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TheFive-FactorModelof
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The Five-Factor Model of Personality Disorder
and DSM-5
Timothy J. Trull
University of Missouri
ABSTRACT The Five-Factor Model of personality disorders
(FFMPD; Widiger & Mullins-Sweatt, 2009) developed from the recognition that the popular Five-Factor Model (FFM) of personality could be
used to describe and understand the official personality disorder (PD)
constructs from the American Psychiatric Association’s (APA) diagnostic
manuals (e.g., DSM-IV-TR, APA, 2000). This article provides an overview of the FFM, highlighting its validity and utility in characterizing PDs
as well as its ability to provide a comprehensive account of personality
pathology in general. In 2013, DSM-5 is scheduled to appear, and the
“hybrid” PD proposal will emphasize a 25–personality trait model. I
present the current version of this new model, compare it to the FFMPD,
and discuss issues related to the implementation of the FFMPD.
This article presents an overview of the Five-Factor Model of
personality disorders (FFMPD; Widiger & Mullins-Sweatt, 2009),
including its historical development, empirical support, and previous
use in evaluating the DSM-IV-TR personality disorders (American
Psychiatric Association [APA], 2000). Next, the proposed “hybrid
model” of personality disorders (PDs) that is being considered for
DSM-5 is discussed, focusing primarily on its 25-trait model of personality, as well as its relationship to the FFMPD. I close with issues
related to the implementation of the FFMPD.
THE FIVE-FACTOR MODEL OF PERSONALITY
Although a number of personality trait models have been discussed
in the context of the DSM personality disorders, the Five-Factor
Correspondence concerning this article should be addressed to Timothy J. Trull,
210 McAlester Hall, Department of Psychological Sciences, University of Missouri,
Columbia, MO 65211. Email: [email protected].
Journal of Personality 80:6, December 2012
© 2012 The Author
Journal of Personality © 2012, Wiley Periodicals, Inc.
DOI: 10.1111/j.1467-6494.2012.00771.x
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Trull
Model of personality has received both the most research attention
and empirical support in this context (e.g., Allik, 2005; Clark, 2007;
Clark & Livesley, 2002; Costa & Widiger, 2002; O’Connor & Dyce,
1998; Samuel & Widiger, 2008; Saulsman & Page, 2004; Trull &
Durrett, 2005; Widiger & Mullins-Sweatt, 2009; Widiger & Simonsen, 2005; Widiger & Trull, 2007). As stated by Clark (2007), “The
five-factor model of personality is widely accepted as representing
the higher-order structure of both normal and abnormal personality
traits” (p. 246).
Indeed, the Five-Factor Model (FFM) of personality is a popular
way to conceptualize major personality traits. It has a long history
and rich tradition, and was derived through factor-analytic studies of
personality trait terms from the English language (see Goldberg,
1993; John & Srivastava, 1999). As Widiger and Mullins-Sweatt
(2009) noted:
Language can be understood as a sedimentary deposit of the
observations of persons over the thousands of years of the language’s development and transformation. The most important
domains of personality functioning are those with the greatest
number of trait terms to describe and differentiate the various
manifestations and nuances of a respective domain, and the structure of personality is suggested by the empirical relationships
among these trait terms. (p. 199)
Thus, the FFM is often termed lexical, in that it reflects the structure
of personality descriptions that occur most frequently in the English
language. It also appears to be fairly universal in that this five-factor
structure in trait terms has been replicated in a variety of other
languages, including German, Dutch, Czech, Polish, Russian,
Italian, Spanish, Hebrew, Hungarian, Turkish, Korean, and Filipino
(Allik, 2005; Ashton & Lee, 2001).
The five major domains of this model are typically referred to as
Neuroticism versus emotional stability, Extraversion versus introversion, Openness versus closedness to experience, Agreeableness
versus antagonism, and Conscientiousness versus negligence. The
FFM was originally developed using nonclinical samples, and the
goal was to provide a comprehensive account of major personality
traits and dimensions. However, several came to realize that the
FFM might also be applied to issues relating to various forms of
Five-Factor Model of Personality Disorder and DSM-5
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psychopathology. Personality traits are indeed dimensional, and personality disorders by definition involve maladaptive or extreme personality traits. Further, the hierarchical structure of FFM traits (i.e.,
higher order domains and lower order facets) has been replicated
across populations (i.e., nonclinical and clinical) and cultures, and
evidence suggests a heritable and biological basis for both higher
order and lower order FFM traits (Trull & Durrett, 2005).
