Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2018 Oct 1.
Published in final edited form as: J Pers Disord. 2017 Sep 14;31(5):577–589. doi: 10.1521/pedi_2017_31_338

THE CHALLENGE OF TRANSFORMING THE DIAGNOSTIC SYSTEM OF PERSONALITY DISORDERS

Sabine C Herpertz 1, Steven K Huprich 1, Martin Bohus 1, Andrew Chanen 1, Marianne Goodman 1, Lars Mehlum 1, Paul Moran 1, Giles Newton-Howes 1, Lori Scott 1, Carla Sharp 1
PMCID: PMC5735999  NIHMSID: NIHMS920917  PMID: 28910213

Abstract

While the DSM-5 alternative model of personality disorder (PD) diagnosis allows the field to systematically compare categorical and dimensional classifications, the ICD-11 proposal suggests a radical change by restricting the classification of PDs to one category, deleting all specific types, basing clinical service provision exclusively upon a severity dimension, and restricting trait domains to secondary qualifiers without defining cutoff points. This article reflects broad international agreement about the state of PD diagnosis. It is argued that diagnosis according to the ICD-11 proposal is based on broad, potentially stigmatizing descriptions of impaired functioning and ignores much of the impressive body of research and treatment guidelines that have advanced the care of adults and adolescents with borderline and other PDs. Before radically changing classification, which highly impacts the provision of health care, head-to-head field trials coupled with the views of patients as well as thorough debate among scientists are urgently needed.

The subject of diagnosis in psychiatry is often polarizing, evoking strong and varied opinions and with no clear framework for achieving consensus. While there is general agreement about the importance of accurately diagnosing mental disease, the best means to accomplish this remain unclear (P. McGorry & van Os, 2013). Over the years, this has been reflected in terms such as “subtypes within categories” (e.g., Gabbard, 1989; Russ, Shedler, Bradley, & Westen, 2008), transdiagnostic approaches (Etkin & Cuthbert, 2014), clinical staging (P. D. McGorry, 2007), higher-order structure of phenotypic expression of psychopathology (Clark, Watson, & Reynolds, 1995), or hierarchical taxonomy of psychopathology (Kotov et al., 2017). Age-old debates continue regarding the best way to represent mental disorders, as either distinct categories with extensive comorbidity or as a continuum that is not more sharply distinct from healthy states.

In the absence of a clear understanding about the etiology and biological underpinnings of mental disorders, psychiatric classification remains inherently limited to a descriptive approach. This has proven particularly problematic in the field of personality disorders (PDs). Debate about the strengths and weaknesses of categories versus dimensions came to the forefront in the preparation of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association [APA], 2013) and has been reignited by the proposal for the 11th edition of the World Health Organization‘s International Classification of Diseases (ICD-11) to reclassify PDs based on an assessment of severity of disturbance in interpersonal functioning and a five-factor, dimensional structure of personality, while completely refraining from a categorical approach (Tyrer, Crawford, Mulder, & ICD-11 Working Group, 2011).

Diagnosis has been described as classification with utility (Kendell & Jablensky, 2003). Beyond satisfying the scientific requirements inherent in any medical diagnosis (E. Robins & Guze, 1970), a diagnostic system should have clinical utility, that is, fulfill the needs of patients, clinicians, and policymakers in mental health care. This key requirement of a diagnostic system should guide clinical decision-making and provide useful information about treatment selection, prognosis, and clinical outcomes. Second, the diagnostic system should assist patients to reach an informed decision about which treatment is most likely to help them in their recovery. Third, classification should ideally inform the public resourcing of mental health services and thus ensure the necessary support for those affected. Fourth, the diagnostic system must be informed by robust science and simultaneously serves as a pragmatic research framework to assist future research endeavors. For all of these reasons, a diagnostic system, such as ICD-11, must create reliable and valid diagnoses underlying communication among clinicians, patients, insurance companies, governments, policymakers, and researchers.

LIMITATIONS OF A CATEGORICAL APPROACH

In the modern era, the use of categorical approaches for disorder-specific research dates back to the 1960s for antisocial PD (L. N. Robins, 1966), the 1980s for borderline PD (Gunderson & Zanarini, 1987), and the 1990s for schizotypal PD (Gunderson & Zanarini, 1987; Siever & Davis, 2004), but there are well-documented limitations to this approach (Clark, 2007; Samuel, South, & Griffin, 2015). Many studies have provided evidence that there is continuity between normal and abnormal personalities (Pukrop, Herpertz, Sass, & Steinmeyer, 1998; Widiger, Simonsen, Krueger, Livesley, & Verheul, 2005). Extensive co-occurrence among PDs—with many individuals meeting three or more categories—suggests that a unique condition, as defined by a categorical PD, is artificially segregated into multiple diagnoses, making it hard to develop a comprehensive understanding of patients’ problems in order to identify specific treatments. Further, the high prevalence of the Personality Disorder Not Otherwise Specified (PDNOS) category provides little information about the psychopathology of a specific patient. Longitudinal studies, such as the Collaborative Longitudinal Study of Personality Disorders (CLPS) and the McLean Study of Adult Development (MSAD), have shown that although patients might “remit” from the disorder over time (i.e., no longer meet criteria for a PD), functional impairment is an enduring feature for many people with PD (Gunderson et al., 2011; Hopwood et al., 2013; Keuroghlian, Frankenburg, & Zanarini, 2013; Walter et al., 2009; Zanarini, Frankenburg, Reich, & Fitzmaurice, 2012). The CLPS data showed that trait-based descriptions performed better in predicting functioning than PD categories (Hopwood et al., 2007). There are also compelling data from other sources showing that change in personality traits predicts change in PDs but not vice versa (Warner et al., 2004), suggesting that traits more closely resemble the reality of PD than categories (Newton-Howes, Clark, & Chanen, 2015).

