Personality Disorders: Theory, Research, and Treatment 2012, Vol. 3, No. 4, 483– 495
© 2012 American Psychological Association 1949-2715/12/$12.00 DOI: 10.1037/per0000006
Antisocial Personality Disorder in DSM-5: Missteps and Missed Opportunities Donald R. Lynam and David D. Vachon Purdue University This paper evaluates the proposal for antisocial personality disorder (ASPD) in the Diagnostic and Statistical Manual of Mental Disorders—fifth edition (DSM-5). Some aspects of the proposal are appealing: personality disorders will be assessed using trait criteria, and these criteria are similar to trait descriptions of DSM–IV ASPD. Other aspects of the proposal are less appealing. First, the DSM-5 will depend on a newly constructed personality trait system rather than relying on a well validated, widely studied one. Second, the trait profile of ASPD is incomplete; although this profile reflects the traits included in DSM–IV, it maps poorly onto the full personality profile of ASPD. Third, the DSM Workgroup missed an opportunity to finally unify ASPD and psychopathy; history and research suggest that these disorders have diverged mistakenly. Fourth, the newly proposed criteria of impairments in self- and interpersonal functioning are of questionable derivation and utility. Keywords: antisocial personality disorder, DSM-5, psychopathy, personality
The new version of the Diagnostic and Statistical Manual of Mental Disorders—fifth edition (DSM-5) is to be released in 2013. Although there will be changes throughout the manual, none are likely to be quite as dramatic as those proposed to the personality disorders (PDs) section (http://www.dsm5.org). The proposal put forth by the DSM-5 Personality and Personality Disorders Workgroup represents a major reconceptualization of personality psychopathology. The proposed changes are extensive and include a hybrid dimensional-categorical model; removal of four PDs (dependent, histrionic, schizoid, paranoid); dropping explicit behavioral criterion sets in favor of personality traits; separate ratings for distinct types of personality functioning (self vs. interpersonal); and a novel 5-domain, 25-facet trait dimensional model of personality. A description and rationale for these changes is provided elsewhere (Skodol et al., 2011b), as are details regarding the clinical application of the new model of assessment (Skodol et al., 2011a).
In brief, a multiple step assessment procedure is described. At the first step, clinicians decide whether impairment in personality functioning (self- and interpersonal functioning) is present and to what degree. Next, clinicians decide whether the patient matches one of the six defined PD types— borderline, obsessive– compulsive, avoidant, schizotypal, antisocial, or narcissistic PD. According to the proposal, a type is present if type-specific impairments in personality functioning are present and if all pathological traits descriptive of a type are present. If a type is not clearly present, then the clinician may indicate PD-Trait Specified by listing the applicable trait domain(s). The final step involves evaluating the patient on each trait within a proposed 25-trait model. Previous General Critiques
Donald R. Lynam and David D. Vachon, Department of Psychological Sciences, Purdue University. Correspondence concerning this article should be addressed to Donald R. Lynam, Department of Psychological Sciences, Purdue University, West Lafayette, IN 47906. E-mail:
[email protected]
The changes proposed by the DSM-5 Personality and Personality Disorders Workgroup have generated much controversy and many critiques. Some critiques have focused on the scope of the changes and the process by which they were arrived at. For example, Zimmerman (2011) has written: “Criteria have been added, removed, and rewritten, without evidence that the new approach is better than the prior one. One cannot help but wonder what the cost has
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been of these repeated changes of diagnostic criteria” (p. 1). Others have focused on specific issues such as the removal of a given PD (e.g., Miller, 2010) or the reformulation of a specific PD (e.g., Samuel et al., 2011). Still others have provided comprehensive critiques of the entire enterprise. After the release of the initial DSM-5 proposal, Widiger (2011a) wrote that “the future of personality disorders is, at best, shaky” (p. 64). Although several of his criticisms dealt with a prototype matching approach that has since been abandoned in a recently released proposal, several still stand. Widiger suggested that the workgroup’s diagnostic procedure is too cumbersome for clinicians. He noted that the workgroup’s deletion of several diagnostic categories (i.e., dependent, paranoid, schizoid, and histrionic) was not empirically supported and would lead to a loss of coverage. Widiger also criticized the choice by the workgroup to construct a new dimensional model of personality that excluded normal personality traits; was unipolar in structure, in defiance of the preponderance of research on personality; and was explicitly distinguished from the predominant dimensional model of personality (see also Widiger, 2011b). Specific Critique of DSM-5 Antisocial Personality Disorder In the present article, we discuss more specific criticisms of the DSM-5 formulation of antisocial personality disorder (ASPD). There are five specific criteria required for a DSM-5 diagnosis of APSD. First, there must be significant impairments in personality functioning as manifested by impairments in self-functioning (i.e., in identity or self-direction) and interpersonal functioning (i.e., in empathy or intimacy). Second, seven specific pathological personality traits must be present: manipulativeness, deceitfulness, callousness, hostility, irresponsibility, impulsivity, and risk-taking. Finally, the impairments in personality functioning must be relatively stable across time and situations, cannot be better understood as developmentally or culturally normative, and cannot be solely due to the direct physiological effects of a substance or medical condition.