Over the last two decades, many studies have assessed the
relations between FFM constructs and personality disorders (see
Widiger & Costa, 2002; Samuel & Widiger, 2008, for reviews). These
studies have sampled clinical subjects, community residents, and
college students. For example, perhaps the first study examining the
relationship between the FFM and PDs in a clinical sample was
conducted by Trull (1992). Importantly, this study demonstrated
strong relationships between the FFM and personality disorder features in a clinical sample of psychiatric outpatients. FFM scores
accounted for significant amounts of variance in individual personality disorders in almost every case, and many of the patterns of
FFM relations for individual personality disorders were replicated
across three different personality disorder measures (i.e., a semistructured interview and two self-report inventories). Many studies using
both clinical and nonclinical samples have followed; studies have
consistently demonstrated significant relations between the traits
included in the FFM and the DSM PD constructs (Samuel &
Widiger, 2008; Saulsman & Page, 2004; Trull & Durrett, 2005;
Widiger & Costa, 2002).
However, simply demonstrating that, overall, these traits are
related to PDs is not particularly surprising. After all, by definition
PDs comprise extreme, maladaptive versions of personality traits
(APA, 2000). Instead, what is of interest is the extent to which
PD–personality trait relations may help distinguish among the official PD diagnoses. Therefore, based on an understanding of the
FFM as well as of personality disorders, Widiger and colleagues
(Lynam & Widiger, 2001; Widiger et al.,1994; Widiger, Trull, et al.,
2002) offered a set of predicted correlates between the five major
dimensions of the FFM, as well as the facets composing each dimension, and the DSM-IV personality disorders. Subsequent studies
have found general support for the relevance of the FFM to the full
range of personality disorders. For example, O’Connor and Dyce
(1998) used a confirmatory factor-analytic strategy to evaluate the
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“fit” of the FFM across 12 data sets of personality disorder symptoms. The authors used the proposals of Widiger et al. (1994) to
predict the covariance structure, and results supported the FFM as a
way of conceptualizing personality disorder pathology. More recent
studies have examined FFM and personality disorder relations at the
facet level. The main reason for this more detailed focus is that better
differentiation among the personality disorders is possible at the level
of first-order versus higher order traits (Samuel & Widiger, 2008).
Most of the personality disorders are associated with elevations on
Neuroticism, introversion, antagonism, and negligence (Saulsman &
Page, 2004; Samuel & Widiger, 2008). However, it appears that the
personality disorders can be distinguished by the patterns of relations
at the first-order, facet trait level (O’Connor & Dyce, 1998; Samuel &
Widiger, 2008; Trull, Widiger, & Burr, 2001).
Although these studies have primarily conceptualized personality pathology and disorder from the perspective of the existing
diagnostic manual, the findings do help explain some of the comorbidity patterns typically reported among the PDs (e.g., see Lynam
& Widiger, 2001). As mentioned, Samuel and Widiger (2008)
recently presented findings from a meta-analysis of studies that
examined the relations between both the five domains and the 30
facets of personality traits included in the FFM and the DSM-IV
PDs. Their results for the relationships between domain scores of
the FFM and individual PDs are consistent with the finding that
most PDs appear to be related to each other and comorbidity is
more the rule than the exception: The majority of PDs are characterized by significant positive relations with Neuroticism, significant negative relations with Extraversion, significant negative
relations with Agreeableness, and significant negative relations with
Conscientiousness. Second, the facet-level relations provide some
understanding of comorbidity patterns between certain pairs of
PDs (Lynam & Widiger, 2001). For example, the relatively parallel
pattern of FFM facet associations with paranoid, schizoid, and
schizotypal PD suggests that these diagnostic constructs might
co-occur with each other (consistent with the finding that these
within–cluster A correlations are significant). Finally, Samuel and
Widiger’s (2008) FFM facet results also are consistent with the
finding that both antisocial and obsessive-compulsive PD, respectively, are consistently less highly associated with other PDs; an
examination of their respective FFM facet profiles indicates that
Five-Factor Model of Personality Disorder and DSM-5
1701
they show less personality trait overlap with the other PDs. In the
case of antisocial PD, it is characterized primarily by low levels of
Agreeableness facets (i.e., low levels of trust, straightforwardness,
altruism, and compliance) and low levels of Conscientiousness
facets (i.e., low levels of competence, dutifulness, self-discipline,
and deliberation). Although borderline PD also shows a similar
pattern of associations with these facets, in addition (unlike antisocial PD), borderline PD is significantly positively related to all
Neuroticism facets (i.e., anxiousness, angry hostility, depressiveness, self-consciousness, impulsiveness, and vulnerability). This
explains why antisocial PD is often most highly associated with
borderline PD. Obsessive-compulsive PD is another case in point.
