Skip to main content
Hauptrubriken
CME Facharzt-Training Webinare Zeitschriften Bücher e.Medpedia Podcast
Service
Jobbörse Info & Hilfe
Fachgebiete
Anästhesiologie Allgemeinmedizin Arbeitsmedizin Augenheilkunde Chirurgie Dermatologie Gynäkologie und Geburtshilfe HNO Innere Medizin Kardiologie Neurologie Onkologie und Hämatologie Orthopädie und Unfallchirurgie Pädiatrie Pathologie Psychiatrie Radiologie Rechtsmedizin Urologie Zahnmedizin
Themen
Klimawandel und Gesundheit Neues aus dem Markt COVID-19 Praxis und Beruf Seltene Erkrankungen GOÄ & EBM Panorama
Sammlungen
Kasuistiken Algorithmen & Infografiken Blickdiagnosen Arthropedia FlapFinder (für Dermatochirurgen) Videos Kongressberichterstattung Medizin für Apothekerinnen und Apotheker Für Ärztinnen und Ärzte in Weiterbildung Für Medizinstudierende
Erweiterte Suche
Anmelden
nach oben
Current Psychiatry Reports
Erschienen in: Current Psychiatry Reports 10/2014

01.10.2014 | Psychiatric Diagnosis (MB First, Section Editor)

Personality Disorder Classification: Stuck in Neutral, How to Move Forward?

