Skodol Et Al 2011 Part II

Proposed Changes in Personality and Personality DisorderAssessment and Diagnosis for DSM-5 Part II: Clinical Application

Andrew E. SkodolUniversity of Arizona College of Medicine

Donna S. BenderUniversity of Arizona College of Medicine

John M. OldhamBaylor College of Medicine

Lee Anna ClarkUniversity of Iowa

Leslie C. MoreyTexas A&M University

Roel VerheulUniversity of Amsterdam

Robert F. KruegerUniversity of Minnesota

Larry J. SieverMt. Sinai School of Medicine

The four-part assessment of personality psychopathology proposed for DSM-5 focusesattention on identifying personality psychopathology with increasing degrees of specificity,based on a clinicians available time, information, and expertise. In Part I of this two-partarticle, we described the components of the new model and presented brief rationales forthem. In Part II, we illustrate the clinical application of the model with vignettes of patientswith varying degrees of personality psychopathology, selected from the DSMIVTRCasebook, to show how assessments might be conducted and diagnoses reached.

Keywords: personality disorders, personality, DSM-5, assessment, diagnosis, clinical application

The four-part assessment of personality psy-chopathology proposed for DSM-5 focuses at-tention on identifying personality psychopathol-ogy with increasing degrees of specificity,based on a clinicians available time, informa-tion, and expertise. In Part I of this two-partarticle, we described the components of the newmodel and presented brief rationales for them.In Part II, we illustrate the clinical applicationof the model with vignettes of patients with

varying degrees of personality psychopathol-ogy, selected from the DSMIV Casebook(Spitzer, Gibbon, Skodol, Williams, & First,2002), to show how assessments might be con-ducted and diagnoses reached. Cases from theDSMIVTR Casebook were chosen explicitlyso that readers can compare the original discus-sions based on the DSMIVTR model to thediscussions of the same cases herein and judgetheir relative clinical utilities.

To see further discussion of the Target Conceptual Articles,Commentaries, and Author Response, as well as to contrib-ute to the ongoing dialogue on this topic, please visit ourOnline Forum at http://pdtrtonline.apa.org/display/PER/Home

Andrew E. Skodol, Department of Psychiatry, Universityof Arizona College of Medicine; Donna S. Bender, Depart-ment of Psychiatry, University of Arizona College of Medi-cine; John M. Oldham, Department of Psychiatry, BaylorCollege of Medicine; Lee Anna Clark, now at Department ofPsychology, University of Notre Dame; Leslie C. Morey,Department of Psychology, Texas A&M University; Roel Ver-heul, Center of Psychotherapy De Viersprong, University of

Amsterdam, The Netherlands; Robert F. Krueger, Departmentof Psychology, University of Minnesota; Larry J. Siever, De-partment of Psychiatry, Mt. Sinai School of Medicine.

Portions of this article appeared on the American Psychi-atric Associations DSM-5 website: www.DSM5.org. Thisarticle is being copublished by Personality Disorders: The-ory, Research, and Treatment and the American PsychiatricAssociation. Lee Anna Clark is the author of the Schedulefor Nonadaptive and Adaptive Personality, published by theUniversity of Minnesota Press.

Correspondence concerning this article should be addressedto Andrew E. Skodol, M.D., Sunbelt Collaborative, 4031 E.Sunrise Drive, Suite 101, Tucson, AZ 85718. E-mail: [email protected]

Personality Disorders: Theory, Research, and Treatment 2011 American Psychiatric Association2011, Vol. 2, No. 1, 2340 1949-2715/11/$12.00 DOI: 10.1037/a0021892

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To review, the assessment model for person-ality psychopathology proposed for DSM-5identifies core impairments in personality func-tioning, pathological personality traits, andprominent pathological personality types. Acomprehensive personality assessment consistsof four components:

(a) Five identified severity levels of person-ality functioning, based on degrees of impair-ment in core self and interpersonal capacities;

(b) Five specific personality disorder (PD)types, each defined by impairments in core ca-pacities and a set of pathological personalitytraits, and one trait-specified type;

(c) Six broad, higher order personality traitdomains, with 410 lower order, more specifictrait facets within each domain, for a total of 37specific trait facets;

(d) New general criteria for PD based onsevere or extreme deficits in core capacities ofpersonality functioning and extreme levels ofpathological personality traits.

The rationale for the proposed changes inpersonality and PD assessment and diagnosisemanates from the myriad problems with theexisting 10-category representation of personal-ity psychopathology in DSMIVTR (seeSkodol et al., this issue). These include an un-substantiated and nonspecific definition of andgeneral criteria for PD; the lack of a PD-specific, clinically useful, severity measure; ex-cessive comorbidity among DSMIVTR PDs;limited validity of some existing types; arbitrarydiagnostic thresholds; within-disorder heteroge-neity; inadequate coverage of the range of PDpathology, and instability of current diagnosticcriteria sets. The proposed new model addressesall of the limitations of the PD diagnostic classin DSMIVTR.

Overview of the DSM-5 Personality andPD Assessment Method

The new assessment model is designed to beflexible, and to telescope clinical attentiononto personality pathology by degrees. Even abusy clinician with limited time or expertise inthe assessment of personality or PDs should beable to decide whether a personality-relatedproblem exists and how severe it is. Furthersteps in the assessment of personality problemswould be to generally characterize their typeaccording to broad characteristics and to assess

the specific traits that describe the type to gen-erate a corresponding trait profile of the patient.The patient can also be evaluated for the re-mainder of the traits, a sort of trait-based re-view of systems, in order to identify otherimportant personality characteristics. The levelsof functioning and trait profile steps are infor-mative whether or not a patient is believed tohave a PD. A trait assessment is also needed todescribe the particular, individual trait profile ofpatients who have sufficient personality psycho-pathology to receive a PD diagnosis, but do notmatch one of the five DSM-5 types. These pa-tients, formerly diagnosed with PD Not Other-wise Specified (PDNOS) in DSMIVTR,would receive a diagnosis of PD Trait Specified(PDTS) in DSM-5. The fourth part of the model,the general criteria for PD, insures that therequired inclusion and exclusion criteria havebeen met.

Assessment of Levels of PersonalityFunctioning

Consideration of the core capacities of per-sonality related to self and interpersonal func-tioning and determining the severity of anyimpairment in these areas is accomplished byusing the Levels of Personality FunctioningScale (see Appendix A). Any rating abovezero (i.e., at least a mild level of impair-ment) indicates personality issues. If not ev-ident from the chief complaint or the historyof the presenting problems, a few basic ques-tions about how patients feel about them-selves and about the nature of their relation-ships with others should enable clinicians tosay with some confidence whether a person-ality problem exists. For example, researchhas shown that a question such as, Do youever get the feeling that you dont know whoyou really are or what you want out of yourlife? has high sensitivity for the kinds ofproblems with identity and self-concept typi-cally associated with PDs. Similarly, a ques-tion such as, Do you feel close to otherpeople and enjoy your relationships withthem (answered negatively) has high sensi-tivity for problems with intimacy. Problemswith identity and self-concept and with inti-macy and interpersonal reciprocity may bethe result of another type of mental disorder(i.e., a mood or anxiety disorder), but they are

24 SKODOL ET AL.


especially characteristic of personality psy-chopathology. Preliminary analyses in a sam-ple of 424 psychiatric patients found that ascore of greater than 3 (out of 5) on a short5-item scale depicted in Table 1 had a sensi-tivity of 79% and a specificity of 54% for asemistructured interview diagnosis of PD(Morey et al., unpublished manuscript).

