The Five-Factor Model of Personality Disorder and DSM- 5

Transcription

1 See discussions, stats, and author profiles for this publication at: The Five-Factor Model of Personality Disorder and DSM- 5 Article in Journal of Personality February 2012 Impact Factor: 2.44 DOI: /j Source: PubMed CITATIONS 19 READS author: Timothy J Trull University of Missouri 173 PUBLICATIONS 7,062 CITATIONS SEE PROFILE Available from: Timothy J Trull Retrieved on: 10 May 2016

2 The Five-Factor Model of Personality Disorder and DSM-5 Timothy J. Trull University of Missouri ABSTRACT The Five-Factor Model of personality disorders (FFMPD; Widiger & Mullins-Sweatt, 2009) developed from the recognition that the popular Five-Factor Model (FFM) of personality could be used to describe and understand the official personality disorder (PD) constructs from the American Psychiatric Association s (APA) diagnostic manuals (e.g., DSM-IV-TR, APA, 2000). This article provides an overview of the FFM, highlighting its validity and utility in characterizing PDs as well as its ability to provide a comprehensive account of personality pathology in general. In 2013, DSM-5 is scheduled to appear, and the hybrid PD proposal will emphasize a 25 personality trait model. I present the current version of this new model, compare it to the FFMPD, and discuss issues related to the implementation of the FFMPD. This article presents an overview of the Five-Factor Model of personality disorders (FFMPD; Widiger & Mullins-Sweatt, 2009), including its historical development, empirical support, and previous use in evaluating the DSM-IV-TR personality disorders (American Psychiatric Association [APA], 2000). Net, the proposed hybrid model of personality disorders (PDs) that is being considered for DSM-5 is discussed, focusing primarily on its 25-trait model of personality, as well as its relationship to the FFMPD. I close with issues related to the implementation of the FFMPD. THE FIVE-FACTOR MODEL OF PERSONALITY Although a number of personality trait models have been discussed in the contet of the DSM personality disorders, the Five-Factor Correspondence concerning this article should be addressed to Timothy J. Trull, 210 McAlester Hall, Department of Psychological Sciences, University of Missouri, Columbia, MO trullt@missouri.edu. Journal of Personality 80:6, December The Author Journal of Personality 2012, Wiley Periodicals, Inc. DOI: /j

3 1698 Trull Model of personality has received both the most research attention and empirical support in this contet (e.g., Allik, 2005; Clark, 2007; Clark & Livesley, 2002; Costa & Widiger, 2002; O Connor & Dyce, 1998; Samuel & Widiger, 2008; Saulsman & Page, 2004; Trull & Durrett, 2005; Widiger & Mullins-Sweatt, 2009; Widiger & Simonsen, 2005; Widiger & Trull, 2007). As stated by Clark (2007), The five-factor model of personality is widely accepted as representing the higher-order structure of both normal and abnormal personality traits (p. 246). Indeed, the Five-Factor Model (FFM) of personality is a popular way to conceptualize major personality traits. It has a long history and rich tradition, and was derived through factor-analytic studies of personality trait terms from the English language (see Goldberg, 1993; John & Srivastava, 1999). As Widiger and Mullins-Sweatt (2009) noted: Language can be understood as a sedimentary deposit of the observations of persons over the thousands of years of the language s development and transformation. The most important domains of personality functioning are those with the greatest number of trait terms to describe and differentiate the various manifestations and nuances of a respective domain, and the structure of personality is suggested by the empirical relationships among these trait terms. (p. 199) Thus, the FFM is often termed leical, in that it reflects the structure of personality descriptions that occur most frequently in the English language. It also appears to be fairly universal in that this five-factor structure in trait terms has been replicated in a variety of other languages, including German, Dutch, Czech, Polish, Russian, Italian, Spanish, Hebrew, Hungarian, Turkish, Korean, and Filipino (Allik, 2005; Ashton & Lee, 2001). The five major domains of this model are typically referred to as Neuroticism versus emotional stability, Etraversion versus introversion, Openness versus closedness to eperience, Agreeableness versus antagonism, and Conscientiousness versus negligence. The FFM was originally developed using nonclinical samples, and the goal was to provide a comprehensive account of major personality traits and dimensions. However, several came to realize that the FFM might also be applied to issues relating to various forms of

4 Five-Factor Model of Personality Disorder and DSM psychopathology. Personality traits are indeed dimensional, and personality disorders by definition involve maladaptive or etreme personality traits. Further, the hierarchical structure of FFM traits (i.e., higher order domains and lower order facets) has been replicated across populations (i.e., nonclinical and clinical) and cultures, and evidence suggests a heritable and biological basis for both higher order and lower order FFM traits (Trull & Durrett, 2005). Over the last two decades, many studies have assessed the relations between FFM constructs and personality disorders (see Widiger & Costa, 2002; Samuel & Widiger, 2008, for reviews). These studies have sampled clinical subjects, community residents, and college students. For eample, perhaps the first study eamining the relationship between the FFM and PDs in a clinical sample was conducted by Trull (1992). Importantly, this study demonstrated strong relationships between the FFM and personality disorder features in a clinical sample of psychiatric outpatients. FFM scores accounted for significant amounts of variance in individual personality disorders in almost every case, and many of the patterns of FFM relations for individual personality disorders were replicated across three different personality disorder measures (i.e., a semistructured interview and two self-report inventories). Many studies using both clinical and nonclinical samples have followed; studies have consistently demonstrated significant relations between the traits included in the FFM and the DSM PD constructs (Samuel & Widiger, 2008; Saulsman & Page, 2004; Trull & Durrett, 2005; Widiger & Costa, 2002). However, simply demonstrating that, overall, these traits are related to PDs is not particularly surprising. After all, by definition PDs comprise etreme, maladaptive versions of personality traits (APA, 2000). Instead, what is of interest is the etent to which PD personality trait relations may help distinguish among the official PD diagnoses. Therefore, based on an understanding of the FFM as well as of personality disorders, Widiger and colleagues (Lynam & Widiger, 2001; Widiger et al.,1994; Widiger, Trull, et al., 2002) offered a set of predicted correlates between the five major dimensions of the FFM, as well as the facets composing each dimension, and the DSM-IV personality disorders. Subsequent studies have found general support for the relevance of the FFM to the full range of personality disorders. For eample, O Connor and Dyce (1998) used a confirmatory factor-analytic strategy to evaluate the

