The DSM's New Model of Personality Disorders: The Good, The Bad, and What's Missing

This episode continues the Heal NPD Seminar Series with Dr. Mark Ettensohn, joined by his associates Deanna Young, Psy.D., and Danté Spencer, Ph.D.

In this session, the group examines the Alternative DSM-5 Model for Personality Disorders (AMPD), a dimensional framework introduced in Section III of the DSM-5 and retained in DSM-5-TR. The model was developed in response to longstanding limitations of the traditional categorical system, including diagnostic overlap, heterogeneity within disorders, and the absence of a clear framework for assessing severity.

The discussion focuses on the two core components of the model. The first, Level of Personality Functioning (Criterion A), assesses impairments in identity, self-direction, empathy, and intimacy. This portion of the model reflects a structural approach to personality and aligns with psychodynamic and developmental perspectives on personality organization.

The second component, Criterion B, introduces a trait-based system organized around five domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. These traits are derived from dimensional personality research and represent an effort to describe maladaptive personality features in a standardized way.

The group explores the strengths of this combined model, as well as its limitations. Particular attention is given to the tension between structural and trait-based approaches, and to the question of whether personality pathology can be adequately captured through trait descriptions alone.

Using narcissistic personality disorder as a focal example, the discussion examines how the model emphasizes grandiosity and attention-seeking traits while underrepresenting vulnerability, shame, and fluctuations in self-state. The conversation highlights the importance of understanding pathological narcissism as a system of self-esteem regulation rather than a fixed set of traits.

Key themes include:

• The shift from categorical to dimensional models of personality disorder
• The distinction between personality functioning (structure) and personality traits (style)
• Limitations of trait-based approaches in capturing dynamic, state-based phenomena
• The role of self-esteem regulation, vulnerability, and oscillation in narcissistic pathology
• Clinical implications for diagnosis, formulation, and treatment

Throughout, the discussion situates the AMPD as a meaningful step forward in personality disorder classification, while also identifying areas where the model remains conceptually limited. The session emphasizes the value of structural and developmentally informed approaches in understanding personality pathology.

This series is intended for clinicians, trainees, and viewers seeking a nuanced, non-moralizing understanding of narcissism and personality disorders.

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Citation: American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Link to alternative model: https://psychiatryonline.org/doi/10.1...

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