A further point of criticism relates to the high heterogeneity of PD diagnoses, which affects the reliability of clinicians’ diagnoses and makes treatment planning difficult. Further criticisms of the categorical model include the arbitrary diagnostic thresholds and restricted clinical ability to predict efficacy of treatment (Skodol et al., 2011). In addition, factor analytic studies have failed to replicate the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; APA, 1994) or DSM-5 Section II structure of personality pathology (Sharp et al., 2015; Wright, Hopwood, Skodol, & Morey, 2016). Finally, with limited resources in health economies, psychiatry is challenged to carefully consider the severity of presenting difficulties in addition to diagnostic labels in order to differentiate the urgency and intensity of treatment needed.

In conclusion, there are several well-founded arguments that categorical diagnoses are not sufficiently empirically grounded and do not provide a reliable enough means for individual treatment planning.

THE ALTERNATIVE MODEL OF PERSONALITY DISORDER ACCORDING TO DSM-5, SECTION III: A HYBRID APPROACH

The alternative model of PD within section III of DSM-5 attempts to take into account some of the above-mentioned limitations. It emphasizes functional impairments of the self and in the interpersonal realm as the principal features of PD and proposes a normative metric against which personality dysfunction is measured (Bender, Morey, & Skodol, 2011). This alternative model of PD also conceptualizes pathological trait dimensions in addition to categories to represent individual differences among patients within one category or beyond categorical diagnoses. This dimensional approach includes 5 factor analytically derived broad trait domains and 25 more specific trait facets that have been operationalized with reference to clinical conditions and are thus potentially helpful for fine-grained descriptions of individual psychopathology and subsequent implications for treatment planning. Additionally, instruments measuring functional impairment (Level of Personality Functioning Scale [PFS]; Bender et al., 2011) as well as trait facets (Personality Inventory for DSM-5 [PID-5]; Krueger, Derringer, Markon, Watson, & Skodol, 2012) have been empirically developed. For instance, in a recent review of the literature, Al-Dajani, Grainick, and Bagby (2016) reported that there are now 29 empirical studies on the PID-5’s psychometric properties; however, only eight of these studies were conducted using clinical samples. Further, Al-Dajani and colleagues note that only one paper (based on six case studies) described the clinical application of the PID-5 (Bach, Markon, Simonsen, & Krueger, 2015), raising unresolved questions about its clinical utility. Thus, while promising, more research is needed to compare this model with the traditional categorical one and to arrive at a more effective integration of the two determinants of diagnosing PDs, that is, functional impairment and trait facets. In addition, the extrapolation of the hybrid model to personality pathology in young people is virtually non-existent (in contrast to the categorical approach). Nonetheless, there remain many important reasons to consider dimensional frameworks and to incorporate this perspective in future diagnostic models.

THE ICD-11 PROPOSAL: LIMITATIONS OF A PURELY DIMENSIONAL APPROACH

In contrast to DSM-5, the ICD-11 proposal restricts the classification of PD to one category: that is, the patient either does or does not meet the general definition of PD. If the general criteria are met, a second step evaluates the severity of the personality disturbance (mild, moderate, severe). The assessment of any specific PD type has been relinquished. Instead, in a third step, five trait domains (negative affectivity, dissociality, disinhibition, anankastia, and detachment) representing broad, heterogeneous constructs can be used to qualify the profile of the personality structure that underlies personality dysfunction. Thus, the ICD-11 proposal differs from the alternative model of Section III of DSM-5, which uses traits as diagnostic criteria for the existing PD categories (Oltmanns & Widiger, 2017). While there are some strengths to the ICD-11 proposal, particularly that it appears to be simple to use and that it considers the measurement of severity (notwithstanding limitations outlined below), there are major limitations.

First, although the general criteria for PD are similar to previous descriptions in ICD-10 and DSM-IV, they will become the prime diagnostic criteria in ICD-11. Yet, there is only one rather small field trial that has assessed the reliability of the yes/no decision based on these general criteria (Kim, Blashfield, Tyrer, Hwang, & Lee, 2014).

Second, the introduction of a severity dimension in ICD-11, with a related assessment instrument, is valuable and appears to be useful, as changes in functional impairments due to age, natural course, and treatment in particular can be better represented. However, the proposed ICD-11 diagnosis is based on only broad descriptions of impaired functioning, that is, illustrating examples for mild, moderate, and severe PD, without providing a “normative image of a well-functioning personality” (Zimmermann, 2015, slide 11). Such a high level of abstraction is likely to diminish reliability of diagnosis. Also, it opens the door to stigmatizing PD diagnosis, arising from the global clinical impression of the very first communication between patient and clinician, instead of one based on objective and reliable criteria. The risk of stigmatizing might be particularly high, given that the estimation of severity is entirely based on functioning and not suffering, with a focus on harm to self or others. An extremely important aspect of any mental health treatment is for the clinician to orient the patient to her/his disorder in a phenomenological and non-pejorative manner that can reduce stigma and generate hope and promote treatment engagement. This approach is key in several current major approaches to treat PD, but we fear that the proposed ICD-11 diagnosis will be unsuitable as a tool for this important psychoeducational task.