5 1700 Trull fit of the FFM across 12 data sets of personality disorder symptoms. The authors used the proposals of Widiger et al. (1994) to predict the covariance structure, and results supported the FFM as a way of conceptualizing personality disorder pathology. More recent studies have eamined FFM and personality disorder relations at the facet level. The main reason for this more detailed focus is that better differentiation among the personality disorders is possible at the level of first-order versus higher order traits (Samuel & Widiger, 2008). Most of the personality disorders are associated with elevations on Neuroticism, introversion, antagonism, and negligence (Saulsman & Page, 2004; Samuel & Widiger, 2008). However, it appears that the personality disorders can be distinguished by the patterns of relations at the first-order, facet trait level (O Connor & Dyce, 1998; Samuel & Widiger, 2008; Trull, Widiger, & Burr, 2001). Although these studies have primarily conceptualized personality pathology and disorder from the perspective of the eisting diagnostic manual, the findings do help eplain some of the comorbidity patterns typically reported among the PDs (e.g., see Lynam & Widiger, 2001). As mentioned, Samuel and Widiger (2008) recently presented findings from a meta-analysis of studies that eamined the relations between both the five domains and the 30 facets of personality traits included in the FFM and the DSM-IV PDs. Their results for the relationships between domain scores of the FFM and individual PDs are consistent with the finding that most PDs appear to be related to each other and comorbidity is more the rule than the eception: The majority of PDs are characterized by significant positive relations with Neuroticism, significant negative relations with Etraversion, significant negative relations with Agreeableness, and significant negative relations with Conscientiousness. Second, the facet-level relations provide some understanding of comorbidity patterns between certain pairs of PDs (Lynam & Widiger, 2001). For eample, the relatively parallel pattern of FFM facet associations with paranoid, schizoid, and schizotypal PD suggests that these diagnostic constructs might co-occur with each other (consistent with the finding that these within cluster A correlations are significant). Finally, Samuel and Widiger s (2008) FFM facet results also are consistent with the finding that both antisocial and obsessive-compulsive PD, respectively, are consistently less highly associated with other PDs; an eamination of their respective FFM facet profiles indicates that

6 Five-Factor Model of Personality Disorder and DSM they show less personality trait overlap with the other PDs. In the case of antisocial PD, it is characterized primarily by low levels of Agreeableness facets (i.e., low levels of trust, straightforwardness, altruism, and compliance) and low levels of Conscientiousness facets (i.e., low levels of competence, dutifulness, self-discipline, and deliberation). Although borderline PD also shows a similar pattern of associations with these facets, in addition (unlike antisocial PD), borderline PD is significantly positively related to all Neuroticism facets (i.e., aniousness, angry hostility, depressiveness, self-consciousness, impulsiveness, and vulnerability). This eplains why antisocial PD is often most highly associated with borderline PD. Obsessive-compulsive PD is another case in point. This PD s FFM facet profile is unique in that there are some small positive associations with Neuroticism facets (but not Etraversion, Openness, or Agreeableness facets) but stronger positive associations with Conscientiousness facets (i.e., high levels of competence, order, dutifulness, achievement striving, self-discipline, and deliberation). Obsessive-compulsive PD is the only PD to show positive relations with these Conscientiousness facets. DSM-IV-TR AND PERSONALITY TRAITS As has been documented for some time now, the categorical model of personality disorders, as eemplified in the DSM-IV-TR and its immediate predecessors, is fraught with problems. These include ecessive heterogeneity within diagnoses, ecessive diagnostic comorbidity, inadequate coverage, arbitrary boundaries with normal psychological functioning, and an inadequate scientific foundation (Clark, 2007; Livesley, 2001; Trull & Durrett, 2005; Widiger & Trull, 2007). Although the DSM-IV-TR embraces the categorical approach to personality pathology diagnosis, it does at least mention the possibility of an alternative dimensional approach: An alternative to the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another (APA, 2000, p. 689). In addition, DSM-IV-TR acknowledges the relevancy of major personality trait models (e.g., the FFM) to the PDs.

