disorder is not made, if the manifestations of  the personality disorder clearly are an ex-
pression of the other mental disorder (e.g., if  features of schizotypal personality disorder
are present only in the context of schizophren ia). On the other hand, personality disorders
can be accurately diagnosed in the presence of  another mental disord er, such as major de-
pressive disorder, and patients with other me ntal disorders should be assessed for comor-
bid personality disorders because personality disorders often impact the course of other
mental disorders. Therefore, it is always appropriate to assess personality functioning and
pathological personality traits to prov ide a context for other psychopathology.
Specific Personality Disorders
Section III includes diagnostic criteria for antisocial, avoidant , borderline, narcissistic, ob-
sessive-compulsive, and schizotypal personality disorders. Each pe rsonality disorder is
defined by typical impairments in personality functioning (Criterion A) and characteristic
pathological personality traits (Criterion B):
• Typical features of antisocial personality disorder  are a failure to conform to lawful
and ethical behavior, and an egocentric, callous lack of concern for others, accompanied
by deceitfulness, irresponsibility, manipulativeness, and/or risk taking.
• Typical features of avoidant personality disorder  are avoidance of social situations and
inhibition in interpersonal relationships related to feelings of ineptitude and inade-
quacy, anxious preoccupation with negative evaluation and rejection, and fears of rid-
icule or embarrassment.
• Typical features of borderline personality disorder are instability of self-image, per-
sonal goals, interpersonal relationships, an d affects, accompanied by impulsivity, risk
taking, and/or hostility.
• Typical features of narcissistic personality disorder  are variable and vulnerable self-
esteem, with attempts at regulation throug h attention and approval seeking, and either


esteem, with attempts at regulation throug h attention and approval seeking, and either
overt or covert grandiosity.


764 Alternative DSM-5 Model for Personality Disorders
• Typical features of obsessive-compulsive personality disorder  are difficulties in estab-
lishing and sustaining close relationships, as sociated with rigid perfectionism, inflexi-
bility, and restricted emotional expression.
• Typical features of schizotypal personality disorder  are impairments in the capacity
for social and close relationships, and eccent ricities in cognition, perception, and behav-
ior that are associated with distorted self-i mage and incoherent personal goals and ac-
companied by suspiciousness and re stricted emotional expression.
The A and B criteria for the six specific pe rsonality disorders and for PD-TS follow. All
personality disorders also meet criteria C through G of the General Criteria for Personality
Disorder.
Antisocial Personality Disorder
Typical features of antisocial personality diso rder are a failure to conform to lawful and
ethical behavior, and an egocentric, callous la ck of concern for others, accompanied by de-
ceitfulness, irresponsibility, manipulativeness, and/or risk taking. Characteristic difficul-
ties are apparent in identity, self-direction, empathy, and/or intimacy, as described below,
along with specific maladaptive traits in the domains of Antagonism and Disinhibition.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1.Identity:  Egocentrism; self-esteem derived from personal gain, power, or pleasure.
2.Self-direction: Goal setting based on personal gratification; absence of prosocial
internal standards, associated with failure to conform to lawful or culturally norma-
tive ethical behavior.
3.Empathy:  Lack of concern for feelings, needs, or suffering of others; lack of re-


morse after hurting or mistreating another.
4.Intimacy:  Incapacity for mutually intimate relationships, as exploitation is a primary
means of relating to others, including by deceit and coercion; use of dominance or
intimidation to control others.
B. Six or more of the following seven pathological personality traits:
1.Manipulativeness  (an aspect of Antagonism): Frequent use of subterfuge to in-
fluence or control others; use of seduction, charm, glibness, or ingratiation to
achieve one’s ends.
2.Callousness (an aspect of Antagonism ): Lack of concern for feelings or problems
of others; lack of guilt or remorse about the negative or harmful effects of one’s ac-
tions on others; aggression; sadism.
3.Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepre-
sentation of self; embellishment or fabrication when relating events.
4.Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or
irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.
5.Risk taking  (an aspect of Disinhibition ): Engagement in dangerous, risky, and poten-
tially self-damaging activities, unnecessarily and without regard for consequences;
boredom proneness and thoughtless initiation of activities to counter boredom; lack of
concern for one’s limitations and denial of the reality of personal danger.
6.Impulsivity  (an aspect of Disinhibition ): Acting on the spur of the moment in re-
sponse to immediate stimuli; acting on a momentary basis without a plan or consid-
eration of outcomes; difficulty establishing and following plans.


Alternative DSM-5 Model for Personality Disorders 765
7.Irresponsibility  (an aspect of Disinhibition ): Disregard for—and failure to honor—
financial and other obligations or commitments; lack of respect for—and lack of fol-
low-through on—agreements and promises.
Note. The individual is at least 18 years of age.
Specify if:
With psychopathic features.
Specifiers. A distinct variant often termed psychopathy  (or “primary” psychopathy) is
marked by a lack of anxiety or fear and by a bold interpersonal style that may mask mal-
adaptive behaviors (e.g., fraudulence). This ps ychopathic variant is characterized by low
levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment do-
main) and high levels of attention seeking (Antagonism domain). High attention seeking
and low withdrawal capture the social pote ncy (assertive/dominant) component of psy-
chopathy, whereas low anxiousness captures the stress immunity (emotional stability/re-
silience) component.
In addition to psychopathic features, trait and personality functioning specifiers may be
used to record other personality features that  may be present in anti social personality dis-
order but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g.,
anxiousness), are not diagnostic criteria for antisocial personality disorder (see Criterion B)
but can be specified when appropriate. Furthe rmore, although moderate or greater impair-
ment in personality functioning is required for the diagnosis of antisocial personality disor-
der (Criterion A), the level of persona lity functioning can also be specified.
Avoidant Person ality Disorder
Typical features of avoidant personality disord er are avoidance of social situations and in-


Typical features of avoidant personality disord er are avoidance of social situations and in-
hibition in interpersonal relationships related to feelings of inep titude and inadequacy,
anxious preoccupation with negative evaluation and rejection, and fears of ridicule or em-
barrassment. Characteristic difficulties are apparent in identity, self-direction, empathy,
and/or intimacy, as described below, along wi th specific maladaptiv e traits in the do-
mains of Negative Affectivity and Detachment.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personal ity functioning, manifest by characteristic
difficulties in two or more of the following four areas:
1.Identity:  Low self-esteem associated with self-appraisal as socially inept, person-
ally unappealing, or inferior; excessive feelings of shame.
2.Self-direction:  Unrealistic standards for behavior associated with reluctance to
pursue goals, take personal risks, or engage in new activities involving interper-
sonal contact.
3.Empathy:  Preoccupation with, and sensitivity to, criticism or rejection, associated
with distorted inference of others’ perspectives as negative.
4.Intimacy:  Reluctance to get involved with people unless being certain of being
liked; diminished mutuality within intimate relationships because of fear of being
shamed or ridiculed.
B. Three or more of the following four pathological personality traits, one of which must
be (1) Anxiousness:
1.Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervous-
ness, tenseness, or panic, often in reaction to social situations; worry about the
negative effects of past unpleasant experiences and future negative possibilities;


766 Alternative DSM-5 Model for Personality Disorders
feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrass-
ment.
2.Withdrawal (an aspect of Detachment ): Reticence in social situations; avoidance
of social contacts and activity; lack of initiation of social contact.
3.Anhedonia  (an aspect of Detachment ): Lack of enjoyment from, engagement in,
or energy for life’s experiences; deficits in the capacity to feel pleasure or take in-
terest in things.
4.Intimacy avoidance (an aspect of Detachment ): Avoidance of close or romantic
relationships, interpersonal attachments, and intimate sexual relationships.
Specifiers. Considerable heterogeneity in the form of additional personality traits is
found among individuals diagnosed with avoida nt personality disorder. Trait and level of
personality functioning specifiers can be used  to record additional personality features
that may be present in avoidant personality disorder. For example, other Negative Affec-
tivity traits (e.g., depressivity, separation insecurity, submissiveness, suspiciousness, hos-
tility) are not diagnostic criter ia for avoidant personality disorder (see Criterion B) but can
be specified when appropriate. Furthermore, although moderate or greater impairment in
personality functioning is required for the diag nosis of avoidant personality disorder (Cri-
terion A), the level of personality functioning also can be specified.
Borderline Personality Disorder
Typical features of borderline  personality disorder are instability of self-image, personal
goals, interpersonal relationships, and affect s, accompanied by impulsivity, risk taking,
and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empa-
thy, and/or intimacy, as described below, along with specific maladaptive traits in the do-
main of Negative Affectivity, and also Antagonism and/or Disinhibition.
Proposed Diagnostic Criteria


Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1.Identity:  Markedly impoverished, poorly developed, or unstable self-image, often
associated with excessive self-criticism; chronic feelings of emptiness; dissociative
states under stress.
2.Self-direction: Instability in goals, aspirations, values, or career plans.
3.Empathy:  Compromised ability to recognize the feelings and needs of others asso-
ciated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); per-
ceptions of others selectively biased toward negative attributes or vulnerabilities.
4.Intimacy:  Intense, unstable, and conflicted close relationships, marked by mistrust,
neediness, and anxious preoccupation with real or imagined abandonment; close
relationships often viewed in extremes of idealization and devaluation and alternat-
ing between overinvolvement and withdrawal.
B. Four or more of the following seven pathological personality traits, at least one of which
must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:
1.Emotional lability  (an aspect of Negative Affectivity): Unstable emotional expe-
riences and frequent mood changes; emotions that are easily aroused, intense,
and/or out of proportion to events and circumstances.
2.Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervous-
ness, tenseness, or panic, often in reaction to interpersonal stresses; worry about
the negative effects of past unpleasant experiences and future negative possibili-


