DSM-5 Steering Committee Considers Dimensional Approach to Personality Disorders

A workgroup on personality disorders appointed by the DSM-5 Steering Committee is recommending the elimination of the existing personality disorders in favor of a single diagnostic category called “personality disorder.”

It is one of several developments impacting the diagnosis of personality disorders, including publication in September of a revised treatment guideline on borderline personality disorder, said past APA President John Oldham, M.D., during the session “Revised APA Guideline for Treatment of Patients With Borderline Personality Disorder: Can It Help Us Understand, Evaluate, and Treat Our Patients?”

Oldham, a member of the workgroup and distinguished emeritus professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, said the recommendation is under review by the APA Steering Committee on DSM-5. If approved, it would establish the use of a “dimensional approach” as the approved method of diagnosing a personality disorder; that approach focuses on severity of personality pathology as it is expressed in impairments in self and interpersonal functioning.

Approval of the dimensional approach to diagnosing a single personality disorder would replace the categorical system of diagnosing personality disorders in Section II of DSM-5-TR. (The current personality disorder categories include paranoid, schizoid, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, and obsessive-compulsive.)

At today’s session, Oldham explained that the dimensional approach was recommended in 2013 by the Personality Disorders Work Group (of which he was co-chair with Andrew Skodol, Ph.D.) but was not accepted by the Board of Trustees; instead, it was placed in Section III (“Emerging Measures and Models”) as an “alternative model.”

“There is a broad consensus that a ‘medical model’ system of diagnostic categories is far from ideal for personality disorders,” he said. He emphasized that since its inclusion in Section III, the dimensional approach is an “official” option for clinical and research use.

The personality disorder workgroup was established in 2022 and charged with evaluating the validity, reliability, and clinical utility of the alternative dimensional approach and comparing it with the DSM-5 personality disorder criteria to decide on the best approach to diagnosing personality disorders. Members include Oldham, Lee Anna Clark, Ph.D. (chair of the workgroup), Diana Clarke, Ph.D., Richard Dudley, M.D., and Lamyaa Yousif, M.D., Ph.D.

Meanwhile, APA’s revised “Practice Guideline for the Treatment of Patients With Borderline Personality Disorder,” approved by the APA Board and Assembly in 2023, offers some significant updates to the existing guideline. Oldham said the new guideline recommends the following:

• A documented, comprehensive person-centered treatment plan.


• Engagement of the patient in collaborative discussion about diagnosis and treatment, including psychoeducation about borderline personality disorder.


• Treatment with a structured approach to psychotherapy, supported in literature, targeting the core features of borderline personality disorder.


• Review of co-occurring disorders, prior therapies, and past and current medications before initiating new medication.


• Review and reconciliation of medications every six months.

The guideline also “suggests” that an initial evaluation include quantitative measures to determine severity of symptoms and impairment in functioning and that any psychotropic medication be time limited, aimed at a specific measurable target symptom, and be adjunctive to psychotherapy. ■