7 1702 Trull But how are personality traits and the DSM-IV-TR personality disorders connected? DSM-IV-TR states: Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are ehibited in a wide range of social and personal contets. Only when personality traits are infleible and maladaptive and cause significant functional impairment or subjective distress do they constitute Personality Disorders. (APA, 2000, p. 686) Nevertheless, an eamination of the criteria sets for the personality disorders reveals that the majority of the criteria are not personality traits per se, but rather behavioral, cognitive, or interpersonal indicators of problematic levels of traits (Widiger & Mullins-Sweatt, 2009). A recent analysis of the personality traits/psychopathology dimensions that underlie the DSM-IV-TR criteria for borderline personality disorder (BPD) is instructive (Trull, Tomko, Brown, & Scheiderer, 2010). As can be seen in Table 1, there are only three BPD symptoms that are directly related to the underlying personality trait dimension of emotional dysregulation and only one directly related to impulsivity/behavioral disinhibition (labeled Direct in Table 1 Personality Traits and Borderline Personality Disorder Symptoms Borderline Symptom Emotional Dysregulation Impulsivity/ Behavioral Disinhibition Frantic efforts to avoid abandonment Indirect Indirect Unstable interpersonal relationships Indirect Indirect Identity disturbance Indirect Indirect Impulsivity Direct Recurrent suicidal behavior/ Indirect Indirect self-harm/suicidal threats Affective instability Direct Chronic emptiness Direct Etreme anger Direct Indirect Transient, stress-related paranoid ideation or dissociation Indirect

8 Five-Factor Model of Personality Disorder and DSM Table 1). The other criteria for BPD may be seen as either indirect indicators of these personality traits or combinations of traits. Although some might disagree with specific entries in Table 1, the major point should not be lost. With the eception of affective instability, chronic emptiness, ecessive anger, and impulsivity, these criteria seem better conceptualized as possible indicators of traits (which may be inferred but are not identified by name). The criteria sets for other personality disorders are similar in their mi of traits and of indicators of unnamed traits. Therefore, the DSM-IV-TR PD criteria are really a miture of personality traits per se and indicators of these traits, the latter of which differ in the degree of inference required for assessment as well as for making the connection to the underlying personality trait. FIVE-FACTOR MODEL OF PERSONALITY DISORDER To this point, I have evaluated the FFM in reference to its ability to characterize and account for the DSM-IV-TR PDs. It is clear that PDs can be understood as maladaptive variants of the FFM (Clark, 2007; Livesley, 2001; Samuel & Widiger, 2008; Saulsman & Page, 2004), and the predominant models of normal and abnormal personality functioning converge onto at least four of the five broad domains of the FFM (Bouchard & Loehlin, 2001; Clark, 2007; John & Srivastava, 1999; Livesley, 2003; Markon, Krueger, & Watson, 2005; Trull & Durrett, 2005; Watson, Clark, & Harkness, 1994; Widiger & Simonsen, 2005). Findings such as these have encouraged investigators to go even one step further. Clearly, the DSM-IV-TR does not present a comprehensive catalog of all personality pathology, nor is it an efficient classification system (given rampant comorbidity among the PDs, heterogeneity within diagnosis, and the high prevalence of the PD not otherwise specified diagnosis; Trull & Durrett, 2005). It makes much more sense to characterize and define personality pathology and disorder through the lens of a widely accepted, comprehensive, and empirically validated model of personality as opposed to the current PD diagnostic system embodied in the official diagnostic manual. Such an approach is likely to improve the weak construct validity of the DSM-IV diagnostic categories (Mullins-Sweatt & Widiger, 2006).

9 1704 Trull The Four Steps So how can the FFM characterize personality pathology and diagnose PD? Widiger, Costa, and McCrae (2002) proposed a four-step procedure for an FFM diagnosis of personality disorder. Briefly, the first step is to obtain a personality trait description of an individual in terms of the five domains and 30 facets of the FFM. This description will provide a comprehensive description of the person s adaptive as well as maladaptive personality traits. There are a number of psychological measures that can be used for this FFM description (De Raad & Perugini, 2002), including, for eample, the questionnairebased Revised NEO Personality Inventory (NEO PI-R; Costa & McCrae, 1992) and the Structured Interview for the Five Factor Model (SIFFM; Trull & Widiger, 1997), a semistructured interview for the assessment of the FFM. Other FFM self-report inventories and brief clinician rating scales can also be used (De Raad & Perugini, 2002; Mullins-Sweatt, Jamerson, Samuel, Olson, & Widiger, 2006). For eample, Few et al. (2010) demonstrated the use of a brief rating form for FFM facets to evaluate patients. The second step involves an assessment of any social and occupational impairments and distress associated with etreme scores on the FFM personality traits. For eample, Widiger, Costa, et al. (2002) and McCrae, Löckenhoff, and Costa (2005) identified problems likely to be found in people scoring high or low on each of the FFM domains and facets. In the case of the SIFFM interviews, there are questions included that assess these maladaptive variants of each of the 30 trait facets of the FFM. Further, both the SIFFM and the Five Factor Model Score Sheet (FFMSS; Mullins-Sweatt et al., 2006) include separate, independent assessments of many of the problems identified by Widiger et al. (2002) and McCrae et al. (2005). The third step is to determine whether the dysfunction and distress reach a clinically significant level of impairment that would warrant a diagnosis of personality disorder. There are several possibilities for this assessment. For eample, one could use the Global Assessment of Functioning (GAF) scale currently used for Ais V of the DSM- IV-TR (APA, 2000). Other possibilities, measures that purport to measure personality-related impairment and dysfunction specifically, include the General Assessment of Personality Dysfunction (GAPD; Livesley, 2010) and the Severity Indices of Personality Problems (SIPP-118; Verheul et al., 2008).

