In DSM-IV-TR, if maladaptive personality traits are part of the clinical picture but do not constitute a formal PD, the clinician is encouraged to record these traits on Axis II. Nevertheless, DSM-IV-TR does not provide a specific model for conceptualizing these traits, beyond their appearance as features of the 10 PDs. This is in spite of the fact that there has been much interest recently in the etiology (van den Oord et al. 2008
; de Moor et al. 2011
), treatment (Tang et al. 2009
), clinical relevance (Hopwood et al. 2008
), and social costs (Cuijpers et al. 2010
) of personality traits in the psychiatric literature.
Our aim in the current research was (a) to construct a preliminary maladaptive personality trait model for DSM-5 and then (b) to test and refine it through the creation of a provisional corresponding assessment instrument. This research was conducted under the auspices of the DSM-5 personality and personality disorders workgroup, by members of the workgroup and workgroup consultants. Nevertheless, it is critical to emphasize that no decisions have been formalized regarding the conceptualization of PDs in DSM-5, or regarding the ways in which the constructs of personality traits and PDs might best be represented in DSM-5. By disseminating our findings to date in this report, our hope is to stimulate additional research from other investigators that can inform DSM-5 and subsequent revisions.
With regard to a personality trait model suitable for DSM-5, a variety of compelling models exist, instantiated in a corresponding variety of assessment instruments (for reviews see Trull & Durrett, 2005
and Clark, 2007
). The DSM-5 workgroup and consultants (a number of whom are authors of published measures of clinically-relevant personality constructs; Clark et al. in press
; Livesley & Jackson, 2009
; Morey, 2003
) began by reviewing these existing models and measures of maladaptive personality traits, with a particular focus on reviews completed as part of a 2004 pre-DSM-5 research planning meeting. In particular, Widiger and Simonsen (2005)
provided evidence that four broad bipolar domains (i.e., domains with two opposite ends) of extraversion vs. introversion, antagonism vs. compliance, constraint vs. impulsivity, and negative affect vs. emotional stability could serve as an organizing framework for traits seen across 18 models that had been described in the literature. They also described a fifth potential domain, “unconventionality versus closedness to experience,” but noted that this domain was not well represented in the models they reviewed, although it is a major domain assessed by the Revised NEO Personality Inventory (NEO PI-R; Costa & McCrae, 1992
). Moreover, a recent meta-analysis showed essentially zero correlation between this domain and DSM-IV PDs (Samuel & Widiger, 2008
). Nevertheless, other research has identified a domain of peculiar or odd traits that provides coverage of features corresponding with some key components of Schizotypal PD, i.e., “cognitive or perceptual distortions and eccentricities of behavior” (DSM-IVTR, p. 685; Chmielewski & Watson, 2008
; Harkness et al. 1995
). Hence, in addition to the four major domains identified by Widiger and Simonsen (2005)
, we also sought to identify and measure traits in a fifth domain of psychoticism, resulting in a model that, at the domain-level, bears a strong resemblance to Harkness' Personality Psychopathology 5 (PSY-5) model of clinically relevant personality variants (Harkness et al. 1995
Our focus was initially on identifying and operationalizing specific maladaptive personality dimensions falling within five broad domains, with a focus on the poles of these domains that are associated with PD (i.e., introversion, antagonism, impulsivity, negative affect, and psychoticism). That is, the features of PD tend to be concentrated at specific poles of these domains. In a meta-analytic review of literature linking the Five Factor Model of personality ([FFM]; see Costa & Widiger, 2002
; Goldberg, 1993
—which bears a strong resemblance to the model described by Widiger and Simonsen)—with the DSM-IV PDs (Samuel & Widiger, 2008
), DSM-IV PDs were associated with introversion (the absence of FFM extraversion), antagonism (the absence of FFM agreeableness), impulsivity (the absence of FFM conscientiousness), and negative affect (FFM neuroticism). There were only two exceptions: an association between histrionic PD and FFM extraversion, and an association between obsessive compulsive PD and FFM conscientiousness. Hence, we endeavored to ensure that our trait list also covered core features of histrionic PD and obsessive compulsive PD. DSM-IV describes the core features of histrionic PD as “excessive emotionality and attention seeking” (p. 685) so we ensured coverage of those two primary traits. DSM-IV describes the core features of obsessive compulsive PD as “preoccupation with orderliness, perfectionism, and control” (p. 685). These traits broadly define the constraint pole of impulsivity vs. constraint in the Widiger and Simonsen model. Hence, we focused on the delineation and measurement of specific maladaptive traits in the domains of (I, high pole) introversion, (II, high pole) antagonism, (III, high pole) impulsivity vs. (III, low pole) constraint, (IV, high pole) negative affect, and (V, high pole) psychoticism. As described below, we subsequently changed the name of the introversion domain to detachment and the name of the impulsivity domain to disinhibition, to better reflect the content of these domains, at least as that content emerged in our project.
In sum, our approach was to synthesize existing models to arrive at a model and assessment instrument that (a) encompass the four major domains of maladaptive personality variation identified by Widiger and Simonsen (2005)
, with explicit measurement of the poles of those domains associated with DSM-IV-TR PDs; (b) also contains an additional fifth domain of psychoticism; and (c) contains multiple specific maladaptive trait facets within all five domains, with a focus on covering the maladaptive trait features of DSM-IV-TR PDs. To our knowledge, no existing model and assessment instrument encompasses this complete set of features. An additional consideration regarding existing models is that these models are not suited to being imported verbatim into the DSM because they are typically operationalized in specific, commercially-available assessment instruments. In sum, our approach was to draw broadly on research on existing models, to frame the generation of an empirically-based model and measure that is freely available and can be employed in research that can inform DSM-5 and beyond.