A full assessment of impairment in personal-ity functioning, however, is considerably morenuanced. Thus, a 5-point rating sale of func-tional impairment in the self and interpersonaldomains is being proposed for DSM-5. Thescale ranges from 0 no impairment to 4 extreme impairment (see Appendix A), withdetailed descriptions of the types of dysfunc-tions defining each level. Based on a review ofexisting measures (Bender, Morey, & Skodol,2011), the assessment of personality function-ing is expected to have clinical utility. For ex-ample, the more severe the level of impairment,the more likely the person is to have a PD, tohave a severe PD, and to receive multiple (morethan 1) PD diagnoses according to DSMIV(Bouchard et al., 2008; Loffler-Stastka,Ponocny-Seliger, Fischer-Kern, & Leithner,2005; Verheul et al., 2008). The severity ofimpairment in personality functioning has alsobeen shown to be an important predictor ofconcurrent and prospective general impairmentin psychosocial functioning (e.g., Hopwood etal., in press) and to be important in planningtreatment and predicting its outcome (e.g., Dia-mond, Kaslow, Coonerty, & Blatt, 1990; Piperet al., 1991).

Assessment of PD Types

The function of the models PD type assess-ment is to generally characterize the type ofpersonality problems a patient exhibits accord-

ing to broad clinically recognizable configura-tions. The constellation of impairments in per-sonality functioning and characteristics of emo-tional, cognitive, and behavioral functioningexhibited by a patient is considered to determinethe extent to which it matches the five typedescriptions proposed for DSM-5 (antisocial/psychopathic, avoidant, borderline, obsessivecompulsive, or schizotypal) on a 5-point match-ing scale ranging from 5 very good match,patient exemplifies this type, to 1 no match,description does not apply (see Table 2). Pro-totype matching often guides diagnostic hy-potheses in practice, recognizes that personalitypathology occurs on continua, and has beenrated very useful by clinicians (Spitzer, First,Shedler, Westen, & Skodol, 2008; Westen, She-dler, & Bradley, 2006). Prototypes also helpclinicians structure their assessments of the traitdomains and facets proposed for DSM-5, bymaking the meaning of the traits more explicitin the context of a particular kind of patient, thatis, by reducing ambiguity (Rottman, Ahn, San-islow, & Kim, 2009). This in turn facilitatesmore accurate diagnoses. An assessment thatcontinues through a type rating will often ap-proximate a DSMIVTR PD diagnosis (unlessthe patient does not have a specified type),which itself does not require documentation ofthe specific criteria of the polythetic criteria setsactually met. The DSM-5 approach also allowsthe clinician to document heterogeneity within atype, by rating the specific trait profile of eachpatient.

Assessment of Personality Trait Domainsand Facets

Trait ratings are of two kinds: domain ratingsand facet ratings (see Appendix B). Trait do-mains and facets are rated on a 4-point scale:0 very little or not at all descriptive; 1 mildly descriptive; 2 moderately descriptive;and 3 extremely descriptive. The six broadtrait domains proposed for DSM-5negativeemotionality, detachment, antagonism, disinhi-bition, compulsivity, and schizotypyare ratedto give a broad brush depiction of a patientsprimary trait structure. Some of these domainsare close counterparts to DSMIVTR PDs. Forexample, the domain of detachment (DT; and itsfacet traits) is virtually synonymous with DSMIVTR schizoid PD and many of the traits of the

Table 1Five-Item Screening Scale for Personality Disorder1. I can hardly remember what kind of person I was only

a few months ago.2. My feelings about people change a great deal from day

to day.3. Most of the time I dont have the feeling of being in

touch with my real self.4. I drift through life without a clear sense of direction.5. I have very contradictory feelings about myself.

25SPECIAL ISSUE: PROPOSED CHANGES IN PDS FOR DSM-5, PART II

T1

T2


domain of antagonism (A) and of negative emo-tionality (NE) suggest narcissistic PD or (DSMIVTR Appendix) depressive PD, respectively.The domains figure prominently in the five PDtypes proposed for DSM-5, as wellfor exam-ple, a combination of traits from the antago-nism and the disinhibition (DS) domainsmake up the trait profile of the antisocial/psychopathic type. Traits from the domains ofnegative emotionality and of detachmentmake up the trait profile of the avoidant type.Other types are more complex, however, andhave contribution of traits from multiple do-mains. The most detailed trait profile is obvi-ously derived from the rating of the 37 traitfacets. These may be found in myriad combi-nations and provide the most specific pictureof a patient from the personality trait point ofview. In addition, the trait domains and facetshave the salutary effect of converting a non-specific PDNOS diagnosis into a specific PDTrait Specified diagnosis.

Assessment of the General Criteria for PD

The fourth part of the evaluation is theapplication of the general criteria for PD. Thegeneral criteria are considered last for threereasons: 1) even if a patient does not have aPD, the descriptive information from theother parts of the assessment can be clinically

useful; 2) the assessment of personality prob-lems and of personality traits are needed torate the general criteria and, so, logicallymust precede them; and 3) the various exclu-sion criteria will probably prove to be themost time-consuming and labor intensiveparts of the assessment and require the mostknowledge about patients and their clinicalstatuses, and thus should not interfere with anassessment of personality problems, types,and traits, which have clinical utility in theirown right. The general criteria for PD werenot actually a required rating in DSMIVTR,but were added to help in the overall concep-tualization of what a PD is.

Application to Clinical Case Vignettes

In the next section, we will present threeclinical case vignettes drawn from the DSMIVTR Casebook (Spitzer, Gibbon, Skodol,Williams, & First, 2002). Each vignette will bediscussed from the point of view of the pro-posed DSM-5 assessment model. For compari-son, the reader can consult the Casebook fordiscussions according to DSMIVTR.

Case Vignette #1

The patient is a 23-year-old veterinary assis-tant admitted for her first psychiatric hospital-

Table 2Obsessive-Compulsive Personality Disorder Type With MatchingIndividuals who match this personality disorder type are ruled by their need for order, precision, and perfection.Activities are conducted in super-methodical and overly detailed ways. They have intense concerns with time,punctuality, schedules, and rules. Affected individuals exhibit an overdeveloped sense of duty and obligation, and aneed to try to complete all tasks thoroughly and meticulously. The need to try to do things perfectly may result in aparalysis of indecision, as the pros and cons of alternatives are weighed, such that important tasks may not ever becompleted. Tasks, problems, and people are approached rigidly, and there is limited capacity to adapt to changingdemands or circumstances. For the most part, strong emotionsboth positive (e.g., love) and negative (e.g., anger)arenot consciously experienced or expressed. At times, however, the individual may show significant insecurity, lack ofself-confidence, and anxiety subsequent to guilt or shame over real or perceived deficiencies or failures. Additionally,individuals with this prototype are controlling of others, competitive with them, and critical of them. They areconflicted about authority (e.g., they may feel they must submit to it or rebel against it), prone to get into powerstruggles either overtly or covertly, and act self-righteous or moralistic. They are unable to appreciate or understand theideas, emotions, and behaviors of other people.Instructions: Rate the patients personality using the 5-point rating scale shown below. Circle the number that bestdescribes the patients personality.5. Very good match: Patient exemplifies this type.4. Good match: Patient significantly resembles this type.3. Moderate match: Patient has prominent features of this type.2. Slight match: Patient has minor features of this type.1. No match: Description does not apply.

26 SKODOL ET AL.


ization. She arrived late at night, referred by alocal psychiatrist, saying, I dont really need tobe here.

Three months before admission, the patientlearned that her mother had become pregnant.She began drinking heavily, ostensibly in orderto sleep nights. While drinking she became in-volved in a series of one-night stands. Twoweeks before admission, she began feeling pan-icky and having experiences in which she felt asif she were removed from her body and in atrance. During one of these episodes, she wasstopped by the police while wandering on abridge late at night. The next day, in response tohearing a voice repeatedly telling her to jumpoff a bridge, she ran to her supervisor and askedfor help. Her supervisor, seeing her distraughtand also noting scars from a recent wrist slash-ing, referred her to a psychiatrist, who thenarranged for her immediate hospitalization.

At the time of her hospitalization, the patientappeared as a disheveled and frail, but appeal-ing, waif. She was cooperative, coherent, andfrightened. Although she did not feel hospital-ization was needed, she welcomed the prospectof relief from her anxiety and depersonalization.She acknowledged that she had feelings of lone-liness and inadequacy and brief periods of de-pressed mood and anxiety since adolescence.Recently she had been having fantasies that shewas stabbing herself or a little baby with aknife. She complained that she was just anempty shell that is transparent to everyone.