This PD’s FFM facet profile is unique in that there are some small
positive associations with Neuroticism facets (but not Extraversion,
Openness, or Agreeableness facets) but stronger positive associations with Conscientiousness facets (i.e., high levels of competence,
order, dutifulness, achievement striving, self-discipline, and deliberation). Obsessive-compulsive PD is the only PD to show positive
relations with these Conscientiousness facets.
DSM-IV-TR AND PERSONALITY TRAITS
As has been documented for some time now, the categorical model of
personality disorders, as exemplified in the DSM-IV-TR and its
immediate predecessors, is fraught with problems. These include
excessive heterogeneity within diagnoses, excessive diagnostic
comorbidity, inadequate coverage, arbitrary boundaries with normal
psychological functioning, and an inadequate scientific foundation
(Clark, 2007; Livesley, 2001; Trull & Durrett, 2005; Widiger & Trull,
2007). Although the DSM-IV-TR embraces the categorical approach
to personality pathology diagnosis, it does at least mention the possibility of an alternative dimensional approach: “An alternative to
the categorical approach is the dimensional perspective that Personality Disorders represent maladaptive variants of personality traits
that merge imperceptibly into normality and into one another”
(APA, 2000, p. 689). In addition, DSM-IV-TR acknowledges the
relevancy of major personality trait models (e.g., the FFM) to the
PDs.
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But how are personality traits and the DSM-IV-TR personality
disorders connected? DSM-IV-TR states:
Personality traits are enduring patterns of perceiving, relating to,
and thinking about the environment and oneself that are exhibited
in a wide range of social and personal contexts. Only when personality traits are inflexible and maladaptive and cause significant
functional impairment or subjective distress do they constitute
Personality Disorders. (APA, 2000, p. 686)
Nevertheless, an examination of the criteria sets for the personality disorders reveals that the majority of the criteria are not personality traits per se, but rather behavioral, cognitive, or interpersonal
indicators of problematic levels of traits (Widiger & Mullins-Sweatt,
2009). A recent analysis of the personality traits/psychopathology
dimensions that underlie the DSM-IV-TR criteria for borderline
personality disorder (BPD) is instructive (Trull, Tomko, Brown, &
Scheiderer, 2010). As can be seen in Table 1, there are only three
BPD symptoms that are directly related to the underlying personality
trait dimension of emotional dysregulation and only one directly
related to impulsivity/behavioral disinhibition (labeled “Direct” in
Table 1
Personality Traits and Borderline Personality
Disorder Symptoms
Borderline Symptom
Frantic efforts to avoid abandonment
Unstable interpersonal relationships
Identity disturbance
Impulsivity
Recurrent suicidal behavior/
self-harm/suicidal threats
Affective instability
Chronic emptiness
Extreme anger
Transient, stress-related paranoid
ideation or dissociation
Emotional
Dysregulation
Indirect
Indirect
Indirect
Indirect
Direct
Direct
Direct
Indirect
Impulsivity/
Behavioral
Disinhibition
Indirect
Indirect
Indirect
Direct
Indirect
Indirect
Five-Factor Model of Personality Disorder and DSM-5
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Table 1). The other criteria for BPD may be seen as either indirect
indicators of these personality traits or combinations of traits.
Although some might disagree with specific entries in Table 1, the
major point should not be lost. With the exception of affective instability, chronic emptiness, excessive anger, and impulsivity, these
criteria seem better conceptualized as possible indicators of traits
(which may be inferred but are not identified by name). The criteria
sets for other personality disorders are similar in their mix of traits
and of indicators of unnamed traits. Therefore, the DSM-IV-TR PD
criteria are really a mixture of personality traits per se and indicators
of these traits, the latter of which differ in the degree of inference
required for assessment as well as for making the connection to the
underlying personality trait.
FIVE-FACTOR MODEL OF PERSONALITY DISORDER
To this point, I have evaluated the FFM in reference to its ability to
characterize and account for the DSM-IV-TR PDs. It is clear that
PDs can be understood as maladaptive variants of the FFM (Clark,
2007; Livesley, 2001; Samuel & Widiger, 2008; Saulsman & Page,
2004), and the predominant models of normal and abnormal personality functioning converge onto at least four of the five broad
domains of the FFM (Bouchard & Loehlin, 2001; Clark, 2007; John
& Srivastava, 1999; Livesley, 2003; Markon, Krueger, & Watson,
2005; Trull & Durrett, 2005; Watson, Clark, & Harkness, 1994;
Widiger & Simonsen, 2005).
Findings such as these have encouraged investigators to go even
one step further. Clearly, the DSM-IV-TR does not present a comprehensive catalog of all personality pathology, nor is it an efficient
classification system (given rampant comorbidity among the PDs,
heterogeneity within diagnosis, and the high prevalence of the PD
not otherwise specified diagnosis; Trull & Durrett, 2005). It makes
much more sense to characterize and define personality pathology
and disorder through the lens of a widely accepted, comprehensive,
and empirically validated model of personality as opposed to the
current PD diagnostic system embodied in the official diagnostic
manual. Such an approach is likely to improve the weak construct
validity of the DSM-IV diagnostic categories (Mullins-Sweatt &
Widiger, 2006).
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Trull
The Four Steps
So how can the FFM characterize personality pathology and diagnose PD? Widiger, Costa, and McCrae (2002) proposed a four-step
procedure for an FFM diagnosis of personality disorder. Briefly, the
first step is to obtain a personality trait description of an individual in
terms of the five domains and 30 facets of the FFM. This description
will provide a comprehensive description of the person’s adaptive as
well as maladaptive personality traits. There are a number of psychological measures that can be used for this FFM description (De
Raad & Perugini, 2002), including, for example, the questionnairebased Revised NEO Personality Inventory (NEO PI-R; Costa &
McCrae, 1992) and the Structured Interview for the Five Factor
Model (SIFFM; Trull & Widiger, 1997), a semistructured interview
for the assessment of the FFM. Other FFM self-report inventories
and brief clinician rating scales can also be used (De Raad &
Perugini, 2002; Mullins-Sweatt, Jamerson, Samuel, Olson, &
Widiger, 2006). For example, Few et al. (2010) demonstrated the use
of a brief rating form for FFM facets to evaluate patients.
The second step involves an assessment of any social and occupational impairments and distress associated with extreme scores on the
FFM personality traits. For example, Widiger, Costa, et al. (2002)
and McCrae, Löckenhoff, and Costa (2005) identified problems likely
to be found in people scoring high or low on each of the FFM domains
and facets. In the case of the SIFFM interviews, there are questions
included that assess these maladaptive variants of each of the 30 trait
facets of the FFM. Further, both the SIFFM and the Five Factor
Model Score Sheet (FFMSS; Mullins-Sweatt et al., 2006) include
separate, independent assessments of many of the problems identified
by Widiger et al. (2002) and McCrae et al. (2005).
The third step is to determine whether the dysfunction and distress
reach a clinically significant level of impairment that would warrant
a diagnosis of personality disorder. There are several possibilities for
this assessment. For example, one could use the Global Assessment
of Functioning (GAF) scale currently used for Axis V of the DSMIV-TR (APA, 2000). Other possibilities, measures that purport to
measure personality-related impairment and dysfunction specifically, include the General Assessment of Personality Dysfunction
(GAPD; Livesley, 2010) and the Severity Indices of Personality
Problems (SIPP-118; Verheul et al., 2008).
Five-Factor Model of Personality Disorder and DSM-5
1705
The fourth step is necessary only if one desires a single quantitative index of the match between an individual’s FFM personality
profile and prototypic profiles of diagnostic constructs (e.g., Miller,
2012; Miller & Lynam, 2003; Trull, Widiger, Lynam, & Costa,
2003). Although this can be used to assess a match between an
individual’s FFM profile and a FFM characterization of the DSMIV-TR PD constructs, it is also possible for clinicians and researchers to develop FFM profiles for personality disorder constructs not
included within DSM-IV (e.g., successful psychopath). However,
prototypal matching with the DSM PDs is not generally recommended, as the purpose of the FFM diagnosis would not simply
be to provide a roundabout method of returning to the DSM
diagnostic categories (Clark, 2007).
DIAGNOSING PDS IN DSM-5: COMPARISONS WITH
THE FFMPD
Before comparing the DSM-5 revisions for PD with the FFMPD, it
is useful to briefly outline this new proposal for PD diagnosis. The
new version of the DSM (DSM-5) proposes that a diagnosis of PD
involves a series of determinations concerning overall personality
dysfunction as well as specific personality trait elevations
(www.dsm5.org). It is important to note that the original DSM-5 PD
proposal (published on the Web site in February 2010) was revised to
address concerns and clarify confusion (Skodol et al., 2011). Most
importantly, it is now clearer how to arrive at a diagnosis of PD, and
the prototype matching approach for PD types has been dropped.