Two Good Aspects Some aspects of this formulation are appealing. First, it assesses ASPD using personality traits, an approach that we and our colleagues have long advocated (Lynam & Widiger, 2001; Miller, Lynam, Widiger, & Leukefeld, 2001; Widiger & Costa, 1994). Using traits to capture types is a reasonable and well-studied approach. Several studies using the Five-Factor Model (FFM) of personality (McCrae & Costa, 2003) have focused on single PDs as well as all PDs simultaneously. All studies have provided general support for the approach. Miller and colleagues conducted four studies examining all 10 DSM–IV PDs; these studies differ in setting, personality assessments, and PD assessments. Results are remarkably consistent across these variations in methods. Miller, Reynolds, and Pilkonis (2004) reported convergent correlations between FFM PD prototype scores and interview ratings of PD symptoms ranging from .13 for obsessive– compulsive personality disorder (OCPD) to .67 for avoidant personality disorder (AVD) with a mean of .46; similarly, the convergent correlations between FFM PD scores and self-report ratings of PD symptoms ranged from .24 for OCPD to .79 for AVD with an average of .62. Miller, Bagby, Pilkonis, Reynolds, and Lynam (2005) examined the convergence between consensus PD ratings and PDs assessed via the FFM using self-report and interview; these authors reported average convergences of .38 and .39 for self-report and interview ratings of the FFM PDs, respectively. In the course of providing normative FFM PD data for the United States, France, and Belgium, Miller et al. (2008) reported on the convergence between FFM PD assessments and explicit PD assessments. These authors report convergences ranging from .17 for OCPD to .65 for AVD with a mean of .43 in the French and Belgian samples. Finally, Miller et al. (2010) reported on the convergence between PDs assessed using a 30item FFM facet rating form and consensus diagnostic counts. Convergent correlations ranged from .23 for schizotypal PD to .74 for AVD with a mean of 52. Moreover, the FFM PD scores were better predictors of impairment than were the consensus diagnostic counts. Most recently, Lawton, Shields, and Oltmanns (2011) extended this research to a representative community sample, a later developmental period,
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and informant-generated prototypes. With the exception of OCPD, these authors found the expected convergence between self- and othergenerated FFM prototypes with ratings based on clinical interview. Additionally, they found congruence between self- and informant prototypes. We have also shown that FFM assessments of psychopathy (Derefinko & Lynam, 2007; Miller et al., 2001; Miller & Lynam, 2003) show high convergence with explicit indices of psychopathy. Additionally, across samples of undergraduates (Miller et al., 2001; Miller & Lynam, 2003) and drug-abusers (Derefinko & Lynam, 2007), relations of FFM psychopathy scores to external criteria (e.g., antisocial behavior, aggression, substance use/misuse, and other forms of psychopathology) have been shown to mirror those found when explicit assessments of psychopathy are used. The same is true for an FFM assessment of borderline personality disorder (BPD). Across three samples, Trull, Widiger, Lynam, and Costa (2003) found that FFM BPD scores correlated as highly with extant BPD measures as the extant measures did among themselves and that FFM BPD bore the expected relation to BPD-related constructs such as a history of childhood sexual and physical abuse, parental psychopathology (e.g., substance use disorders; mood disorders), and impairment (global; interpersonal). Most germane to the present discussion, we have shown that an FFM assessment of ASPD is quite similar to ASPD assessed using explicit DSM–IV criteria scored via interviewer ratings (Gudonis, Miller, Miller, & Lynam, 2008). In this study, Gudonis et al. (2008) found that FFM ASPD was positively correlated with various externalizing behaviors including early conduct problems; self-reported delinquency, aggression, arrests, psychopathy, and risky sexual behavior; and early and problematic levels of substance use. FFM ASPD was unrelated to internalizing problems. Additionally, FFM ASPD was related to poor family relations and poor school performance in early adolescence as well as to lower educational attainment and worse occupational functioning in young adulthood. Moreover, these relations were virtually identical in absolute size to those obtained when DSM–IV ASPD was examined; in fact, the similarity in correlational profiles for the two ASPD assessments was .85. Therefore, the general move to traits is quite reasonable.
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Second, we believe that the DSM-5 traits offered as descriptive of ASPD are fairly similar to those present in the diagnostic criteria for ASPD in DSM–IV–TR. Table 1 provides the traits required for DSM-5 and the seven symptoms from Criterion A for ASPD from DSM– IV–TR. There are fairly direct, one-to-one mappings for five of the seven DSM–IV–TR symptoms. A sixth symptom, deceitfulness, seems to be captured by the two DSM-5 traits of deceitfulness and manipulativeness. Some of these mappings are more complete than others. For example, DSM–IV–TR Criteria 3 (i.e., impulsivity or failure to plan ahead), 6 (i.e., consistent irresponsibility), and 7 (i.e., lack of remorse) seem very well captured by their DSM-5 trait counterparts. The remaining two DSM– IV–TR criteria are a bit less isomorphic with their DSM-5 trait counterparts. DSM–IV–TR Criterion 4 references actual acts of physical aggression such as repeated assaults or fights, whereas the DSM-5 trait of hostility primary references feelings of anger and irritability. Likewise, DSM–IV–TR Criterion 5, which refers to reckless disregard for the safety of self or others, maps partially onto the DSM-5 trait of risk-taking simply because the DSM-5 trait description does not include the safety of others. In general, six of the seven DSM–IV–TR Criterion A symptoms appear to be adequately represented in the DSM-5 traits. Only the first symptom—the most behaviorally based one, failure to conform to social norms with respect to lawful behaviors— does not map directly onto one of the DSM-5 traits. It should be noted that such complete mapping is not apparent for several other disorders. Some PDs were changed dramatically. In DSM– IV, narcissistic personality disorder (NPD) requires the presence of five or more of the following symptoms: grandiosity; preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love; belief one is special or unique; requiring excessive admiration; sense of entitlement; interpersonally exploitive; lack of empathy; envious of others or belief others are envious of self; and arrogant, haughty behaviors or attitudes. In the DSM-5, the narcissistic type is to be described by only two traits— grandiosity and attention seeking. Other PDs have changed less dramatically but still consequentially. For example, Samuel et al. (2011) examined the nature of the effect of the
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Table 1 DSM IV and Proposed DSM-5 Criteria for Antisocial Personality Disorder DSM IV Criterion A Symptoms 1. Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. 2. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal gain or pleasure.
3. Impulsivity or failure to plan ahead.
4. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. 5. Reckless disregard for the safety of self or others.
6. Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. 7. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.
DSM-5 Trait Descriptors
Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events. Manipulativeness: Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one‘s ends. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans; a sense of urgency and self-harming behavior under emotional distress. Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Risk-Taking: Engagement in dangerous, risky, and potentially 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. Irresponsiblity: Disregard for—and failure to honor— financial and other obligations or commitments; lack of respect for—and lack of follow through on—agreements and promises. Callousness: Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one‘s actions on others; aggression; sadism.
Note. DSM-IV symptoms are taken from the DSM IV-TR (APA, 2000). DSM-5 trait descriptors are taken from the proposed DSM-5 Clinicians’ Personality Rating Form (DSM-5 Personality and Personality Disorders Workgroup, 2012a).
proposed changes to the criteria for BPD. These authors documented that DSM-5 BPD is more similar to dependent PD, contains less antagonism and disinhibition, and will likely be less strongly related to dysfunction and impairment. Concerns Despite these positive aspects of the DSM-5 proposal for ASPD, we have several significant concerns. Each one of these concerns can be traced back to a seeming failure on the part of the DSM-5 Workgroup to draw on extant research to inform the diagnosis of ASPD in DSM-5. These concerns involve (a) the construction of a new personality trait model, (b) an incomplete specification of the trait profile for ASPD, (c) a missed opportunity to reunite
ASPD and psychopathy, and (d) inclusion of self- and interpersonal impairments. Brand New Trait Model Research examining the basic building blocks of personality has been around for decades. Multiple models have been advanced, examined, and supported, including Eysenck’s Psychoticism-Extraversion-Neuroticism (PEN) model (Eysenck, 1977), Tellegen’s (1985) three-factor model, Wiggins’ (2003) Interpersonal Circumplex, Cloninger’s Temperament and Character Inventory (Cloninger, Svrakic, & Przybec, 1993), and the FFM (McCrae & Costa, 2003). Each model has also been offered as a basis for a dimensional model of PD (see Widiger & Simonsen, 2005). Explicit references to
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dimensional models, and the FFM specifically, were included in the text on PDs in DSM–IV (American Psychiatric Association, 2000). Multiple studies on how these models overlap with one another have been conducted, and they generally support a five-factor structure. For example, Markon, Krueger, and Watson (2005) conducted a meta-analytic factor analysis of numerous measures of normal and abnormal personality functioning. They found that a consistent five-factor structure emerged that “strongly resembles the Big Five structure commonly described in the literature” (p. 144). Other researchers have come to similar conclusions (e.g., Stepp et al., 2012; Widiger, Livesley, & Clark, 2009; Widiger & Simonsen, 2005). The FFM has been examined in relation to PDs in hundreds of studies (Widiger & Costa, 2002). There are scores of studies that have examined how the 5 domains and 30 facets of the FFM map onto DSM–IV–TR PDs. Miller et al. (2008) have even provided norms and cutscores for reproducing DSM–IV–TR PDs using dimensional scoring of the FFM. However, rather than draw on this immense literature, the DSM-5 Workgroup chose to develop a new trait measure (see Widiger, 2011b for a fuller discussion of this issue). Although recent writing on the current 25trait version of the model attempts to tie it to the FFM (e.g., Krueger, Derringer, Markon, Watson, & Skodol, 2012; Wright et al., 2012), this connection appears somewhat post hoc. The original proposal included 37 traits organized into 6 higher-order domains: negative emotionality, introversion, antagonism, compulsivity, disinhibition, and schizotypy (Krueger, 2010). At some point in the process, compulsivity was folded into disinhibition (e.g., rigid perfectionism became lack of rigid perfectionism), introversion became detachment, and schizotypy became psychoticism. The 37 original traits were generated by workgroup members and consultants as exemplars to cover the proposed domains (Krueger et al., 2012). Items were written for each of the 37 traits, which were reduced to 25 traits through 2 rounds of data collection (Krueger, 2012). The current model consists of seven traits assessing negative affect, five assessing detachment, five assessing antagonsim, five assessing disinhibition, and three assessing psychoticism. Although the final model does seem to map onto the FFM, the derivation of the
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model limits its connection to the vast FFM literature. The FFM can be considered fairly complete in its coverage of personality space given its derivation from the natural language (Digman, 1990; John & Srivastava, 1999; Wiggins & Pincus, 1992). The new trait model cannot claim such coverage. More importantly, to the degree that the DSM-5 trait model is not the FFM, it cannot draw as directly from the large literature base on the FFM to inform assessment, etiology, and treatment of the PDs. For example, the extensive empirical base mapping the 30 facets of the FFM onto specific PDs is rendered less useful to the extent that the DSM model departs from the FFM. The same is true for previously established norms and cutpoints. Incomplete Trait Description of ASPD Our second concern is that although the DSM-5 traits map on fairly well to the DSM–IV–TR symptoms, they do not map particularly well onto what is known about the personality trait profile of ASPD. Table 2 presents a consensus FFM profile for ASPD taken from three different approaches: a meta-analysis of studies that correlated NEO PI-R (NEO Personality Inventory– Revised) scores with measures of ASPD (Decuyper, De Pauw, De Fruyt, De Bolle, & De Clercq, 2009), an average profile of FFM ratings obtained from experts on ASPD (Lynam & Widiger, 2001), and a direct translation of the DSM criteria into FFM terms (Costa & Widiger, 2002).1 The consensus profiles indicate that ASPD is described by high levels of angry hostility, impulsiveness, and excitement-seeking and by low levels of trust, straightforwardness, altruism, tender-mindedness, dutifulness, selfdiscipline, and deliberation. The fourth column presents our mapping of the DSM-5 trait terms onto the FFM facets. The seven DSM-5 traits assigned to ASPD by the DSM-5 Workgroup appear to capture eight specific FFM facets: angry hostility, impulsiveness, excitementseeking, straightforwardness (reversed), altru1 A trait was included in the profile if was identified as characteristic by two of the three approaches. Characteristic was defined as having an absolute weighted mean effect size greater than r ⫽ .20 in the Decuyper et al. (2009) metaanalysis, a mean expert rating lower than 2 or higher than 4 on a 1 to 5 scale in the expert profile of Lynam and Widiger (2001), or being included in the translation by Costa and Widiger (2002).