The patients parents divorced when shewas 3, and for the next 5 years she lived withher maternal grandmother and her mother, whohad a severe drinking problem. The patient hadnight terrors during which she would frequentlyend up sleeping with her mother. At 6 she wentto a special boarding school for a year and ahalf, after which she was withdrawn by hermother, against the advice of the school. Whenshe was 8, her maternal grandmother died, andshe recalls trying to conceal her grief about thisfrom her mother. She spent most of the next 2years living with various relatives, including aperiod with her father, whom she had not seensince the divorce. When she was 9, her motherwas hospitalized with a diagnosis of schizo-phrenia. From age 10 through college, the pa-tient lived with an aunt and uncle but had on-going and frequent contacts with her mother.Her school record was consistently good.

Since adolescence she has dated regularly,having an active, but rarely pleasurable, sex life.Her relationships with men usually end abruptlyafter she becomes angry with them when theydisappoint her in some apparently minor way.She then concludes that they were no good tobegin with. She has had several roommates,but has had trouble establishing a stable livingsituation because of her jealousy about sharingher roommates with others and her manipula-tive efforts to keep them from seeing otherpeople.

Since college she has worked steadily andwell as a veterinary assistant. At the time ofadmission, she was working a night shift in aveterinary hospital and living alone.1

Discussion. The young veterinary assistantdescribed in this case has severe problems inself and interpersonal functioning. She de-scribed herself as an empty shell . . . transpar-ent to everyone and she has felt lonely andinadequate for many years. Though having at-tempted to hurt herself and harboring suicidaland homicidal fantasies, she is ambivalent aboutneeding help. She dissociates from her body andhears a voice telling her to jump off a bridge.The immediate precipitant for her deteriorationis the knowledge that her mother, who hasschizophrenia, is pregnant. Thus, the patient hasa very fragile and unstable sense of self, influ-enced by external events, and experiences a lackof identity. Her self-image is simplistic andconcrete and she has little ability to self-reflect.Her interpersonal relationships are also unsta-ble. She sees others in terms of their meetingher needs and she seems to have very littleunderstanding or appreciation of their needs(e.g., to see other people) or behavior. Whendisappointed by men she is dating, she becomesangry, turns on them, and denigrates them. Shedoes not enjoy sexual intimacy. Because of theseverity of her problems in identity, self-concept, empathy, and intimacy, she would re-ceive a rating of 3 serious impairment onthe Levels of Personality Functioning Scale.

The patients general pattern of personalitypathology and pathological personality traits fitsthe borderline type (See Part I, Table 2). She

1Empty Shell. Reprinted with permission from the

DSMIVTR Casebook, (Copyright, 2002). American Psy-chiatric Association.


Fn1


has a fragile self-concept that becomes frag-mented under stress, a lack of identity and feel-ings of emptiness, and difficulty maintainingenduring intimate relationships. She has intenseand reactive emotions; can become depressed,anxious, and angry, and feels disappointed andmistreated. Her interpersonal relationships areunstable and she appears to have little empathyfor others. She engages in black-and-white, all-or-nothing thinking and has dissociated. She isimpulsive (drinking, sex), has engaged in self-harm (cutting), and has suicidal ideation in re-sponse to her mothers pregnancy. On thematching rating scale she warrants a score of5 very good match to the borderline type.Although this patients level of personalityfunctioning is typical for the borderline type,patients with this type may also function eitherbetter (i.e., mild or moderate impairment) orworse.

Rating on the traits associated with the bor-derline type are as follows: emotional lability3 (extremely descriptive), self-harm 3, sep-aration insecurity 2 (moderately descrip-tive), anxiousness 2, low self-esteem 3;depressivity 3, hostility 3; aggression 0(very little or not at all descriptive), impul-sivity 3; and dissociation proneness 2.

An alternative assessment approach would beto start with an assessment of the trait profile forthis patient. Considering the broad trait do-mains, negative emotionality appears to be ex-tremely descriptive (rating 3), character-ized further by emotional lability, depressivity,low self-esteem, self-harm, anxiousness, andseparation insecurity. She would also receiveratings of moderately descriptive on the dis-inhibition domain (for her impulsivity) and forthe trait of recklessness (not currently listed asan associated trait for the borderline type), be-cause she engages in dangerous and risky be-haviors (e.g., one night stands, wandering aboutlate at night). She might also receive a rating ofmildly or moderately descriptive on theantagonism domain (for her hostility). If herepisodes of depersonalization were recurrent,then the domain of schizotypy would be con-sidered mildly descriptive, because of thetrait facet of dissociation proneness. Althoughthe patient reports an auditory hallucination onenight, there is no evidence that this is a recurrentexperience, therefore the trait of unusual per-ceptions, connoting a tendency toward these

experiences, would not apply. A clinician mightalso be tempted to rate the trait facet cognitivedysregulation in the schizotypy domain becauseof the patients tendency toward black-and-white, all-or-nothing thinking, but the currentdefinition of cognitive dysregulation does notinclude these particular thought processes char-acteristic of the borderline patient.

Finally, the clinician considers the generalcriteria for PD. In this case, the serious impair-ment in both self and interpersonal functioning,and the extreme levels of a number of patho-logical personality traits leave little doubt thatcriteria A and B (see Part I, Table 4) are met.Although there has been a recent deteriorationin this young womans condition, there is someevidence that these difficulties are chronic, havebeen exhibited in a number of situations, andclearly began in adolescence. She may have haddiagnosable episodes of major depressive dis-order, alcohol abuse (most likely), depersonal-ization disorder, or a psychotic disorder (NOS),but these in and of themselves do not seemsufficiently chronic to account for her long-standing impairments in personality function-ing. There is no evidence of an etiologicallyrelevant general medical condition. Thus, shemeets the general criteria for PD.

Summary of Case Vignette #1 Assessment

Levels of personality functioning. 3 (seri-ous impairment).

Type. Borderline (5 very good match).Clinically significant traits. Trait do-

mains: negative emotionality, disinhibition.Trait facets: emotional lability, self-harm, lowself-esteem, depressivity, hostility, impulsivity,separation insecurity, anxiousness, dissociationproneness.

PD general criteria met? Yes.

Case Vignette # 2

Dr. Wilson, a 34-year-old psychiatrist, is 15minutes late for his first appointment. He hasrecently been asked to resign from his job in amental health center because, according to hisboss, he is frequently late for work and meet-ings, has missed appointments, has forgottenabout assignments, is late with his statistics,refused to follow instructions, and seems unmo-tivated. Dr. Wilson was surprised and resent-

28 SKODOL ET AL.


fulhe thought he had been doing a particu-larly good job under trying circumstances andexperienced his boss as excessively obsessiveand demanding. Nonetheless, he reports a long-standing pattern of difficulties with authority.

The patient had a childhood history of severeand prolonged temper tantrums that were a legendin his family. He had been a bossy child whodemanded that other kids play his way or else hewouldnt play at all. With adults, particularly hismother and female teachers, he was sullen, insub-ordinate, oppositional, and often unmanageable.He had been sent to an all-boys preparatory schoolthat had primarily male teachers, and he graduallybecame more subdued and disciplined. He contin-ued, however, to stubbornly want things his ownway and to resent instruction or direction fromteachers. He was a brilliant but erratic student,working only as hard as he himself wanted to; hepunished teachers he didnt like by not doingtheir assignments. He was argumentative and self-righteous when criticized, and claimed that he wasnot being treated fairly.

