Personality Traits Play Major Role in the Alternative DSM-5 Model for Personality Disorders

Personality traits are tendencies to perceive, think, feel, and act in relatively consistent ways across time and situations. Personality traits may be adaptive (for example, optimism, self-efficacy, conscientiousness) or maladaptive (for example, depressivity, submissiveness, impulsivity). Adaptive personality traits contribute to resiliency under stress. Maladaptive personality traits are thought to predispose to many mental disorders, not just personality disorders (PDs) and to contribute to the frequently observed co-occurrence of groups of mental disorders. Thus, personality traits can be viewed as foundations of both psychological health and psychopathology.

Personality constructs are organized empirically into three to five broad domains. According to the widely studied five-factor model (FFM) of personality, these domains are labeled neuroticism (a tendency to be depressed, anxious, and stress-reactive), agreeableness (oriented toward empathy and getting along with other people), extraversion (a disposition to be outgoing, friendly, and emotionally positive), openness (a tendency to be curious and imaginative and to try new things), and conscientiousness (a tendency to be orderly and achievement oriented).

These domains organize both normal and abnormal personality, because normal- and abnormal-range personality variations are continuous with each other. In introducing an empirically based trait assessment into DSM-5, the Personality and Personality Disorders Work Group developed a model that was consistent with the well-established FFM but focused on its pathological “poles” to capture the personality dispositions of people with PDs. The work group’s trait model appears as part of an “alternative” hybrid dimensional-categorical model for PDs in DSM-5 Section III, “Emerging Measures and Models.”

The Alternative DSM-5 Model for Personality Disorders (AMPD) describes personality pathology according to five broad trait “domains”:

• Negative affectivity: Frequent and intense experiences of high levels of a wide range of negative emotions (for example, anxiety, depression, guilt/shame, worry, anger, etc.), and their behavioral (for example, self-harm) and interpersonal (for example, dependency) manifestations.

• Detachment: Avoidance of socio-emotional experience, including both withdrawal from interpersonal interactions (ranging from casual, daily interactions to friendships to intimate relationships) and restricted affective experience and expression, particularly limited hedonic capacity.

• Antagonism: Behaviors that put the individual at odds with other people, including an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings and a readiness to use others in the service of self-enhancement.

• Disinhibition: Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences.

• Psychoticism: Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both thought process (for example, perception, dissociation) and content (for example, beliefs).

Each of the five broad trait domains of the AMPD includes from three to eight more specific, component trait “facets” (total of 25). The trait facets and their definitions can be found in DSM-5 (pp. 779-781). A new semi-structured interview, the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders (SCID-5-AMPD) Module II for Personality Traits, has recently been published to assist clinicians and researchers in the assessment of AMPD pathological personality traits, regardless of whether an interviewee is suspected of having a PD.

The trait domain of neuroticism (AMPD negative affectivity) adversely affects physical health and the quality and longevity of life. In recent years, neuroticism has been found to be associated with asthma, obesity, Alzheimer’s disease, and coronary heart disease. The trait domain of conscientiousness (AMPD low disinhibition) is protective for a number of physical conditions. Personality traits predict concurrent and prospective psychosocial functioning in psychiatric patients with some specificity. Within the FFM, neuroticism is broadly related to impairment across domains of social, occupational, and recreational functioning. Extraversion (low) is primarily related to social and recreational dysfunction and conscientiousness (low) to work dysfunction. AMPD pathological personality traits incrementally predict psychosocial impairment over normal range personality traits, PD criterion counts, and common psychiatric symptoms.

Each of the “official” DSM-5 PDs can be characterized by specific impairments in personality functioning and by pathological personality traits in one or more of the DSM-5 trait domains. The AMPD includes six specific PDs: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal, selected because of their prevalence, empirical bases, or utility for clinicians. PD trait domain and facet assignments, as well as the diagnostic algorithms for both personality functioning (“A”) and trait (“B”) criteria, are all empirically based. According to the AMPD, the other four official PDs in DSM-5, as well as any other PD presentations may be diagnosed as personality disorder—trait specified (PD-TS). Dependent PD, for example, can be described by moderate or greater impairment in personality functioning and three traits in the negative affectivity domain: submissiveness, separation insecurity, and anxiousness.

Personality traits are useful for communication with patients about their tendencies to perceive, think, feel, and act in ways that may adversely affect their health and cause problems in psychosocial functioning. Clinicians can use the AMPD’s personality trait domains and facets to perform a personality “review of systems” to discern general patterns of problematic personality features (domain-level assessment) and to focus attention on particular problematic pathological personality traits (facet-level assessment) for diagnosis and for treatment planning. ■