Alternative DSM-5 Model of Personality Disorders Can Be Used Now

Personality disorders are best conceptualized dimensionally, in contrast to the categorical approach adopted in DSM-III, DSM-IV, and Section II of DSM-5, according to John Oldham, M.D., and Andrew Skodol, M.D. In an interactive session at APA’s 2015 annual meeting in Toronto, they set the stage for their discussion by reviewing over a decade of clinical experience and research.

Oldham is the senior vice president and chief of staff at the Menninger Clinic and a former APA president. Skodol is a research professor of psychiatry at the University of Arizona College of Medicine and an adjunct professor of psychiatry at the Columbia University College of Physicians and Surgeons. Skodol and Oldham were the chair and vice chair, respectively, of the DSM-5 Work Group on Personality and Personality Disorders.

Oldham pointed out that in the early published monographs of a series of planning conferences jointly sponsored by APA and the National Institute of Mental Health, called “A Research Agenda for DSM-V,” a strong argument was made for a dimensional approach to many diagnostic areas, particularly to the personality disorders. In spite of this apparent consensus, however, the field had not succeeded in adopting a dimensional approach, such as the Five Factor Model, for clinical use, he said.

Participants in the session discussed the pros and cons of each approach. Some participants were surprised that the Alternative Model is truly just that—an alternative to the categorical system in Section II of DSM-5, which is unchanged from DSM-IV. In contrast to “Conditions for Further Study,” also in Section III of DSM-5, which are not “ready for prime time,” the Alternative Model can be “officially” used in clinical work, applying the same codes as those in Section II.

Oldham and Skodol summarized field-trial data and subsequent published data that demonstrate a strong preference for the new model by experienced clinicians. The new definition of a personality disorder, they argued, is coherent and conceptually and intuitively persuasive. Oldham and Skodol reviewed the essence of the new model—that a personality disorder involves moderate or greater impairment in self and interpersonal functioning combined with the presence of pathological personality traits—before asking the participants to consider how this framework could be applied to specific conditions such as borderline personality disorder.

Oldham and Skodol are co-editors, along with Donna Bender, Ph.D., of Textbook of Personality Disorders, Second Edition, from American Psychiatric Publishing. APA members may order the book at a discount here.