Dr. Wilson is unhappily married. He com-plains that his wife does not understand him andis a nitpicker. She complains that he is unre-liable and stubborn. He refuses to do anythingaround the house and often forgets to completethe few tasks he has accepted as within hisresponsibility. Tax forms are submitted severalmonths late; bills are not paid. The patient issociable and has considerable charm, butfriends generally become annoyed at his unwill-ingness to go along with the wishes of the group(e.g., if a restaurant is not his choice, he maysulk all night or forget to bring his wallet).2

Discussion. This psychiatrist displays alifelong pattern of oppositional behavior inplay, school, work, and interpersonal relation-ships that seems to be a textbook case of pas-sive-aggressive PD, with narcissistic features.Passive-aggressive PD was relegated to an ap-pendix in DSMIVTR for criteria sets andaxes provided for further study. Neither passive-aggressive PD nor narcissistic PD is a type cur-rently included in the proposed model for DSM-5.How can this patients personality psychopathol-ogy be represented in the new system?

The first step is again to determine if thepatient has impairments in self and interper-sonal functioning. In the realm of the self, thispatient clearly has problems in identity integra-tion, self-concept, and self-direction. He has

difficulties maintaining boundaries betweenhimself and those around him. Although it is hewho has been late for work, missed appoint-ments, forgotten assignments, been late withstatistics, and refused to follow instructions, heblames his failings on his boss, who is exces-sively . . . demanding. When criticized for de-liberately not doing assignments, he believesthat he is being treated unfairly. That he issurprised when asked to resign his job andthinks that he is doing a good job, is evidencethat he has a distorted self-appraisal. His lack ofself-awareness indicates impairment in his ca-pacity to self-reflect. Despite having pursued ahigh level of education to attain a professionaldegree and career, he has undermined it with hisrefusal to meet the standards expected fromsomeone in his position. On the interpersonalside, he seems to have considerable lack ofempathy for his wife and friends and does notattempt to develop other than superficial rela-tionships with them. These impairments in per-sonality functioning warrant a rating of 2 moderate impairment on the proposed Levelsof Personality Functioning Scale.

In turning to the types, it may be possible toconsider the obsessivecompulsive type (seeTable 2) because of the patients resistance toauthority, manifest in his proneness to get intopower struggles, his self-righteousness, and hisgeneral rigidity. Missing, however are a needfor order, precision, and perfection; detail-orientation; and concerns with time and punc-tuality, duty and obligation, thoroughness andmeticulousness. If anything, this patient exhib-its the opposite pattern. Furthermore, his im-pairments in self and interpersonal functioningare more severe than those generally observedin patients with the obsessivecompulsive type.He does not show the periodic insecurity, self-doubt, and anxiety or guilt over his deficienciesor failures of the individual with an obsessivecompulsive personality type. Thus, at most, arating of 2 slight match (minor features ofthe type) would apply. The antisocial/psycho-pathic type (see Table 3) might be consideredbecause the patient seems arrogant and self-centered, and is manipulative, irresponsible, su-

2Stubborn Psychiatrist. Reprinted with permission

from the DSMIVTR Casebook, (Copyright, 2002). Amer-ican Psychiatric Association.


Fn2

T3


perficially charming, and unempathic. Missinghere, however, are the extreme levels of callous-ness and exploitativeness, the overt aggression,the recklessness, and the unlawful and criminalbehavior characteristic of this type. A rating of3 moderate match (prominent features ofthe type) would apply.

For a patient who has impaired personalityfunctioning, but who does not match signifi-cantly to a proposed type, the assessment be-comes more purely trait driven. From the traitperspective, the major relevant trait domain inthe case of this psychiatrist would be antago-nism. A rating of 2 moderately descriptivewould apply. Oppositionality (rating 3), narcis-sism (3), irresponsibility (3), manipulativeness (2),hostility (2), and perhaps even callousness (1)could be noted. Looking at the DSMIVTR toDSM-5 Crosswalk (see Part I, Table 3), DSMIVTR passive-aggressive PD is represented bythe traits of oppositionality, hostility, and guilt/shame. The current patient has two of these threetraits. Narcissistic PD is represented by the traitsof narcissism, manipulativeness, histrionism, and

callousness. The patient has two or perhaps threeof these traits. The crosswalk shows that person-ality pathology (even according to DSMIVTRconstructs) that is not represented by a DSM-5type can be described in trait terms. It also illus-trates, however, the lack of clear boundaries be-tween DSMIVTR PDs, and the trait heterogene-ity within them.

In considering whether this patient meets thegeneral criteria for a PD according to the newlyproposed system, his poorly delineated interper-sonal boundaries and low, or at least conflicted,self-directedness noted above in the assessmentof levels of functioning suggest an impairedsense of self or identity (criterion A1) and thelack of empathy for and intimacy with otherssuggest impairment in effective interpersonalfunctioning (criterion A2). Most striking, how-ever, is his lifelong inability to cooperate withothers (A2iii). He exhibits extreme levels of sev-eral pathological personality traits (criterion B).He has had this pattern of maladaptive personalityfunctioning stretching back to childhood and it hasaffected his relationships with peers, teachers,

Table 3Antisocial/Psychopathic Personality Disorder Type With MatchingIndividuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled. Theyhave a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals. They seekpower over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm orto achieve their goals. They are callous and have little empathy for others needs or feelings unless they coincide with theirown. They show disregard for the rights, property, or safety of others and experience little or no remorse or guilt if theycause any harm or injury to others. They may act aggressively or sadistically toward others in pursuit of their personalagendas and appear to derive pleasure or satisfaction from humiliating, demeaning dominating, or hurting others. Theyalso have the capacity for superficial charm and ingratiation when it suits their purposes. They profess and demonstrateminimal investment in conventional moral principles and they tend to disavow responsibility for their actions and toblame others for their own failures and shortcomings.Individuals with this personality type are temperamentally aggressive and have a high threshold for pleasurableexcitement. They engage in reckless sensation-seeking behaviors, tend to act impulsively without fear or regard forconsequences, and feel immune or invulnerable to adverse outcomes of their actions. Their emotional expression ismostly limited to irritability, anger, and hostility; acknowledgement and articulation of other emotions, such as love oranxiety, are rare. They have little insight into their motivations and are unable to consider alternative interpretations oftheir experiences.Individuals with this disorder often engage in unlawful and criminal behavior and may abuse alcohol and drugs.Extremely pathological types may also commit acts of physical violence in order to intimidate, dominate, and controlothers. They may be generally unreliable or irresponsible about work obligations or financial commitments and oftenhave problems with authority figures.Instructions: Rate the patients personality using the 5-point rating scale shown below. Circle the number that bestdescribes the patients personality.5. Very good match: Patient exemplifies this type.4. Good match: Patient significantly resembles this type.3. Moderate match: Patient has prominent features of this type.2. Slight match: Patient has minor features of this type.1. No match: Description does not apply.

30 SKODOL ET AL.


bosses, friends, and his spouse. So, criterion C isclearly met. There is no evidence in this case ofeither another mental disorder or a substance orgeneral medical condition that could account forhis personality problems. In sum, the general cri-teria for PD are met.


Levels of personality functioning. 2(moderate impairment).

Type. Antisocial/psychopathic (3 mod-erate match); Obsessive compulsive (2 slight match).

Clinically significant traits. Trait domain:antagonism. Trait facets: oppositionality, narcis-sism, irresponsibility, manipulativeness, hostility.

PD general criteria met? Yes.

Case Vignette # 3

A 28-year-old junior executive was referredby a senior psychoanalyst for supportivetreatment. She had obtained a masters degreein business administration and moved to Cali-fornia 112 years earlier to begin work in a largefirm. She complained of being depressedabout everything: her job, her husband, and herprospects for the future.

She had extensive psychotherapy previously.She had seen an analyst twice a week for 3 yearswhile in college, and a behaviorist for 112 yearswhile in graduate school. Her complaints were ofpersistent feelings of depressed mood, inferiority,and pessimism, which she claims to have hadsince she was 16 or 17. Although she did reason-ably well in college, she consistently ruminatedabout those students who were genuinely intelli-gent. She dated during college and graduateschool, but claimed that she would never go aftera guy she thought was special, always feelinginferior and intimidated. Whenever she saw ormet such a man, she acted stiff and aloof, oractually walked away as quickly as possible, onlyto berate herself afterward and then fantasizeabout him for many months. She claimed that hertherapy had helped, although she still could notremember a time when she didnt feel somewhatdepressed.