10 Five-Factor Model of Personality Disorder and DSM The fourth step is necessary only if one desires a single quantitative inde of the match between an individual s FFM personality profile and prototypic profiles of diagnostic constructs (e.g., Miller, 2012; Miller & Lynam, 2003; Trull, Widiger, Lynam, & Costa, 2003). Although this can be used to assess a match between an individual s FFM profile and a FFM characterization of the DSM- IV-TR PD constructs, it is also possible for clinicians and researchers to develop FFM profiles for personality disorder constructs not included within DSM-IV (e.g., successful psychopath). However, prototypal matching with the DSM PDs is not generally recommended, as the purpose of the FFM diagnosis would not simply be to provide a roundabout method of returning to the DSM diagnostic categories (Clark, 2007). DIAGNOSING PDS IN DSM-5: COMPARISONS WITH THE FFMPD Before comparing the DSM-5 revisions for PD with the FFMPD, it is useful to briefly outline this new proposal for PD diagnosis. The new version of the DSM (DSM-5) proposes that a diagnosis of PD involves a series of determinations concerning overall personality dysfunction as well as specific personality trait elevations ( It is important to note that the original DSM-5 PD proposal (published on the Web site in February 2010) was revised to address concerns and clarify confusion (Skodol et al., 2011). Most importantly, it is now clearer how to arrive at a diagnosis of PD, and the prototype matching approach for PD types has been dropped. According to the latest version of the proposal (updated June 21, 2011, on the DSM-5 Web site: vision/pages/personalitydisorders.asp), the diagnostician is asked to first determine whether impairment in personality functioning is present and, if so, to what degree. The clinician is asked to rate a patient s level of personality functioning; specifically, ratings are made as to the level of self and interpersonal functioning for each individual (see also Livesley, 2001, 2003). Self functioning is defined in two areas (identity and self-direction), as is interpersonal functioning (empathy and intimacy). A 5-point scale is used to rate overall level of personality functioning for this purpose (0 = no impairment;1= mild impairment; 2= moderate impairment; 3= serious impairment; and 4 = etreme impairment). Descriptions of each quantitative rating are

11 1706 Trull provided, and the diagnostician is reminded that the ratings must reflect functioning that is of multiple years in duration, not due solely to another mental disorder/physical condition/effect of a substance, and not a norm within a person s cultural background. Net, if significant personality dysfunction is present, the clinician considers whether one (or more?) of the si proposed personality disorder types are present: borderline, obsessive-compulsive, avoidant, schizotypal, antisocial, or narcissistic. For each of these proposed PD types, a listing of characteristic trait elevations is provided. Table 2 presents the current DSM-5 proposal for borderline personality disorder, and one can see that for this PD type the clinician is asked to consider whether there are elevations on seven traits tapping negative affectivity (emotional lability, aniousness, separation insecurity, and depressivity), disinhibition (impulsivity, risk taking), and antagonism (hostility). For obsessive-compulsive, the clinician considers two primary traits, for avoidant four primary traits, for schizotypal si primary traits, for antisocial seven primary traits, and for narcissistic two primary traits. If a specific PD type is not indicated but personality dysfunction is present, then the clinician may designate a diagnosis of personality disorder trait specified (PDTS), which replaces the DSM-IV-TR designation of personality disorder not otherwise specified (PDNOS). Table 3 indicates how each of the 25 proposed DSM-5 PD primary traits is mapped onto the PD types (as well as the General definition of personality disorder ), according to the latest proposal. Of most relevance to the present article are the 25 traits, as well as the higher-order trait domains, included in the DSM-5 PD proposal. The current proposal lists 25 maladaptive personality traits, organized within five broad domains, which can be rated for each individual. The 25 facet traits are organized into five higher order trait domains: Negative Affectivity (emotional lability, aniousness, separation aniety, perseveration, submissiveness, hostility, restricted affectivity [lack of], depressivity, and suspiciousness); Detachment (restricted affectivity, depressivity, suspiciousness, withdrawal, anhedonia, and intimacy avoidance); Antagonism (hostility, manipulativeness, deceitfulness, grandiosity, attention seeking, and callousness); Disinhibition (irresponsibility, impulsivity, rigid perfectionism [lack of], distractibility, and risk taking); and Psychoticism (unusual beliefs and eperiences, eccentricity, and cognitive and perceptual dysregulation).

12 Five-Factor Model of Personality Disorder and DSM Table 2 New DSM-5 Proposal for Diagnosing Borderline Personality Disorder (BPD) A diagnosis of BPD requires all of the following: Significant impairment in Personality Functioning manifest by: Impairments in self functioning: Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with ecessive self-criticism; chronic feelings of emptiness; dissociative states under stress Self-direction: Instability in goals, aspirations, values, or career plans Impairments in interpersonal functioning: Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes and vulnerabilities. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anious preoccupation with real or imagined abandonment; close relationships often viewed in etremes or idealization and devaluation and alternating between over involvement and withdrawal. Elevated Personality Traits in the following domains: Negative affectivity characterized by: Emotional lability: Unstable emotional eperiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances. Aniousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative events of past unpleasant eperiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control. Separation insecurity: Fears of rejection by and/or separation from significant others, associated with fears of ecessive dependency and complete loss of autonomy. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; thoughts of suicide and suicidal behavior. Disinhibition, characterized by: Impulsivity: Difficulty controlling behavior, including self-harm behavior, under emotional distress; acting with urgency or on the spur of the moment in response to immediate stimuli; acting on momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences. Antagonism, characterized by: Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults. The impairments in personality functioning and the individual s personality trait epression are relatively stable across time and consistent across situations. The impairments in personality functioning and the individual s personality trait epression are not better understood as normative for the individual s developmental stage or socio-cultural environment. The impairments in personality functioning and the individual s personality trait epression are not solely due to the direct physiological effects ofa substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma). Source:

13 1708 Trull Table 3 Mapping of DSM-5 Personality Traits onto Personality Disorder Types DSM-5 Facet Trait BRD OBC AVD SZT ATS NAR GEN Emotional Lability Aniousness Separation Aniety Perseveration Submissiveness Hostility Restricted Affectivity Depressivity Suspiciousness Withdrawal Anhedonia Intimacy Avoidance Manipulativeness Deceitfulness Grandiosity Attention Seeking Callousness Irresponsibility Impulsivity Rigid Perfectionism Distractibility Risk Taking Unusual Beliefs and Eperiences Eccentricity Cognitive and Perceptual Dysregulation Note. BRD = borderline; OBC = obsessive-compulsive; AVD = avoidant; SZT = schizotypal; ATS = antisocial; NAR = narcissistic; GEN = general definition of personality disorder. Integration of the Work Group Proposal With the FFM Table 4 provides an illustration of how the 25 trait scales proposed by the DSM-5 Work Group would be classified within the FFM domains (also see Widiger, 2011). The placement of several of the 25 primary

14 Five-Factor Model of Personality Disorder and DSM Table 4 Placement of the 25 DSM-5 Facet Traits Within the Domains of the Five-Factor Model FFM Domain Neuroticism-High Neuroticism-Low Etraversion-High Etraversion-Low Openness-High Openness-Low Agreeableness-High Agreeableness-Low Conscientiousness-High Conscientiousness-Low DSM-5 Traits Emotional Lability, Separation Insecurity, Depressivity, Aniousness None Attention Seeking Intimacy Avoidance, Withdrawal, Restricted Affectivity, Anhedonia Cognitive and Perceptual Dysregulation, Unusual Beliefs and Eperiences, Eccentricity None Submissiveness Suspiciousness, Hostility, Deceitfulness, Manipulativeness, Grandiosity, Callousness Perseveration, Rigid Perfectionism Irresponsibility, Distractibility, Impulsivity, Risk Taking traits by the DSM-5 Personality and Personality Disorders Work Group within certain personality domains appears inconsistent with the personality literature. For eample, the etensive research on the FFM indicates that suspiciousness (i.e., FFM low trust) is within antagonism (not negative affectivity and detachment), submissiveness (i.e., FFM compliance) is within Agreeableness (not negative affectivity), histrionism/attention seeking (i.e., FFM gregariousness) is within Etraversion (not antagonism), and disinhibition and compulsivity/rigid perfectionism are opposite ends of one bipolar dimension (i.e., FFM Conscientiousness; Widiger, 2011). Related to this latter point, although there is good evidence to suggest that certain personality traits are bipolar in nature, the DSM-5 Work Group chose to only include unipolar facet traits. Although the Work Group acknowledged that the higher order trait domains are bipolar in nature, they chose to include only unipolar markers of the etreme poles. The major consequence is that the interpretation of a low score on a uniploar trait is ambiguous. For eample, does a low score on emotional lability mean that one has a

15 1710 Trull normal range level of emotionality or that one s lack of emotionality is pathological (e.g., aleithymia; Luminet et al., 1999; Taylor & Bagby, 2004)? In addition, when viewed though an FFM lens, it appears that the DSM-5 trait model undersamples certain maladaptive poles of personality trait domains. In particular, there are no traits that assess lower levels of Neuroticism, only one trait that assesses high Etraversion, no traits for low Openness, and one trait for high Agreeableness. Therefore, quite a few important traits are still missing. Table 5 presents a translation of the DSM-5 PD types into the personality traits from the DSM-5 personality model. For comparison, this table also lists the FFM traits corresponding to each of the five PDs, as proposed by Lynam & Widiger (2001) in their FFMPD trait model. Once again, one is struck by the gaps in coverage for the PD types. For eample, where is the fearlessness (low Neuroticism) that is crucial to the antisocial/psychopathy construct? Where is the aleithymia and closed-minded dogmatism (low Openness) that characterizes obsessive-compulsive PD? Where is the meekness and modesty that characterizes avoidant PD? In addition, several traits are included within two trait domains without eplanation (e.g., restricted affectivity, depressivity, suspiciousness). Finally, some of the choices for DSM-5 traits seem odd: Anhedonia for avoidant PD? Why not submissiveness for avoidant PD? These eamples only concern the si PD types retained for DSM-5. Skodol (2010) argued that the personality disorders deleted from the prior diagnostic manual (paranoid, schizoid, histrionic, dependent) can be recovered from the new trait model (see 5TypeandTraitCross-Walk.asp). However, the gaps in trait coverage are also apparent when one considers traits relevant to dependent PD (high Agreeableness), paranoid and schizoid PD (low Openness), and histrionic PD (high Etraversion). Finally, it is unclear whether the four PDs ecluded from DSM-5 are recoverable from the DSM-5 traits. Specifically, paranoid PD is characterized by a relatively small number of traits (e.g., suspiciousness, hostility, unusual beliefs and eperiences, intimacy avoidance), as is true for schizoid (e.g., restricted affectivity, withdrawal, intimacy avoidance, anhedonia), histrionic (e.g., emotional lability, manipulativeness, attention seeking), and dependent (e.g., aniousness, separation insecurity, submissiveness) PDs.