Third, in the ICD-11 proposal, the trait domains are secondary qualifiers with no facet-level detail being provided. Clinical service provision is exclusively based on the severity dimension without considering the trait domains and trait facets that ultimately will direct clinical management. Consequently, services might be asked to deliver treatment to “severe” patients with no indication of what problems this might denote. In addition, no guidance is provided on the threshold at which a trait might be considered pathological. While impressive research has been conducted on the measurement of the dimensions, a trait model without empirically defined cutoff points could prompt clinicians, and—what might be more critical—health policymakers and funding bodies to be the ones making decisions about whether a patient is sufficiently distressed or impaired to warrant a clinical service. Instead of basing these important clinical decisions on two levels of the diagnostic process, that is, severity of malfunctioning and trait-based descriptions of the personality profile including relationships between them, they will be restricted to the assessment of severity alone, thereby separating the decision about whether treatment is needed from the one about which treatment to offer (e.g., when to provide hospitalization, when to recommend which psychotherapy method or/and medication, or when to shift a patient into a specialized treatment). We assume that as confusion plays out with the roll-out of the new ICD-11 proposal, clinicians will most likely continue to use a prototypic category-matching process in order to organize clinical information and to facilitate treatment decisions.

Fourth, although PDs could, in principle, be subsumed within a trait-based dimensional framework, personality traits per se are not usually the reason for a clinical referral. For instance, difficulties in interpersonal functioning or relational patterns that are enacted with a psychotherapist often become the focus of clinical attention (Westen, 1997), and the ICD-11 model has no clear means with which to assess these issues. Borderline PD is the most important PD in clinical practice, and a large volume of research shows that for patients with this disorder explicit attention to relationship dynamics is central to successful treatment outcome (e.g., Clarkin, Lenzenweger, Yeomans, Levy, & Kernberg, 2007; Clarkin, Levy, Lenzenweger, & Kernberg, 2007; Fonagy & Bateman, 2008; Ryle, 2004; Stanley & Brodsky, 2009).

Fifth, for general care settings, the ICD-11 group has recommended that the field should be content with the assessment of the degree of severity, and assessment of trait domains is only expected to be conducted by a specialist (Tyrer, Reed, & Crawford, 2015). Yet it is unclear who might be appropriately qualified to undertake this specialist role and—most importantly—how this designation might translate to treatment recommendations. We think it is unlikely that patients will be satisfied with a provider who suggests there is a problem with their personality, but without offering more specification of the problem. Will a patient consulting a mental health care provider understand that no distinction is made between habitual antisocial attitudes and behaviors on the one hand and negative affectivity associated with, for example, avoidant and dependent PD symptoms on the other? Critically, we currently lack the understanding of the patient perspective about classification and, in particular, whether patients prefer a categorical or a dimensional approach for communicating with them about their difficulties. We think that empirical data on this key issue is required in order to inform any revision to classification.

Sixth, in arguing for accepting the ICD-11 proposal in its current form, Hopwood and colleagues (Hopwood et al., in press) write that the “majority of clinicians and researchers support a transition to a more dimensional, evidence-based framework” (p. 4). This statement is inaccurate and conflates the science in support of a dimensional structure of personality pathology with a diagnostic system for PD. Studies actually indicate mixed findings about the support for dimensions over categories (Lowe & Widiger, 2009; Morey, Skodol, & Oldham, 20141; Rottman, Ahn, Sanislow, & Kim, 2009; Spitzer, First, Shedler, Westen, & Skodol, 2008). While a recent study (Nelson, Huprich, Shankar, Sohnleitner, & Paggeot, 2017) found that psychology graduate students and interns preferred the DSM-5 Section IIII trait ratings over categorical or prototype models, it also found that the Psychodynamic Diagnostic Manual (PDM) framework (PDM Task Force, 2006) was more appreciated for its comprehensiveness and that trainee age was positively correlated with favorable ratings of the PDM. These findings are consistent with a number of others that show that practicing clinicians with many years of experience find prototype models preferable to dimensional models. Thus, it is important that future research evaluates not only the perceived utility of dimensional and categorical models, but also how clinical judgment, discipline, and experience shape the perceived utility.

Seventh, in the case of borderline PD, one of the most highly prevalent and relevant categories in clinical samples, recent studies have reported that this PD cannot be sufficiently represented on the five domains but that a further broad domain incorporating borderline, histrionic, and narcissistic symptoms needs further research (Mulder, Horwood, Tyrer, Carter, & Joyce, 2016). Alternatively, borderline PD is assumed to be rather a general factor that should not be separated as a specific domain but “captures common variance in diverse expressions of personality” (Sharp et al., 2015, p. 394) or might reflect more symptoms than traits (Tyrer, 2009), compared with other domains. Thus, it is essential that research validate the factor structure of personality pathology with external criteria before overhauling the entire diagnostic system.