Just after graduation, she married the man shewas going out with at the time. She thought of himas reasonably desirable, though not special, andmarried him primarily because she felt she

needed a husband for companionship. Shortlyafter their marriage, the couple started to bicker.She was very critical of his clothes, his job, andhis parents; he, in turn, found her rejecting, con-trolling, and moody. She began to feel that she hadmade a mistake in marrying him.

Recently she has also been having difficultiesat work. She is assigned the most menial tasksat the firm and is never given an assignment ofimportance or responsibility. She admits thatshe frequently does a slipshod job of what isgiven her, never does more than is required, andnever demonstrates any assertiveness or initia-tive to her supervisors. She views her boss asself-centered, unconcerned, and unfair, but nev-ertheless admires his success. She feels that shewill never go very far in her profession becauseshe does not have the right connections, andneither does her husband; yet she dreams ofmoney, status, and power.

Her social life with her husband involvesseveral other couples. The man in these couplesis usually a friend of her husbands. She is surethat the women find her uninteresting and un-impressive and that the people who seem to likeher are probably no better off than she.

Under the burden of her dissatisfaction withher marriage, her job, and her social life, feelingtired and uninterested in life, she now enterstreatment for the third time.3

Discussion. This young executive complainsof pervasive depression in all aspects of her life,dating back to adolescence. In DSMIVTR, herproblems would have most likely been character-ized as dysthymic disorder, although criteria fordepressive PD were included in the appendix forcriteria sets and axes provided for further study. Itis controversial whether a depressive PD can bedistinguished from dysthymic disorder andwhether it would make a difference to either theclinician or the patient, but the criteria for depres-sive PD emphasized cognitive, interpersonal, andintrapsychic personality traits, as opposed to phys-ical symptoms of depression, which were moreprominent in the criteria for dysthymic disorder.Other clinicians might conceptualize her problemsas a self-defeating PD (an appendix diagnosis inDSMIIIR).

3Junior Executive. Reprinted with permission from the

DSMIVTR Casebook, (Copyright, 2002). American Psy-chiatric Association.


Fn3


The patients pervasive feelings of inferiorityand low self-esteem are indicators of problemswith the regulation of self-states consistent with aproblem in personality functioning. Although shedreams of money, status, and power, she doesthe minimum required of her at work, and a poorjob of it at that, and lacks assertiveness and initia-tive, preferring to blame others for her lack ofsuccess. This suggests significant problems inself-direction, as well. Her simultaneous self-defeating patterns of behavior and attempts todiminish others, while also envying them anddreaming of their success, suggests the constructof covert narcissism, an important variant of nar-cissism that is not well represented in DSMIVTR. She has little capacity for appreciating othersexperiences, little understanding of processes ofsocial causality, and little regard even for herhusband. The combination of these problems inself and interpersonal functioning warrant a ratingof 2 moderate impairment on the Levels ofPersonality Functioning Scale.

This patient also does not appear to bear aclose resemblance to any of the five proposedPD types for DSM-5. The flavor of her per-sonality pathology, therefore, needs to be de-scribed in terms of her trait profile. The pre-dominant trait domain in her case is negativeemotionality. An appropriate rating might be a2moderately descriptive, primarily becausethe traits she exhibits in this domain are mostlylimited to traits that describe her depressivepersonality style. She would receive ratings of3 extremely descriptive on the trait facets ofdepressivity, pessimism, and low self-esteem.Other traits of the NE domain (e.g., anxious-ness) are not notable. She also exhibits someless characteristic traits from the detachment(e.g., anhedonia, restricted affectivity) and an-tagonism (e.g., hostility) domains.

In applying the general criteria for PD, an im-paired sense of self or identity is manifested al-most exclusively by problems in self-directedness,that is, her difficulty in setting and achieving (andthe disconnect between these) satisfying and re-warding personal goals. The degree of identitydisintegration and deficient integrity of self-concept described in the currently proposed gen-eral criteria for PD are at a level of dysfunctionthat does not fit this case. Impaired empathic ca-pacity and capacity for intimate interpersonal re-lationships also suggest a PD. Depressive traits areclearly extreme, longstanding, and exhibited

across interpersonal contexts. As stated at the out-set of this case discussion, whether and why a PDdiagnosis should be made in a patient who meetscriteria for dysthymic disorder is controversial. Itwould be hard to argue that this womans person-ality trait characteristics are independent of herdysthymic disorder (the criteria for which includedepressed mood, low self-esteem, and feelings ofhopelessness), so a PD diagnosis would not bemade. The information about her impairments inpersonality functioning, however, would nonethe-less be useful to the clinician in formulating atreatment plan that should include psychotherapy,in forming an alliance in that treatment, and inconsidering likely treatment outcomes.


Levels of personality functioning. 2(moderate impairment).

Type. None.Clinically significant traits. Trait domain:

negative emotionality. Trait facets: depressiv-ity, pessimism, low self-esteem.

PD general criteria met? No.

Conclusions

The four-part assessment of personality psy-chopathology proposed for DSM-5 focuses at-tention on identifying personality psychopathol-ogy with increasing degrees of specificity,based on a clinicians available time, informa-tion, and expertise. In Part II, of this two-partarticle, we have illustrated the clinical applica-tion of the model with vignettes of patients withvarying degrees of personality psychopathol-ogy, selected from the DSMIV Casebook, toshow how assessments might be conducted anddiagnoses reached.

Impairments in personality functioning areoften evident in a patients clinical presenta-tion. A global rating of the level of personal-ity functioning can be elicited by a few basic,and presumably routine, questions that allmental health providers can ask and under-stand. If this is as far as an assessment can go,it will nevertheless provide information thatis predictive of more formal diagnoses of PDsand give guidance to treatment planning andoutcome. In some instances, a referral willneed to be made for a more thorough evalu-ation by a clinician experienced in personality

32 SKODOL ET AL.


and PD assessment, or conversely, a morethorough exam can be conducted as treatmentor follow-up proceeds with the initially eval-uating clinician.

Further characterization of personality typesand traits are the next steps. Certain PD types(e.g., borderline, antisocial) have implicationsfor treatment approaches with the greatest like-lihoods of success, as well as highlight thespecific therapeutic challenges associated withalliance building (Bender, 2009). Personalitytraits, at least at the domain level, have beenshown to predict physical health and psychoso-cial outcomes, overall mental health treatmenteffectiveness, as well as components of effec-tiveness, such as treatment compliance(Krueger & Eaton, in press). Thus, each step inthe evaluation of personality and personalitydisorders according to DSM-5 is expected toadd clinically relevant information, to be pur-sued as much as time, information, and exper-tise will allow.

References

Bender, D. S. (2009). Therapeutic alliance. In J. M.Oldham, A. E. Skodol, & Bender, D. S. (Eds.). Es-sentials of personality disorders (pp. 289308).Washington, DC: American Psychiatric Publishing.

Bender, D. S., Morey, L. C., & Skodol, A. E. (2011).Toward a model for assessing level of personalityfunctioning for DSM-5: An empirical review. Man-uscript submitted for publication.

Bouchard, M.-A., Target, M., Lecours, S., Fonagy,P., Tremblay, L.-M., Schachter, A., & Stein, H.(2008). Mentalization in adult attachment narra-tives: Reflective functioning, mental states, andaffect elaboration compared. Psychoanalytic Psy-chology, 25, 4766.

Diamond, D., Kaslow, N., Coonerty, S., & Blatt, S. J.(1990). Changes in separation-individuation andintersubjectivity in long-term treatment. Psycho-analytic Psychology, 7, 363397.

Hopwood, C. J., Malone, J. C., Ansell, E. B., Sanislow,C. A., Grilo, C. M., Pinto, A., . . . Morey, L. C. (inpress). Personality assessment in DSM-V: Empirical

support for rating severity, style, and traits. Journal ofPersonality Disorders.

Krueger, R. F., & Eaton, N. R. (in press). Personalitytraits and the classification of mental disorders: To-ward a more complete integration in DSM-V and anempirical model of psychopathology. PersonalityDisorders: Theory, Research, and Treatment.