16 Five-Factor Model of Personality Disorder and DSM Table 5 Translation of PD Types/Traits Into FFMPD Traits Personality Disorder DSM-5 Type Traits FFMPD Traits 1 Schizotypal Eccentricity (P), Cognitive and Perceptual Dysregulation (P), Unusual Beliefs and Eperiences (P), Withdrawal (DT), Restricted Affectivity (DT and NA), Suspiciousness (NA) Antisocial/ Dyssocial Callousness (A), Hostility (NA and A), Manipulativeness (A), Deceitfulness (A), Irresponsibility (DS), Impulsivity (DS), Risk Taking (DS) Borderline Emotional Lability (NA), Aniousness (NA), Separation Insecurity (NA), Hostility (NA), Depressivity (NA), Impulsivity (DS), Risk Taking (DS) Avoidant Aniousness (NA), Withdrawal (DT), Anhedonia (DT), Intimacy Avoidance (DT) Obsessivecompulsive Ideas (O), low Warmth (E), low Gregariousness (E), low Positive Emotions (E), Aniousness (N), Self-Consciousness (N), low Order (C) Low Trust (A), low Straightforwardness (A), low Altruism (A), low Compliance (A), low Modesty (A), low Tender-mindedness (A), low Dutifulness (C), low Self-Discipline (C), low Deliberation (C), low Aniousness (N), Angry Hostility (N), low Self-Consciousness (N), Impulsiveness (N), Assertiveness (E), Activity (E), Ecitement Seeking (E) Aniousness (N), Angry Hostility (N), Depressiveness (N), Impulsiveness (N), Vulnerability (N), low Compliance (A), low Competence (C), low Deliberation (C), Feelings (O), Actions (O) Aniousness (N), Self-Consciousness (N), low Impulsiveness (N), Vulnerability (N), low Gregariousness (E), low Assertiveness (E), low Ecitement Seeking (E), low Positive Emotions (E), Modesty (A), Actions (O) Rigid Perfectionism (DS), Perseveration (NA) Competence (C), Order (C), Dutifulness (C), Achievement Striving (C), Self-Discipline (C), Deliberation (C), Aniousness (N), low Impulsiveness (N), low Ecitement Seeking (E), low Feelings (O), low Actions (O), low Ideas (O), low Values (O) Narcissistic Grandiosity (A), Attention Seeking (A) Angry Hostility (N), low Self-Consciousness (N), low Warmth (E), Assertiveness (E), Ecitement Seeking (E), low Feelings (O), Actions (O), low Trust (A), low Straightforwardness (A), low Altruism (A), low Compliance (A), low Modesty (A), low Tender-mindedness (A) Note. NA = Negative Affectivity; DT = Detachment; A = Antagonism; DS = Disinhibition; P = Psychoticism; N = Neuroticism; E = Etraversion; O = Openness; A = Agreeableness; C = Conscientiousness. 1 FFMPD predicted relations based on Lynam and Widiger (2001).

17 1712 Trull These problems perhaps reflect that the traits selected were in part the result of Work Group member nominations (Krueger, 2010), rather than a systematic, comprehensive attempt to adequately sample major domains of personality (and to do so as distinctly as possible). Many have decried the overlapping PD constructs that have appeared in previous diagnostic manuals, as evidenced by the high levels of comorbidity (Clark, 2007; Livesley, 2007; Widiger & Trull, 2007). However, many of the 25 traits appear to be closely related and perhaps difficult to distinguish (e.g., separation insecurity and aniousness; perseveration and rigid perfectionism; cognitive and perceptual dysregulation and unusual beliefs and eperiences or eccentricity). Therefore, the new proposal does not seem to adequately address the concern regarding overlap and redundancy. CONCERNS AND COMMENTS ON THE FFMPD Although the evidence supporting the use of the FFM to characterize and diagnose personality pathology is strong, there are some criticisms and limitations that should be noted as well. In particular, Krueger et al. (2011) argued that there is much confusion over eactly what constitutes the FFM. In particular, they highlighted that there are some differences in the conceptual models of the FFM as operationalized by the various FFM and Big Five measures that are available. Although it is true that there are differences in these measures, we must not conflate measures with conceptual models (Haigler & Widiger, 2001; Krueger et al., 2011). A measure is simply an operationalization of the conceptual model, and some measures may emphasize certain aspects of the model over others. Further, in the case of briefer measures, it is sometimes not possible to adequately sample all aspects of a conceptual model with precision; for eample, some brief FFM/Big Five measures do not adequately sample the facets or primary traits of the five major personality domains of the FFM. In the end, however, Krueger and colleagues (2011) argument could be applied to other measures of alternative personality models. Ironically, the 25-trait model of personality disorder adopted by the DSM-5 Personality and Personality Disorders Work Group suffers from a more damning problem it is not based on a well-established model of personality or personality pathology at all. Although the

