What is the classification of personality disorders according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)?

Classification of Personality Disorders in DSM-5

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), personality disorders are classified using a categorical model with specific diagnostic types, while an alternative dimensional model is included in Section III for further study.

Traditional Categorical Classification (Section II)

The DSM-5 maintains the traditional categorical approach to personality disorders in its main diagnostic section, organizing them into three clusters:

Cluster A (Odd or Eccentric)

• Paranoid Personality Disorder 1
• Schizoid Personality Disorder 1
• Schizotypal Personality Disorder 2

Cluster B (Dramatic, Emotional, or Erratic)

• Antisocial Personality Disorder 2, 3
• Borderline Personality Disorder 2, 3
• Histrionic Personality Disorder 4
• Narcissistic Personality Disorder 4, 3

Cluster C (Anxious or Fearful)

• Avoidant Personality Disorder 2, 3
• Dependent Personality Disorder 4, 3
• Obsessive-Compulsive Personality Disorder 2, 3

Alternative Model for Personality Disorders (Section III)

DSM-5 includes an alternative dimensional-categorical hybrid model in Section III ("Emerging Measures and Models") that represents a significant shift in conceptualizing personality disorders 1, 5:

Key Components of the Alternative Model:

• Criterion A: Assessment of impairments in personality functioning (self and interpersonal) 5
• Criterion B: Evaluation of pathological personality traits across five domains 3, 5:
  • Negative Affectivity
  • Detachment
  • Antagonism
  • Disinhibition
  • Psychoticism

Specific Personality Disorder Types in the Alternative Model:

• Antisocial/Psychopathic 2
• Avoidant 2
• Borderline 2
• Obsessive-Compulsive 2
• Schizotypal 2

Limitations and Controversies

• The DSM-5 Personality and Personality Disorders Work Group initially proposed eliminating five personality disorders (paranoid, schizoid, histrionic, narcissistic, and dependent), but this proposal was not accepted by the American Psychiatric Association Board of Trustees 4, 1
• The alternative model was placed in Section III rather than replacing the traditional categorical system due to concerns about implementation and clinical utility 1, 5
• Research shows mixed empirical support for the elimination of certain personality disorders, with evidence suggesting dependent personality disorder has similar validity to disorders proposed for retention 4

Clinical Implications

• The traditional categorical system continues to be the official diagnostic approach for clinical practice 1
• The dimensional approach in Section III addresses limitations of the categorical system, including excessive comorbidity, arbitrary diagnostic thresholds, and instability of criteria sets 2, 5
• Research on the alternative model shows acceptable interrater reliability, consistent latent structures, and convergence with clinically relevant external measures 5
• The high correlation between Criterion A (severity) and Criterion B (traits) poses conceptual challenges for the alternative model 5

Comparison with ICD-11 Approach

• The ICD-11 has moved to a primarily dimensional approach to personality disorders, similar to the DSM-5 alternative model 5
• In ICD-11, personality disorders are characterized by problems in functioning of aspects of self and interpersonal dysfunction 6
• ICD-11 differentiates personality disorders by severity (mild, moderate, severe) rather than discrete categories 6
• ICD-11 allows specification of maladaptive personality traits: negative affectivity, detachment, dissociality, disinhibition, anankastia, and borderline pattern 6

The DSM-5 categorical system remains the standard for clinical diagnosis in the United States, while the alternative dimensional model continues to be researched for potential implementation in future editions 1, 5.