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Table 2 Comparison of FFM Profiles for ASPD and Psychopathy Across Methods APD Profile N1 Anxiety N2 Angry Hostility N3 Depression N4 Self-Consciousness N5 Impulsiveness N6 Vulnerability E1 Warmth E3 Assertiveness E5 Excitement Seeking A1 Trust A2 Straightforwardness A3 Altruism A4 Compliance A5 Modesty A6 Tender-Mindedness C3 Dutifulness C5 Self-Discipline C6 Deliberation
High
High
High Low Low Low Low Low Low Low Low
EPA Unconcern Anger-Hostility Self-contentment Self-assurance Urgency Invulnerability Coldness Dominance Thrill-seeking Distrust Manipulation Self-centeredness Opposition Arrogance Callousness Disobliged Impersistence Rashness
Relevant DSM-5 Trait Anxiousness (low) Hostility Depressivity (low)
Assigned to BPD and AVD Assigned to BPD Absent from trait model
Impulsivity Absent from trait model Absent from trait model Absent from trait model Risk-Taking Suspiciousness Manipulativeness Deceitfulness
Grandiosity Callousness Irresponsibility Distractibility Impulsivity
Assigned to schizotypal PD Absent from trait model Absent from trait model Assigned to NPD
Not assigned to any PD
Note. Bold traits are traits that are assigned by the DSM-5 Workgroup to ASPD. Nonbold traits are traits that would appear to map directly onto APD/psychopathy but that have not been assigned to ASPD by the workgroup.
ism (reversed), tender-mindedness (reversed), dutifulness (reversed), and deliberation (reversed). However, there are four other FFM traits that characterize ASPD across approaches that are not included in the DSM-5 description: trust (reversed), altruism (reversed), compliance (reversed), and self-discipline (reversed). Two of these traits exist within the 25-trait model adopted by the DSM-5 (i.e., suspiciousness and distractibility) and should be included in the description. In the case of suspiciousness, it was assigned to schizotypal PD and not to ASPD, presumably in an attempt to reduce comorbidity among the PDs. Distractibility does not appear to be assigned to any specific PD. Two other traits, low compliance (i.e., oppositionality) and low altruism (i.e., self-centeredness), have no representation in the 25-trait model of DSM-5, although oppositionality was represented in the original 37-trait version of the model. The omission of these latter two traits is regrettable because both appear characteristic of ASPD across all three profile methods. In the end, only 7 of the 11 personality traits identified as characteristic of ASPD by previous research are captured by the DSM-5 description, resulting in an incomplete trait description of ASPD.