According to the latest version of the proposal (updated June 21,
2011, on the DSM-5 Web site: http://www.dsm5.org/proposedre
vision/Pages/PersonalityDisorders.aspx), the diagnostician is asked
to first determine whether impairment in personality functioning is
present and, if so, to what degree. The clinician is asked to rate a
patient’s level of personality functioning; specifically, ratings are
made as to the level of self and interpersonal functioning for each
individual (see also Livesley, 2001, 2003). Self functioning is defined in
two areas (identity and self-direction), as is interpersonal functioning
(empathy and intimacy). A 5-point scale is used to rate overall level of
personality functioning for this purpose (0 = no impairment; 1 = mild
impairment; 2 = moderate impairment; 3 = serious impairment; and
4 = extreme impairment). Descriptions of each quantitative rating are
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Trull
provided, and the diagnostician is reminded that the ratings must
reflect functioning that is of multiple years in duration, not due solely
to another mental disorder/physical condition/effect of a substance,
and not a norm within a person’s cultural background.
Next, if significant personality dysfunction is present, the clinician
considers whether one (or more?) of the six proposed personality
disorder types are present: borderline, obsessive-compulsive,
avoidant, schizotypal, antisocial, or narcissistic. For each of these
proposed PD types, a listing of characteristic trait elevations is provided. Table 2 presents the current DSM-5 proposal for borderline
personality disorder, and one can see that for this PD type the
clinician is asked to consider whether there are elevations on seven
traits tapping negative affectivity (emotional lability, anxiousness,
separation insecurity, and depressivity), disinhibition (impulsivity,
risk taking), and antagonism (hostility). For obsessive-compulsive,
the clinician considers two primary traits, for avoidant four primary
traits, for schizotypal six primary traits, for antisocial seven primary
traits, and for narcissistic two primary traits.
If a specific PD type is not indicated but personality dysfunction
is present, then the clinician may designate a diagnosis of personality
disorder trait specified (PDTS), which replaces the DSM-IV-TR designation of personality disorder not otherwise specified (PDNOS).
Table 3 indicates how each of the 25 proposed DSM-5 PD primary
traits is mapped onto the PD types (as well as the “General definition
of personality disorder”), according to the latest proposal.
Of most relevance to the present article are the 25 traits, as well as
the higher-order trait domains, included in the DSM-5 PD proposal.
The current proposal lists 25 maladaptive personality traits, organized within five broad domains, which can be rated for each individual. The 25 facet traits are organized into five higher order trait
domains: Negative Affectivity (emotional lability, anxiousness,
separation anxiety, perseveration, submissiveness, hostility, restricted
affectivity [lack of], depressivity, and suspiciousness); Detachment
(restricted affectivity, depressivity, suspiciousness, withdrawal, anhedonia, and intimacy avoidance); Antagonism (hostility, manipulativeness, deceitfulness, grandiosity, attention seeking, and callousness);
Disinhibition (irresponsibility, impulsivity, rigid perfectionism
[lack of], distractibility, and risk taking); and Psychoticism (unusual
beliefs and experiences, eccentricity, and cognitive and perceptual
dysregulation).
Source: http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=17.
•
•
•
•
•
A diagnosis of BPD requires all of the following:
Significant impairment in Personality Functioning manifest by:
䊊 Impairments in self functioning:
䊏 Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness;
dissociative states under stress
䊏 Self-direction: Instability in goals, aspirations, values, or career plans
䊊 Impairments in interpersonal functioning:
䊏 Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted
or insulted); perceptions of others selectively biased toward negative attributes and vulnerabilities.
䊏 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 or idealization and devaluation and alternating between over involvement and withdrawal.
Elevated Personality Traits in the following domains:
䊊 Negative affectivity characterized by:
䊏 Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to
events and circumstances.
䊏 Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative events of past
unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing
control.
䊏 Separation insecurity: Fears of rejection by—and/or separation from—significant others, associated with fears of excessive dependency and complete
loss of autonomy.
䊏 Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future;
pervasive shame; thoughts of suicide and suicidal behavior.
䊊 Disinhibition, characterized by:
䊏 Impulsivity: Difficulty controlling behavior, including self-harm behavior, under emotional distress; acting with urgency or on the spur of the moment
in response to immediate stimuli; acting on momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans.