Loffler-Stastka, H., Ponocny-Seliger, E., Fischer-Kern, M., & Leithner, K. (2005). Utilization ofpsychotherapy in patients with personality disor-der: The impact of gender, character traits, affectregulation, and quality of object-relations. Psy-chology and Psychotherapy: Theory, Researchand Practice, 78, 531548.

Morey, L. C., Bender, D. S., Verheul, R., Krueger,R. F., Livesley, J. L., & Skodol, A. E. Empiricalarticulation of a core dimension of personalitypathology. Unpublished manuscript.

Piper, W. E., Azim, H. F. A., Joyce, A. S., McCal-lum, M., Nixon, G. W. H., & Segal, P. S. (1991).Quality of object relations vs. interpersonal func-tioning as predictors of therapeutic alliance andpsychotherapy outcome. Journal of Nervous andMental Disease, 179, 432438.

Rottman, B. M., Ahn, W. K., Sanislow, C. A., &Kim, N. S. (2009). Can clinicians recognizeDSMIV personality disorders from five-factormodel descriptions of patient cases? AmericanJournal of Psychiatry, 166, 427433.

Spitzer, R. L., First, M. B., Shedler, J., Westen, D.,& Skodol, A. E. (2008). Clinical utility of fivedimensional systems for personality diagnosis:A consumer preference study. Journal of Ner-vous and Mental Disease, 196, 356 374.

Spitzer, R. L., Gibbon, M., Skodol, A. E., Williams,J. B. W., & First, M. B. (2002). DSMIVTRcasebook: A learning companion to the diagnosticand statistical manual of mental disorders, fourthedition, text revision. Washington, DC: AmericanPsychiatric Press.

Verheul, R., Andrea, H., Berghout, C. C., Dolan,C., Busschbach, J. J., van der Kroft, P. J. A., . . .Fonagy, P. (2008). Severity Indices of Person-ality Problems (SIPP-118): Development, factorstructure, reliability and validity. PsychologicalAssessment, 20, 2334.

Westen, D., Shedler, J., & Bradley, R. (2006). A pro-totype approach to personality disorder diagnosis.American Journal of Psychiatry, 163, 846856.

(Appendices follow)



Appendix A

Levels of Personality Functioning

Personality psychopathology fundamentallyemanates from disturbances in thinking aboutself and others. Because there are greater andlesser degrees of disturbance of the self andinterpersonal domains, individual patientsshould be assessed using the following contin-uum comprised of levels of self and interper-sonal functioning.

Each level is characterized by typical func-tioning in the following areas:

Self

1. Identity integration. Regulation of self-states; coherence of sense of time and personalhistory; ability to experience a unique self andto identify clear boundaries between self andothers; capacity for self-reflection.

2. Integrity of self-concept. Regulation ofself-esteem and self-respect; sense of autono-mous agency; accuracy of self-appraisal; qual-ity of self-representation (e.g., degrees of com-plexity, differentiation, and integration).

3. Self-directedness. Establishment of in-ternal standards for ones behavior; coherenceand meaningfulness of both short-term and lifegoals.

Interpersonal

1. Empathy. Ability to mentalize (createan accurate model of anothers thoughts andemotions); capacity for appreciating others ex-periences; attention to range of others perspec-tives; understanding of social causality.

2. Intimacy and cooperativeness. Depthand duration of connection with others; toler-ance and desire for closeness; reciprocity ofregard and support and its reflection in interper-sonal/social behavior.

3. Complexity and integration of represen-tations of others. Cohesiveness, complexityand integration of mental representations of oth-ers; use of other-representations to regulate self.

As with the General Diagnostic Criteria forPersonality Disorder, in applying these dimen-sions diagnostically, self and interpersonal dif-ficulties must:

A. Be multiple years in duration.B. Not be solely a manifestation or conse-

quence of another mental disorder.C. Not be due solely to the direct physiolog-

ical effects of a substance or general medicalcondition.

D. Not be better understood as a norm withinan individuals cultural background.

Self and Interpersonal FunctioningContinuum

Please indicate the level of personalityfunctioning that most closely characterizesthe patient:

_____ 0 No impairment._____ 1 Mild impairment._____ 2 Moderate impairment._____ 3 Serious impairment._____ 4 Extreme Impairment.

Definitions of Levels

0 No Impairment

Self. There is awareness of having a uniqueidentity, grounded in personal history, alongwith continuity in self states and the ability tothink about and make sense of internal experi-ence. Identity remains intact and alive in thecontext of relationships. The self-concept is as-sociated with a relatively consistent and self-regulated level of positive self-esteem and self-respect, and self-appraisal is accurate. The selfrepresentation is complex and multifaceted,with a sense of appropriate autonomy andagency, and the ability to set and aspire toreasonable personal goals and behavior stan-dards, and to attain a sense of fulfillment in life.

(Appendices continue)

34 SKODOL ET AL.


Interpersonal. The capability to understandand appreciate the full range of others experi-ences is intact and there is ongoing awareness ofothers perspectives. The effect of personal ac-tions on others is readily comprehended, and theresponse to a range of others ideas, emotions andbehaviors is flexible. There is desire for and en-gagement in multiple affiliative and reciprocal re-lationships. Others are viewed as complex, multi-faceted, autonomous individuals, and contradic-tions and shortcomings are adequately reconciled.Representations of others are used for constructiveself-regulation.

1 Mild Impairment

Self. A sense of a unique, historical identity isrelatively intact, but there may be some variationin self states and interpersonal boundaries due tostrong emotions. There is the ability to reflectupon internal experiences, but possible overem-phasis on a single (e.g., intellectual, emotional)type of self-knowledge rather than integrating alltypes. Typical self-representation is multifaceted,and self-esteem is moderately well-regulated, al-though self-criticism may be too strong or tooweak. There is an appropriate sense of autonomyand agency, but goal-directedness may be exces-sive or somewhat maladaptive. Conversely, theremay be conflicts among goals or goal-inhibitionrelated to an unrealistic or socially inappropriateset of personal standards. Satisfaction in someaspects of life is attainable.

Interpersonal. The ability to appreciateand understand others experiences is somewhatcompromised, and others may be seen as havingunreasonable expectations or a wish for control.Awareness of the effect of personal behavior onothers is inconsistent. There is the capacity anddesire to form affiliative relationships, but ex-pression of this may be inhibited or constrainedby any intense emotion or conflict. The abilityto respond to the full range of others ideas,emotions and behaviors is somewhat limited, asis the capacity for understanding ones owncontributions to ongoing relationships. Othersare viewed as multifaceted, autonomous indi-viduals, with some ability to reconcile contra-

dictions and shortcomings. Representations ofothers can be used for self-regulation if notunder internal or perceived external pressure.

2 Moderate Impairment

Self. The regulation of self-states often de-pends on context, and there is impaired capacityto think about internal experience. A tendencytoward strong identifications with others may bemanifested in a somewhat less differentiatedsense of uniqueness, and an inconsistent per-sonal history. Self-esteem is controlled by ex-aggerated attention to external evaluation, witha wish for approval and admiration from otherpeople. A sense of incompleteness or inferioritymay be present, and self-appraisal is based onperceptions of external appraisals rather than oninternal assessment. Reactions may take theform of overidentification with negative ap-praisalsdeflation of self-esteemor compen-sation via an overt sense of self-importance orentitlement. Goals are often context-dependent,pursued to gain approval. Personal standardsmay be unreasonably high (e.g., with a con-structed self-view as special or in response tointernal or perceived external expectations), orlow (i.e., not consonant with prevailing socialvalues). Personal fulfillment is compromised bya sense of lack of authenticity.

