Table of Contents

  1. Introduction
  2. Alternative criteria
    1. General criteria, A & B
    2. AsPD
    3. AvPD
    4. BPD
    5. NPD
    6. OCPD
    7. StPD
    8. PD-TS

The DSM-5-TR Alternative Model

Introduction

The appendix of the DSM-5-TR includes an alternative model for PDs, since the current model for diagnosing personality disorders has issues that the DSM itself acknowledges (especially the fact that there’s a huge amount of overlap and most people would better fit the ‘other specified PD’ definition due to that overlap).

In the following alternative DSM-5 model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. This approach also includes a diagnosis of personality disorder—trait specified (PD-TS) that can be made when a personality disorder is considered present but the criteria for a specific disorder are not met.

The PDs included in this model are antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal PDs, as well as Personality Disorder - Trait Specified (similar to OSPD). It doesn’t include dependent, histrionic, paranoid or schizoid PDs.

Questions about the DSM-5-TR alternative model:

Alternate Criteria for Personality Disorders

The general criteria of a personality disorder is the same for all specific personality disorders. In this model, criteria A and B change depending on the specific PD, while criteria C to G stay the same for all PDs.

Criteria A describes the level of impairment the person with a PD has. “Impairments in functioning of the self” means impairment in identity and self-direction.

Identity is defined as:

“Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience.”

Self-direction is defined as:

“Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.”

“Impairments in interpersonal functioning” means impairment in empathy and intimacy.

Empathy is defined as:

“Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding of the effects of one’s own behavior on others.”

Intimacy is defined as:

“Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.”

Each PD criteria requires impairments in two or more of those (identity, self-direction, empathy and intimacy), and each PD has different ways of those impairments presenting.

Examples:

  • An identity impairment in AsPD looks like “Egocentrism; self-esteem derived from personal gain, power, or pleasure.”
  • A self-direction impairment in NPD looks like “Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.”
  • An empathy impairment in StPD looks like “Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others’ motivations and behaviors.”
  • An intimacy impairment in OCPD looks like “Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.”

Criteria B: The alternate model uses impairments in self (identity and self-direction) and interpersonal (empathy and intimacy) functioning to define a personality disorder. Within those, there are different trait domains. Each domain is characterised as the trait vs their polar opposite (i.e., unhealthy vs healthy traits).

  • Negative Affectivity (vs. Emotional Stability)
  • Detachment (vs. Extraversion)
  • Antagonism (vs. Agreeableness)
  • Disinhibition (vs. Conscientiousness)
  • Psychoticism (vs. Lucidity)

Negative Affectivity is defined as:

“Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger) and their behavioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations.”

Detachment is defined as:

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

Antagonism is defined as:

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

Disinhibition is defined as:

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

Psychoticism is defined as:

“Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs).”

This makes 25 trait facets, of different combinations, which each result in different personality traits and disorders. These domains are known as “The Big 5″ or the “Five Factor Model”.

The facets of the trait domains are:

  1. Negative Affectivity:
    1. Emotional lability (intense, unstable moods)
    2. Anxiousness
    3. Separation insecurity
    4. Submissiveness
    5. Hostility
    6. Perseveration (persistence)
    7. Depressivity
    8. Suspiciousness
    9. [Lack of] Restricted affectivity (* lack of restricted affectivity being a trait of Negative Affectivity, and the presence of restricted affectivity being a trait of Emotional Stability, Negative Affectivity’s opposite)
  2. Detachment:
    1. Withdrawal
    2. Intimacy avoidance
    3. Anhedonia (lack of enjoyment in life & activities, even fun ones)
    4. Depressivity
    5. Restricted affectivity (lack of emotional responses; indifference)
    6. Suspiciousness
  3. Antagonism:
    1. Manipulativeness
    2. Deceitfulness
    3. Grandiosity
    4. Attention seeking
    5. Callousness
    6. Hostility
  4. Disinhibition:
    1. Irresponsibility
    2. Impulsivity
    3. Distractability
    4. Risk taking
    5. [Lack of] Rigid perfectionism (* lack of rigid perfectionism being a trait of Disinhibition, and the presence of rigid perfectionism being a trait of Conscientiousness, Disinhibition’s opposite)
  5. Psychoticism:
    1. Unusual beliefs and experiences
    2. Eccentricity
    3. Cognitive and perceptual dysregulation (odd speech & thoughts, dissociation, etc)

As you can see, there is some overlap between domains. You can probably also see that some PDs fit a lot of the facets of a domain, like NPD & AsPD fitting many of the facets of Antagonism, or AvPD with Detachment.

Trait facets have their own polar opposites, for example callousness & kindness. Just because callousness is seen as ‘negative’ doesn’t mean that kindness can’t be destructive - being unable to see the negative sides of people makes it easy for someone to be taken advantage of.

While these traits are persistent in people with PDs, they can wax and wane in their severity. People without PDs also have these traits; it’s the combination and severity of them that make them symptoms of personality disorders.

Of each domain, every PD is high in one aspect and low in another. AsPD, for example, is high in Antagonism and Disinhibition, and therefore low in Agreeableness & Conscientiousness. Out of all the PDs in the Alternate Model, only OCPD is high in a domain’s polar opposite (Conscientiousness, as opposed to Disinhibition).