Alternative DSM-5 Model for Personality Disorders 767
ties; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling
apart or losing control.
3.Separation insecurity  (an aspect of Negative Affectivity ): Fears of rejection by—
and/or separation from—significant others, associated with fears of excessive de-
pendency and complete loss of autonomy.
4.Depressivity  (an aspect of Negative Affectivity): Frequent feelings of being down,
miserable, and/or hopeless; difficulty recovering from such moods; pessimism
about the future; pervasive shame; feelings of inferior self-worth; thoughts of sui-
cide and suicidal behavior.
5.Impulsivity  (an aspect of Disinhibition ): Acting on the spur of the moment in re-
sponse to immediate stimuli; acting on a momentary basis without a plan or consid-
eration of outcomes; difficulty establishing or following plans; a sense of urgency
and self-harming behavior under emotional distress.
6.Risk taking  (an aspect of Disinhibition ): Engagement in dangerous, risky, and po-
tentially self-damaging activities, unnecessarily and without regard to conse-
quences; lack of concern for one’s limitations and denial of the reality of personal
danger.
7.Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger
or irritability in response to minor slights and insults.
Specifiers. Trait and level of personalit y functioning specifiers may be used to record ad-
ditional personality features that may be pres ent in borderline personality disorder but are
not required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and per-
ceptual dysregulation) are not diagnostic crit eria for borderline personality disorder (see


ceptual dysregulation) are not diagnostic crit eria for borderline personality disorder (see
Criterion B) but can be specif ied when appropriate. Furthermore, although moderate or
greater impairment in personality functioning is required for the di agnosis of borderline
personality disorder (Criterion A), the level of personality func tioning can also be specified.
Narcissistic Personality Disorder
Typical features of narcissistic personality disorder are variable and vulnerable self-esteem,
with attempts at regulation through attentio n and approval seeking, and either overt or
covert grandiosity. Characteristic difficulties are apparent in identity, self-direction, em-
pathy, and/or intimacy, as desc ribed below, along with specif ic maladaptive traits in the
domain of Antagonism.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1.Identity:  Excessive reference to others for self-definition and self-esteem regula-
tion; exaggerated self-appraisal inflated or deflated, or vacillating between extremes;
emotional regulation mirrors fl uctuations in self-esteem.
2.Self-direction:  Goal setting based on gaining approval from others; personal stan-
dards unreasonably high in order to see oneself as exceptional, or too low based
on a sense of entitlement; often unaware of own motivations.
3.Empathy:  Impaired ability to recognize or identify with the feelings and needs of
others; excessively attuned to reactions of others, but only if perceived as relevant
to self; over- or underestimate of own effect on others.
4.Intimacy:  Relationships largely superficial and exist to serve self-esteem regula-
tion; mutuality constrained by little genuine interest in others’ experiences and pre-
dominance of a need for personal gain.


768 Alternative DSM-5 Model for Personality Disorders
B. Both of the following pathological personality traits:
1.Grandiosity (an aspect of Antagonism ): Feelings of entitlement, either overt or co-
vert; self-centeredness; firmly holding to the belief that one is better than others;
condescension toward others.
2.Attention seeking  (an aspect of Antagonism ): Excessive attempts to attract and
be the focus of the attention of others; admiration seeking.
Specifiers. Trait and personality functioning specifie rs may be used to record additional
personality features that may be  present in narcissistic person ality disorder but are not re-
quired for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, de-
ceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see
Criterion B) but can be specified when more pervasive antagonistic features (e.g., “malignant
narcissism”) are present. Other traits of Negative Affectivity (e.g., depressivity, anxiousness)
can be specified to record more “vulnerable”  presentations. Furthermore, although moderate
or greater impairment in person ality functioning is required for the diagnosis of narcissistic
personality disorder (Criterion A), the level of  personality functioning can also be specified.
Obsessive-Compulsive Personality Disorder
Typical features of obsessive-compulsive person ality disorder are difficulties in establish-
ing and sustaining close relationships, associated with rigid perfectionism, inflexibility,
and restricted emotional expression. Characteristic difficulties are apparent in identity,
self-direction, empathy, and/or intimacy, as described below, along with specific mal-
adaptive traits in the domains of Ne gative Affectivity and/or Detachment.
Proposed Diagnostic Criteria


Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1.Identity:  Sense of self derived predominantly fr om work or productivity; constricted
experience and expression of strong emotions.
2.Self-direction: Difficulty completing tasks and realizing goals, associated with rigid
and unreasonably high and inflexible internal standards of behavior; overly consci-
entious and moralistic attitudes.
3.Empathy:  Difficulty understanding and appreciating the ideas, feelings, or behav-
iors of others.
4.Intimacy:  Relationships seen as secondary to work and productivity; rigidity and
stubbornness negatively affect relationships with others.
B. Three or more of the following four pathological personality traits, one of which must
be (1) Rigid perfectionism:
1.Rigid perfectionism  (an aspect of extreme Conscientiousness [the opposite pole
of Disinhibition]): Rigid insistence on everything being flawless, perfect, and without
errors or faults, including one’s own and ot hers’ performance; sacrificing of timeli-
ness to ensure correctness in every detail; believing that there is only one right way
to do things; difficulty changing ideas and/or viewpoint; preoccupation with details,
organization, and order.
2.Perseveration  (an aspect of Negative Affectivity ): Persistence at tasks long after
the behavior has ceased to be functional or effective; continuance of the same be-
havior despite repeated failures.
3.Intimacy avoidance (an aspect of Detachment ): Avoidance of close or romantic
relationships, interpersonal attachments, and intimate sexual relationships.


Alternative DSM-5 Model for Personality Disorders 769
4.Restricted affectivity (an aspect of Detachment ): Little reaction to emotionally
arousing situations; constricted emotional experience and expression; indifference
or coldness.
Specifiers. Trait and personality functioning specifie rs may be used to record additional
personality features that may be  present in obsessive-compulsive personality disorder but are
not required for the diagnosis. Fo r example, other traits of Negative Affectivity (e.g., anxious-
ness) are not diagnostic criteria  for obsessive-compulsive personal ity disorder (see Criterion B)
but can be specified when appropriate. Furthe rmore, although moderate or greater impair-
ment in personality functioning is required for the diagnosis of obsessive-compulsive person-
ality disorder (Criterion A), the level of personality functioning can also be specified.
Schizotypal Personality Disorder
Typical features of schizotypal personality diso rder are impairments in the capacity for so-
cial and close relationships and eccentricities in cognition, perception, and behavior that
are associated with distorted self-image an d incoherent personal goals and accompanied
by suspiciousness and restricted emotional ex pression. Characteristic difficulties are ap-
parent in identity, self-direction, empathy, and/or intimacy, along with specific maladap-
tive traits in the domains of Psychoticism and Detachment.
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following four areas:
1.Identity:  Confused boundaries between self and others; distorted self-concept;
emotional expression often not congruent with context or internal experience.
2.Self-direction:  Unrealistic or incoherent goals; no clear set of internal standards.
3.Empathy:  Pronounced difficulty understanding impact of own behaviors on others;


3.Empathy:  Pronounced difficulty understanding impact of own behaviors on others;
frequent misinterpretations of others’ motivations and behaviors.
4.Intimacy:  Marked impairments in developing close relationships, associated with
mistrust and anxiety.
B. Four or more of the following six pathological personality traits:
1.Cognitive and perceptual dysregulation  (an aspect of Psychoticism ): Odd or
unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or
stereotyped thought or speech; odd sensations in various sensory modalities.
2.Unusual beliefs and experiences  (an aspect of Psychoticism ): Thought content
and views of reality that are viewed by others as bizarre or idiosyncratic; unusual
experiences of reality.
3.Eccentricity  (an aspect of Psychoticism ): Odd, unusual, or bizarre behavior or
appearance; saying unusual or inappropriate things.
4.Restricted affectivity (an aspect of Detachment ): Little reaction to emotionally
arousing situations; constricted emotional experience and expression; indifference
or coldness.
5.Withdrawal (an aspect of Detachment ): Preference for being alone to being with
others; reticence in social situations; avoidance of social contacts and activity; lack
of initiation of social contact.
6.Suspiciousness (an aspect of Detachment ): Expectations of—and heightened
sensitivity to—signs of interpersonal ill-intent or harm; doubts about loyalty and fi-
delity of others; feelings of persecution.


770 Alternative DSM-5 Model for Personality Disorders
Specifiers. Trait and personality functioning specifie rs may be used to record additional
personality features that may be present in sc hizotypal personality disorder but are not re-
quired for the diagnosis. For ex ample, traits of Negative Affectivity (e.g., depressivity,
anxiousness) are not diagnostic criteria for sc hizotypal personality disorder (see Criterion
B) but can be specified when appropriate. Fu rthermore, although moderate or greater im-
pairment in personality functioning is required  for the diagnosis of schizotypal personal-
ity disorder (Criterion A), the level of pe rsonality functioning can also be specified.
Personality Disorder —Trait Specified
Proposed Diagnostic Criteria
A. Moderate or greater impairment in personality functioning, manifested by difficulties in
two or more of the following four areas:
1.Identity
2.Self-direction
3.Empathy
4.Intimacy
B. One or more pathological personality trait domains OR specific trait facets within do-
mains, considering ALL of the following domains:
1.Negative Affectivity (vs. Emotional Stability): Frequent and intense experiences
of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/
shame, worry, anger), and their behavioral (e.g., self-harm) and interpersonal (e.g.,
dependency) manifestations.
2.Detachment  (vs. Extraversion): Avoidance of socioemotional experience, includ-
ing both withdrawal from interpersonal interactions, ranging from casual, daily in-
teractions to friendships to intimate relationships, as well as restricted affective
experience and expression, particularly limited hedonic capacity.
3.Antagonism (vs. Agreeableness): Behaviors that  put the individual at odds with


other people, including an exaggerated sense of self-importance and a concomi-
tant expectation of special treatment, as well as a callous antipathy toward others,
encompassing both unawareness of others’ needs and feelings, and a readiness
to use others in the service of self-enhancement.
4.Disinhibition  (vs. Conscientiousness): Orientation toward immediate gratification,
leading to impulsive behavior driven by current thoughts, feelings, and external
stimuli, without regard for past learning or consideration of future consequences.
5.Psychoticism  (vs. Lucidity): Exhibiting a wide range of culturally incongruent odd,
eccentric, or unusual behaviors and cognitions, including both process (e.g., per-
ception, dissociation) and content (e.g., beliefs).
Subtypes. Because personality features vary continuously along multiple trait dimen-
sions, a comprehensive set of potential expr essions of PD-TS can be represented by DSM-
5’s dimensional model of maladaptive personality trait variants (see Table 3, pp. 779–781).
Thus, subtypes are unnecessary for PD-TS, and instead, the descriptiv e elements that con-
stitute personality are provided, arranged in  an empirically based model. This arrange-
ment allows clinicians to tailor the descript ion of each individual’s personality disorder
profile, considering all five broad domains of personality trait variation and drawing on
the descriptive features of these domains as  needed to characterize the individual.