A single study conducted by Hopwood, Thomas, Markon, Wright, and Krueger (2012) attempted to empirically examine the sufficiency of the trait descriptors offered by the workgroup. Specifically, in a sample of 808 undergraduates, Hopwood and colleagues regressed DSM–IV PD scales from the Personality Diagnostic Questionnaire-4⫹ (PDQ-4⫹; Hyler, 1994) onto the traits identified by the DSM-5 Workgroup as descriptive of each disorder (seven traits in the case of APSD) to examine how well these traits predicted the disorder. Additionally, they also examined whether the remaining traits (18 in the case of ASPD) contributed additional variance to the prediction. In the case of ASPD, they concluded that the seven traits identified by the workgroup were sufficient. Unfortunately, there are several issues with this study in addition to its singularity and reliance on undergraduates that prevent it from fully countering the concerns raised above. First, the study used the PDQ-4⫹, which explicitly assesses the symptoms of DSM–IV; therefore, the study could not identify any traits outside of that particular operationalization. Second, the study used the revised 25-trait model; to the degree that the model omits important traits (i.e., self-centeredness and oppositional-
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ity), these traits were not included in the study. Finally, there were problems with the analyses themselves. A stronger demonstration of the sufficiency of the workgroup descriptions would require that no other individual traits provide incremental predictive utility rather than demonstrating that the remaining 18 traits as a group fail to provide an increment in prediction. Including all 18 traits as a set allows for the operation of suppression mechanisms and divides any increment in variance accounted for across all 18 traits. Thus, this analysis lacks power. A Missed Opportunity Our third major criticism of the DSM-5 proposal for ASPD is that it represents a missed opportunity to reunite two constructs that have grown slightly apart over time—ASPD and psychopathy. We were hopeful this might happen when the first DSM-5 proposal referenced ASPD/psychopathy, but the more recent revision replaced psychopathy with the term “dyssocial”. Although ASPD and psychopathy as currently assessed are not isomorphic in their operationalizations, this has more to do with differences in the approach to assessment (i.e., the use of open vs. closed concepts) and threshold (e.g., Rogers & Rogstad, 2010) than it does to any real conceptual difference between them. Historical reviews of the psychiatric literature trace our conceptions of ASPD and psychopathy back to earlier conceptions of manie sans delire (Pinel, 1801/1962), “innate, preternatural moral depravity” (Rush, 1812), and “moral insanity” (Prichard, 1835)—all ways of understanding individuals who repeatedly committed impulsive, antisocial, and self-damaging acts but who seemed sane. In at least the first two versions of the DSM, the conceptions were fairly well aligned. In the first DSM, sociopathic personality disturbance, antisocial reaction was defined as follows: “chronically antisocial individuals who are always in trouble, profiting neither from experience nor punishment, and maintaining no real loyalties to any person, group, or code. They are frequently callous and hedonistic, showing marked emotional immaturity, with lack of sense of responsibility, lack of judgment, and an ability to rationalize their behavior so that it appears warranted, reasonable, and justified.” (p. 38, APA, 1952).
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Even Cleckley, the progenitor of our modernday conception of psychopathy, believed this diagnosis captured the individuals he described in his book The Mask of Sanity. After describing the DSM-I conception, Cleckley wrote “here the familiar psychopath could be accurately and officially classified” (Cleckley, 1941/1988, p. 242). He seemed even more pleased with the second version of the DSM, which changed the name to antisocial personality—“here the psychopath is officially designated as personality disorder, antisocial type, a recognizable entity in a fairly large group of different and distinct disorders” (Cleckley, 1941/1988, p. 242). To increase reliability and the uniformity of diagnoses, the DSM–III and DSM–III–R committees adopted a more behaviorally based criterion set derived in large part from work by Robins (1966). To receive a diagnosis of ASPD in DSM–III–R, an individual had to display a pattern of irresponsible and antisocial behavior as evidenced by four of the following: inability to sustain consistent work behavior, failure to conform to social norms, irritability and aggression, repeated failure to honor financial obligations, failure to plan ahead, having no regard for the truth, recklessness regarding one’s own or others’ safety, irresponsibility as a parent, failure to sustain a monogamous relationship, and a lack remorse. Although the DSM–III and DSMIII-R APSD diagnoses appeared to increase reliability, they did so at some expense to the overlap with psychopathy. In their critique of DSM–III–R ASPD, Hare, Hart, and Harpur (1991) wrote that it constituted “a rather radical break with clinical tradition . . ., with clinical practice . . ., with earlier versions of the DSM, and with international diagnostic nomenclature . . .” (p. 392). Their specific concerns involved the failure to include such characteristics as selfishness, egocentricity, callousness, manipulativeness, and lack of empathy. In DSM–IV, the ASPD criteria moved away from explicit behavioral criteria and back toward psychopathy, although it did not fully adopt a criterion set based on psychopathy (Widiger et al., 1996). The current DSM–IV criteria include the presence of three or more of the following (see Table 1): failure to conform to social norms, deceitfulness, impulsivity/failure to plan ahead, irritability/aggressiveness, reckless disregard for safety of self or others, irresponsibility, and lack of remorse.