verfasst von: Andrew E. Skodol

Erschienen in: Current Psychiatry Reports | Ausgabe 10/2014

Einloggen, um Zugang zu erhalten

Abstract

An “Alternative DSM-5 Model for Personality Disorders” was published in Sect. III of DSM-5, while the identical categories and criteria from DSM-IV for the personality disorders (PDs) are in Sect. II. Given strong shifts from categorical diagnoses toward dimensional representations in psychiatry, how did the PDs end up “stuck in neutral,” with the flawed DSM-IV model perpetuated? This article reviews factors that influenced the development of the new model and data to encourage and facilitate its use by clinicians. These include recognizing 1) a dimensional structure for psychopathology for which personality may be foundational; 2) a consensus on the structure of normal and abnormal personality; 3) the clinical significance of personality; 4) PD-specific severity required to establish disorder; 5) disruption, discontinuity, and perceived clinical utility of the Alternative Model may not be problems; and 6) a way forward involving collaborative research on neurobiological and psychosocial processes, treatment planning, and outcomes.
Literatur
1.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Association; 2013.
2.
Eaton NR et al. Contrasting prototypes and dimensions in the classification of personality pathology: evidence that dimensions, but not prototypes, are robust. Psychol Med. 2011;41:1151–63.PubMedCrossRef
3.•
Haslam N, Holland E, Kuppens P. Categories versus dimensions in personality and psychopathology: a quantitative review of taxometric research. Psychol Med. 2012;42:903–20. A meta-analysis of 177 articles with a combined sample of 533,377 participants found little evidence of taxa (categories) for normal personality and mood, anxiety, eating, externalizing, and personality disorders other than schizotypal. Therefore, most variables of interest to psychiatrists and psychologists are dimensional. PubMedCrossRef
4.
Verheul R, Widiger TA. A meta-analysis of the prevalence and usage of the personality disorder not otherwise specified (PDNOS) diagnosis. J Personal Disord. 2004;18:309–19.CrossRef
5.
Grant BF et al. Co-occurrence of DSM-IV personality disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Compr Psychiatry. 2005;46:1–5.PubMedCrossRef
6.
Zimmerman M, Rothchild L, Chelminski I. The prevalence of DSM-IV personality disorders in psychiatric outpatients. Am J Psychiatry. 2005;162:1911–8.PubMedCrossRef
7.
Widiger TA. Official classification systems. In: Livesley WJ, editor. Handbook of personality disorders. New York: Guilford; 2001. p. 60–83.
8.
Spitzer RL, Endicott J, Gibbon M. Crossing the border into borderline personality and borderline schizophrenia. Arch Gen Psychiatry. 1979;36:17–24.PubMedCrossRef
9.
Johansen M et al. An investigation of the prototype validity of the borderline DSM-IV construct. Acta Psychiatr Scand. 2004;109:289–98.PubMedCrossRef
10.
Frances A. The DSM-III personality disorders section: a commentary. Am J Psychiatry. 1980;137:1050–4.PubMed
11.
Frances A. Categorical and dimensional systems of personality diagnosis: a comparison. Compr Psychiatry. 1982;23:516–27.PubMedCrossRef
12.
Widiger TA, Trull TJ. Plate tectonics in the classification of personality disorder: shifting to a dimensional model. Am Psychol. 2007;62:71–83.PubMedCrossRef
13.
Rounsaville BJ, Alarcón RD, Andrews G, Jackson JS, Kendell RE, Kendler K. Basic nomenclature issues for DSM-V. In: Kupfer DJ, First MB, Regier DE, editors. A research agenda for DSM-V. Washington, DC: American Psychiatric Association; 2002. p. 1–29.
14.
Bernstein DP et al. Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system. J Personal Disord. 2007;21:536–51.CrossRef
15.
Benjamin LS. Dimensional, categorical, or hybrid analyses of personality: a response to Widiger’s proposal. Psychol Inq. 1993;4:91–132.CrossRef
16.
Blashfield RK. Variants of categorical and dimensional models. Psychol Inq. 1993;4:95–8.CrossRef
17.
Krueger RF et al. Synthesizing dimensional and categorical approaches to personality disorders: refining the research agenda for DSM-V Axis II. Int J Methods Psychiatr Res. 2007;16 Suppl 1:S65–73.PubMedCrossRef
18.
Helzer JE et al., editors. Dimensional approaches in diagnostic classification: refining the research agenda for DSM-V. Arlington: American Psychiatric Association; 2008.
19.
Hyman SE. The diagnosis of mental disorders: the problem of reification. Annu Rev Clin Psychol. 2010;6:155–79.PubMedCrossRef
20.
Insel TR et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010;167:748–51.PubMedCrossRef
21.••