Alternative DSM-5 Model for Personality Disorders 771
Specifiers. The specific personality features of in dividuals are always recorded in eval-
uating Criterion B, so the comb ination of personality features characterizing an individual
directly constitutes the specifiers in each case. For example, two individuals who are both
characterized by emotional lability, hostility, and depressivity may differ such that the
first individual is characterized additionally by callousness, whereas the second is not.
Personality Disorder Scoring Algorithms
The requirement for any two of the four A criter ia for each of the six personality disorders
was based on maximizing the relationship of these criteria to their corresponding person-
ality disorder. Diagnostic thresholds for the B criteria were also set empirically to minimize
change in prevalence of the disorders from DSM-IV an d overlap with other personality
disorders, and to maximize relationships with functional impairment. The resulting diag-
nostic criteria sets represent clinically usef ul personality disorders with high fidelity, in
terms of core impairments in personality functioning of varying degr ees of severity and
constellations of pathological personality traits.
Personality Disorder Diagnosis
Individuals who have a pattern of impairment  in personality functioning and maladaptive
traits that matches one of the six defined personality disorders should be diagnosed with
that personality disorder. If an individual also  has one or even several prominent traits that
may have clinical relevance in addition to those requ ired for the diagnosis (e.g., see narcis-
sistic personality disorder), the option exists for these to be noted as specifiers. Individuals
whose personality functioning or trait pattern is substantially different from that of any of
the six specific personality disorders should be diagnosed with PD-T S. The individual may
not meet the required number of A or B criter ia and, thus, have a su bthreshold presentation


of a personality disorder. The individual may have a mix of features of personality disorder
types or some features that are less characteri stic of a type and more accurately considered
a mixed or atypical presentation. The specific level of impairment in personality function-
ing and the pathological personality traits that characterize the individual’s personality can
be specified for PD-TS, using the Level of Personality Functioning Scale (Table 2) and the
pathological trait taxonomy (T able 3). The current diagnoses of paranoid, schizoid, histri-
onic, and dependent personality disorders are represented also by the diagnosis of PD-TS;
these are defined by moderate or greater impairment in personality functioning and can be
specified by the relevant pathological personality trait combinations.
Level of Personality Functioning
Like most human tendencies, personality func tioning is distributed on a continuum. Cen-
tral to functioning and adaptation are indivi duals’ characteristic ways of thinking about
and understanding themselves and their intera ctions with others. An optimally function-
ing individual has a complex, fully elaborat ed, and well-integrated psychological world
that includes a mostly positive,  volitional, and adaptive self-concept; a rich, broad, and ap-
propriately regulated emotional life; and the ca pacity to behave as a productive member of
society with reciprocal and fulfilling interper sonal relationships. At the opposite end of
the continuum, an individual with severe personality pathology has an impoverished, dis-
organized, and/or conflicted psychological world that includes a weak, unclear, and mal-
adaptive self-concept; a propensity to negative, dysregulated emotions; and a deficient
capacity for adaptive interpersona l functioning and social behavior.


772 Alternative DSM-5 Model for Personality Disorders
Self- and Interpersonal  Functioning
Dimensional Definition
Generalized severity may be the most import ant single predictor of concurrent and pro-
spective dysfunction in assessing personalit y psychopathology. Pers onality disorders are
optimally characterized by a generalized pers onality severity continuum with additional
specification of stylistic elem ents, derived from personalit y disorder symptom constella-
tions and personality traits. At the same time , the core of personality psychopathology is
impairment in ideas and feelin gs regarding self and interper sonal relationships; this no-
tion is consistent with multiple theories of personality disorder and their research bases. The
components of the Level of Personality Func tioning Scale—identity, self-direction, empa-
thy, and intimacy (see Table 1)—are particularly  central in describing a personality func-
tioning continuum.
Mental representations of the self and interpersonal relationships are reciprocally in-
fluential and inextricably tied , affect the nature of interaction with mental health pro-
fessionals, and can have a significant impact  on both treatment efficacy and outcome,
underscoring the importance of assessing an individual’s characteristic self-concept as
well as views of other people and relationships. Although the degree of disturbance in the
self and interpersonal functioning is continuous ly distributed, it is useful to consider the
level of impairment in functioning for clinical characterization and for treatment planning
and prognosis.
Rating Level of Pers onality Functioning
To use the Level of Personality Functioning Sc ale (LPFS), the clinician selects the level that
most closely captures  the individual’s current overall  level of impairment in personality func-
tioning. The rating is necessary for the diagnosi s of a personality disord er (moderate or greater


impairment) and can be used to specify the seve rity of impairment pr esent for an individual
with any personality disorder at  a given point in time. The LPFS may also be used as a global
indicator of personality functi oning without specification of a personality disorder diagnosis,
or in the event that personality impairment  is subthreshold for a disorder diagnosis.
Personality Traits
Definition and Description
Criterion B in the alternative model involves assessments of personality traits that are
grouped into five domains. A personality trait is a tendency to feel, perceive, behave, and
think in relatively consistent ways across time  and across situations in which the trait may
manifest. For example, individuals with a high level of the personality trait of anxiousness
would tend to feel anxious readily, including in circumstances in which most people
would be calm and relaxed.  Individuals high in trait anxiousness also would perceive  sit-
uations to be anxiety-provoking more freque ntly than would individuals with lower lev-
els of this trait, and those high in the trait would tend to behave  so as to avoid situations that
they think  would make them anxious. They would thereby tend to think  about the world as
more anxiety provoking than other people.
Importantly, individuals high in trait anxiousness would not nece ssarily be anxious at
all times and in all situations. Individuals’ trait levels also can and do change throughout
life. Some changes are very general and reflect maturation (e.g., teenagers generally are
higher on trait impulsivity than are older ad ults), whereas other ch anges reflect individ-
uals’ life experiences.
Dimensionality of personality traits. All individuals can be located on the spectrum of
trait dimensions; that is, personality traits apply to everyone in different degrees rather


Alternative DSM-5 Model for Personality Disorders 773
than being present versus absent. Moreover, personality traits, including those identified
specifically in the Section III model, exist on a spectrum with two opposing poles. For ex-
ample, the opposite of the trait of callousness is the tendency to be empathic and kind-
hearted, even in circumstances in which most persons would not feel that way. Hence, al-
though in Section III th is trait is labeled callousness, because that pole of the dimension is
the primary focus, it coul d be described in full as callousness versus kind-heartedness.  More-
over, its opposite pole can be  recognized and may not be adaptive in all circumstances
(e.g., individuals who, due to extreme kind-heartedness, repeatedly allow themselves to
be taken advantage of by unscrupulous others).
Hierarchical structure of personality. Some trait terms are quite specific (e.g., “talkative”)
and describe a narrow range of behaviors, wh ereas others are quite broad (e.g., Detach-
ment) and characterize a wide range of beha vioral propensities. Broad trait dimensions
are called domains, and specific trait dimensions are called facets.  Personality trait domains
comprise a spectrum of more specific personality facets  that tend to occur together. For ex-
ample, withdrawal and anhedonia are specific trait facets  in the trait domain  of Detachment.
Despite some cross-cultural variation in pe rsonality trait facets, the broad domains they
collectively comprise are relati vely consistent across cultures.
The Personality Trait Model
The Section III personality trait system includ es five broad domains of personality trait
variation—Negative Affectivity (vs. Emotiona l Stability), Detachment (vs. Extraversion),


Antagonism (vs. Agreeableness), Disinhibition  (vs. Conscientiousness), and Psychoticism
(vs. Lucidity)—comprising 25 specific personalit y trait facets. Table 3 provides definitions
of all personality domains and facets. These five broad domains are maladaptive variants
of the five domains of the extensively valid ated and replicated personality model known
as the “Big Five”, or Five Factor Model of pe rsonality (FFM), and are also similar to the do-
mains of the Personality Psychopathology Five (PSY-5). The specific 25 facets represent a
list of personality facets chosen for their clinical relevance.
Although the Trait Model focuses on persona lity traits associated with psychopathol-
ogy, there are healthy, adaptive, and resilien t personality traits identified as the polar
opposites of these traits, as noted in the pa rentheses above (i.e., Em otional Stability, Ex-
traversion, Agreeableness, Conscientiousness, and Lucidity). Their presence can greatly
mitigate the effects of mental disorders and facilitate coping and re covery from traumatic
injuries and other medical illness.
Distinguishing Traits, Symptoms, and Specific Behaviors
Although traits are by no means immutable and do change throughout the life span, they
show relative consistency compared with sy mptoms and specific behaviors. For example,
a person may behave impulsively at a specific ti me for a specific reason (e.g., a person who
is rarely impulsive suddenly decides to spend a great deal of money on a particular item
because of an unusual opportunity to purchase  something of unique value), but it is only
when behaviors aggregate across time and circumstance, such that a pattern of behavior
distinguishes between individuals, that they re flect traits. Nevertheless, it is important to


distinguishes between individuals, that they re flect traits. Nevertheless, it is important to
recognize, for example,  that even people wh o are impulsive are not acting impulsively all
of the time. A trait is a tendency or dispositio n toward specific behaviors; a specific behav-
ior is an instance or manifestation of a trait.
Similarly, traits are distin guished from most symptoms  because symptoms tend to
wax and wane, whereas traits are relatively more stable. For example, individuals with