18 Five-Factor Model of Personality Disorder and DSM Work Group noted that it bears some resemblance to the Personality Psychopathology Five (PSY-5; Harkness, McNulty, & Ben-Porath, 1995), this appears to be more of a post hoc observation instead of the outcome of a theory-driven approach to measurement. Although four of the five domains are recognizable from the FFM, the Work Group grafted a new personality dimension onto four of the five personality domains included in the FFM. Specifically, the Work Group included the new domain of Schizotypy, which is now labeled Psychoticism. DSM-5 Psychoticism is defined by only three facet traits, all of which emphasize the quasi-psychotic eperiences and behavior of schizotypal PD. Although there is only limited support to date for this new personality dimension in clinical samples, when this fifth personality domain is conceptualized as FFM Openness, there is a wealth of supporting data from clinical samples (see Samuel & Widiger, 2008). One of the strongest arguments being raised against the FFMPD, as well as other dimensional models, is clinical utility (e.g., First, 2005). However, the implication of such an argument is that the eisting diagnostic system has clinical utility (Kupfer, First, & Regier, 2002; Rounsaville et al., 2002; Trull & Widiger, 2008; Westen & Arkowitz-Westen, 1998). Although on the surface it might appear that a categorical diagnosis of PD is congruent with the clinical decisions that must be made (i.e., whether to hospitalize, whether to medicate, whether to provide disability, and whether to provide insurance coverage), DSM-IV (or even DSM-5) PD diagnoses do not seem suitable for any of these decisions. The diagnostic boundaries and thresholds were not developed with these clinical decisions in mind. Dimensional systems can easily be converted to categorical systems, provided appropriate cut-offs are available as well as decision algorithms (Trull & Widiger, 2008). We believe that a dimensional model of classification has considerably greater potential to be clinically useful because one can set different cutoff points along the respective dimensions that are optimal for different clinical decisions. One can identify the level of emotional instability that suggests the need for insurance coverage, pharmacotherapy, hospitalization, or disability. The diagnostic system would be constructed eplicitly for maimizing utility for different clinical decisions, an approach that is currently non-eistent and very cumbersome (if not impossible) to imple-

19 1714 Trull ment for the eisting diagnostic categories. (Trull & Widiger, 2008, pp ) Although there are published treatment manuals for many DSM- IV-TR disorders, official treatment guidelines have been developed for only one personality disorder: borderline (APA, 2001). One eplanation is that the DSM-IV-TR PDs are generally not well suited for treatment manuals because each PD involves an array of maladaptive personality traits, behaviors, and other indicators of these traits. Furthermore, there is great heterogeneity within diagnoses (e.g., patients diagnosed with the same PD may share few of the same traits), and traits may cut across different PD categories (e.g., impulsivity for both borderline PD and antisocial PD). In contrast, the FFM appears much better suited to develop specific treatment plans and guidelines. First, because the model was developed iteratively, the FFM is a more conceptually (as well as empirically) coherent personality structure. For eample, by definition, personality disorders are diagnosed when the maladaptive personality traits result in clinical significant distress or impairment in social, occupational, or other important areas of functioning (APA, 2000, p. 689). The FFM model assesses traits relevant to emotional dysregulation/distress (e.g., Neuroticism traits), to social/interpersonal (e.g., Etraversion and Agreeableness traits), to work-oriented behavior and responsibility (e.g., Conscientiousness traits), and to cognitive (e.g., Openness traits) domains of functioning. Further, Miller, Pilkonis, and Mulvey (2006) demonstrated that FFM traits provided unique information about treatment utilization and satisfaction above and beyond what could be accounted for by general distress and by the DSM-IV-TR PDs themselves. FFM traits may also have implications for treatment choices as well as within-treatment behavior. Etraversion and Agreeableness are relevant to relationship quality both within and outside the consultation room. Interpersonal models of therapy, marital and family therapy, and group therapy might be suggested by maladaptive variants of Etraversion and Agreeableness traits. Neuroticism traits are relevant to mood, aniety, and emotional dyscontrol, and problems here might suggest pharmacologic interventions (e.g., mood stabilizers) or cognitive interventions targeting these dysfunctions. In the case of Conscientiousness, maladaptively high levels might suggest

20 Five-Factor Model of Personality Disorder and DSM treatments that target obsessionality or compulsivity (e.g., eposure plus response prevention or SSRIs). In contrast, low levels might suggest treatments for attention deficit, hyperactivity, and impulsivity (e.g., ADHD stimulant medication). Finally, maladaptively high Openness could indicate cognitive-perceptual aberrations and problems with reality testing, conditions that might be amenable to pharmacologic treatment (e.g., low-dose antipsychotic medication). These eamples are offered to show the treatment implications of an FFM of personality disorder, and that these are substantially more distinct and specific than those for the DSM-IV-TR personality disorders. However, an important question is whether clinicians actually find FFM information useful in their clinical formulations. Several studies have provided encouraging findings. For eample, Samuel and Widiger (2006) provided practicing psychologists with detailed descriptions of actual persons with maladaptive personality traits (e.g., Ted Bundy). When asked to describe the person with respect to the FFM and, alternatively, with the DSM-IV-TR personality disorders, clinicians indicated that an FFM dimensional rating was more useful than the DSM-IV-TR with respect to providing a global description of the individual s personality, communicating information to clients, encompassing all of the individual s important personality difficulties, and even assisting in formulating effective treatment interventions. Another concern raised regarding the FFMPD is that it is cumbersome and not user-friendly. However, as detailed above, an FFMPD evaluation can proceed in logical steps, and evaluating individuals standing on 30 trait facets is much easier and more time-efficient than assessing almost 100 DSM-IV-TR PD criteria or than assessing the 25 DSM-5 traits, si PD types, and four variants of personality functioning called for in the current DSM-5 Work Group proposal (Trull & Widiger, 1997; Widiger & Coker, 2002; Widiger & Lowe, 2007). CONCLUSION For years, researchers have called for a switch to a dimensional model of personality disorders (Clark, 2007; Livesley, 2007; Widiger & Frances, 1985; Widiger & Trull, 2007), and there have even been references to dimensional models within the tet of the DSM-IV-TR