Eighth, it is noteworthy and unusual that ICD-11 intends to codify some nosological categories but not others. For instance, dissociative identity disorder or possession trance disorder and specific subtypes of impulse control disorders can be diagnosed in a rather differentiated and categorical manner. Yet, the ICD-11 proposal advocates for removal of PD types including borderline PD, which affects up to 3% of the general population. Only relatively recently have PDs, and particularly borderline PD, become recognized as common mental disorders associated with increased long-term impairment, morbidity, and mortality among adults (Fok et al., 2014; Quirk et al., 2016). For adolescents, our recognition of PDs as diagnosable conditions (Bjorkenstam, Bjorkenstam, Holm, Gerdin, & Ekselius, 2015; Sharp & Fonagy, 2015) with very serious long-term implications for mental health and social functioning (Moran et al., 2016) is even more recent. This recognition has had a strong and positive impact on the development, adaptation, and implementation of treatments for patients, particularly young people (Chanen, 2015). Nevertheless, the proposed system completely ignores this impressive body of research and clinical guidelines that have advanced the care of adolescent and adults with this disorder. While Hopwood and colleagues (Hopwood et al., in press) claim that many of the extant categories are “clinically problematic” (p. 4), there are well documented accounts of the empirical scope and clinical management of DSM–derived borderline (Linehan, 1993), dependent (Bornstein, 1993) and narcissistic (Ronningstam, Gunderson, & Lyons, 1995) PDs, as well as empirically derived descriptions of most of the DSM-IV/5 PDs and how to engage and treat patients with these diagnoses (Clarkin, Fonagy, & Gabbard, 2010; Livesley, 1995). What should be done with this information and body of (largely publicly funded) research and clinical experience, especially since it was never conducted within a trait-based dimensional framework?

Ninth, much of the preexisting work points to a number of issues about personality pathology that are outside of the ICD-11 dimensional framework, such as object relatedness, attachment patterns, coping behaviors, situational specificity of problems, patient-therapist interactions, developmental history, sequelae of trauma, accessibility of unconscious or nonconscious schema or representations, and habitualized patterns of learned behavior. There are, in particular, decades of research on the construct of borderline PD which have led to the understanding that affectivity of borderline PD is not sufficiently described by negative emotions but is closely interwoven with rejection hypersensitivity (Gunderson, 2010) and damaged self-esteem (Winter, Bohus, & Lis, 2017), and that social dysfunctioning in borderline PD is not sufficiently described by either disinhibition/dissociality or negative affectivity or both but is mediated by a complex interplay of social threat sensitivity, low affect regulation capacity, and poor social cognition (Herpertz, Jeung, Mancke, & Bertsch, 2014). Probably even more important, evidence-based psychotherapy programs have substantially helped patients with categorically diagnosed borderline PD, with comparable effect sizes to treatments in other mental disorders (Cristea et al., 2017). Thus, if the borderline PD diagnosis were to disappear in the ICD-11 (and other diagnostic manuals), what would this do to groups of patients who have already suffered from discrimination and under-provision of mental health care for too long?

The selection of the optimal classification scheme needs to be informed by evidence, but to our knowledge, there has only been one rather small head-to-head field trial (Kim et al. 2014) comparing the face or predictive validity of DSM-5 section II versus ICD-11 proposals. We would encourage such studies, as they might help to guide the field forward. Moreover, we are not aware of any guidelines in the clinical or empirical literature that document how broad trait domains might be utilized in clinically meaningful ways (see Clarkin & Huprich, 2011, and Meehan & Clarkin, 2015, for a further discussion of these issues), except for a recent set of published case studies based on the DSM-5 alternative model (Bach et al., 2015).

To conclude, a radical revision to the classification of PDs must result in reliable and valid diagnoses that provide clinical utility and that minimize the risk of stigmatizing patients. Future classification of PDs should incorporate the hard-won scientific gains about the disorders’ etiology, course, and treatment. We fear, however, that the proposed changes in the ICD-11 could cause more harm than good, by promulgating confusion in our field and alienating the very members of society we are trying to help.

CONCLUSION: RECOMMENDING A HYBRID MODEL

The magnitude of the changes proposed for ICD-11 is immense, while the rationale is still incomplete and the evidence inconsistent and limited. Although PD criteria belonging to the current categorical classification have justifiably been accused of being inconsistent amalgams of impairments, traits, and symptomatic behaviors, we first have to clarify the relations among these features. In addition, the optimal factor structure that best represents the meta-structure of personality pathology needs to be validated by means of field trials.

Importantly, several of the critiques of categorical diagnosis of PD put forward by the ICD-11 work group on PDs are in fact critiques against psychiatric nosology in general (Chanen, 2011). Thus, the current discussion about dimensional versus categorical classification of PDs reflects a wider problem in mental health research and demands a debate in psychiatry in general. PDs are, or at least should be, an equal partner with other mental disorders. Thus, the classification of PDs should be constructed in an analogous way to the other mental disorders, and any move to dimensions should be a meta-decision for the whole of ICD—not one that is sequestered off and confined to PDs.

Recently, Huprich (2015) compared the classification and assessment of PDs to what happens in orthopedics. He noted that the classification of bone fractures occurs within certain types of taxonomies (e.g., open or closed fracture, complete vs. partial fracture) that help to guide their classification and subsequent treatment. While research on bone growth and pathophysiology (among other domains) is critically important to understand what mechanisms are associated with healing, it is not necessarily a framework that is well-suited to become the organizing framework for a taxonomy of bone fractures—at least not yet. By comparison, some of the categorical organizing systems associated with personality pathology have heuristic value and meaning (despite being very flawed), and as such, dimensional models and frameworks hold much promise for improving the classification scheme. But for the many reasons articulated above, the field is not yet ready for an exclusive transition to this perspective. Our shared concern among personality disorder societies across the globe and presented here is empirically supported, and we urge for caution and extreme care in moving forward. There are no adverse consequences to delaying a radical revision to the WHO’s taxonomy until we have good data from head-to-head field trials of different approaches, coupled with the views of patients and the public as well as thorough debate among scientists. In parallel with further research, efforts to bridge the gap between categorical and dimensional models could be facilitated with more cross-talk and collaboration between researchers, clinicians, and patients. Concrete guidelines or “roadmaps” could be collaboratively and iteratively developed to help pave the way for the integration of new models into existing assessment and intervention approaches.

Consequently, presuming that the time for further research is limited in face of planning to publish ICD-11 in 2019, we strongly suggest retaining a hybrid model of PD classification. This, in addition to dimensional assessment, would allow clinicians and insurers to continue using categories until the science and consensus have been firmed up. A hybrid model, as it is included in Section III of DSM-5, allows the field to systematically compare categorical and dimensional classifications with 6 out of 10 specific PDs from DSM-IV being redefined by criterion A (impairment in personality functioning) and criterion B (pathological personality traits) and is thus backward compatible with traditional categories (Zimmermann, 2014). It therefore provides the best basis for further research, which is urgently needed and should be cross-disciplinary and robust.

Footnotes

1

This article is the product of a collaboration among the boards of directors of the International Society for the Study of Personality Disorders (ISSPD), the European Society for the Study of Personality Disorders (ESSPD), and the North American Society for the Study of Personality Disorders (NASSPD). It was prompted by concerns about inadequacies in the current proposal for personality disorders in ICD-11. The manuscript was approved by the elected boards of the ISSPD, ESSPD, and NASSPD. While individuals in each society might have positions different from the one described below, this article represents the consensus of each Society’s board, the current position of each Society, and a broad international agreement about the state of personality disorder assessment and diagnosis.

It should be noted that Hopwood and colleagues wrote that this study supported the preference of clinicians for dimensional models; yet, the findings were more mixed than what they reported.