Cuthbert BN, Insel TR. Toward the future of psychiatric diagnosis: the seven pillars of RDoC. BMC Med. 2013;11:126. Article summarizes the rationale, status, and goals of the NIMH Research Domain Criteria. RDoC are translational, dimensional, measurement based; they employ novel sampling and independent (non-diagnostic) variables, integrate behavior and neuroscience, focus on constructs with solid existing evidence, and are free from fixed definitions of disorders. PubMedCentralPubMedCrossRef
22.
Skodol AE et al. The ironic fate of the personality disorders in DSM-5. Personal Disord. 2013;4:342–9.PubMedCrossRef
23.
Kessler RC et al. The prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 2005;62:617–27.PubMedCentralPubMedCrossRef
24.
Kessler RC et al. Lifetime prevalence and age-at-onset distributions of mental disorders in the World Health Organization’s World Mental Survey initiative. World Psychiatry. 2007;6:168–76.PubMedCentralPubMed
25.
Kessler et al. Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Cormorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2012;69:372–80.PubMedCentralPubMedCrossRef
26.
27.
Krueger RF et al. Linking antisocial behavior, substance use, and personality: an integrative quantitative model of the adult externalizing spectrum. J Abnorm Psychol. 2007;116:645–66.PubMedCentralPubMedCrossRef
28.
Krueger RF, Eaton NR. Personality traits and the classification of mental disorders: towards a more complete integration in DSM-5 and an empirical model of psychopathology. Personal Disord. 2010;1:97–118.PubMedCrossRef
29.
30.
Skodol AE. Manifestations, assessment, and differential diagnosis. In: Oldham JM, Skodol AE, Bender DS, editors. The American psychiatric publishing textbook of personality disorders. 2nd ed. Arlington: American Psychiatric Publishing; 2014. p. 131–64.
31.
Kendler KS, Myers J. The boundaries of the internalizing and externalizing genetic spectra in men and women. Psychol Med. 2014;44:647–55.PubMedCrossRef
32.
Tackett JL et al. A unifying perspective on personality pathology across the life span: developmental considerations for the fifth edition of the Diagnostic and Statistical Model of Mental Disorders. Dev Psychopathol. 2009;21:687–713.PubMedCentralPubMedCrossRef
33.•
Shiner RL, Allen TA. Seven guiding principles for assessing personality disorder in adolescents. Clin Psychol Sci Pract. 2013;20:361–77. Article suggests seven guiding principles for assessing PDs in adolescents: remember to assess PDs; use the DSM-5 alternative model; assess acute symptoms and underlying personality; evaluate contextual factors; gather information from adolescents and informants; focus on problematic patterns of behavior, thinking and feeling as treatment targets not diagnoses; recognize personality strengths and resources for change. CrossRef
34.
Johnson JG et al. Cumulative prevalence of PDs between adolescence and adulthood. Acta Psychiatr Scand. 2008;118:410–3.PubMedCrossRef
35.
Feenstra DJ et al. Prevalence and comorbidity of Axis I and Axis II disorders among treatment refractory adolescents admitted for specialized psychotherapy. J Personal Disord. 2011;25:842–50.CrossRef
36.
Grilo CM et al. Frequency of PDs in two age cohorts of psychiatric inpatients. Am J Psychiatry. 1998;155:140–2.PubMed
37.
De Clercq B et al. Childhood personality pathology: dimensional stability and change. Dev Psychopathol. 2009;21:853–69.PubMedCrossRef
38.
Johnson JG et al. Age-related change in PD trait levels between early adolescence and adulthood: a community-based longitudinal investigation. Acta Psychiatr Scand. 2000;102:265–75.PubMedCrossRef
39.
Chen H et al. Adolescent PDs and conflict with romantic partners during the transition to adulthood. J Personal Disord. 2004;18:507–25.CrossRef
40.
Crawford TN et al. Comorbid Axis I and Axis II disorders in early adolescence: outcomes 20 years later. Arch Gen Psychiatry. 2008;65:641–8.PubMedCrossRef
41.
Johnson JG et al. Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood. Arch Gen Psychiatry. 1999;56:805–11.PubMedCrossRef
42.
Johnson JG et al. Adolescent PDs associated with violence and criminal behavior during adolescence and early adulthood. Am J Psychiatry. 2000;157:1406–12.PubMedCrossRef
43.
Johnson JG, Chen H, Cohen P. PD traits during adolescence and relationships with family members during the transition to adulthood. J Consult Clin Psychol. 2004;72:923–32.PubMedCrossRef
44.
45.
Gunderson JG et al. Major depressive disorder and borderline personality disorder revisited: longitudinal interactions. J Clin Psychiatry. 2004;65:1049–56.PubMedCrossRef
46.
Grilo CM et al. Two-year prospective naturalistic study of remission from major depressive disorder as a function of personality disorder co-morbidity. J Consult Clin Psychol. 2005;73:78–85.PubMedCentralPubMedCrossRef
47.
Grilo CM et al. Personality disorders predict relapse after remission from an episode of major depressive disorder: a six-year prospective study. J Clin Psychiatry. 2010;71:1629–35.PubMedCrossRef
48.
Skodol AE et al. Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample. Am J Psychiatry. 2011;168:257–64.PubMedCentralPubMedCrossRef
