Axis II in DSM-III and DSM-IV facilitated extensive research and clinical progress in our understanding of these conditions. Oldham clarified, however, that there is no “gospel” of absolutes here, but, rather, a clinical language that we have successfully learned that has helped us understand and treat the PDs. He recalled when, years ago in DSM-III days, he administered a new semi-structured PD interview to a hospitalized patient, it turned out that the patient was at or above threshold for 10 out 11 DSM-III PDs. As he argued, nobody would contend that this patient had 10 co-occurring, independent personality disorders. Instead, this patient had severe PD pathology perhaps better captured dimensionally.

The charge given to the PDWG was to review the field and, if the time was right, to consider a dimensional model that could position the disorders as extremes, like high or low blood pressure, on the ends of the major personality types or styles, said Oldham, the winner of this year’s APA Judd Marmor Award. Though controversy abounded, the PDWG, after posting for public review several versions of a new model, did recommend a revised model for the PDs that might best be described as a hybrid model, re-defining the essential elements of any PD as moderate or greater impairment of self and/or interpersonal functioning, along with the presence of pathological personality traits. This new model, called the Alternative Model for Personality Disorders, was voted by the Board of Trustees to be included in Section III of DSM-5, the section on “Emerging Methods and Models.” It is available for clinical use for those who choose to do so, and the essentials of the model were reviewed by Oldham and Skodol in session, stimulating a great deal of interest and discussion.

Detailed information about the new model is available in the last chapter of the Second Edition of the American Psychiatric Publishing Textbook of Personality Disorders, edited by Oldham, Skodol, and Bender. It was published just prior to this meeting, hot off the press. APA members can purchase it at a discount here or at the annual meeting.