References

  1. Al-Dajani N, Gralnick TM, Bagby RM. A psychometric review of the Personality Inventory for DSM-5 (PID-5): Current status and future directions. Journal of Personality Assessment. 2016;98(1):62–81. doi: 10.1080/00223891.2015.1107572. [DOI] [PubMed] [Google Scholar]
  2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4. Washington, DC: Author; 1994. [Google Scholar]
  3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5. Washington, DC: Author; 2013. [Google Scholar]
  4. Bach B, Markon K, Simonsen E, Krueger RF. Clinical utility of the DSM-5 alternative model of personality disorders: Six cases from practice. Journal of Psychiatric Practice. 2015;21(1):3–25. doi: 10.1097/01.pra.0000460618.02805.ef. [DOI] [PubMed] [Google Scholar]
  5. Bender DS, Morey LC, Skodol AE. Toward a model for assessing level of personality functioning in DSM-5, part I: A review of theory and methods. Journal of Personality Assessment. 2011;93(4):332–346. doi: 10.1080/00223891.2011.583808. [DOI] [PubMed] [Google Scholar]
  6. Bjorkenstam E, Bjorkenstam C, Holm H, Gerdin B, Ekselius L. Excess cause-specific mortality in in-patient-treated individuals with personality disorder: 25-year nationwide population-based study. British Journal of Psychiatry. 2015;207(4):339–345. doi: 10.1192/bjp.bp.114.149583. [DOI] [PubMed] [Google Scholar]
  7. Bornstein RF. The dependent personality. New York, NY: Guilford; 1993. [Google Scholar]
  8. Chanen AM. New era or false dawn? Personality and Mental Health. 2011;5(4):281–285. [Google Scholar]
  9. Chanen AM. Borderline personality disorder in young people: Are we there yet? Journal of Clinical Psychology. 2015;71(8):778–791. doi: 10.1002/jclp.22205. [DOI] [PubMed] [Google Scholar]
  10. Clark LA. Assessment and diagnosis of personality disorder: Perennial issues and an emerging reconceptualization. Annual Review of Psychology. 2007;58:227–257. doi: 10.1146/annurev.psych.57.102904.190200. [DOI] [PubMed] [Google Scholar]
  11. Clark LA, Watson D, Reynolds S. Diagnosis and classification of psychopathology: Challenges to the current system and future directions. Annual Review of Psychology. 1995;46:121–153. doi: 10.1146/annurev.ps.46.020195.001005. [DOI] [PubMed] [Google Scholar]
  12. Clarkin JF, Fonagy P, Gabbard GO. Psychodynamic psychotherapy for personality disorders: A clinical handbook. Washington, DC: American Psychiatric Publishing; 2010. [Google Scholar]
  13. Clarkin JF, Huprich SK. Do DSM-5 personality disorder proposals meet criteria for clinical utility? Journal of Personality Disorders. 2011;25(2):192–205. doi: 10.1521/pedi.2011.25.2.192. [DOI] [PubMed] [Google Scholar]
  14. Clarkin JF, Lenzenweger MF, Yeomans F, Levy KN, Kernberg OF. An object relations model of borderline pathology. Journal of Personality Disorders. 2007;21(5):474–499. doi: 10.1521/pedi.2007.21.5.474. [DOI] [PubMed] [Google Scholar]
  15. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry. 2007;164(6):922–928. doi: 10.1176/ajp.2007.164.6.922. [DOI] [PubMed] [Google Scholar]
  16. Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. 2017;74(4):319–328. doi: 10.1001/jamapsychiatry.2016.4287. [DOI] [PubMed] [Google Scholar]
  17. Etkin A, Cuthbert B. Beyond the DSM: Development of a transdiagnostic psychiatric neuroscience course. Academic Psychiatry. 2014;38(2):145–150. doi: 10.1007/s40596-013-0032-4. [DOI] [PubMed] [Google Scholar]
  18. Fok M, Hotopf M, Stewart R, Hatch S, Hayes R, Moran P. Personality disorder and self-rated health: A population-based cross-sectional survey. Journal of Personality Disorders. 2014;28(3):319–333. doi: 10.1521/pedi_2013_27_119. [DOI] [PubMed] [Google Scholar]
  19. Fonagy P, Bateman A. The development of borderline personality disorder—A mentalizing model. Journal of Personality Disorders. 2008;22(1):4–21. doi: 10.1521/pedi.2008.22.1.4. [DOI] [PubMed] [Google Scholar]
  20. Gabbard GO. Two subtypes of narcissistic personality disorder. Bulletin of the Menninger Clinic. 1989;53(6):527–532. [PubMed] [Google Scholar]
  21. Gunderson JG. Revising the borderline diagnosis for DSM-V: An alternative proposal. Journal of Personality Disorders. 2010;24(6):694–708. doi: 10.1521/pedi.2010.24.6.694. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, … Skodol AE. Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of General Psychiatry. 2011;68(8):827–837. doi: 10.1001/archgenpsychiatry.2011.37. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Gunderson JG, Zanarini MC. Current overview of the borderline diagnosis. Journal of Clinical Psychiatry. 1987;48(Suppl):5–14. [PubMed] [Google Scholar]
  24. Herpertz SC, Jeung H, Mancke F, Bertsch K. Social dysfunctioning and brain in borderline personality disorder. Psychopathology. 2014;47(6):417–424. doi: 10.1159/000365106. [DOI] [PubMed] [Google Scholar]
  25. Hopwood CJ, Kotov R, Krueger RF, Watson D, Widiger TA, Althoff RR, … Zimmermann J. The time has come for dimensional personality disorder diagnosis. Personality and Mental Health. doi: 10.1002/pmh.1408. in press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Hopwood CJ, Morey LC, Donnellan MB, Samuel DB, Grilo CM, McGlashan TH, … Skodol AE. Ten-year rank-order stability of personality traits and disorders in a clinical sample. Journal of Personality. 2013;81(3):335–344. doi: 10.1111/j.1467-6494.2012.00801.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Hopwood CJ, Morey LC, Shea MT, McGlashan TH, Sanislow CA, Grilo CM, … Skodol AE. Personality traits predict current and future functioning comparably for individuals with major depressive and personality disorders. Journal of Nervlous and Mental Disease. 2007;195(3):266–269. doi: 10.1097/01.nmd.0000253747.44836.61. [DOI] [PubMed] [Google Scholar]