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Although there may be some remaining differences between diagnostic criterion sets for ASPD and psychopathy, there is very little difference between the personality trait profiles that describe each syndrome. In addition to providing the FFM profiles for ASPD taken from three approaches, Table 2 also provides the FFM description of psychopathy present in the Elemental Psychopathy Assessment (EPA), which was created to assess traits consensually defined across three approaches—meta-analysis (Decuyper et al., 2009), expert ratings (Miller et al., 2001), and a translation of psychopathy criteria in to FFM terms (Widiger & Lynam, 1998). Within each method, the FFM profiles of ASPD and psychopathy are quite similar to one another; the correlations of the profiles within each method are .67, .87, and .90 for translational, expert, and empirical approaches, respectively. Using a simple ⫺1, 0, ⫹1 coding for the consensus profiles yields a correlation of 0.76. All 11 traits in the consensus ASPD profile appear in the EPA. There are seven additional traits assessed by the EPA that are not present in the consensus APD profile, but four of these traits are present in the expert profile for ASPD: unconcern (i.e., low FFM anxiety), self-assurance (i.e., low FFM self-consciousness), dominance (i.e., FFM assertiveness), and arrogance (i.e., low FFM modesty). In the end, only three traits might be considered uniquely descriptive of psychopathy2: self-contentment (i.e., low FFM depression), invulnerability (i.e., low FFM vulnerability), and coldness (i.e., low FFM warmth). Thus, history and research suggest that ASPD and psychopathy should be combined in DSM-5. It is interesting to note that this issue, beyond the change in designation from the first proposal to the second, seems to have received little attention. There is no discussion of it on the website or in the literature so far. This lack of discussion is somewhat surprising given that the relation between ASPD and psychopathy received explicit attention in the development of DSM–IV (see Hare et al., 1991). In fact, the DSM–IV–TR describes several of these additional traits as associated features of ASPD (e.g., self-assurance, dominance, selfcontentment, and arrogance) and explicitly references psychopathy in this discussion. Beyond simple neglect of extant literature, one reason for not combining ASPD and psy-
chopathy in the DSM-5 may have to do with inadequacies within the trait model. The DSM-5 trait model would appear to fare worse in its description of psychopathy than it does in its description of ASPD. Four of the seven traits that appear only in the EPA (i.e., self-assurance, invulnerability, coldness, and dominance) are not represented at all in the 25 traits of the DSM-5 model. Two other traits (i.e., unconcern and self-contentment) are represented by their opposite poles (i.e., anxiousness and depressivity), which raises concerns about the ability of the unipolar trait descriptors to capture the opposite ends of those traits. After all, the absence of anxiety does not necessitate immunity to it. Only one of the psychopathy-related traits (i.e., arrogance) has an explicit representation in the 25-trait model— grandiosity. In this case, grandiosity has already been assigned to NPD; assigning it also to ASPD/psychopathy would no doubt engender problematic levels of comorbidity with NPD, which is characterized by only two traits— grandiosity and attention-seeking. Impairments in Self- and Interpersonal Functioning The DSM–IV criterion that required clinically significant distress or impairment in social, occupational, or other important areas of functioning has been replaced in the revised DSM-5 proposal. The new criterion requires impairments in at least one of two areas of selffunctioning (identity or self-direction) and in at least one of two areas of interpersonal functioning (empathy or intimacy). Although impairments in identity, self-direction, empathy, and intimacy are present in each PD, the specific manifestations are described differently across PDs. Table 3 gives the descriptions for impairments in self-direction and empathy for each PD. For example, impaired self-direction in ASPD involves “setting goals based on personal gratification rather than prosocial or legal standards.” In schizotypal PD, impaired self2 Of course, this depends on one’s view of which approach gives the best description of ASPD. Our own preference is for the expert ratings because these are not bound to current diagnostic descriptions or to current assessment of these diagnostic descriptions.
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Table 3 Descriptions of Impairments in Self-Direction and Empathy Across PDs PD
Description of Impairment in Self-Direction
Borderline
“Instability in goals, aspirations, values, or career plans.”
Obsessive–Compulsive
“Difficulty completing tasks and realizing goals associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.” “Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.” “Unrealistic or incoherent goals; no clear set of internal standards.”
Avoidant
Schizotypal
Antisocial
Narcissistic
“Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behavior.” “Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.”