Similarly, traits are distin guished from most symptoms  because symptoms tend to
wax and wane, whereas traits are relatively more stable. For example, individuals with
higher levels of depressivity  have a greater likelihood of experiencing discrete episodes of a
depressive disorder and of showing the sympto ms of these disorders, such difficulty con-
centrating. However, even patients  who have a trait propensity to depressivity  typically cy-
cle through distinguishable episodes of mood disturbance, and specific symptoms such as


774 Alternative DSM-5 Model for Personality Disorders
difficulty concentrating tend to wax and wane in  concert with specific episodes, so they do
not form part of the trait definition. Import antly, however, symptoms and traits are both
amenable to intervention, and many interven tions targeted at symptoms can affect the
longer term patterns of pers onality functioning that are ca ptured by personality traits.
Assessment of the DSM-5 Section III
Personality Trait Model
The clinical utility of the Section III multidimensio nal personality trait model lies in its ability
to focus attention on multiple relevant areas of personality variation in each individual patient.
Rather than focusing attention on the identification of one and only one optimal diagnostic
label, clinical ap plication of the Section III personality trait model involves reviewing all five
broad personality domains portrayed in Table 3. The clinical approach to personality is similar
to the well-known review of systems in clinical medicine. For example, an individual’s pre-
senting complaint may focus on a specific ne urological symptom, yet during an initial
evaluation clinicians still systematically review  functioning in all relevant systems (e.g., car-
diovascular, respiratory, gastrointestinal), lest  an important area of diminished functioning
and corresponding opportunity for effective intervention be missed.
Clinical use of the Section III personality trait model proceeds similarly. An initial in-
quiry reviews all five broad doma ins of personality. This systematic review is facilitated
by the use of formal psychome tric instruments designed to me asure specific facets and do-
mains of personality. For example, the person ality trait model is operationalized in the
Personality Inventory for DSM-5 (PID-5), which can be completed in its self-report form by
patients and in its informant-report form by those who know the patient well (e.g., a


patients and in its informant-report form by those who know the patient well (e.g., a
spouse). A detailed clinical assessment would involve collect ion of both patient- and in-
formant-report data on all 25 facets of the pe rsonality trait model. However, if this is not
possible, due to time or other co nstraints, assessment focused at the five-domain level is an
acceptable clinical option when only a general (vs. detailed) portrait of a patient’s person-
ality is needed (see Criterion B of PD-TS). Ho wever, if personality- based problems are the
focus of treatment, then it will be important to assess individual s’ trait facets as well as do-
mains.
Because personality traits are continuously distributed in the population, an approach
to making the judgment that a specific trait is elevated (and therefor e is present for diag-
nostic purposes) could involve comparing indi viduals’ personality tr ait levels with pop-
ulation norms and/or clinical judgment. If a trait is elevated—that is, formal psychometric
testing and/or interview data support the clinical judgment of elevation—then it is con-
sidered as contributing to meeting Criterion B of Section III personality disorders.
Clinical Utility of the Multidimensional Personality
Functioning a nd Trait Model
Disorder and trait constructs each add value to the other in  predicting important anteced-
ent (e.g., family history, hist ory of child abuse), concurrent (e.g., functional impairment,
medication use), and predictive (e.g., hospit alization, suicide attempts) variables. DSM-5
impairments in personality functioning and pa thological personality traits each contrib-
ute independently to clinical decisions about degree of disability; risks for self-harm, vio-


ute independently to clinical decisions about degree of disability; risks for self-harm, vio-
lence, and criminality; reco mmended treatment type and intensity; and prognosis—all
important aspects of the utility of psychiatric diagnoses. Notably, knowing the level of an
individual’s personality functioning and his or  her pathological trait profile also provides
the clinician with a rich base of information and is valuable in treatment planning and in


individual’s personality functioning and his or  her pathological trait profile also provides
the clinician with a rich base of information and is valuable in treatment planning and in
predicting the course and outcome of many me ntal disorders in addition to personality
disorders. Therefore, assessment of persona lity functioning and pathological personality
traits may be relevant whether an indivi dual has a personality disorder or not.


Alternative DSM-5 Model for Personality Disorders 775TABLE 2 Level of Personality Functioning Scale
SELF INTERPERSONAL
Level of
impairment Identity Self-d irection Empathy Intimacy
0—Little or no
impairmentHas ongoing awareness of a
unique self; maintains role-
appropriate boundaries.
Has consistent and self-regulated
positive self-esteem, with accu-
rate self-appraisal.
Is capable of experiencing, toler-
ating, and regulating a full
range of emotions.Sets and aspires to reasonable
goals based on a realistic
assessment of personal
capacities.
Utilizes appropriate stan-
dards of behavior, attaining
fulfillment in multiple
realms.
Can reflect on, and make con-
structive meaning of, inter-
nal experience.Is capable of accurately under-
standing others’ experiences
and motivations in most situ-
ations.
Comprehends and appreciates
others’ perspectives, even if
disagreeing.
Is aware of the effect of own
actions on others.Maintains multiple satisfying and
enduring relationships in personal
and community life.
Desires and engages in a number of
caring, close, and reciprocal rela-
tionships.
Strives for cooperation and mutual
benefit and flexibly responds to a
range of others’ ideas, emotions,
and behaviors.
1—Some
impairmentHas relatively intact sense of self,
with some decrease in clarity of
boundaries when strong emo-
tions and mental distress are
experienced.
Self-esteem dimini shed at times,
with overly critical or some-
what distorted self-appraisal.
Strong emotions may be distress-


what distorted self-appraisal.
Strong emotions may be distress-
ing, associated with a restric-
tion in range of emotional
experience.Is excessively goal-directed,
somewhat goal-inhibited, or
conflicted about goals.
May have an unrealistic or
socially inappropriate set of
personal standards, limiting
some aspects of fulfillment.
Is able to reflect on internal
experiences, but may over-
emphasize a single (e.g.,
intellectual, emotional) type
of self-knowledge.Is somewhat compromised in
ability to appreciate and
understand others’ experi-
ences; may tend to see others
as having unreasonable
expectations or a wish for
control.
Although capable of consider-
ing and understanding dif-
ferent perspectives, resists
doing so.
Has inconsistent awareness of
effect of own behavior on
others.Is able to establish enduring rela-
tionships in personal and commu-
nity life, with some limitations on
degree of depth and satisfaction.
Is capable of forming and desires to
form intimate and reciprocal rela-
tionships, but may be inhibited in
meaningful expression and some-
times constrained if intense emo-
tions or conflicts arise.
Cooperation may be inhibited by
unrealistic standards; somewhat
limited in ability to respect or
respond to others’ ideas, emo-
tions, and behaviors.


776 Alternative DSM-5 Model for Personality Disorders2—Moderate
impairmentDepends excessively on others
for identity definition, with
compromised boundary delin-
eation.
Has vulnerable self-esteem con-
trolled by exaggerated concern
about external evaluation, with
a wish for approval. Has sense
of incompleteness or inferior-
ity, with compensatory
inflated, or deflated,
self-appraisal.
Emotional regulation depends
on positive external appraisal.
Threats to self-esteem may
engender strong emotions such
as rage or shame.Goals are more often a means
of gaining external approval
than self-generated, and
thus may lack coherence
and/or stability.
Personal standards may be
unreasonably high (e.g., a
need to be special or please
others) or low (e.g., not con-
sonant with prevailing
social values). Fulfillment is
compromised by a sense of
lack of authenticity.
Has impaired capacity to
reflect on internal experi-
ence.Is hyperattuned to the experi-
ence of others, but only with
respect to perceived rele-
vance to self.
Is excessively self-referential;
significantly compromised
ability to appreciate and
understand others’ experi-
ences and to co nsider alterna-
tive perspectives.
Is generally unaware of or
unconcerned about effect of
own behavior on others, or
unrealistic appraisal of own
effect.Is capable of forming and desires to
form relationships in personal and
community life, but connections
may be largely superficial.
Intimate relationships are predomi-


may be largely superficial.
Intimate relationships are predomi-
nantly based on meeting self-regu-
latory and self-esteem needs, with
an unrealistic expectation of being
perfectly understood by others.
Tends not to view relationships in
reciprocal terms, and cooperates
predominantly for personal gain.TABLE 2 Level of Personality Functioning Scale (continued)
SELF INTERPERSONAL
Level of
impairment Identity Self-d irection Empathy Intimacy


Alternative DSM-5 Model for Personality Disorders 7773—Severe
impairmentHas a weak sense of autonomy/
agency; experience of a lack of
identity, or emptiness. Bound-
ary definition is poor or rigid:
may show overidentification
with others, overemphasis on
independence from others, or
vacillation between these.
Fragile self-esteem is easily influ-
enced by events, and self-image
lacks coherence. Self-appraisal
is un-nuanced: self-loathing,
self-aggrandizing, or an illogi-
cal, unrealistic combination.
Emotions may be rapidly shifting
or a chronic, unwavering feel-
ing of despair.Has difficulty establishing
and/or achieving personal
goals.
Internal standards for behav-
ior are unclear or contradic-
tory. Life is experienced as
meaningless or dangerous.
Has significantly compro-
mised ability to reflect on
and understand own mental
processes.Ability to consider and under-
stand the thoughts, feelings,
and behavior of other people
is significantly limited; may
discern very specific aspects
of others’ experience, particu-
larly vulnerabilities and suf-
fering.
Is generally unable to consider
alternative perspectives;
highly threatened by differ-
ences of opinion or alterna-
tive viewpoints.
Is confused about or unaware
of impact of own actions on
others; often bewildered
about peoples’ thoughts and
actions, with destructive
motivations frequently
misattributed to others.Has some desire to form relation-
ships in community and personal
life is present, but capacity for pos-
itive and enduring connections is
significantly impaired.


itive and enduring connections is
significantly impaired.
Relationships are based on a strong
belief in the absolute need for the
intimate other(s), and/or expecta-
tions of abandonment or abuse.
Feelings about intimate involve-
ment with others alternate
between fear/rejection and des-
perate desire for connection.
Little mutuality: others are concep-
tualized primarily in terms of how
they affect the se lf (negatively or
positively); cooperative efforts are
often disrupted due to the percep-
tion of slights from others.TABLE 2 Level of Personality Functioning Scale (continued)
SELF INTERPERSONAL
Level of
impairment Identity Self-d irection Empathy Intimacy


778 Alternative DSM-5 Model for Personality Disorders4—Extreme
impairmentExperience of a unique self and
sense of agency/autonomy are
virtually absent, or are orga-
nized around perceived exter-
nal persecution. Boundaries
with others are confused or
lacking.
Has weak or distorted self-image
easily threatened by interac-
tions with others; significant
distortions and confusion
around self-appraisal.
Emotions not congruent with
context or internal experience.
Hatred and aggression may be
dominant affects, although they
may be disavowed and attrib-
uted to others.Has poor differentiation of
thoughts from actions, so
goal-setting ability is
severely compromised, with
unrealistic or incoherent
goals.
Internal standards for behav-
ior are virtually lacking.
Genuine fulfillment is virtu-
ally inconceivable.
Is profoundly unable to con-
structively reflect on own
experience. Personal moti-
vations may be unrecog-
nized and/or experienced
as external to self.Has pronounced inability to
consider and understand
others’ experience and
motivation.
Attention to others’ perspec-
tives is virtually absent
(attention is hypervigilant,
focused on need fulfillment
and harm avoidance).
Social interactions can be
confusing and disorienting.Desire for affiliation is limited
because of profound disinterest or
expectation of harm. Engagement
with others is detached, disorga-
nized, or consistently negative.
Relationships are conceptualized
almost exclusively in terms of
their ability to provide comfort or
inflict pain and suffering.


their ability to provide comfort or
inflict pain and suffering.
Social/interpersonal behavior is not
reciprocal; rather, it seeks fulfill-
ment of basic needs or escape from
pain.TABLE 2 Level of Personality Functioning Scale (continued)
SELF INTERPERSONAL
Level of
impairment Identity Self-d irection Empathy Intimacy


Alternative DSM-5 Model for Personality Disorders 779
TABLE 3 Definitions of DSM-5 personality disorder trait domains
and facets
DOMAINS (Polar Opposites)
and Facets Definitions
NEGATIVE AFFECTIVITY
(vs. Emotional Stability)Frequent and intense experiences of high levels of a wide range of
negative emotions (e.g., anxiet y, depression, guilt/ shame, worry,
anger) and their behavioral (e.g., self-harm) and interpersonal (e.g.,
dependency) manifestations.
Emotional lability Instability of emotional experiences and mood; emotions that are
easily aroused, intense, and/or out of proportion to events and cir-
cumstances.
Anxiousness Feelings of nervousness, tensenes s, or panic in reaction to diverse situa-
tions; frequent worry about the negative effects of past unpleasant
experiences and future negative possibilities; feeling fearful and
apprehensive about un certainty; expecting the worst to happen.
Separation insecurity Fears of being alone due to rejection by—and /or separation from—
significant others, based in a lack of confidence in one’s ability to
care for oneself, both ph ysically and emotionally.
Submissiveness Adaptation of one’s behavior to the actual or perceived interests and
desires of others even when doing so is antithetical to one’s own
interests, needs, or desires.
Hostility Persistent or frequent angry feelings; anger or irritability in response
to minor slights and insults; mean, nasty, or vengeful behavior. See
also Antagonism.
Perseveration Persistence at tasks or in a particular way of doing things long after the
behavior has ceased to be functional  or effective; co ntinuance of the


behavior has ceased to be functional  or effective; co ntinuance of the
same behavior despite repeated fail ures or clear reasons for stopping.
Depressivity See Detachment.
Suspiciousness See Detachment.
Restricted affectivity
(lack of)The lack of  this facet characterizes low levels  of Negative Affectivity.
See Detachment for definition of this facet.
DETACHMENT
(vs. Extraversion)Avoidance of socioemotional experi ence, including both withdrawal
from interpersonal interactions (ranging from casual, daily interac-
tions to friendships to intimate relationships) and restricted affective
experience and expression, partic ularly limited hedonic capacity.
Withdrawal Preference for bein g alone to being with others; reticence in social sit-
uations; avoidance of social contacts and activity; lack of initiation
of social contact.
Intimacy avoidance Avoidance of close or ro mantic relationships, interpersonal attach-
ments, and intimate sexual relationships.
Anhedonia Lack of enjoyment from, engagement  in, or energy for life’s experiences;
deficits in the capacity to feel pleasure and take interest in things.
Depressivity Feelings of being down, mise rable, and/or hopeless; difficulty recov-
ering from such moods; pessimism about the future; pervasive
shame and/or guilt; feelings of inferior self-worth; thoughts of sui-
cide and suicidal behavior.
Restricted affectivity Little reaction to emot ionally arousing situations; constricted emo-
tional experience and expression; indifference and aloofness in nor-
matively engaging situations.
Suspiciousness Expectations of—and sensitivity to—signs of interpersonal ill-
intent or harm; doubts about loyalty and fidelity of others; feelings


intent or harm; doubts about loyalty and fidelity of others; feelings
of being mistreated, used, and/or persecuted by others.


780 Alternative DSM-5 Model for Personality Disorders
ANTAGONISM (vs.
Agreeableness)Behaviors that put the individual at odds with other people, includ-
ing an exaggerated sense of self-importance and a concomitant
expectation of special treatment, as well as a callous antipathy
toward others, encompassing both an unawareness of others’
needs and feelings and a readiness to use others in the service of
self-enhancement.
Manipulativeness Use of subterfuge to influence or control others; use of seduction,
charm, glibness, or ingratia tion to achieve one’s ends.
Deceitfulness Dishonesty and fraudulence; misrepresentation of self; embellish-
ment or fabrication when relating events.
Grandiosity Believing that one is superior  to others and deserves special treat-
ment; self-centeredness; feelings  of entitlement;  condescension
toward others.
Attention seeking Engaging in behavior designed to attract notice and to make oneself
the focus of others’ attention and admiration.
Callousness Lack of concern for the feelings or problems of others; lack of guilt
or remorse about the negative or harmful effects of one’s actions
on others.
Hostility See Negative Affectivity.
DISINHIBITION
(vs. Conscientiousness)Orientation toward immediate gratification, leading to impulsive
behavior driven by current though ts, feelings, and external stim-
uli, without regard fo r past learning or consideration of future
consequences.
Irresponsibility Disregard for—and failure  to honor—financial and other obliga-
tions or commitments; lack of respect for—and lack of follow-
through on—agreements and promises; carelessness with others’
property.


through on—agreements and promises; carelessness with others’
property.
Impulsivity Acting on the spur of the moment in response to immediate stimuli;
acting on a momentary basis with out a plan or consideration of
outcomes; difficulty establishing and following plans; a sense of
urgency and self-harming behavi or under emotional distress.
Distractibility Difficulty concentrating and focusing on tasks; attention is easily
diverted by extraneous stimuli; difficulty maintaining goal-
focused behavior, including both planning and completing tasks.
Risk taking Engagement in dangerous,  risky, and potentially self-damaging
activities, unnecessarily and withou t regard to consequences; lack
of concern for one’s limitations and denial of the reality of per-
sonal danger; reckless pursuit of goals regardless of the level of
risk involved.
Rigid perfectionism (lack of) Rigid insistence on everything being flawless, perfect, and without
errors or faults, including one’s own and others’ performance; sac-
rificing of timeliness to ensure correctness in every detail; believ-
ing that there is only one right way to do things; difficulty
changing ideas and/or viewpoint; preoccupation with details,
organization, and order. The lack of  this facet characterizes low
levels  of Disinhibition.TABLE 3 Definitions of DSM-5 personality disorder trait domains
and facets (continued)
DOMAINS (Polar Opposites)
and Facets Definitions


Alternative DSM-5 Model for Personality Disorders 781
PSYCHOTICISM
(vs. Lucidity)Exhibiting a wide range of cultura lly incongruent odd,  eccentric, or
unusual behaviors and cognitions, including both process (e.g.,
perception, dissociation) and content (e.g., beliefs).
Unusual beliefs and
experiencesBelief that one has unusual abilities, such as mind reading, telekine-
sis, thought-action fusion, unusual experiences of reality, includ-
ing hallucination-like experiences.
Eccentricity Odd, unusual, or bizarre behavior, appearance, and/or speech;
having strange and unpredictable thoughts; saying unusual or
inappropriate things.
Cognitive and perceptual
dysregulationOdd or unusual thought processes and experiences, including
depersonalization, derealization,  and dissociative experiences;
mixed sleep-wake state experience s; thought-control experiences.TABLE 3 Definitions of DSM-5 personality disorder trait domains
and facets (continued)
DOMAINS (Polar Opposites)
and Facets Definitions


783Conditions for
Further Study
Proposed criteria  sets are presented fo r conditions on which future research is en-
couraged. The specific items, thresholds, and durations contained in these research crite-
ria sets were set by expert co nsensus—informed by literature review, data reanalysis, and
field trial results, where available—and are intended to provide a common language for
researchers and clinicians who are interested in  studying these disord ers. It is hoped that
such research will allow the field to better  understand these conditions and will inform
decisions about possible placement in fort hcoming editions of DSM. The DSM-5 Task
Force and Work Groups subjecte d each of these proposed crit eria sets to a careful empir-
ical review and invited wide commentary from the field as well as from the general public.
The Task Force determined that there was in sufficient evidence to warrant inclusion of
these proposals as official mental disorder diagnoses in Section II. These proposed criteria
sets are not intended for clinical use; only th e criteria sets and disorders in Section II of
DSM-5 are officially recognized and can be used for clinical purposes.
Attenuated Psychosis Syndrome
Proposed Criteria
A. At least one of the following symptoms is present in attenuated form, with relatively in-
tact reality testing, and is of sufficient seve rity or frequency to warr ant clinical attention:
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
B. Symptom(s) must have been present at least once per week for the past month.
C. Symptom(s) must have begun or worsened in the past year.
D. Symptom(s) is sufficiently distressing and disabling to the individual to warrant clinical
attention.
E. Symptom(s) is not better explained by another mental disorder, including a depressive


E. Symptom(s) is not better explained by another mental disorder, including a depressive
or bipolar disorder with psychotic features , and is not attributable to the physiological
effects of a substance or another medical condition.
F. Criteria for any psychotic disorder have never been met.
Diagnostic Features
Attenuated psychotic symptoms, as defined in Criterion A, are psychosis-like but below the
threshold for a full psychotic disorder. Comp ared with psychotic disorders, the symptoms
are less severe and more transient, and insight is relatively maintained . A diagnosis of atten-
uated psychosis syndrome requires state psychopathology associated with functional
impairment rather than long-standing trait pathology. The psychopathology has not pro-
gressed to full psychotic severi ty. Attenuated psychosis syndrome is a disorder based on the
manifest pathology and impaired function and distress. Changes in experiences and behav-


784 Conditions for Further Study
iors are noted by the individual  and/or others, suggesting a change in mental state (i.e., the
symptoms are of sufficient severi ty or frequency to warrant clin ical attention) (Criterion A).
Attenuated delusions (Criterion  A1) may have suspiciousness /persecutory ideational con-
tent, including persecutory ideas of reference. The individual may have a guarded, distrust-
ful attitude. When the delusions are moderate in severity, the individual views others as
untrustworthy and may be hyperv igilant or sense ill will in others. When the delusions are
severe but still within the attenuated range, the individual entertains  loosely organized be-
liefs about danger or hostile in tention, but the delusions do no t have the fixed nature that is
necessary for the diagnosis of a psychotic diso rder. Guarded behavior in the interview can
interfere with the ability to gath er information. Rea lity testing and perspective can be elic-
ited with nonconfirming evidence, but the prop ensity for viewing the world as hostile and
dangerous remains strong. Attenuated delusions may have grandiose content presenting as
an unrealistic sense of superior capacity. Wh en the delusions are moderate, the individual
harbors notions of being gifted, influential, or special. When the delusions are severe, the in-
dividual has beliefs of superiority that often alienate friends and worry relatives. Thoughts
of being special may lead to unrealistic plans and investments, yet skepticism about these at-
titudes can be elicited with persis tent questioning and confrontation.
Attenuated hallucinations (Criterion A2) include alterations in sensory perceptions,
usually auditory and/or visual. When the hallucinations are moderate, the sounds and


usually auditory and/or visual. When the hallucinations are moderate, the sounds and
images are often unformed (e.g ., shadows, trails, halos, mu rmurs, rumbling), and they are
experienced as unusual or puzzling. When the hallucinations are severe, these experiences
become more vivid and frequent (i.e., recurring illusions or hallucinations that capture at-
tention and affect thinking and concentratio n). These perceptual abnormalities may dis-
rupt behavior, but skepticism about their reality can still be induced.
Disorganized communica tion (Criterion A3) may manifest as odd speech (vague, meta-
phorical, overelaborate, stereoty ped), unfocused speech (confuse d, muddled, too fast or too
slow, wrong words, irrelevant context, off trac k), or meandering speech (circumstantial, tan-
gential). When the disorganization is moderately  severe, the individual frequently gets into
irrelevant topics but re sponds easily to clarifying questi ons. Speech may be odd but under-
standable. At the moderately severe level, speech becomes meandering and circumstantial,
and when the disorganization is severe, the in dividual fails to get to the point without
external guidance (tangential). At the severe level, some thought blocking and/or loose as-
sociations may occur infrequently, especially wh en the individual is under pressure, but re-
orienting questions quickly re turn structure and organiza tion to the conversation.
The individual realizes that changes in mental state and/or in relationships are taking
place. He or she maintains reasonable insigh t into the psychotic-like experiences and gen-
erally appreciates that altered perceptions are not real and magical ideation is not compel-
ling. The individual must experience distress and/or impaired performance in social or role


ling. The individual must experience distress and/or impaired performance in social or role
functioning (Criterion D), and the individual or responsible others must note the changes
and express concern, such that clinic al care is sought (Criterion A).
Associated Features Supporting Diagnosis
The individual may experience magical thinking, perceptual aberrations, difficulty in con-
centration, some disorganization in thought or behavior, excessive suspiciousness, anxi-
ety, social withdrawal, and disruption in sl eep-wake cycle. Impaired cognitive function


centration, some disorganization in thought or behavior, excessive suspiciousness, anxi-
ety, social withdrawal, and disruption in sl eep-wake cycle. Impaired cognitive function
and negative symptoms are often observed. Neuroimaging variables distinguish cohorts
with attenuated psychosis syndro me from normal control coho rts with patterns similar to,
but less severe than, that observed in schi zophrenia. However, neuroimaging data is not
diagnostic at the individual level.
Prevalence
The prevalence of attenuated psychosis syndrome is unknown. Symptoms in Criterion A
are not uncommon in the non-help-seeking population, ranging from 8%–13% for hallu-


Conditions for Further Study 785
cinatory experiences and delusional thinking. There appears to be a slight male prepon-
derance for attenuated psychosis syndrome.
Development and Course
Onset of attenuated psychosis syndrome is usually in mid-to-late adolescence or early
adulthood. It may be preceded by normal development or evidence for impaired cogni-
tion, negative symptoms, and/or impaired so cial development. In help-seeking cohorts,
approximately 18% in 1 year and 32% in 3 years may progress symptomatically and met
criteria for a psychotic disorder . In some cases, the syndrome may transition to a depres-
sive or bipolar disorder with psychotic featur es, but development to a schizophrenia spec-
trum disorder is more frequent. It appears that the diagnosis is  best applied to individuals
ages 15–35 years. Long-term course is not yet describe d beyond 7–12 years.
Risk and Prognostic Factors
Temperamental. Factors predicting prognosis of attenuated psychosis syndrome have
not been definitively characterized, but the presence of negative symptoms, cognitive im-
pairment, and poor functionin g are associated with poor outcome and increase risk of
transition to psychosis.
Genetic and physiological. A family history of psychosis places the individual with at-
tenuated psychosis syndrome at  increased risk for developing a full psychotic disorder.
Structural, functional, and neurochemical  im aging data are associated with increased risk
of transition to psychosis.
Functional Consequences of
Attenuated Psychosis Syndrome
Many individuals may experience functional impairments. Modest-to-moderate impair-
ment in social and role functioning may pers ist even with abatement of symptoms. A sub-
stantial portion of individuals with the diagnosis will improve over time; many continue


stantial portion of individuals with the diagnosis will improve over time; many continue
to have mild symptoms and impairment, and many others will have a full recovery.
Differential Diagnosis
Brief psychotic disorder. When symptoms of attenuated psychosis syndrome initially
manifest, they may resemble sy mptoms of brief psychotic di sorder. However, in attenu-
ated psychosis syndrome, the symptoms do no t cross the psychosis threshold and reality
testing/insight remains intact.
Schizotypal personality disorder. Schizotypal personality disorder, although having
symptomatic features that are similar to thos e of attenuated psychosis syndrome, is a rel-
atively stable trait disorder not meeting the st ate-dependent aspects (Criterion C) of atten-
uated psychosis syndrome. In addition, a br oader array of symptoms is required for
schizotypal personality disorder, although in the early stages of pr esentation it may re-
semble attenuated psychosis syndrome.
Depressive or bipolar disorders. Reality distortions that are temporally limited to an
episode of a major depressive disorder or bipolar disorder and are descriptively more
characteristic of those disorders do not me et Criterion E for attenuated psychosis syn-
drome. For example, feelings of low self-esteem  or attributions of low regard from others
in the context of major depressive disorder  would not qualify fo r comorbid attenuated
psychosis syndrome.
Anxiety disorders. Reality distortions that are temporally limited to an episode of an
anxiety disorder and are descriptively more ch aracteristic of an anxiety disorder do not


786 Conditions for Further Study
meet Criterion E for attenuated psychosis sy ndrome. For example, a feeling of being the
focus of undesired attention in the context of social anxiety disorder  would not qualify for
comorbid attenuated psychosis syndrome.
Bipolar II disorder. Reality distortions that are temporal ly limited to an episode of ma-
nia or hypomania and are descriptively more ch aracteristic of bipolar disorder do not meet
Criterion E for attenuated psyc hosis syndrome. For example, inflated self-esteem in the
context of pressured speech and reduced need for sleep would not qua lify for comorbid at-
tenuated psychosis syndrome.
Borderline personality disorder. Reality distortions that ar e concomitant with border-
line personality disorder and are descriptively mo re characteristic of it do not meet Crite-
rion E for attenuated psychosis syndrome. For example, a sense of being unable to
experience feelings in the context of an inte nse fear of real or im agined abandonment and
recurrent self-mutilation  would not qualify fo r comorbid attenuated psychosis syndrome.
Adjustment reaction of adolescence. Mild, transient symptoms typical of normal de-
velopment and consistent with the degree of stress experienced do not qualify for attenu-
ated psychosis syndrome.
Extreme end of perceptual aberration and magical thinking in the non-ill population.
This diagnostic possibility should be strongly entertained when reality distortions are not
associated with distress and functional impairment and need for care.
Substance/medication-induced psychotic disorder. Substance use is common among
individuals whose symptoms meet attenuated  psychosis syndrome criteria. When other-
wise qualifying characteristic symptoms are strongly temporally related to substance use
episodes, Criterion E for attenuated psychosis syndrome may not be met, and a diagnosis


episodes, Criterion E for attenuated psychosis syndrome may not be met, and a diagnosis
of substance/medication-induced ps ychotic disorder may be preferred.
Attention-deficit/hyperactivity disorder. A history of attentional impairment does not
exclude a current attenuated psychosis syndro me diagnosis. Earlier attentional impair-
ment may be a prodromal condit ion or comorbid at tention-deficit/hype ractivity disorder.
Comorbidity
Individuals with attenuated psychosis syndrome often experience anxiety and/or depres-
sion. Some individuals with an attenuated psychosis syndrome diagnosis will progress to
another diagnosis, including anxi ety, depressive, bipolar, and personality disorders. In such
cases, the psychopathology asso ciated with the attenuated psychosis syndrome diagnosis is
reconceptualized as the prodromal phase of another disorder, not a comorbid condition.
Depressive Episodes With Short-Duration Hypomania
Proposed Criteria
Lifetime experience of at least one majo r depressive episode meeting the following
criteria:
A. Five (or more) of the following criteria have been present during the same 2-week pe-
riod and represent a change from previous functioning; at least one of the symptoms
is either (1) depressed mood or (2) loss of interest or pleasure. ( Note:  Do not include
symptoms that are clearly attributable to a medical condition.)
1. Depressed mood most of the day, nearly every day, as indicated by either subjec-
tive report (e.g., feels sad, empty, or hopeless) or observation made by others (e.g.,
appears tearful). ( Note:  In children and adolescents, can be irritable mood.)
2. Markedly diminished interest or pleasure in al l, or almost all, activities most of the


day, nearly every day (as indicated by either subjective account or observation).


Conditions for Further Study 787
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than
5% of body weight in a month), or dec rease or increase in appetite nearly every
day. ( Note:  In children, consider failure to make expected weight gain.)
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delu-
sional) nearly every day (not merely self-reproach or guilt about being sick).
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (ei-
ther by subjective account or as observed by others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with-
out a specific plan, or a suicide attempt or a specific plan for committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
C. The disturbance is not attributable to the physiological effects of a substance or an-
other medical condition.
D. The disturbance is not better explained by schizoaffective disorder and is not superim-
posed on schizophrenia, schizophreniform disorder , delusional disorder, or other spec-
ified or unspecified schizophrenia spectrum and other psychotic disorder.
At least two lifetime episodes of hypomanic periods that involve the required crite-
rion symptoms below but are of  insufficient duration (a t least 2 days but less than
4 consecutive days) to meet criteria fo r a hypomanic episode. The criterion symp-


4 consecutive days) to meet criteria fo r a hypomanic episode. The criterion symp-
toms are as follows:
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-directed activity or energy.
B. During the period of mood disturbance and in creased energy and activity, three (or more)
of the following symptoms have persisted (four if the mood is only irritable), represent a no-
ticeable change from usual behavior, and have been present to a significant degree:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressured to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation.
7. Excessive involvement in activities that have a high potential for painful conse-
quences (e.g., the individual engages in unrestrained buying sprees, sexual indis-
cretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is uncharac-
teristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupa-
tional functioning or to necessitate hospitalization. If there are psychotic features, the
episode is, by definition, manic.


episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance (e.g., a drug
of abuse, a medication or other treatment).


788 Conditions for Further Study
Diagnostic Features
Individuals with short-durati on hypomania have experienced at least one major depres-
sive episode as well as at least two episodes of 2–3 days’ duration  in which criteria for a hy-
pomanic episode were met (except for symptom duration). These episodes are of sufficient
intensity to be categorized as a hypomanic ep isode but do not meet the 4-day duration re-
quirement. Symptoms are present to a signific ant degree, such that they represent a no-
ticeable change from the individual’s normal behavior.
An individual with a history of a syndromal hypomanic episode and a major depres-
sive episode by definition has bipolar II disord er, regardless of current duration of hypo-
manic symptoms.
Associated Features Supporting Diagnosis
Individuals who have experienced both shor t-duration hypomania and a major depres-
sive episode, with their increased comorbidit y with substance use disorders and a greater
family history of bipolar diso rder, more closely resemble in dividuals with bipolar disor-
der than those with major depressive disorder.
Differences have also been found between individuals with short-duration hypomania
and those with syndromal bipolar disorder. Work impairment was greater for individuals
with syndromal bipolar disorder, as was the es timated average number of episodes. Indi-
viduals with short-duration hypomania may exhibit less se verity than individuals with
syndromal hypomanic episodes, including less mood lability.
Prevalence
The prevalence of short-duration hypomania is un clear, since the criteria are new as of this
edition of the manual. Using somewhat different  criteria, however, it has been estimated


edition of the manual. Using somewhat different  criteria, however, it has been estimated
that short-duration hypomania occurs in 2.8%  of the population (compared with hypoma-
nia or mania in 5.5% of the population). Short-duration hypomani a may be more common
in females, who may present with more  features of atypical depression.
Risk and Prognostic Factors
Genetic and physiological. A family history of mania is two to three times more common in
individuals with short-duration hypomania co mpared with the general population, but less
than half as common as in individuals with  a history of syndromal mania or hypomania.
Suicide Risk
Individuals with short-duration hypomania ha ve higher rates of suicide attempts than
healthy individuals, although not as high as the rates in individuals with syndromal bipo-
lar disorder.
Functional Consequences of Short-Duration Hypomania
Functional impairments associated specifically  with short-duration hypomania are as yet
not fully determined. However, research suggests that individuals with this disorder have
less work impairment than individuals with  syndromal bipolar disorder but more comor-
bid substance use disorders, particularly alco hol use disorder, than individuals with major
depressive disorder.
Differential Diagnosis
Bipolar II disorder. Bipolar II disorder is characterized by a period of at least 4 days of
hypomanic symptoms, whereas short-duration hypomania is characterized by periods of


Conditions for Further Study 789
2–3 days of hypomanic symptoms. Once an individual has experienced a hypomanic ep-
isode (4 days or more), the diagnosis beco mes and remains bipolar II disorder regardless
of future duration of hy pomanic symptom periods.
Major depressive disorder. Major depressive disorder is al so characterized by at least
one lifetime major depressive ep isode. However, the additional presence of at least two life-
time periods of 2–3 days of hypomanic symptoms leads to a diagnosis of short-duration hy-
pomania rather than to major depressive disorder.
Major depressive disorder with mixed features. Both major depressive disorder with
mixed features and short-duration hypomania are characterized by the presence of some
hypomanic symptoms and a major depressive episode. However, major depressive disor-
der with mixed features is characteri zed by hypomanic features present concurrently  with
a major depressive episode, while individual s with short-duration hypomania experience
subsyndromal hypomania and fully syndroma l major depression at different times.
Bipolar I disorder. Bipolar I disorder is differentiat ed from short-duration hypomania
by at least one lifetime manic episode, which is longer (at least 1 week) and more severe
(causes more impaired social functioning) than a hypomanic episode. An episode (of any
duration) that involves psychotic symptoms or necessitates hospitalization is by definition
a manic episode rather than a hypomanic one.
Cyclothymic disorder. While cyclothymic disorder is characterized by periods of de-
pressive symptoms and periods of hypomanic symptoms, the lifetime presence of a major
depressive episode precludes the di agnosis of cyclothymic disorder.
Comorbidity


Comorbidity
Short-duration hypomania, similar to full hypomanic episodes, has been associated with
higher rates of comorbid anxi ety disorders and substance use disorders than are found in
the general population.
Persistent Complex Bereavement Disorder
Proposed Criteria
A. The individual experienced the death of someone with whom he or she had a close re-
lationship.
B. Since the death, at least one of the following symptoms is experienced on more days
than not and to a clinically significant degree and has persisted for at least 12 months
after the death in the case of bereaved adults and 6 months for bereaved children:
1. Persistent yearning/longing for the deceased. In young children, yearning may be
expressed in play and behavior, including behaviors that reflect being separated
from, and also reuniting with, a caregiver or other attachment figure.
2. Intense sorrow and emotional pain in response to the death.
3. Preoccupation with the deceased.
4. Preoccupation with the circumstances of the death. In children, this preoccupation
with the deceased may be expressed through the themes of play and behavior and
may extend to preoccupation with possible death of others close to them.
C. Since the death, at least six of the following symptoms are experienced on more days
than not and to a clinically significant degree, and have persisted for at least 12 months
after the death in the case of bereaved adults and 6 months for bereaved children:


790 Conditions for Further Study
Reactive distress to the death
1. Marked difficulty accepting the death. In children, this is dependent on the child’s
capacity to comprehend the meaning and permanence of death.
2. Experiencing disbelief or emotional numbness over the loss.
3. Difficulty with positive reminiscing about the deceased.
4. Bitterness or anger related to the loss.
5. Maladaptive appraisals about oneself in relation to the deceased or the death (e.g.,
self-blame).
6. Excessive avoidance of reminders of the loss (e.g., avoidance of individuals,
places, or situations associated with the deceased; in children, this may include
avoidance of thoughts and feelings regarding the deceased).
Social/identity disruption
7. A desire to die in order to be with the deceased.
8. Difficulty trusting other individuals since the death.
9. Feeling alone or detached from other individuals since the death.
10. Feeling that life is meaningless or empty without the deceased, or the belief that
one cannot function without the deceased.
11. Confusion about one’s role in life, or a diminished sense of one’s identity (e.g., feel-
ing that a part of oneself died with the deceased).
12. Difficulty or reluctance to pursue interests since the loss or to plan for the future
(e.g., friendships, activities).
D. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
E. The bereavement reaction is out of proportion to  or inconsistent with cultural, religious,
or age-appropriate norms.
Specify if:
With traumatic bereavement:  Bereavement due to homicide or suicide with persis-
tent distressing preoccupations regarding the traumatic nature of the death (often in re-


tent distressing preoccupations regarding the traumatic nature of the death (often in re-
sponse to loss reminders), including the deceased’s last moments, degree of suffering
and mutilating injury, or the malicious or intentional nature of the death.
Diagnostic Features
Persistent complex bereavement disorder is diagnosed only if at least 12 months (6 months
in children) have elapsed since the death of someone with whom the bereaved had a close
relationship (Criterion A). This time fram e discriminates normal grief from persistent
grief. The condition typically involves a pe rsistent yearning/longing for the deceased
(Criterion B1), which may be associated with  intense sorrow and frequent crying (Crite-
rion B2) or preoccupation with  the deceased (Criterion B3).  The individual may also be
preoccupied with the manner in which the person died (Criterion B4).
Six additional symptoms are required, includ ing marked difficulty accepting that the in-
dividual has died (Criterion C1) (e.g. preparing meals for them), disbelief that the individual is
dead (Criterion C2), distressing memories of the deceased (Criterion C3), anger over the loss
(Criterion C4), maladaptive appraisals about oneself in relation to the deceased or the death
(Criterion C5), and excessive avoidance of reminders of the loss  (Criterion C6). Individuals
may also report a desire to die because they wish to be with the deceased (Criterion C7); be dis-
trustful of others (Criterion C8);  feel isolated (Criterion C9); believe that life has no meaning or
purpose without the deceased (C riterion C10); experience a di minished sense of identity in
which they feel a part of themselves has died or been lost (Criterion C11); or have difficulty en-


gaging in activities, pursuing relationships, or planning for the future (Criterion C12).


Conditions for Further Study 791
Persistent complex bereavement disorder requires clinically significant distress or im-
pairment in psychosocial functioning (Criteri on D). The nature and severity of grief must
be beyond expected norms for the relevant cu ltural setting, religio us group, or develop-
mental stage (Criterion E). Although there are variations in  how grief can manifest, the
symptoms of persistent complex bereavement disorder occur in both genders and in di-
verse social and cultural groups.
Associated Features Supporting Diagnosis
Some individuals with persistent complex bereavement disorder experience hallucina-
tions of the deceased (auditory or visual) in which they temporarily perceive the deceased’s
presence (e.g., seeing the deceased sitting in his or her favorite chai r). They may also ex-
perience diverse somatic complaints (e.g., digestive complaints, pain, fatigue), including
symptoms experienced by the deceased.
Prevalence
The prevalence of persistent complex bere avement disorder is approximately 2.4%–4.8%.
The disorder is more prevalent in females than in males.
Development and Course
Persistent complex bereavement disorder can o ccur at any age, beginning after the age of
1 year. Symptoms usually begin within the initial months af ter the death, although there
may be a delay of months, or even years, before the full syndrome a ppears. Although grief
responses commonly appear immediately following bereavemen t, these reactions are not
diagnosed as persistent comp lex bereavement disorder unless the symptoms persist be-
yond 12 months (6 months for children).
Young children may experience the loss of a primary caregiver as traumatic, given the
disorganizing effects the caregiver’s absence ca n have on a child’s coping response. In chil-


dren, the distress may be expressed in play and behavior, developmental regressions, and
anxious or protest behavior at times of separation and reunion. Separation distress may be
predominant in younger children, and social/i dentity distress and risk for comorbid de-
pression can increasingly manifest in older children and adolescents.
Risk and Prognostic Factors
Environmental. Risk for persistent complex bereavem ent disorder is heightened by in-
creased dependency on the deceased person pr ior to the death and by the death of a child.
Disturbances in caregiver support increase the risk for bereaved children.
Genetic and physiological. Risk for the disorder is height ened by the bereaved individ-
ual being female.
Culture-Related Diagnostic Issues
The symptoms of persistent complex bereav ement disorder are observed across cultural
settings, but grief responses may manifest in cu lturally specific ways. Diagnosis of the dis-
order requires that the persistent and severe responses go beyond cultural norms of grief
responses and not be better explained by culturally specific mourning rituals.
Suicide Risk
Individuals with persistent complex bereavement disorder frequently report suicidal
ideation.


792 Conditions for Further Study
Functional Consequences of
Persistent Complex Bereavement Disorder
Persistent complex bereavement di sorder is associated with deficits in work and social func-
tioning and with harmful health behaviors, such as increased tobacco and alcohol use. It is also
associated with marked increases in risks for serious medical conditions, including cardiac dis-
ease, hypertension, cancer, immunological deficiency, and reduced quality of life.
Differential Diagnosis
Normal grief. Persistent complex bereavement diso rder is distinguished from normal
grief by the presence of severe grief reactions that persist at least 12 months (or 6 months in
children) after the death of the bereaved. It is only when severe levels of grief response per-
sist at least 12 months following the death an d interfere with the in dividual’s capacity to
function that persisten t complex bereavement disorder is diagnosed.
Depressive disorders. Persistent complex bereavement disorder, major depressive dis-
order, and persistent depressive disorder (dysthymia) share sadness, crying, and suicidal
thinking. Whereas major depressi ve disorder and persistent de pressive disorder can share
depressed mood with persistent complex bereavement disorder, the latter is characterized
by a focus on the loss.
Posttraumatic stress disorder. Individuals who experience bereavement as a result of trau-
matic death may develop both posttraumatic stre ss disorder (PTSD) and persistent complex
bereavement disorder. Both conditions ca n involve intrusive th oughts and avoidance.
Whereas intrusions in PTSD revolve around the traumatic event, intrusive memories in per-
sistent complex bereavement diso rder focus on thoughts about many aspects of the relation-
ship with the deceased, including positive asp ects of the relationship and distress over the


ship with the deceased, including positive asp ects of the relationship and distress over the
separation. In individuals with the traumatic be reavement specifier of persistent complex be-
reavement disorder, the distressin g thoughts or feelings may be more overtly related to the
manner of death, with distressing fantasies of  what happened. Both persistent complex be-
reavement disorder and PTSD can involve avoi dance of reminders of distressing events.
Whereas avoidance in PTSD is characterized by  consistent avoidance of  internal and external
reminders of the traumatic experience, in persistent complex bereavement disorder, there is
also a preoccupation with the loss and yearning  for the deceased, which is absent in PTSD.
Separation anxiety disorder. Separation anxiety disorder is characterized by anxiety
about separation from current attachment figures, whereas persistent complex bereavement
disorder involves distress about separation from a deceased individual.
Comorbidity
The most common comorbid disorders with pe rsistent complex bere avement disorder are
major depressive disorder, PT SD, and substance use disorders. PTSD is more frequently
comorbid with persistent complex bereavement disorder when the deat h occurred in trau-
matic or violent circumstances.
Caffeine Use Disorder
Proposed Criteria
A problematic pattern of caffeine use leading to clinically significant impairment or distress, as
manifested by at least the first three of the following criteria occurring within a 12-month period:
1. A persistent desire or unsuccessful efforts to cut down or control caffeine use.
2. Continued caffeine use despite knowledge of having a persistent or recurrent physical
or psychological problem that is likely to have been caused or exacerbated by caffeine.


Conditions for Further Study 793
3. Withdrawal, as manifested by either of the following:
a. The characteristic withdrawal syndrome for caffeine.
b. Caffeine (or a closely related) substance is taken to relieve or avoid withdrawal
symptoms.
4. Caffeine is often taken in larger amounts or over a longer period than was intended.
5. Recurrent caffeine use resulting in a failure to fulfill major role obligations at work,
school, or home (e.g., repeated tardiness or absences from work or school related to
caffeine use or withdrawal).
6. Continued caffeine use despite having persist ent or recurrent social or interpersonal
problems caused or exacerbated by the effects of caffeine (e.g., arguments with
spouse about consequences of use, medical problems, cost).
7. Tolerance, as defined by either of the following:
a. A need for markedly increased amounts of caffeine to achieve desired effect.
b. Markedly diminished effect with continued use of the same amount of caffeine.
8. A great deal of time is spent in activities necessary to obtain caffeine, use caffeine, or
recover from its effects.
9. Craving or a strong desire or urge to use caffeine.
A diagnosis of substance dependence due to caffeine is recognized by the World Health
Organization in ICD-10. Since the publication of DSM-IV in 1994, considerable research on
caffeine dependence has been published, an d several recent reviews provide a current
analysis of this literature. There is now sufficie nt evidence to warran t inclusion of caffeine
use disorder as a research diagnosis in DSM-5 to encourage additional research. The work-
ing diagnostic algorithm propos ed for the study of caffeine use disorder differs from that
of the other substance use disorders, reflecting  the need to identify only cases that have


of the other substance use disorders, reflecting  the need to identify only cases that have
sufficient clinical importance to warrant the la beling of a mental disorder. A key goal of in-
cluding caffeine use disorder in  this section of DSM-5 is to stimulate research that will
determine the reliability, validity, and preval ence of caffeine use disorder based on the
proposed diagnostic schema, with particular attention to the association of the diagnosis
with functional impairments as part of validity testing.
The proposed criteria for caff eine use disorder reflect the need for a diagnostic thresh-
old higher than that used for the other subs tance use disorders. Such a threshold is in-
tended to prevent overdiagnosis of caffeine us e disorder due to the high rate of habitual
nonproblematic daily caffeine use in the general population.
Diagnostic Features
Caffeine use disorder is characterized by the continued use of caffeine and failure to con-
trol use despite negative physical and/or psyc hological consequences. In a survey of the
general population, 14% of caffeine users met the criterion of use despite harm, with most
reporting that a physician or counselor had advised them to stop or reduce caffeine use
within the last year. Medical and psychological problems attributed to caffeine included
heart, stomach, and urinary problems, and co mplaints of anxiety, depression, insomnia,
irritability, and difficulty thinking. In the sam e survey, 45% of caffei ne users reported de-
sire or unsuccessful efforts to control caffeine use, 18% repo rted withdrawal, 8% reported
tolerance, 28% used more than intended, and 50% reported spending a great deal of time
using caffeine. In addition, 19% reported a strong desire for caffeine that they could not re-


sist, and less than 1% reported that caffein e had interfered with social activities.
Among those seeking treatment for quitting  problematic caffeine use, 88% reported
having made prior serious attempts to modify  caffeine use, and 43% reported having been
advised by a medical professional to reduce or eliminate caffeine. Ninety-three percent
endorsed signs and symptoms meeting DSM-IV criteria for caffeine dependence, with the