Interpersonal. There is a considerable in-ability to consider multiple points of view,and extreme attention to the views of others,but only with respect to perceived self-relevance. A capacity and desire to form re-lationships is present, but connections may besuperficial and limited to meeting self-regulatory and self-esteem needs, and there isa general unawareness of the effect of per-sonal behavior on others. The ability to re-spond appropriately to others is compromisedand reciprocity is lacking; conversely there isan unrealistic expectation of being magicallyand perfectly understood by others. Views ofothers are limited and relatively simple, basedprimarily on need-fulfillment. Representa-tions of others are necessary, but sometimesinsufficient, means of self-regulation.




3 Serious Impairment

Self. Self-states are poorly regulated and un-stable, accompanied by confusion or lack of conti-nuity in personal history. Boundary definition is pooror rigid, there may be overidentification with others,overemphasis on independence from others, or vac-illation between these. The ability to think aboutones mental processes is significantly compromised.Self-concept is very fragile, easily influenced byevents and circumstances, and lacking coherence.The sense of agency is weak and the experience oflack of identity or emptiness is common. Self-appraisal is characterized by self-loathing, self-aggrandizing, or an illogical, unrealistic combinationof these. Self-representations are simplistic and con-crete, focused primarily on negative or positive attri-butes, or shifting between extremes. There is diffi-culty establishing and/or achieving personal goals.Internal standards for behavior are unclear, contra-dictory, and/or circumstantial. Life is often felt to bemeaningless or dangerous.

Interpersonal. The ability to understand thethoughts, feelings, and behavior of other people issignificantly limited, and there is confusion orunawareness of social causality, including the im-pact of ones actions on others. However, veryspecific aspects of others experience may be fo-cused upon, particularly vulnerabilities and short-comings. The ability to consider multiple points ofview is greatly impaired. Relationships are basedon a strong belief in the absolute need for intimateother(s), and/or expectations of abandonmentand/or abuse. Feelings about intimate involvementwith others alternate between fear or rejection anddesperate desire for connection. Relationships areminimally reciprocal; others are conceptualizedprimarily in terms of how they affect the self(negatively or positively). Ideas about others arefocused on others capacity for need fulfillment orabuse, and thus may vacillate between idealizationand denigration. Extreme and unstable represen-tations of others undermine self-regulation.

4 Extreme Impairment

Self. There is a profound inability to thinkabout ones experience. Self-states are virtu-ally unregulated and may go unnoticed and/orbe experienced as external to self. Experienceof a unique identity is virtually absent, as isany sense of continuity of personal history.Boundaries with others are confused or lack-ing. Self-concept is diffuse, and prone to sig-nificant distortions in self-appraisal. Self-representation is impoverished and concrete,and a sense of agency/autonomy is virtuallyabsent, or is organized around perceived ex-ternal persecution. Thoughts and actions arepoorly differentiated, so goal-setting ability isseverely compromised. Goals often are unre-alistic, and goal-setting is incoherent. Internalstandards for behavior are virtually lacking.Genuine fulfillment is elusive and virtuallyinconceivable, and extensive engagement infantasy may be used to compensate.

Interpersonal. The ability to consider andunderstand others experience and motivationis significantly impaired, and attention to oth-ers perspectives is virtually absent (attentionis hypervigilant, focused on need-fulfillmentand harm avoidance). Social interactions canbe confusing and disorienting. Desire for af-filiation is limited because of expectation ofharm. Engagement with others is detached,disorganized or consistently negative. Rela-tionships are conceptualized primarily aspower based, and considered in terms of theirability to provide comfort or inflict pain andsuffering. Social/interpersonal behavior is notreciprocal; rather, it represents basic approach(e.g., need fulfillment) and avoidance (e.g.,escape from pain) tendencies. Representa-tions of others are vague, global, and typicallydominated by negative and persecutory im-ages. Preoccupation with painful ideas aboutothers is destructive to self-regulation.


36 SKODOL ET AL.


Appendix B

DSM-5 Clinicians Personality Trait Rating Form

On the following pages are descriptive defini-tions of six broad personality trait domains,followed by definitions of specific trait facetsthat comprise each domain.4 All individualstrait levels fall somewhere on these dimensions,ranging from not at all descriptive to ex-tremely descriptive.

Some personality traits are easily summa-rized by a single label, whereas others are morecomplex. Therefore, we have defined each traitdimension, rather than simply providing labels.The extent to which a patient has each definedtrait is rated using the scale shown below. Theexample shown is the second broad trait do-main, Introversion. Please read the domain def-inition, think about the patient you are rating,and decide the extent to which the definingcharacteristics describe the patient.

Depending on the role of personality in pa-tients clinical pictures, you may rate their traitsin one of three ways:

(1) just the six broad trait domains for apersonality overview,

(2) all trait facets for a comprehensive per-sonality profile, or

(3) the six trait domains, followed by thecomponent trait facets comprising each of thosedomains for which the characteristics describethe patient 2 Moderately or 3 Extremelywell.

Please rate patients usual personality, whatthey are like most of the time.Example: Detachment5 Domain

Withdrawal from other people, ranging fromintimate relationships to the world at large; re-stricted affective experience and expression;limited hedonic capacity.

_____ 0 Very little or not at all descriptive._____ 1 Mildly descriptive._____ 2 Moderately descriptive._____ 3 Extremely descriptive.

For this trait, rate the extent to which thepatient shows (1) detachment from other peopleacross the range of relationships from intimateto the world at large, (2) restricted affectiveexperience and expression, and (3) limited he-donic capacity. If the definition describes thepatient very little or not at all, or is just mildlydescriptive, rate a 0 or a 1, respectively,whereas if the definition describes the patientmoderately or extremely well, rate a 2 or 3,respectively.

The six trait domains and the specific traitfacets comprising the domains follow:

_______ Negative emotionality. Experi-ences a wide range of negative emotions (e.g.,anxiety, depression, guilt/shame, worry, etc.),and the behavioral and interpersonal manifesta-tions of those experiences.

Trait facets. Emotional lability, anxiousness, sub-missiveness, separation insecurity, pessimism, lowself-esteem, guilt/shame, self-harm, depressivity,suspiciousness.

________ Detachment. Withdrawal fromother people, ranging from intimate relationshipsto the world at large; restricted affective experi-ence and expression; limited hedonic capacity.

Trait facets. Social withdrawal, social detachment,restricted affectivity, anhedonia, intimacy avoidance.

________ Antagonism. Exhibits diversemanifestations of antipathy toward others, and acorrespondingly exaggerated sense of self-importance.

4 The proposed set of trait domains and facets is beingtested for structural validity and is subject to change de-pending on the analytic results.

5 In the Work Groups original proposal, this domain wasnamed introversion, but in response to comments posted on theDSM-5 website, we are proposing changing it to detachment.This increases the consistency of labeling, because all of theother domain names reflect the high, typically maladaptive,end of the dimension, and the new label does so as well.



Fn4

Fn5


Trait facets. Callousness, manipulativeness, narcis-sism, histrionic style, hostility, aggression, opposition-ality, deceitfulness.

________ Disinhibition. Diverse manifes-tations of being present- (vs. future- or past-)oriented, so that behavior is driven by currentinternal and external stimuli, rather than bypast learning and consideration of futureconsequences.

Trait facets. Impulsivity, distractibility, recklessness,irresponsibility.

________ Compulsivity. The tendency tothink and act according to a narrowly definedand unchanging ideal, and the expectation thatthis ideal should be adhered to by everyone.

Trait facets. Perfectionism, perseveration, rigidity, or-derliness, risk aversion.

________ Schizotypy. Exhibits a range ofodd or unusual behaviors and cognitions, in-cluding both process (e.g., perception) and con-tent (e.g., beliefs).

Trait facets. Unusual perceptions, unusual beliefs,eccentricity, cognitive dysregulation, dissociationproneness.

Full Rating Scale

Negative emotionality. Experiences awide range of negative emotions (e.g., anxiety,depression, guilt/shame, worry, etc.), and thebehavioral and interpersonal manifestations ofthose experiences.

________ Emotional liability. Having un-stable emotional experiences and frequent, largemood changes; having emotions that are easilyaroused, intense, and/or out of proportion toevents and circumstances.