䊏 Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences.
䊊 Antagonism, characterized by:
䊏 Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.
The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s
developmental stage or socio-cultural environment.
The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a
substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
Table 2
New DSM-5 Proposal for Diagnosing Borderline Personality Disorder (BPD)
Five-Factor Model of Personality Disorder and DSM-5
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Trull
Table 3
Mapping of DSM-5 Personality Traits onto Personality
Disorder Types
DSM-5 Facet Trait
Emotional Lability
Anxiousness
Separation Anxiety
Perseveration
Submissiveness
Hostility
Restricted Affectivity
Depressivity
Suspiciousness
Withdrawal
Anhedonia
Intimacy Avoidance
Manipulativeness
Deceitfulness
Grandiosity
Attention Seeking
Callousness
Irresponsibility
Impulsivity
Rigid Perfectionism
Distractibility
Risk Taking
Unusual Beliefs
and Experiences
Eccentricity
Cognitive and Perceptual
Dysregulation
BRD OBC AVD SZT ATS NAR GEN
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Note. BRD = borderline; OBC = obsessive-compulsive; AVD = avoidant; SZT =
schizotypal; ATS = antisocial; NAR = narcissistic; GEN = general definition of personality disorder.
Integration of the Work Group Proposal With the FFM
Table 4 provides an illustration of how the 25 trait scales proposed by
the DSM-5 Work Group would be classified within the FFM domains
(also see Widiger, 2011). The placement of several of the 25 primary
Five-Factor Model of Personality Disorder and DSM-5
1709
Table 4
Placement of the 25 DSM-5 Facet Traits Within the Domains of
the Five-Factor Model
FFM Domain
Neuroticism-High
Neuroticism-Low
Extraversion-High
Extraversion-Low
Openness-High
Openness-Low
Agreeableness-High
Agreeableness-Low
Conscientiousness-High
Conscientiousness-Low
DSM-5 Traits
Emotional Lability, Separation Insecurity,
Depressivity, Anxiousness
None
Attention Seeking
Intimacy Avoidance, Withdrawal, Restricted
Affectivity, Anhedonia
Cognitive and Perceptual Dysregulation,
Unusual Beliefs and Experiences, Eccentricity
None
Submissiveness
Suspiciousness, Hostility, Deceitfulness,
Manipulativeness, Grandiosity, Callousness
Perseveration, Rigid Perfectionism
Irresponsibility, Distractibility, Impulsivity, Risk
Taking
traits by the DSM-5 Personality and Personality Disorders Work
Group within certain personality domains appears inconsistent with
the personality literature. For example, the extensive research on the
FFM indicates that suspiciousness (i.e., FFM low trust) is within
antagonism (not negative affectivity and detachment), submissiveness
(i.e., FFM compliance) is within Agreeableness (not negative affectivity), histrionism/attention seeking (i.e., FFM gregariousness) is
within Extraversion (not antagonism), and disinhibition and
compulsivity/rigid perfectionism are opposite ends of one bipolar
dimension (i.e., FFM Conscientiousness; Widiger, 2011).
Related to this latter point, although there is good evidence to
suggest that certain personality traits are bipolar in nature, the
DSM-5 Work Group chose to only include unipolar facet traits.
Although the Work Group acknowledged that the higher order trait
domains are bipolar in nature, they chose to include only unipolar
markers of the extreme poles. The major consequence is that the
interpretation of a low score on a uniploar trait is ambiguous. For
example, does a low score on emotional lability mean that one has a
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“normal” range level of emotionality or that one’s lack of emotionality is pathological (e.g., alexithymia; Luminet et al., 1999; Taylor &
Bagby, 2004)? In addition, when viewed though an FFM lens, it
appears that the DSM-5 trait model undersamples certain maladaptive poles of personality trait domains. In particular, there are no
traits that assess lower levels of Neuroticism, only one trait that
assesses high Extraversion, no traits for low Openness, and one trait
for high Agreeableness. Therefore, quite a few important traits are
still missing.
Table 5 presents a “translation” of the DSM-5 PD types into the
personality traits from the DSM-5 personality model. For comparison, this table also lists the FFM traits corresponding to each of the
five PDs, as proposed by Lynam & Widiger (2001) in their FFMPD
trait model. Once again, one is struck by the gaps in coverage for the
PD types. For example, where is the fearlessness (low Neuroticism)
that is crucial to the antisocial/psychopathy construct? Where is the
alexithymia and closed-minded dogmatism (low Openness) that
characterizes obsessive-compulsive PD? Where is the meekness and
modesty that characterizes avoidant PD? In addition, several traits
are included within two trait domains without explanation (e.g.,
restricted affectivity, depressivity, suspiciousness). Finally, some of
the choices for DSM-5 traits seem odd: Anhedonia for avoidant PD?
