What is the special issue about?
In 2013, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American Psychiatric Association, 2013) was released. Arguably the most influential diagnostic nosology for mental illness in the world, each new iteration is met with considerable interest from mental health providers and researchers alike. After decades of discussion regarding the need for a massive reframing of the diagnostic system for personality disorders, the DSM–5 included two distinct diagnostic approaches. Section II contains the traditional system, which has remained largely unchanged over several decades. Section III, which is devoted to emerging models and measures, presents the proposed Alternative Model for Personality Disorders (AMPD) with the intention of stimulating research on the AMPD that might support the model’s future inclusion in the main body of the DSM (i.e., Section II). The AMPD had been intended to be the primary diagnostic system by the DSM–5 Personality and Personality Disorder Work Group, but the model was rejected by oversight committees. The July special issueopens in new window of Personality Disorders: Theory, Research, and Treatment reviews the state of the science on the AMPD nearly 10 years after its publication to evaluate how close it is to being legitimized and moved to Section II.
In the first section of the special issue, we have four major articles. We were fortunate to have DSM–5 Personality and Personality Disorder Work Group members write articles on Criterion A (personality dysfunction; Morey et al., 2022) and Criterion B (pathological personality traits; Clark & Watson, 2022). An article providing an overall summary of the model was cowritten by a key DSM–IV member (Widiger & Hines, 2022). The final major article summarizes the clinical utility of the AMPD (Bach & Tracy, 2022). For each of these four articles, we obtained three expert commentaries to bring a diversity of opinions and perspectives to bear on each topic.
The next section of the special issue consists of six brief reviews of the success of the AMPD in capturing the six traditional DSM personality disorders included in the AMPD: schizotypal, antisocial/psychopathic, borderline, narcissistic, avoidant, and obsessive-compulsive.
Ultimately, the goal of this special issue is that readers—both those well-informed about key issues and those with less expertise in this content area—can come away with a good sense of the research base on the AMPD, areas of agreement and disagreement, and key issues that need further study.
What is the significance of the issue?
Given widespread disapproval of the traditional, categorical approach to the diagnostic system for personality disorders, the AMPD represents for many a significant advancement that improves the diagnosis of personality disorders. The AMPD diagnoses personality disorder on the basis of the presence of personality dysfunction (i.e., difficulties in relation to self and others) and pathological personality traits (i.e., problematic levels of negative affectivity, detachment, antagonism, disinhibition, and/or psychoticism). As with the Section II diagnostic model, these difficulties have to be long-standing, persistent, and pervasive and cause significant distress and/or impairment. This model offers quite a bit of flexibility in allowing for traditional, categorical diagnoses (e.g., borderline), as well as more dimensional diagnoses via the personality disorder—trait specified approach. However, its major innovation lies in its dimensionalization of personality pathology—that is, it describes personality from typical to atypical and uses dimensions instead of categories to explain covariation of symptoms of psychopathology and to denote personality pathology. As such, the AMPD addresses many of the validity issues of the categorical personality disorders currently contained in Section II of the DSM–5.
Tell us about a few key takeaways.
An impressive amount of research has been conducted on the AMPD since the DSM–5’s publication in 2013. Important aspects of the validity, reliability, and clinical utility of both the entry criterion of the AMPD (level of personality functioning) and the second criterion of the AMPD (maladaptive trait model) have been demonstrated. In addition, excellent convergence between Section III defined personality disorder types and Section II defined personality disorders was demonstrated (with the exception of obsessive-compulsive personality disorder). The latter demonstration goes relatively far in allaying concerns that the adoption of the AMPD would effectively erase decades of research and clinical practice in these personality disorder categories.
The reviews and commentaries also highlight several areas for further discussion and improvement. First, attention should continue to be paid to optimizing measurement precision in the assessment of the level of both personality functioning and maladaptive traits. Second, research is needed to show that AMPD-defined personality disorders demonstrate at least similar, if not superior, patient outcomes as Section II–defined personality disorders. In addition, most of the research of the last 10 years has focused on components of the AMPD (either the level of personality functioning or the maladaptive trait model), and more research is needed on the AMPD as the integrated, hierarchical two-step process that it was designed to be.
Despite these areas of needed improvement, the evidence reported in support of the validity, reliability, and clinical utility of the AMPD in this special issue points to the potential readiness of the AMPD to be legitimized by being moved to Section II of the DSM.
What are some practical implications of the articles featured in the issue?
The main practical implication of the articles in this special issue is that the assessment and diagnosis of personality disorder can be changed to a dimensional system in which a clinician diagnoses personality disorder by first identifying the severity of impairment in self- and interpersonal function and then determining the level of severity in maladaptive trait domains. A major practical implication of adopting such a dimensional system would be the downgrading of the traditional categorial personality disorders of Section II to specifiers. Such downgrading would harmonize the DSM system with the new International Statistical Classification of Diseases and Related Problems (11th ed.; i.e., ICD-11) system in which all categorial personality disorders were removed, with the exception of borderline personality disorder, which was retained as a specifier. Legitimizing the AMPD in Section II of the DSM would have another important practical implication: It would stimulate the research needed to address the areas of needed improvement identified in this special issue.
This article is in the Clinical Psychology topic area. View more articles in the Clinical Psychology topic area.