49.
50.
51.
Hasin D et al. Relationship of personality disorders to the three-year course of alcohol, cannabis and nicotine disorders. Arch Gen Psychiatry. 2011;68:1158–67.PubMedCentralPubMedCrossRef
52.
Low LF, Harrison F, Lackersteen SM. Does personality affect risk for dementia? A systematic review and meta-analysis. Am J Geriatr Psychiatry. 2013;21:713–28.PubMedCrossRef
53.
Widiger TA, Simonsen E. Alternative dimensional models of personality disorder: finding a common ground. J Personal Disord. 2005;19:110–30.CrossRef
54.
Costa Jr PT, Widiger TA. Personality disorders and the five-factor model of personality. 3rd ed. Washington, DC: American Psychological Association; 2012.
55.
De Fruyt F et al. General and maladaptive traits in a five-factor framework for DSM-5 in a university student sample. Assessment. 2013;20:295–307.PubMedCrossRef
56.
Fossati A et al. Reliability and validity of the Personality Inventory for DSM-5 (PID-5): predicting DSM-IV personality disorders and psychopathy in community-dwelling Italian adults. Assessment. 2013;20:689–708.PubMedCrossRef
57.
Morey LC, Krueger RF, Skodol AE. The hierarchical structure of clinician ratings of DSM-5 pathological personality traits. J Abnorm Psychol. 2013;122:836–41.PubMedCrossRef
58.
59.
Gore WL, Widiger TA. The DSM-5 dimensional trait model and five-factor models of general personality. J Abnorm Psychol. 2013;122:816–21.PubMedCrossRef
60.
Thomas KM et al. The convergent structure of DSM-5 personality trait facets and Five-Factor Model trait domains. Assessment. 2013;20:308–11.PubMedCrossRef
61.
62.
Ozer DJ, Benet-Martinez V. Personality and the prediction of consequential outcomes. Annu Rev Psychol. 2006;57:401–21.PubMedCrossRef
63.
Ironson GH et al. Personality and HIV disease progression: role of NEO-PI-R openness, extraversion, and profiles of engagement. Psychosom Med. 2008;70:245–53.PubMedCentralPubMedCrossRef
64.
65.
66.
Morey LC et al. Comparison of alternative models for personality disorders. Psychol Med. 2007;37:983–94.PubMedCrossRef
67.••
Morey LC et al. Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up. Psychol Med. 2012;42:1705–13. In a 10-year follow-up of patients with PDs, approaches to assessment of personality pathology that integrated normative personality traits and personality pathology were most predictive of long-term outcomes, including psychosocial functioning, chronicity of Axis I psychopathology, and medication use. DSM-IV diagnostic categories were less valid than dimensional criteria counts. PubMedCrossRef
68.
Crawford MJ et al. Classifying personality disorder according to severity. J Personal Disord. 2011;25:321–30.CrossRef
69.
Livesley WJ, Jang KL. Toward an empirically based classification of personality disorder. J Personal Disord. 2000;14:137–51.CrossRef
70.
Parker G et al. Defining personality disordered functioning. J Personal Disord. 2002;16:503–22.CrossRef
71.
Tyrer P. The problem of severity in the classification of personality disorders. J Personal Disord. 2005;19:309–14.CrossRef
72.
Hopwood CJ et al. Personality assessment in DSM-V: empirical support for rating severity, style, and traits. J Personal Disord. 2011;25:305–20.CrossRef
73.
Wakefield JC. The perils of dimensionalization: challenges in distinguishing negative traits from personality disorders. Psychiatr Clin N Am. 2008;31:379–93.CrossRef
74.
Bender DS, Morey LC, Skodol AE. Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods. J Pers Assess. 2011;93:332–46.PubMedCrossRef
75.
Morey LC et al. Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology. J Pers Assess. 2011;93:347–53.PubMedCrossRef
76.•
Morey LC, Bender DS, Skodol AE. Validating the proposed DSM-5 severity indicator for personality disorder. J Nerv Ment Dis. 2013;201:729–35. Data from a national sample of 337 clinicians indicated that The Level of Personality Functioning Scale in DSM-5 Section III was substantially correlated with other measures of personality pathology and with clinical judgments of psychosocial functioning, risk of violence or self-harm, prognosis, and optimal treatment intensity. A “moderate” or greater rating of impairment in personality functioning identified patients who met criteria for a DSM-IV PD with high sensitivity and specificity, confirming that the single-item LPFS can identify personality disorders efficiently and effectively. PubMedCrossRef
77.
78.
Clarkin JF, Huprich SK. Do DSM-5 personality disorder proposals meet criteria for clinical utility? J Personal Disord. 2011;25:192–205.CrossRef
79.
Luyten P, Blatt SJ. Integrating theory-driven and empirically-derived models of personality development and psychopathology: a proposal for DSM V. Clin Psychol Rev. 2011;31:52–68.PubMedCrossRef
80.