Why not submissiveness for avoidant PD?
These examples only concern the six PD types retained for
DSM-5. Skodol (2010) argued that the personality disorders
deleted from the prior diagnostic manual (paranoid, schizoid,
histrionic, dependent) can be recovered from the new trait
model (see http://www.dsm5.org/ProposedRevisions/Pages/DSM5TypeandTraitCross-Walk.aspx). However, the “gaps” in trait coverage are also apparent when one considers traits relevant to
dependent PD (high Agreeableness), paranoid and schizoid PD (low
Openness), and histrionic PD (high Extraversion). Finally, it is
unclear whether the four PDs excluded from DSM-5 are “recoverable” from the DSM-5 traits. Specifically, paranoid PD is characterized by a relatively small number of traits (e.g., suspiciousness,
hostility, unusual beliefs and experiences, intimacy avoidance), as is
true for schizoid (e.g., restricted affectivity, withdrawal, intimacy
avoidance, anhedonia), histrionic (e.g., emotional lability, manipulativeness, attention seeking), and dependent (e.g., anxiousness,
separation insecurity, submissiveness) PDs.
Rigid Perfectionism (DS), Perseveration (NA)
Grandiosity (A), Attention Seeking (A)
Obsessivecompulsive
Narcissistic
Anxiousness (N), Self-Consciousness (N), low Impulsiveness (N), Vulnerability
(N), low Gregariousness (E), low Assertiveness (E), low Excitement Seeking
(E), low Positive Emotions (E), Modesty (A), Actions (O)
Competence (C), Order (C), Dutifulness (C), Achievement Striving (C),
Self-Discipline (C), Deliberation (C), Anxiousness (N), low Impulsiveness
(N), low Excitement Seeking (E), low Feelings (O), low Actions (O), low
Ideas (O), low Values (O)
Angry Hostility (N), low Self-Consciousness (N), low Warmth (E),
Assertiveness (E), Excitement Seeking (E), low Feelings (O), Actions (O), low
Trust (A), low Straightforwardness (A), low Altruism (A), low Compliance
(A), low Modesty (A), low Tender-mindedness (A)
Low Trust (A), low Straightforwardness (A), low Altruism (A), low
Compliance (A), low Modesty (A), low Tender-mindedness (A), low
Dutifulness (C), low Self-Discipline (C), low Deliberation (C), low
Anxiousness (N), Angry Hostility (N), low Self-Consciousness (N),
Impulsiveness (N), Assertiveness (E), Activity (E), Excitement Seeking (E)
Anxiousness (N), Angry Hostility (N), Depressiveness (N), Impulsiveness (N),
Vulnerability (N), low Compliance (A), low Competence (C), low
Deliberation (C), Feelings (O), Actions (O)
Ideas (O), low Warmth (E), low Gregariousness (E), low Positive Emotions (E),
Anxiousness (N), Self-Consciousness (N), low Order (C)
FFMPD Traits1
FFMPD predicted relations based on Lynam and Widiger (2001).
1
Note. NA = Negative Affectivity; DT = Detachment; A = Antagonism; DS = Disinhibition; P = Psychoticism; N = Neuroticism; E = Extraversion;
O = Openness; A = Agreeableness; C = Conscientiousness.
Avoidant
Emotional Lability (NA), Anxiousness (NA),
Separation Insecurity (NA), Hostility (NA),
Depressivity (NA), Impulsivity (DS), Risk
Taking (DS)
Anxiousness (NA), Withdrawal (DT),
Anhedonia (DT), Intimacy Avoidance (DT)
Eccentricity (P), Cognitive and Perceptual
Dysregulation (P), Unusual Beliefs and
Experiences (P), Withdrawal (DT), Restricted
Affectivity (DT and NA), Suspiciousness (NA)
Callousness (A), Hostility (NA and A),
Manipulativeness (A), Deceitfulness (A),
Irresponsibility (DS), Impulsivity (DS), Risk
Taking (DS)
DSM-5 Type Traits
Borderline
Antisocial/
Dyssocial
Schizotypal
Personality
Disorder
Table 5
Translation of PD Types/Traits Into FFMPD Traits
Five-Factor Model of Personality Disorder and DSM-5
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These problems perhaps reflect that the traits selected were in part
the result of Work Group member nominations (Krueger, 2010),
rather than a systematic, comprehensive attempt to adequately
sample major domains of personality (and to do so as distinctly as
possible). Many have decried the overlapping PD constructs that
have appeared in previous diagnostic manuals, as evidenced by the
high levels of comorbidity (Clark, 2007; Livesley, 2007; Widiger &
Trull, 2007). However, many of the 25 traits appear to be closely
related and perhaps difficult to distinguish (e.g., separation
insecurity and anxiousness; perseveration and rigid perfectionism;
cognitive and perceptual dysregulation and unusual beliefs and
experiences or eccentricity). Therefore, the new proposal does not
seem to adequately address the concern regarding overlap and
redundancy.
