What are the DSM‑5 criteria for diagnosing a personality disorder?

DSM-5 General Criteria for Personality Disorders

The DSM-5 defines a personality disorder as an enduring pattern of inner experience and behavior that deviates markedly from cultural expectations, is pervasive and inflexible, has onset in adolescence or early adulthood, is stable over time, and leads to clinically significant distress or impairment in functioning. 1

Core Diagnostic Requirements

To diagnose any personality disorder in DSM-5, the following general criteria must be met:

Pattern Requirements

• An enduring pattern manifesting in at least two of these areas: 1, 2
  • Cognition (ways of perceiving and interpreting self, others, and events)
  • Affectivity (range, intensity, lability, and appropriateness of emotional response)
  • Interpersonal functioning
  • Impulse control

Clinical Significance Criteria

• The pattern must be pervasive and inflexible across a broad range of personal and social situations 1, 2
• Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning 3, 1
• The pattern is stable and of long duration, with onset traceable to at least adolescence or early adulthood 1, 2

Exclusion Criteria

• Not better explained by another mental disorder 1
• Not attributable to the physiological effects of a substance (drug of abuse, medication) or another medical condition (head trauma) 1
• Not a manifestation of another developmental stage 1

DSM-5 Alternative Model (Section III)

The DSM-5 includes an alternative dimensional-categorical hybrid model that represents a significant reconceptualization: 1, 4

Two-Component Assessment

• Impairments in personality functioning involving problems with self (identity and self-direction) and/or interpersonal functioning (empathy and intimacy) 1, 4
• Pathological personality traits evaluated across five broad domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism 1, 4

Severity Grading

• The alternative model allows dimensional rating of severity rather than categorical present/absent diagnosis 5, 4
• This addresses the problem of arbitrary diagnostic thresholds and excessive comorbidity seen with the traditional categorical approach 5

Specific Personality Disorder Types in DSM-5

The traditional DSM-5 (Section II) retains 10 specific personality disorder types, while the alternative model (Section III) proposes only 5 types: 5

Five Types Retained in Alternative Model

• Antisocial/Psychopathic
• Avoidant
• Borderline
• Obsessive-Compulsive
• Schizotypal 5

Borderline Personality Disorder Specific Criteria

• Onset in early adulthood with pervasive pattern including: 1
  • Repeated suicide attempts and non-lethal self-injury
  • Pervasive impulsivity strongly associated with suicidality
  • Unstable mood and interpersonal relationships
  • Varying self-concept
  • Dissociative symptoms
  • Self-damaging behaviors

Critical Assessment Considerations

Multi-Informant Approach Required

• Gather information from multiple sources using varied developmentally sensitive techniques, as self-reporting is unreliable in personality disorders 6, 1
• Use structured interviews rather than self-report questionnaires due to patients' impaired insight 1
• Informant discrepancies should be expected and do not invalidate the diagnosis 1

Common Diagnostic Pitfalls to Avoid

• Do not diagnose based solely on stressor exposure without documented functional impairment across multiple settings 3
• Lack of patient insight is expected and does not exclude diagnosis—it is a core feature distinguishing personality disorders from other psychiatric conditions 1
• Assess who initiated the consultation and whether the patient over- or under-emphasizes disability, as these observations provide diagnostic information independent of patient insight 1
• Do not pathologize normal developmental variations or culturally normative behaviors 1

ICD-11 Comparison

The World Health Organization's ICD-11 has moved to a fully dimensional approach: 6, 1

• Single personality disorder diagnosis characterized by problems in self-functioning and interpersonal dysfunction 6, 1
• Severity grading: mild, moderate, or severe 6, 1
• Optional trait specification including dissociality, negative affectivity, detachment, disinhibition, anankastia, or borderline pattern 6, 1
• Field studies demonstrate greater clinical utility for treatment planning and communication compared to categorical systems 1