Luyten P, Blatt SJ. Interpersonal relatedness and self-definition in normal and disrupted personality development: retrospect and prospect. Am Psychol. 2013;68:172–83.PubMedCrossRef
81.
Pincus AL. Some comments on nomology, diagnostic process, and narcissistic personality disorder in the DSM-5 proposal for personality and personality disorders. Personal Disord. 2011;2:41–53.PubMedCrossRef
82.
Skodol AE, Bender DS, Oldham JM. An alternative model for personality disorders: DSM-5 section III and beyond. In: Oldham JM, Skodol AE, Bender DS, editors. The American psychiatric publishing textbook of personality disorders. Arlington: American Psychiatric Publishing; 2014. p. 511–44.
83.
Ro E, Clark LA. Psychosocial functioning in the context of diagnosis: assessment and theoretical issues. Psychol Assess. 2009;21:313–24.PubMedCrossRef
84.
Sanislow CA et al. Developing constructs for psychopathology research: research domain criteria. J Abnorm Psychol. 2010;119:631–9.PubMedCrossRef
85.
Stanley B, Siever LJ. The interpersonal dimension of borderline personality disorder: toward a neuropeptide model. Am J Psychiatry. 2010;167:24–39.PubMedCrossRef
86.
Donaldson ZR, Young LJ. Oxytocin, vasopressin, and the neurogenetics of sociality. Science. 2008;322:900–4.PubMedCrossRef
87.
88.
Northoff G et al. Self-referential processing in our brain – a meta-analysis of imaging studies on the self. Neuroimage. 2006;31:440–57.PubMedCrossRef
89.
90.
Qin P, Northoff G. How is our self related to midline regions and the default-mode network? Neuroimage. 2011;57:1221–33.PubMedCrossRef
91.
Gunderson JG. Seeking clarity for future revisions of the personality disorders in DSM-5. Personal Disord. 2013;4:368–76.PubMedCrossRef
92.
Morey LC, Skodol AE. Convergence between DSM-IV and DSM-5 diagnostic models for personality disorder: evaluation of strategies for establishing diagnostic thresholds. J Psychiatr Pract. 2013;19:179–93.PubMedCrossRef
93.
Morey LC. Personality disorders under DSM-III and DSM-III-R: an examination of convergence, coverage, and internal consistency. Am J Psychiatry. 1988;145:573–7.PubMed
94.
Regier DA et al. DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses. Am J Psychiatry. 2013;170:59–70.PubMedCrossRef
95.
Zimmerman J et al. Assessing DSM-5 level of personality functioning from videotaped clinical interviews: a pilot study with untrained and clinically inexperienced students. J Pers Assess. 2014. doi:10.​1080/​00223891.​2013.​852563.
96.
Moscicki EK et al. Testing DSM-5 in routine clinical practice settings: feasibility and clinical utility. Psychiatr Serv. 2013;64:952–60.PubMedCrossRef
97.••
Morey LC, Skodol AE, Oldham JM. Clinician judgments of clinical utility: a comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5 personality disorders. J Abnorm Psychol. 2014;123:398–405. In a national sample of 337 clinicians who rated patients with both DSM-IV-TR criteria (now DSM-5 Section II) and the DSM-5 alternative model for PDs, DSM-IV-TR was seen as easy to use and useful for professional communication. In all other respects, including communication with patients, comprehensiveness, descriptiveness, and utility for treatment planning, the DSM-5 Section III model (especially the dimensional trait model) was seen as equally or more useful than DSM-IV-TR. These views were held regardless of whether the clinician was a psychiatrist or a psychologist. PubMedCrossRef
98.
First MB, Bell CC, Cuthbert B, Krystal JH, Malison R, Offord DR, et al. Personality disorders and relational disorders. In: Kupfer DJ, First MB, Regier DA, editors. A research agenda for DSM-V. Washington, DC: American Psychiatric Association; 2002. p. 123–99.
99.
Shiner RL, Masten AS. Childhood personality as a harbinger of competence and resilience in adulthood. Dev Psychopathol. 2012;24:507–28.PubMedCrossRef
100.
101.
Skodol AE. The resilient personality. In: Reich JW, Zautra AJ, Hall JS, editors. Handbook of adult resilience. New York: Guilford Press; 2010. p. 112–25.
102.•
Krueger RF, Markon KE. The role of the DSM-5 personality trait model in moving toward a quantitative and empirically based approach to classifying personality and psychopathology. Annu Rev Clin Psychol. 2014;10:477–501. Article reviews research to date on the DSM-5 personality trait model. Studies to date suggest reasonable coverage of personality pathology, but also areas for continued improvement. PubMedCrossRef
103.
Krueger RF et al. DSM-5 and the path toward empirically based and clinically useful conceptualization of personality and psychopathology. Clin Psychol Sci Prac. 2014. In press.
Metadaten
Titel
Personality Disorder Classification: Stuck in Neutral, How to Move Forward?
verfasst von
Andrew E. Skodol
Publikationsdatum
01.10.2014
Verlag
Springer US
Erschienen in
Current Psychiatry Reports / Ausgabe 10/2014
Print ISSN: 1523-3812
Elektronische ISSN: 1535-1645
DOI
https://doi.org/10.1007/s11920-014-0480-x

