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Journal of Personality Disorders, 25(2), 136–169, 2011© 2011 The Guilford Press
From University of Arizona College of Medicine and Sunbelt Collaborative, Tucson, AZ (A. E. S., D. S. B.); Texas A&M University, College Station, TX (L. C. M.); University of Notre Dame, South Bend, IN (L. A. C.); Menninger Clinic and Baylor College of Medicine, Houston, TX (J. M. O.); Mayo Clinic College of Medicine, Rochester, MN (R. D. A.); University of Minnesota, Minneapolis, MN (R. F. K.); University of Amsterdam, Amsterdam, NL (R. V.); University of Illinois at Chicago, Chicago, IL (C. C. B.); and Mt. Sinai School of Medicine, New York, NY (L. J. S.)
Address correspondence to Andrew E. Skodol, MD, Sunbelt Collaborative, 6340 N. Campbell Ave., Suite 130, Tucson, AZ 85718; E-mail: askodol@gmail.
Personality DisorDer tyPes ProPoseD for DsM-5
Andrew E. Skodol, MD, Donna S. Bender, PhD,
Leslie C. Morey, PhD, Lee Anna Clark, PhD, John M. Oldham, MD, Renato D. Alarcon, MD, Robert F. Krueger, PhD,
Roel Verheul, PhD, Carl C. Bell, MD, and Larry J. Siever, MD
The Personality and Personality Disorders Work Group has proposed
five specific personality disorder (PD) types for DSM-5, to be rated on a
dimension of fit: antisocial/psychopathic, avoidant, borderline, obses-
sive-compulsive, and schizotypal. Each type is identified by core im-
pairments in personality functioning, pathological personality traits,
and common symptomatic behaviors. The other DSM-IV-TR PDs and
the large residual category of personality disorder not otherwise speci-
fied (PDNOS) will be represented solely by the core impairments com-
bined with specification by individuals’ unique sets of personality traits.
This proposal has three main features: (1) a reduction in the number of
specified types from 10 to 5; (2) description of the types in a narrative
format that combines typical deficits in self and interpersonal function-
ing and particular configurations of traits and behaviors; and (3) a di-
mensional rating of the degree to which a patient matches each type.
An explanation of these modifications in approach to diagnosing PD
types and their justifications—including excessive co-morbidity among
DSM-IV-TR PDs, limited validity for some existing types, lack of speci-
ficity in the definition of PD, instability of current PD criteria sets, and
arbitrary diagnostic thresholds—are the subjects of this review.
The Personality and Personality Disorder Work Group has proposed five specific personality disorder (PD) types for DSM-5, to be rated on a dimen-sion of fit: antisocial/psychopathic, avoidant, borderline, obsessive-compul-sive, and schizotypal. Each type is identified by core impairments in personality fun
ctioning, pathological personality traits, and common symptomatic behaviors. Each is derived from—though not identical to—
TYPES PROPOSED 137 the corresponding DSM-IV-TR PD. The other DSM-IV-TR PDs and the large residual category of PDNOS will be represented solely by the core impairments combined with specification by individuals’ unique sets of personality traits, and a diagnosis of personality disorder trait-specified (PDTS) will be given. See Table 1, DSM-5 Borderline Personality Disorder Type with Matching Scale, for an example of a type description and the rating scale. See Krueger et al. in this issue for a description and discus-sion of the personality trait structure proposed for DSM-5.1
The proposal for the specified PD types in DSM-5 has three main fea-tures: (1) a reduction in the number of specified types from 10 to 5; (2) description of the types in a narrative format that combines typical defi-cits in self and interpersonal functioning and particular configurations of traits and behaviors; and (3) a dimensional rating of the degree to which a patient matches each type. The justifications for these modifications in approach to diagnosing PD types include excessive co-morbidity among DSM-IV-TR PDs, limited validity for some existing types, lack of specificity in the definition of PD, instability of current PD criteria sets, and arbitrary diagnostic thresholds.2
Considerable research has shown excessive co-occurrence among PDs diagnosed using the categorical system of the DSM (Clark, 2007; Oldham, Skodol, Kellman, Hyler, & Rosnick, 1992; Zimmerman, Rothchild, & Chel-minski, 2005). In fact, most patients diagnosed with PDs meet criteria for more than one. Some DSM-IV-TR PDs that rarely occur in the absence of other Axis I and II disorders also have little evidence of validity. The cur-rent DSM-IV-TR general criteria for PD3 were not empirically based and are not sufficiently specific, so they may apply equally well to other types of mental disorders (e.g., schizophrenia). PD diagnoses have been shown in longitudinal follow-along studies to be significantly less stable over time than their definition in DSM-IV-TR implies (e.g., Grilo et al., 2004). Final-ly, all of the PD categories have arbitrary diagnostic thresholds (i.e., the number of criteria necessary for a diagnosis). A reduction in the number of types is expected to reduce co-morbid PD diagnoses by eliminating less valid types. The requirement of core impairments in self and interpersonal functioning helps to distinguish personality pathology from other disor-1. Since the posting of proposed changes by the Personality and Personality Disorders Work Group on the APA’s DSM-5 Website () in early 2010, revisions of the proposal have been made.  Most relevant to this article, the type descriptions have been edited to be
more concise and the type ratings have been separated from trait ratings, with the intention of determi
ning these relationships empirically in the DSM-5 Field Trials.  Core impairments in personality functioning represented by the Levels of Personality Functioning have been simplified and the levels, type, and trait ratings have been incorporated into revised General Criteria for Personality Disorder.