Description of Impairment in Empathy “Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.” “Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.”
“Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others’ perspectives as negative.” “Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others’ motivations and behaviors.” “Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.”
“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.”
Note. Descriptions are taken from the proposed DSM-5 PD criteria (DSM-5 Personality and Personality Disorders Workgroup, 2012c).
direction involves “unrealistic or incoherent goals; no clear set of internal standards.” Although there seems to some empirical support for using these specific categories of impairment (see DSM-5 Personality & Personality Disorders Workgroup, 2012b), we have several concerns about these specific descriptions. First, many descriptions are quite specific. For example, the description of impairment in self-direction in NPD is quite complicated: “goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.” This description can be compared with the one offered for impaired self-direction in BPD: “Instability in goals, aspirations, values, or career plans.” Second, some distinctions
are quite subtle. In ASPD, impairments in empathy are described as “lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.” For NPD, the same impairment references “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.” Third, many descriptions require relatively strong inferences about the dynamics underlying the impairment. In the end, we doubt that such complicated and differentiated ratings can be made with any reliability or that the fine distinctions in the descriptions will prove to be important. However, most problematic is that the descriptions of self- and interpersonal functioning
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are often identical to the traits that describe the types. For example, the impairment in empathy in ASPD is described as a “lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.” This is almost identical to the description of callousness that appears in Table 1: “lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one‘s actions on others; aggression; sadism.” Likewise, the problems in intimacy associated with ASPD (i.e., “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”) sound like the description of manipulativeness (i.e., “frequent use of subterfuge to influence or control others”). To the degree that the criteria for impairment simply recapitulate the descriptions of the traits involved in a given PD, an independent assessment of impairment is lost and one is thrown back to extremity as a proxy for impairment. Concluding Thoughts In sum, although we are pleased that the DSM-5 is moving toward trait descriptors of personality pathology, we believe that the characterization of ASPD leaves something to be desired. First, the newly developed trait model lacks strong ties to other well-validated models that have been extensively studied in relation to the PDs. Thus, the knowledge accumulated on the description, development, and biological underpinnings using these other trait models is rendered less useful. Second, the trait profile of ASPD is incomplete. Although it maps on well to the traits explicitly included in the DSM–IV– TR, it maps poorly onto the personality profile of ASPD. Third, the DSM Workgroup missed an opportunity to unify two classifications (ASPD and psychopathy) that history and research suggest have diverged mistakenly. Finally, the new conceptualizations of impairment in self- and interpersonal functioning seem flawed. Some of these concerns can be easily addressed. It is easy enough to revisit the trait characterization of ASPD and include the two
traits that are in the model and that are also descriptive of ASPD—suspiciousness and distractibility. In addition, the inclusion of three additional traits ([lack of] anxiousness, [lack of] depressivity, and grandiosity) would serve to move the APSD type closer to psychopathy. It is also possible to remediate the descriptions of impairments in self- and interpersonal functioning to make them more consistent, easier to use, and less dependent on inference about underlying dynamics. More substantial changes involve revisiting the proposed trait model. The first change would involve revisiting the specific traits. Even if suspiciousness, distractibility, grandiosity, (lack of) anxiousness, and (lack of) depressivity were included in the type profile, 6 of 18 traits descriptive of psychopathy are still missing— self-assurance, invulnerability, coldness, dominance, self-centeredness, and opposition. A second change would involve adoption of a bipolar trait model that recognizes both ends of each trait (e.g., maladaptively high anxiety and maladaptively low anxiety). As discussed by Widiger (2011a), there is little justification for the unipolar scheme present in the DSM-5 proposal. Including both ends would allow ASPD/ psychopathy to be more fully described using traits such as low anxiety (vs. anxiousness) and low depressivity. Although we strongly advocate the use of traits for conceptualizing and assessing PD, we do not support the abandonment of traditional PD types. These PD types are familiar to clinicians and represent useful shorthand for describing consequential collections of traits. We believe that there is no cost associated with retaining all of the PD types in DSM–IV. As long as there is a coherent set of traits underlying the disorders—traits from a valid structural model that explain the epidemiological facts surrounding PD types, such as their continuity, comorbidity, and so forth— clinicians will be able to generate specific descriptions of personality dysfunction while enjoying the traditional shorthand of PD types.
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