Weitere Artikel der Ausgabe 10/2014

Current Psychiatry Reports 10/2014 Zur Ausgabe

Attention-Deficit Disorder (A Rostain, Section Editor)

Using Stimulants to Treat ADHD-Related Emotional Lability

Sleep Disorders (P Gehrman, Section Editor)

Sleep and Substance Use Disorders: An Update

Geriatric Disorders (W McDonald, Section Editor)

Bereavement: Course, Consequences, and Care

Attention-Deficit Disorder (A Rostain, Section Editor)

Delivering Evidence-Based Treatments for Child Attention-Deficit/Hyperactivity Disorder (ADHD) in the Context of Parental ADHD

Attention-Deficit Disorder (A Rostain, Section Editor)

Managing the Risks of ADHD Treatments

Geriatric Disorders (W McDonald, Section Editor)

Mild Cognitive Impairment: Diagnosis, Longitudinal Course, and Emerging Treatments

Neu im Fachgebiet Psychiatrie

Demenzkranke durch Antipsychotika vielfach gefährdet

23.04.2024 Demenz Nachrichten

Wenn Demenzkranke aufgrund von Symptomen wie Agitation oder Aggressivität mit Antipsychotika behandelt werden, sind damit offenbar noch mehr Risiken verbunden als bislang angenommen.

Weniger postpartale Depressionen nach Esketamin-Einmalgabe

23.04.2024 Depression antepartal oder postpartal Nachrichten

Bislang gibt es kein Medikament zur Prävention von Wochenbettdepressionen. Das Injektionsanästhetikum Esketamin könnte womöglich diese Lücke füllen.

„Psychotherapie ist auch bei sehr alten Menschen hochwirksam!“

22.04.2024 DGIM 2024 Kongressbericht

Die Kombination aus Medikamenten und Psychotherapie gilt als effektivster Ansatz bei Depressionen. Das ist bei betagten Menschen nicht anders, trotz Besonderheiten.

Auf diese Krankheiten bei Geflüchteten sollten Sie vorbereitet sein

22.04.2024 DGIM 2024 Nachrichten

Um Menschen nach der Flucht aus einem Krisengebiet bestmöglich medizinisch betreuen zu können, ist es gut zu wissen, welche Erkrankungen im jeweiligen Herkunftsland häufig sind. Dabei hilft eine Internetseite der CDC (Centers for Disease Control and Prevention).

Update Psychiatrie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen
Bildnachweise