2. The authors of this article requested an opportunity to see and respond to the specific comments and critiques made by other contributors to this special issue, to ensure that their concerns were addressed.  The editor of the journal and those of this special issue denied our request.
3. Briefly, “An enduring pattern of inner experience and behavior manifested in two or more of the following: cognition, affectivity, interpersonal functioning, and impulse control.”
138 SKODOL ET AL.
ders. The addition of specific traits to behavioral PD criteria is anticipated to increase diagnostic stability. And, the use of a dimensional rating of the types recognizes that personality psychopathology occurs on continua.nUMBer anD sPeCifiCation of tyPes
Five specific PDs are being recommended for retention in DSM-5: anti-social/psychopathic, borderline, schizotypal, avoidant, and obsessive-compulsive. Space limitations preclude a complete justification fo
r the five PDs retained, but each DSM-IV-TR PD was the subject of a literature review performed by Work Group members and advisors. Antisocial/ psychopathic, borderline, and schizotypal PDs have the most extensive empirical evidence of validity and clinical utility (e.g., Chemerinski, Trieb-wassen, Roussos, & Siever, under review; New, Triebwasser, & Charney, 2008; Patrick, Fowles, & Krueger, 2009; Skodol, Siever, et al., 2002; Skodol, Gunderson, Pfohl, et al., 2002; Siever & Davis, 2004). In contrast, there are almost no empirical studies focused explicitly on paranoid, schizoid, or histrionic PDs.The DSM-IV-TR PDs not represented by a specific type (paranoid, schiz-taBle 1. Borderline Personality Disorder type with Matching scale
Individuals who resemble this personality disorder type have an impoverished and/or unstable self-structure and difficulty maintaining enduring and fulfilling intimate relationships. Self-concept is easily disrupted under stress, and often associated with the experience of a lack of identity or chronic feelings of emptiness. Self-appraisal is filled with loathing, excessive criticism, and despondency. There is sensitivity to perceived interpersonal slights, loss or disappointments, linked with reactive, rapidly changing, intense, and unpredictable emotions. Anxiety and depression are common. Anger is a typical reaction to feeling misunderstood, mistreated, or victimized, which may lead to acts of aggression toward self and others. Intense distress and characteristic impulsivity may also prompt oth
er risky behaviors, including substance misuse, reckless driving, binge eating, or dangerous sexual encounters.
Relationships are often based on excessive dependency, a fear of rejection and/or abandonment, and urgent need for contact with significant others when upset. Behavior may sometimes be highly submissive or subservient. At the same time, intimate involvement with another person may induce fear of loss of identity as an individual—psychological and emotional engulfment. Thus, interpersonal relationships are commonly unstable and alternate between excessive dependency and flight from involvement. Empathy for others is significantly compromised, or selectively accurate but biased toward negative elements or vulnerabilities. Cognitive functioning may become impaired at times of interpersonal stress, leading to concrete, black-and-white, all-or-nothing thinking, and sometimes to quasi-psychotic reactions, including paranoia and dissociation.
Instructions: Rate the patient’s personality using the 5-point rating scale shown below. Circle the number that best describes the patient’s 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
TYPES PROPOSED 139 oid, histrionic, narcissistic, and dependent), the Appendix PDs (depressive and negativistic), and the residual category of PDNOS will be diagnosed as PD trait-specified (PDTS) and will be represented by mild impairment or greater on the Levels of Personality Functioning (Table 2) continuum (Bender, Maeg, & Skodol, under review), combined with descriptive speci-fication of patients’ personality trait profiles. In general, these PDs are in contrast to the above proposed types, which are structurally more com-plex and represent combinations of multiple traits from across different higher order trait domains. Thus, the proposed types represent a consid-eration of types as particularly salient configurations or interactions of traits—in contrast to the remaining disorders, which can be largely mod-eled using fewer traits, often from a single, specific trait domain.