21 1716 Trull (APA, 2000), the most recent diagnostic manual. The time seemed ripe for making this change, but, regrettably, the DSM-5 Work Group s proposal for a trait-based PD system falls flat for several reasons (Widiger, 2011). First, the Work Group had the opportunity to integrate normal personality trait models researched within psychology with the personality disorders of psychiatry. Instead, they decided to construct a new five-dimensional model of personality disorder. This five-dimensional model ecludes normal personality traits, does not incorporate years of research on personality and personality pathology, and is operationalized in ways so as to miss important areas of personality functioning. The DSM-5 Personality and Personality Disorders Work Group s proposal includes 25 maladaptive personality traits that differentially saturate major domains of personality, that are unipolar in nature, and that overlap ecessively with each other. As noted earlier, the failure to recognize the bipolarity of personality structure contributes to a number of problems for the DSM-5 proposal, including the failure to include some important traits and the misplacement of others. Furthermore, as discussed, this 25-trait model does not adequately cover the personality pathology that is assessed in the proposed si PD types as well as that of the ecluded PDs from DSM-IV-TR (the latter which can purportedly be accounted for by this model). In the end, the FFMPD seems better suited for the task of representing personality and personality disorder than the DSM-5 Work Group 25-trait model. The FFMPD has a strong conceptual and empirical base, its relationship to PD diagnoses has been demonstrated, and it can also point to areas of personality dysfunction that are not currently represented in diagnostic systems (e.g., racism, aleithymia; Bell, 2004, 2006; Luminet et al., 1999; Taylor & Bagby, 2004; Trull, 2005). In addition, the FFMPD holds promise in its ability to inform and guide treatment, as well as in other areas of clinical utility. REFERENCES Allik, J. (2005). Personality dimensions across cultures. Journal of Personality Disorders, 19, American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., tet rev.). Washington, DC: Author.

22 Five-Factor Model of Personality Disorder and DSM American Psychiatric Association. (2001). Practice guidelines for the treatment of patients with borderline personality disorder. Washington, DC: Author. Ashton, M. C., & Lee, K. (2001). A theoretical basis for the major dimensions of personality. European Journal of Personality, 15, Bell, C. C. (2004). Taking issue: Racism. A mental illness? Psychiatric Services, 55, Bell, C. C. (2006). Reservations and hopes. In T. A. Widiger, E. Simonsen, P. J. Sirovatka, & D. A. Regier (Eds.), Dimensional models of personality disorders: Refining the research agenda for DSM-V (pp ). Washington, DC: American Psychiatric Association. Bouchard, T. J., & Loehlin, J. C. (2001). Genes, evolution, and personality. Behavior Genetics, 31, Clark, L. A. (2007). Assessment and diagnosis of personality disorder: Perennial issues and an emerging reconceptualization. Annual Review of Psychology, 58, Clark, L. A., & Livesley, W. J. (2002). Two approaches to identifying the dimensions of personality disorder: Convergence on the five-factor model. In P. T. Costa & T. A. Widiger (Eds.), Personality disorders and the five-factor model of personality (2nd ed., pp ). Washington, DC: American Psychological Association. Costa, P. T., & McCrae, R. R. (1992). Revised NEO Personality Inventory (NEO PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Odessa, FL: Psychological Assessment Resources. Costa, P.T., Jr., & T. A. Widiger. (2002). Personality disorders and the five-factor model of personality (2nd ed.). Washington, DC: American Psychological Association. De Raad, B., & Perugini, M. (Eds.). (2002). Big Five assessment. Bern, Switzerland: Hogrefe & Huber. Few, L. R., Miller, J. D., Morse, J. Q., Yaggi, K. E., Reynold, S. K.., & Pilkonis, P. A. (2010). Eamining the reliability and validity of clinician ratings on the Five-Factor Model Score Sheet. Assessment, 17, First, M. B. (2005). Clinical utility: A prerequisite for the adoption of a dimensional approach in DSM. Journal of Abnormal Psychology, 114, Goldberg, L. R. (1993). The structure of phenotypic personality traits. American Psychologist, 48, Haigler, E. D., & Widiger, T. A. (2001). Eperimental manipulation of NEO-PI-R items. Journal of Personality Assessment, 77, Harkness, A. R., McNulty, J. L., & Ben-Porath, Y. S. (1995). The Personality Psychopathology-Five: Constructs and MMPI-2 scales. Psychological Assessment, 7, John, O. P., & Srivastava, S. (1999). The Big Five trait taonomy: History, measurement, and theoretical perspectives. In L. A. Pervin & O. P. John (Eds.), Handbook of personality: Theory and research (2nd ed., pp ). New York: Guilford Press. Krueger, R. F. (2010, March). Personality traits: Prospects for DSM-V. In C. J. Hopwood (Chair), Personality assessment in contet of DSM-V. Symposium