  28. Huprich SK. Introduction: Personality disorders into the 21st century. In: Huprich SK, editor. Personality disorders: Toward theoretical and empirical integration in diagnosis and assessment. Washington, DC: American Psychological Association; 2015. pp. 3–20. [Google Scholar]
  29. Kendell R, Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry. 2003;160(1):4–12. doi: 10.1176/appi.ajp.160.1.4. [DOI] [PubMed] [Google Scholar]
  30. Keuroghlian AS, Frankenburg FR, Zanarini MC. The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up. Journal of Psychiatric Research. 2013;47(10):1499–1506. doi: 10.1016/j.jpsychires.2013.06.012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Kim YR, Blashfield R, Tyrer P, Hwang ST, Lee HS. Field trial of a putative research algorithm for diagnosing ICD-11 personality disorders in psychiatric patients: 1. Severity of personality disturbance. Personality and Mental Health. 2014;8(1):67–78. doi: 10.1002/pmh.1248. [DOI] [PubMed] [Google Scholar]
  32. Kotov R, Krueger RF, Watson D, Achenbach TM, Althoff RR, Bagby RM, … Zimmerman M. The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology. 2017;126(4):454–477. doi: 10.1037/abn0000258. [DOI] [PubMed] [Google Scholar]
  33. Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE. Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychological Medicine. 2012;42(9):1879–1890. doi: 10.1017/S0033291711002674. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford; 1993. [Google Scholar]
  35. Livesley WJ, editor. The DSM-IV personality disorders. New York, NY: Guilford; 1995. [Google Scholar]
  36. Lowe JR, Widiger TA. Clinicians’ judgments of clinical utility: A comparison of the DSM-IV with dimensional models of general personality. Journal of Personality Disorders. 2009;23(3):211–229. doi: 10.1521/pedi.2009.23.3.211. [DOI] [PubMed] [Google Scholar]
  37. McGorry P, van Os J. Redeeming diagnosis in psychiatry: Timing versus specificity. Lancet. 2013;381(9863):343–345. doi: 10.1016/S0140-6736(12)61268-9. [DOI] [PubMed] [Google Scholar]
  38. McGorry PD. Issues for DSM-V: Clinical staging: A heuristic pathway to valid nosology and safer, more effective treatment in psychiatry. American Journal of Psychiatry. 2007;164(6):859–860. doi: 10.1176/ajp.2007.164.6.859. [DOI] [PubMed] [Google Scholar]
  39. Meehan KB, Clarkin JF. A critical evaluation of moving toward a trait system for personality disorder assessment. In: Huprich SK, editor. Personality disorders: Toward theoretical and empirical integration in diagnosis and assessment. Washington, DC: American Psychological Association; 2015. pp. 85–106. [Google Scholar]
  40. Moran P, Romaniuk H, Coffey C, Chanen A, Degenhardt L, Borschmann R, Patton GC. The influence of personality disorder on the future mental health and social adjustment of young adults: A population-based, longitudinal cohort study. Lancet Psychiatry. 2016;3(7):636–645. doi: 10.1016/S2215-0366(16)30029-3. [DOI] [PubMed] [Google Scholar]
  41. Morey LC, Skodol AE, Oldham JM. Clinician judgments of clinical utility: A comparison of DSM-IV-TR personality disorders and the alternative model for DSM-5 personality disorders. Journal of Abnormal Psychology. 2014;123(2):398–405. doi: 10.1037/a0036481. [DOI] [PubMed] [Google Scholar]
  42. Mulder RT, Horwood J, Tyrer P, Carter J, Joyce PR. Validating the proposed ICD-11 domains. Personality and Mental Health. 2016;10(2):84–95. doi: 10.1002/pmh.1336. [DOI] [PubMed] [Google Scholar]
  43. Nelson SM, Huprich SK, Shankar S, Sohnleitner A, Paggeot AV. A quantitative and qualitative evaluation of trainee opinions of four methods of personality disorder diagnosis. Personality Disorders. 2017;8(3):217–227. doi: 10.1037/per0000227. [DOI] [PubMed] [Google Scholar]
  44. Newton-Howes G, Clark LA, Chanen A. Personality disorder across the life course. Lancet. 2015;385(9969):727–734. doi: 10.1016/S0140-6736(14)61283-6. [DOI] [PubMed] [Google Scholar]
  45. Oltmanns JR, Widiger TA. A self-report measure for the ICD-11 Dimensional Trait Model Proposal: The Personality Inventory for ICD-11. Psychological Assessment. 2017 doi: 10.1037/pas0000459. Advance online publication. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. PDM Task Force. Psychodynamic diagnostic manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations; 2006. [Google Scholar]
  47. Pukrop R, Herpertz S, Sass H, Steinmeyer EM. Special feature: Personality and personality disorders. A facet theoretical analysis of the similarity relationships. Journal of Personality Disorders. 1998;12(3):226–246. doi: 10.1521/pedi.1998.12.3.226. [DOI] [PubMed] [Google Scholar]
  48. Quirk SE, Berk M, Chanen AM, Koivumaa-Honkanen H, Brennan-Olsen SL, Pasco JA, Williams LJ. Population prevalence of personality disorder and associations with physical health comorbidities and health care service utilization: A review. Personality Disorders. 2016;7(2):136–146. doi: 10.1037/per0000148. [DOI] [PubMed] [Google Scholar]
  49. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry. 1970;126(7):983–987. doi: 10.1176/ajp.126.7.983. [DOI] [PubMed] [Google Scholar]
  50. Robins LN. Deviant children grown up: A sociological and psychiatric study of sociopathic personality. Baltimore, MD: Williams & Wilkins; 1966. [Google Scholar]
  51. Ronningstam E, Gunderson J, Lyons M. Changes in pathological narcissism. American Journal of Psychiatry. 1995;152(2):253–257. doi: 10.1176/ajp.152.2.253. [DOI] [PubMed] [Google Scholar]