In the following sections, we highlight literature relevant to the retention vs. deletion of DSM-IV-TR PDs as specified types in DSM-5. Most DSM-IV-TR PDs suffer from the problem of excessive co-occurrence with other PDs (i.e., poor discriminative validity), but the relative weight of evidence of clini
cal utility and external validity favors retention of some of these disor-ders more than others. For most PDs, neurobiological and/or genetic data
taBle 2. levels of Personality functioning1
Self:
1. I dentity: Experience of oneself as unique, with boundaries between self and others;
coherent sense of time and personal history; stability and accuracy of self-appraisal and self-esteem; capacity for a range of emotional experience and its regulation
2. S elf-direction: Pursuit of coherent and meaningful short-term and life goals; utilization
of constructive and prosocial internal standards of behavior; ability to productively self-reflect
Interpersonal:
1. E mpathy: Comprehension and appreciation of others’ experiences and motivations;
tolerance of differing perspectives; understanding of social causality
2. I ntimacy: Depth and duration of connection with others; desire and capacity for closeness;
mutuality of regard reflected in interpersonal behavior
In applying these dimensions, self and interpersonal difficulties should not be better understood as a norm within an individual’s dominant cultural.
Self and Interpersonal Functioning Continuum
Please indicate the level that most closely characterizes the patient’s functioning in the self and interpersonal realms:
_____ No Impairment
_____ Mild Impairment
_____ Moderate Impairment
_____ Serious Impairment
_____ Extreme Impairment
reaction to a book or an article1The original full scale with definitions of terms and detailed definitions of scale points is provided elsewhere (see Skodol, Bender, et al., 2011).
140 SKODOL ET AL. are sparse and findings are nonspecific (as is also the case for most Axis I disorders).
ANTISOCIAL/PSYCHOPATHIC
The median prevalence of ASPD across 12 epidemiological studies is 1.1%, roughly average for PDs in the community (Torgersen, 2009). Individuals with ASPD in the community have been found to have significantly- reduced quality of life, but not to the degree of individuals with avoidant PD (AVPD) or several other PDs (Cramer, Torgersen, & Kringlen, 2006). Individuals with ASPD have been found to have problems with status and wealth and with successful intimate relationships (Ulrich, Farrington, & Coid, 2007), but not with psychosexual dysfunction (Zimmerman & Cory-ell, 1989). ASPD was also associated with poor quality of life in the NESARC (Grant et al., 2004) and with moderate dysfunction on the GAFS (Crawford et al., 2005). In two large clinical populations (combined N = 1975) diag-nosed with semi-structured PD interviews, the prevalence of ASPD was 3.9%, making it one of the less-commonly found PDs in clinical settings (Stuart et al., 1998; Zimmerman, Rothchild, & Chelminski, 2005).
ASPD is one of the most frequently studied PDs, however. The construct of ASPD is widely accepted, although there are controversies about spe-cific aspects of the disorder. In general, the core features include egocen-trism, callousness, exploitation, immorality, aggressiveness, hostility, impulsiveness, irresponsibility, criminality, sadism, risk behaviors, and fearlessness. With respect to current models of psychopathy (Patrick et al., 2009), the proposed prototype for antisocial/psychopathic PD includes both traits related to a disinhibition component (i.e., traits corresponding most directly to the adult features of DSM-IV-TR antisocial PD) and traits related to the construct of meanness (i.e., traits related to callousness/ lack of remorse, conning/manipulativeness, and predatory aggression). There is abundant evidence that the impulsive-antisocial (disinhibited-externalizing) and affective-interpersonal (boldness-meanness) compo-nents of psychopathy substantially co-occur, but differ in terms of their neurobiological correlates and etiologic determinants (e.g., see Moffit, 2005; Patrick, 2006), which provides a strong foundation for formulating and testing questions in relation to distinctive antisocial and psychopath-ic PD trait profiles, both within ASPD and across other PDs and other mental disorders (Edens, Marcus, Lilienfeld, & Poythress, 2006; Rutter, 2005).
Due to its history, well-established validity, obvious importance in fo-rensic settings, and relationships to other types of psychopathology (e.g., alcohol and substance use disorders, see Compton, Conway,
Stinson, Col-liver, & Grant, 2005), and other problems (e.g., poor physical health, ob-sesity, see Goldstein et al., 2008), a revised construct of ASPD that in-cludes psychopathic personality features has been recommended for retention in DSM-5.

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