General criteria for Personality Disorder

  1. Moderate or greater impairment in personality (self/interpersonal) functioning.
  2. One or more pathological personality traits.
  3. The impairments in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.
  4. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.
  5. The impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder.
  6. The impairments in personality functioning and the individual’s personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).
  7. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normal for an individual’s developmental stage or sociocultural environment.

Antisocial Personality Disorder

Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Antagonism and Disinhibition.
  1. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
    1. Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure.
    2. Self-direction: Goal setting based on personal gratification; absence of prosocial internal standards, associated with failure to conform to lawful or culturally normative ethical behavior.
    3. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.
    4. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.
  2. Six or more of the following seven pathological personality traits:
    1. Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends.
    2. Callousness (an aspect of Antagonism): Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others; aggression; sadism.
    3. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.
    4. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
    5. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to counter boredom; lack of concern for one’s limitations and denial of the reality of personal danger.
    6. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.
    7. Irresponsibility (an aspect of Disinhibition): Disregard for—and failure to honor—financial and other obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises.

Specify if with psychopathic features.

Psychopathy (or “primary” psychopathy) is marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence). This psychopathic variant is characterized by low levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment domain) and high levels of attention seeking (Antagonism domain). High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/resilience) component.

Avoidant Personality Disorder

Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Negative Affectivity and Detachment.
  1. Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:
    1. Identity: Low self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame.
    2. Self-direction: Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.
    3. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others’ perspectives as negative.
    4. Intimacy: Reluctance to get involved with people unless being certain of being liked; diminished mutuality within intimate relationships because of fear of being shamed or ridiculed.
  2. Three or more of the following four pathological personality traits, one of which must be (1) Anxiousness:
    1. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to social situations; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrassment.
    2. Withdrawal (an aspect of Detachment): Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
    3. Anhedonia (an aspect of Detachment): Lack of enjoyment from, engagement in, or energy for life’s experiences; deficits in the capacity to feel pleasure or take interest in things.
    4. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

Borderline Personality Disorder

Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition.
  1. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
    1. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.
    2. Self-direction: Instability in goals, aspirations, values, or career plans.
    3. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.
    4. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between overinvolvement and withdrawal.
  2. Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:
    1. Emotional lability (an aspect of Negative Affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.
    2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.
    3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection by—and/or separation from—significant others, associated with fears of excessive dependency and complete loss of autonomy.
    4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.
    5. Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.
    6. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.
    7. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

Narcissistic Personality Disorder

Typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Antagonism.
  1. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
    1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.
    2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.
    3. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimation of own effect on others.
    4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.
  2. Both of the following pathological personality traits:
    1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.
    2. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.

Obsessive-Compulsive Personality Disorder

Typical features of obsessive-compulsive personality disorder are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Negative Affectivity and/or Detachment.
  1. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
    1. Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.
    2. Self-direction: Difficulty completing tasks and realizing goals, associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.
    3. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.
    4. Intimacy: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.
  2. Three or more of the following four pathological personality traits, one of which must be (1) Rigid perfectionism:
    1. Rigid perfectionism (an aspect of extreme Conscientiousness [the opposite pole of Disinhibition]): Rigid insistence on everything being flawless, perfect, and without errors or faults, including one’s own and others’ performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order.
    2. Perseveration (an aspect of Negative Affectivity): Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.
    3. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.
    4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.

Schizotypal Personality Disorder

Typical features of schizotypal personality disorder are impairments in the capacity for social and close relationships and eccentricities in cognition, perception, and behavior that are associated with distorted self-image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, along with specific maladaptive traits in the domains of Psychoticism and Detachment.
  1. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
    1. Identity: Confused boundaries between self and others; distorted self-concept; emotional expression often not congruent with context or internal experience.
    2. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
    3. Empathy: Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others’ motivations and behaviors.
    4. Intimacy: Marked impairments in developing close relationships, associated with mistrust and anxiety.
  2. Four or more of the following six pathological personality traits:
    1. Cognitive and perceptual dysregulation (an aspect of Psychoticism): Odd or unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or stereotyped thought or speech; odd sensations in various sensory modalities.
    2. Unusual beliefs and experiences (an aspect of Psychoticism): Thought content and views of reality that are viewed by others as bizarre or idiosyncratic; unusual experiences of reality.
    3. Eccentricity (an aspect of Psychoticism): Odd, unusual, or bizarre behavior or appearance; saying unusual or inappropriate things.
    4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.
    5. Withdrawal (an aspect of Detachment): Preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.
    6. Suspiciousness (an aspect of Detachment): Expectations of—and heightened sensitivity to—signs of interpersonal ill-intent or harm; doubts about loyalty and fidelity of others; feelings of persecution.

Personality Disorder - Trait Specified

This diagnosis is intentionally broad, allowing clinicians to tailor the diagnosis to their client’s unique disordered personality.
  1. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:
    1. Identity
    2. Self-direction
    3. Empathy
    4. Intimacy
  2. One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains:
    1. Negative Affectivity (vs. Emotional Stability): Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger), and their behavioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations.
    2. Detachment (vs. Extraversion): Avoidance of socioemotional experience, including both withdrawal from interpersonal interactions, ranging from casual, daily interactions to friendships to intimate relationships, as well as restricted affective experience and expression, particularly limited hedonic capacity.
    3. Antagonism (vs. Agreeableness): Behaviors that put the individual at odds with other people, including an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self-enhancement.
    4. Disinhibition (vs. Conscientiousness): Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences.
    5. Psychoticism (vs. Lucidity): Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs).