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A dimensional model of personality disorder

Thomas A. Widiger
Purpose of review
Research planning workgroups sponsored by the American
Psychiatric Association have called for the development of a
dimensional model of personality disorder for a future
edition of the diagnostic manual.
Recent findings
This paper provides a brief summary of current research
relevant to the proposal to integrate basic science research
on the five-factor model of general personality structure with
the diagnosis of personality disorders. Recent studies and
the particular advantages of a five-factor model of
personality disorder are presented.
Summary
Future editions of diagnostic manuals will move toward a
more dimensional model of personality disorder
classification. Clinicians will benefit from a greater familiarity
with this approach to diagnosis, as researchers continue to
develop their validity and clinical utility.
Keywords
classification, diagnosis, dimensional, five-factor model,
personality disorder
Curr Opin Psychiatry 18:4143. # 2005 Lippincott Williams & Wilkins.
Department of Psychology, University of Kentucky, Lexington, Kentucky, USA
Correspondence to Thomas A. Widiger, PhD, 115 Kastle Hall, Department of
Psychology, University of Kentucky, Lexington, Kentucky, 40506-0044, USA
e-mail: widiger@uky.edu
Current Opinion in Psychiatry 2005, 18:4143
Abbreviations
DSM
FFM

Diagnostic and Statistical Manual of Mental Disorders


five-factor model

# 2005 Lippincott Williams & Wilkins


0951-7367

Introduction
The American Psychiatric Association and the National
Institute of Mental Health recently co-sponsored work
groups to guide research in the direction that would be
most productive for future editions of diagnostic manuals.
It was the conclusion of the Nomenclature Work Group
that it is important that consideration be given to
advantages and disadvantages of basing part or all of
DSM-V [Diagnostic and Statistical Manual of Mental
Disorders-V] on dimensions rather than categories
(p. 12) [1]. They recommended in particular that a
dimensional model of personality disorder be developed.
Toward this goal, the American Psychiatric Association is
sponsoring an international conference to be focused on
developing the research base that would eventually lead
to a dimensional classification of personality disorders
(see the website, www.dsm.org).
The limitations of the diagnostic categories have been
well documented, including an inadequate scientific
base, excessive diagnostic co-occurrence, arbitrary and
inconsistent boundaries, and inadequate coverage
[2,3,4]. A compelling alternative to the Diagnostic and
Statistical Manual of Mental Disorders (DSM)-IV
personality disorder diagnostic categories is a dimensional model that would integrate the personality disorder
nomenclature with basic science research on general
personality functioning [4].
Much of this attention has been focused on the five-factor
model (FFM). This paper provides a brief summary of
current research relevant to the proposal to integrate
basic science research on the FFM of general personality
structure with the diagnosis of personality disorders.
Recent studies and the particular advantages of a FFM
of personality disorder will be presented.

Five-factor model of personality disorder


The FFM was derived originally through empirical
studies of the trait terms within various languages. The
relative importance of a trait is indicated by the number
of terms that have been developed within a language to
describe the intensities and nuances of that trait, and the
structure of the traits is evident by the relationship among
the trait terms [5]. This lexical approach to personality
description has emphasized five broad domains of personality, presented in their order of importance (i.e.
size within the language) as extraversion (or surgency)
versus introversion, agreeableness versus antagonism,
conscientiousness (or constraint), emotional instability
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42 Personality disorders and neuroses

(or neuroticism), and unconventionality (or openness).