  52. Rottman BM, Ahn WK, Sanislow CA, Kim NS. Can clinicians recognize DSM-IV personality disorders from five-factor model descriptions of patient cases? American Journal of Psychiatry. 2009;166(4):427–433. doi: 10.1176/appi.ajp.2008.08070972. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Russ E, Shedler J, Bradley R, Westen D. Refining the construct of narcissistic personality disorder: Diagnostic criteria and subtypes. American Journal of Psychiatry. 2008;165(11):1473–1481. doi: 10.1176/appi.ajp.2008.07030376. [DOI] [PubMed] [Google Scholar]
  54. Ryle A. The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. Journal of Personality Disorders. 2004;18(1):3–35. doi: 10.1521/pedi.18.1.3.32773. [DOI] [PubMed] [Google Scholar]
  55. Samuel DB, South SC, Griffin SA. Factorial invariance of the Five-Factor Model Rating Form across gender. Assessment. 2015;22(1):65–75. doi: 10.1177/1073191114536772. [DOI] [PubMed] [Google Scholar]
  56. Sharp C, Fonagy P. Practitioner review: Borderline personality disorder in adolescence—Recent conceptualization, intervention, and implications for clinical practice. Journal of Child Psychology and Psychiatry. 2015;56(12):1266–1288. doi: 10.1111/jcpp.12449. [DOI] [PubMed] [Google Scholar]
  57. Sharp C, Wright AG, Fowler JC, Frueh BC, Allen JG, Oldham J, Clark LA. The structure of personality pathology: Both general (‘g’) and specific (‘s’) factors? Journal of Abnormal Psychology. 2015;124(2):387–398. doi: 10.1037/abn0000033. [DOI] [PubMed] [Google Scholar]
  58. Siever LJ, Davis KL. The pathophysiology of schizophrenia disorders: Perspectives from the spectrum. American Journal of Psychiatry. 2004;161(3):398–413. doi: 10.1176/appi.ajp.161.3.398. [DOI] [PubMed] [Google Scholar]
  59. Skodol AE, Bender DS, Morey LC, Clark LA, Oldham JM, Alarcon RD, … Siever LJ. Personality disorder types proposed for DSM-5. Journal of Personality Disorders. 2011;25(2):136–169. doi: 10.1521/pedi.2011.25.2.136. [DOI] [PubMed] [Google Scholar]
  60. Spitzer RL, First MB, Shedler J, Westen D, Skodol AE. Clinical utility of five dimensional systems for personality diagnosis: A “consumer preference” study. Journal of Nervous and Mental Disease. 2008;196(5):356–374. doi: 10.1097/NMD.0b013e3181710950. [DOI] [PubMed] [Google Scholar]
  61. Stanley B, Brodsky BS. Dialectical behavior therapy. In: Oldham M, Skodol AE, Bender DS, editors. Essentials of personality disorders. Washington, DC: American Psychiatric Press; 2009. pp. 235–252. [Google Scholar]
  62. Tyrer P. Why borderline personality disorder is neither borderline nor a personality disorder. Personality and Mental Health. 2009;3(2):86–95. doi: 10.1002/pmh.1422. [DOI] [PubMed] [Google Scholar]
  63. Tyrer P, Crawford M, Mulder R ICD-11 Working Group for the Revision of Classification of Personality Disorders. Reclassifying personality disorders. Lancet. 2011;377(9780):1814–1815. doi: 10.1016/S0140-6736(10)61926-5. [DOI] [PubMed] [Google Scholar]
  64. Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet. 2015;385(9969):717–726. doi: 10.1016/S0140-6736(14)61995-4. [DOI] [PubMed] [Google Scholar]
  65. Walter M, Gunderson JG, Zanarini MC, Sanislow CA, Grilo CM, McGlashan TH, … Skodol AE. New onsets of substance use disorders in borderline personality disorder over 7 years of follow-ups: Findings from the Collaborative Longitudinal Personality Disorders Study. Addiction. 2009;104(1):97–103. doi: 10.1111/j.1360-0443.2008.02413.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Warner MB, Morey LC, Finch JF, Gunderson JG, Skodol AE, Sanislow CA, … Grilo CM. The longitudinal relationship of personality traits and disorders. Journal of Abnormal Psychology. 2004;113(2):217–227. doi: 10.1037/0021-843X.113.2.217. [DOI] [PubMed] [Google Scholar]
  67. Westen D. Divergences between clinical and research methods for assessing personality disorders: Implications for research and the evolution of axis II. American Journal of Psychiatry. 1997;154(7):895–903. doi: 10.1176/ajp.154.7.895. [DOI] [PubMed] [Google Scholar]
  68. Widiger TA, Simonsen E, Krueger R, Livesley WJ, Verheul R. Personality disorder research agenda for the DSM-V. Journal of Personality Disorders. 2005;19(3):315–338. doi: 10.1521/pedi.2005.19.3.315. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Winter D, Bohus M, Lis S. Understanding negative self-evaluations in borderline personality disorder: A review of self-related cognitions, emotions, and motives. Current Psychiatry Reports. 2017;19(3):17. doi: 10.1007/s11920-017-0771-0. [DOI] [PubMed] [Google Scholar]
  70. Wright AG, Hopwood CJ, Skodol AE, Morey LC. Longitudinal validation of general and specific structural features of personality pathology. Journal of Abnormal Psychology. 2016;125(8):1120–1134. doi: 10.1037/abn0000165. [DOI] [PMC free article] [PubMed] [Google Scholar]
  71. Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: A 16-year prospective follow-up study. American Journal of Psychiatry. 2012;169(5):476–483. doi: 10.1176/appi.ajp.2011.11101550. [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Zimmermann J. Paradigmenwechsel in der Klassifikation von Persönlichkeitsstörungen—Die neuen Modelle in DSM-5 und ICD-11 [Change of paradigms in classification of personality disorders—New models in DSM-5 and ICD-11] Psychotherapie im Dialog. 2014;3:e1–e10. doi: 10.1055/S-0034-1388629PiD3/2014,S. [DOI] [Google Scholar]
  73. Zimmermann J. The next generation of classification systems for personality disorders. Comparing the alternative model in DSM-5 Section III and the proposal for ICD-11. Paper presented at ISSPD XIV; Montreal, Canada. 2015. Oct 15, [Google Scholar]

RESOURCES