________ Anxiousness. Having frequent,persistent, and intense feelings of nervousness/tenseness/being on edge; worry and nervousnessabout the negative effects of past unpleasant ex-periences and future negative possibilities; feelingfearful and threatened by uncertainty.

________ Submissiveness. Subservienceand unassertiveness; advice and reassurance

seeking; lack of confidence in decision-making;subordination of ones needs to those of others;adaptation of ones behavior to the interests anddesires of others.

________ Separation insecurity. Havingfears of rejection by, and/or separation from, sig-nificant others; feeling distress when significantothers are not present or readily available; activeavoidance of separation from significant others,even at a cost to other areas of life.

________ Pessimism. Having a negativeoutlook on life; focusing on and accentuating theworst aspects of current and past experiences orcircumstances; expecting the worst outcome.

________ Low self-esteem. Having a pooropinion of ones self and abilities; believing thatone is worthless or useless; disliking or beingdissatisfied with ones self; believing that onecannot do things or do them well.

________ Guilt/shame. Having frequentand persistent feelings of guilt/shame/blame-worthiness, even over minor matters; believingone deserves punishment for wrongdoing.

________ Self-harm. Engaging inthoughts and behaviors related to self-harm(e.g., intentional cutting or burning) and sui-cide, including suicidal ideation, threats, ges-tures, and attempts.

________ Depressivity. Having frequentfeelings of being down/miserable/depressed/hope-less; difficulty bounding back from such moods;belief that one is simply a sad/depressed person.

________ Suspiciousness. Mistrust of oth-ers; expectations of and hyperalertness to signsof interpersonal ill-intent or harm; havingdoubts about others loyalty and fidelity; feel-ings of persecution.

Detachment. Withdrawal from other people,ranging from intimate relationships to the world atlarge; restricted affective experience and expres-sion; limited hedonic capacity.

________ Social withdrawal. Preferencefor being alone to being with others; reticence insocial situations; avoidance of social contactsand activity; lack of initiation of social contact.


38 SKODOL ET AL.


________ Social detachment. Indifferenceto or disinterest in local and worldly affairs;disinterest in social contacts and activity; inter-personal distance; having only impersonal rela-tions and being taciturn with others (e.g., solelygoal- or task-oriented interactions).

________ Intimacy avoidance. Disinter-est in and avoidance of close relationships,interpersonal attachments, and intimate sex-ual relationships.

________ Restricted affectivity. Lack ofemotional experience and display; emotionalreactions, when evident, are shallow and tran-sitory; unemotional, even in normally emotion-ally arousing situations.

________ Anhedonia. Lack of enjoymentfrom, engagement in, or energy for lifes expe-riences; deficit in the capacity to feel pleasure ortake interest in things.

Antagonism. Exhibits diverse manifesta-tions of antipathy toward others, and a corre-spondingly exaggerated sense of self-impor-tance.

________ Callousness. Lack of empathyor concern for others feelings or problems;lack of guilt or remorse about the negative orharmful effects of ones actions on others;exploitativeness.

________ Manipulativeness. Use of cun-ning, craft, or subterfuge to influence or controlothers; casual use of others to ones own advan-tage; use of seduction/charm/glibness/ingratia-tion to achieve ones own ends.

________ Narcissism. Vanity/boastful-ness/exaggeration of ones achievements andabilities; self-centeredness; feeling and actingentitled, firmly holding the belief that one isbetter than others and deserves only the best ofeverything in life.

________ Histrionism. Behaving so as toattract and be the focus of others attention; admi-ration seeking; flamboyance; audacity; inappropri-ate sexualization of interpersonal relationships.

________ Hostility. Irritability, hot tem-peredness; being unfriendly/rude/surly/nasty;responding angrily to minor slights and insults.

________ Aggression. Being mean/cruel/cold-hearted; verbally/relationally/physicallyabusive; engaging willingly and willfully in be-haviors that humiliate and demean others, andin acts of violence against persons and objects;active and open belligerence/vengefulness; useof dominance/intimidation to control others.

________ Oppositionality. Displaying de-fiance by refusing to cooperate with requests,meet obligations, and complete tasks; resent-ment of and behavioral resistance to reasonableperformance expectations; acting to undermineauthority figures.

________ Deceitfulness. Dishonesty, un-truthfulness; embellishment or fabricationwhen relating events; misrepresentation ofself; fraudulence.

Disinhibition. Diverse manifestations ofbeing present- (vs. future- or past) oriented,so that behavior is driven by current internaland external stimuli, rather than by past learn-ing and consideration of futureconsequences.

________ Impulsivity. Acting on the spurof the moment in response to immediate stim-uli; acting on a momentary basis without a planor consideration of outcomes; difficulty estab-lishing and following plans; failure to learnfrom experience.

________ Distractibility. Difficulty con-centrating and focusing on tasks (e.g., attentioneasily diverted by extraneous stimuli); difficultymaintaining goal-focused behavior, including afocus on conversations.

________ Recklessness. Engaging in dan-gerous, risky activities/behaviors unnecessarilyand without regard for consequences; boredomproneness and unplanned initiation of activitiesto counter boredom; lack of concern for oneslimitations; denial of the reality of personaldanger; high tolerance for uncertainty andunfamiliarity.

________ Irresponsibility. Disregard for,or failure to honor, financial and other obliga-tions or commitments; lack of respect and fol-low through on agreements and promises;




unreliability; failure to keep appointments or tocomplete tasks or assignments; carelessnesswith own and/or others possessions.

Compulsivity. The tendency to think andact according to a narrowly defined and un-changing ideal, and the expectation that thisideal should be adhered to by everyone.

________ Perfectionism. Insistence on ev-erything being flawless, without errors or faults,including ones own and others performance;conviction that reality should conform to onesown ideal vision; holding oneself and others tounrealistically high standards; sacrificing oftimeliness to ensure correctness in every detail.

________ Perseveration. Persistence attasks long after behavior has ceased to be func-tional or effective; belief that lack of success isdue solely to lack of effort or skill; continuanceof the same behavior despite repeated failures.

________ Rigidity. Being rule- and habit-governed; belief that there is only one right wayto do things; insistence on an unchanging rou-tine; difficulty adapting behaviors to changingcircumstances; processing of information on thebasis of fixed ideas and expectations; difficultychanging ideas and/or viewpoint, even withoverwhelming contrary evidence.

________ Orderliness. Need for order andstructure; insistence on everything having a cor-rect place or order; intolerance of things beingout of place; concern with details, lists, ar-rangements, schedules.

________ Risk aversion. Complete lack ofrisk-taking; unwillingness even to consider tak-ing even minimal risks; avoidance of activitiesthat have even a small potential to cause injury

or harm to oneself; strict adherence to behaviorsto minimize health and other risks.

Schizotypy. Exhibits a range of odd or un-usual behaviors and cognitions, including bothprocess (e.g., perception) and content (e.g., be-liefs).

________ Unusual perceptions. Havingodd experiences in various sensory modalities;experiencing synesthesia (cross-modal percep-tion); perceiving events and things in odd waysthat others do not.

________ Unusual beliefs. Content ofthoughts that is viewed by others of the sameculture and society as bizarre; idiosyncratic butdeeply held convictions that are not well justi-fied by objective evidence; interest in the occultand in unusual views of reality.

________ Eccentricity. Unusual behavior(e.g., unusual mannerisms; wearing clothes ob-viously inappropriate to the occasion or sea-son); saying unusual or inappropriate things;frequent use of neologisms; concrete and im-poverished speech; seen by others of the sameculture and society as bizarre, odd, and strange.

________ Cognitive dysregulation. Un-usual thought processes; having thoughts andideas that do not follow logically from eachother; derailment of ones train of thought; mak-ing loose associations or nonsequiturs; disorga-nized and/or confused thought, especially whenstressed.

________ Dissociation proneness. Ten-dency to experience disruptions in the flow ofconscious experience; losing time, (e.g., be-ing unaware of how one got to ones location);experiencing ones surroundings as strange orunreal.

40 SKODOL ET AL.


Skodol Et Al 2011 Part II

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