These five broad domains have been replicated in studies
of the trait terms contained within a wide variety of other
languages [5]. Each of the five domains has also been
differentiated into more specific facets. For example, the
facets of agreeableness versus antagonism are trust versus
skepticism (mistrust), straightforwardness versus deception, altruism (self-sacrifice) versus exploitation, compliance versus opposition (aggression), modesty (selfeffacement) versus arrogance, and tender-mindedness
(empathy) versus tough-mindedness (callousness).
There are other dimensional models of personality and
personality disorder [6]. Space limitations prohibit an
adequate coverage of them. Recently published studies
of particular relevance to some of these models have been
provided by Ando and his colleagues [7] and by Piersma
and his colleagues [8]. The FFM is the predominant
model in general personality research, with widereaching applications in the fields of health psychology,
aging, and developmental psychology [9]. Empirical
support for the FFM is extensive, including convergent
and discriminant validity at both the domain and facet
levels across self, peer, and spouse ratings [10], temporal
stability across many years [9], consistency with genetic
structure [11], and substantial cross-cultural replication
[5,12]. Adaptive and maladaptive variants of each of the
two poles of the 30 facets have been described [13], and
highly convergent FFM descriptions of personality
disorders have been provided by researchers [14] and
by clinicians [15,16].
The FFM is a particularly robust model that has succeeded well in representing diverse collections of the
traits of alternative models within a single, integrative,
hierarchical structure [17]. For example, many studies
have identified four broad factors of personality disorder
symptoms [3,18,19], identified by Livesley [3] as
emotional dysregulation, dissocial, inhibitedness, and
compulsivity. These four broad domains align well with
four of the five domains of the FFM (i.e. neuroticism,
antagonism, introversion, and conscientiousness, respectively) [4]. The fundamental temperaments of personality (e.g. negative affectivity, positive affectivity, and
constraint) also correspond closely to three domains of the
FFM (i.e. neuroticism, extraversion, and conscientiousness, respectively) [20]. The two dimensions of the interpersonal circumplex (agency and affiliation) are rotated
variants of FFM extraversion and agreeableness [21].
Quite a few studies have indicated that the DSM-IV
personality disorders are readily understood as
maladaptive variants of the domains and facets of the
FFM. Widiger and Costa [22] summarized the findings of
over 50 such studies. Livesley [23] concluded on the basis
of his review of much of this research that multiple

studies provide convincing evidence that the DSM


personality disorders diagnoses show a systematic relationship to the five factors and that all categorical
diagnoses of DSM can be accommodated within the
five-factor framework (p. 24). Saulsman and Page [24]
provided a meta-analysis of a subset of these studies and
reached the same conclusion. Many more informative
studies have been published since these recent reviews
[14,16,2533,34,35,36].
Widiger, Costa, and McCrae [13] provide a straightforward, four step procedure for the diagnosis of personality
disorders using the FFM. The first step is to obtain a
hierarchical description of an individuals general
personality functioning in terms of the FFM [37], providing thereby a reasonably comprehensive description of
the persons adaptive as well as maladaptive personality
traits. The second step is to identify social and
occupational impairments and distress associated with
the individuals characteristic personality traits. Widiger
and his colleagues list common impairments associated
with each of the 60 poles of the 30 facets of the FFM. The
third step is to determine whether the dysfunction and
distress reach a clinically significant level of impairment.
The fourth step is a quantitative matching of the
individuals personality profile to prototypic profiles of
diagnostic constructs. This last step is provided for
clinicians and researchers who wish to continue to provide single diagnostic labels to characterize a persons
personality profile. To the extent that an individuals
profile does match the FFM profile of a prototypic case, a
single term (e.g. psychopathic) would provide a succinct
means of communication [38]. However, prototypic
profiles are likely to be quite rare within clinical practice.
In such cases, the matching can serve to indicate the
extent to which any particular diagnostic category would
be adequately descriptive.

Conclusion
A dimensional model of personality disorder classification
is helpful in addressing the problems of excessive
diagnostic co-occurrence, heterogeneity among persons
with the same diagnosis, and illusory diagnostic distinctions. Patients would be provided with more individualized and distinct personality descriptions. A dimensional
classification would also address the inadequate coverage
without requiring additional diagnostic categories by
avoiding the inclusion of redundant, overlapping
diagnoses, by organizing the traits within a hierarchical
structure, by representing a broader range of maladaptive
personality functioning along a single dimension, and by
allowing for the representation of relatively unique or
atypical personality profiles [6]. An integration of the
personality disorder nomenclature with more general
models of personality functioning would also allow
clinicians to identify adaptive personality traits that

Personality disorder dimensional model Widiger

facilitate treatment response. Finally, integrating the


diagnosis of personality disorders with research in general
personality functioning will provide a stronger scientific
base for the diagnostic nomenclature.

References and recommended reading


Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
1

Rounsaville BJ, Alarcon RD, Andrews G, et al. Basic nomenclature issues for
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29.

First MB, Bell CB, Cuthbert B, et al. Personality disorders and relational
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Livesley WJ. Diagnostic dilemmas in classifying personality disorder. In:


Phillips KA, First MB, Pincus HA, editors. Advancing DSM. Dilemmas in
psychiatric diagnosis. Washington, DC: American Psychiatric Association;
2003. pp. 153190.
This provides an excellent critique of a categorical model.

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