CONCERNS AND COMMENTS ON THE FFMPD
Although the evidence supporting the use of the FFM to characterize
and diagnose personality pathology is strong, there are some criticisms and limitations that should be noted as well. In particular,
Krueger et al. (2011) argued that there is much confusion over exactly
what constitutes the FFM. In particular, they highlighted that there
are some differences in the conceptual models of the FFM as operationalized by the various FFM and Big Five measures that are available. Although it is true that there are differences in these measures,
we must not conflate measures with conceptual models (Haigler &
Widiger, 2001; Krueger et al., 2011). A measure is simply an operationalization of the conceptual model, and some measures may
emphasize certain aspects of the model over others. Further, in the
case of briefer measures, it is sometimes not possible to adequately
sample all aspects of a conceptual model with precision; for example,
some brief FFM/Big Five measures do not adequately sample the
facets or primary traits of the five major personality domains of the
FFM. In the end, however, Krueger and colleagues’ (2011) argument
could be applied to other measures of alternative personality models.
Ironically, the 25-trait model of personality disorder adopted by the
DSM-5 Personality and Personality Disorders Work Group suffers
from a more damning problem—it is not based on a well-established
model of personality or personality pathology at all. Although the
Five-Factor Model of Personality Disorder and DSM-5
1713
Work Group noted that it bears some resemblance to the Personality
Psychopathology Five (PSY-5; Harkness, McNulty, & Ben-Porath,
1995), this appears to be more of a post hoc observation instead of the
outcome of a theory-driven approach to measurement.
Although four of the five domains are recognizable from the
FFM, the Work Group grafted a “new” personality dimension onto
four of the five personality domains included in the FFM. Specifically, the Work Group included the new domain of Schizotypy,
which is now labeled Psychoticism. DSM-5 Psychoticism is defined
by only three facet traits, all of which emphasize the quasi-psychotic
experiences and behavior of schizotypal PD. Although there is only
limited support to date for this “new” personality dimension in
clinical samples, when this fifth personality domain is conceptualized
as FFM Openness, there is a wealth of supporting data from clinical
samples (see Samuel & Widiger, 2008).
One of the strongest arguments being raised against the FFMPD,
as well as other dimensional models, is clinical utility (e.g., First,
2005). However, the implication of such an argument is that the
existing diagnostic system has clinical utility (Kupfer, First, &
Regier, 2002; Rounsaville et al., 2002; Trull & Widiger, 2008; Westen
& Arkowitz-Westen, 1998). Although on the surface it might appear
that a categorical diagnosis of PD is congruent with the clinical
decisions that must be made (i.e., whether to hospitalize, whether
to medicate, whether to provide disability, and whether to provide
insurance coverage), DSM-IV (or even DSM-5) PD diagnoses do not
seem suitable for any of these decisions. The diagnostic boundaries
and thresholds were not developed with these clinical decisions in
mind. Dimensional systems can easily be converted to categorical
systems, provided appropriate cut-offs are available as well as decision algorithms (Trull & Widiger, 2008).
We believe that a dimensional model of classification has considerably greater potential to be clinically useful because one can set
different cutoff points along the respective dimensions that are
optimal for different clinical decisions. One can identify the level
of emotional instability that suggests the need for insurance coverage, pharmacotherapy, hospitalization, or disability. The diagnostic system would be constructed explicitly for maximizing
utility for different clinical decisions, an approach that is currently
non-existent and very cumbersome (if not impossible) to imple-
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ment for the existing diagnostic categories. (Trull & Widiger,
2008, pp. 958–959)
Although there are published treatment manuals for many DSMIV-TR disorders, official treatment guidelines have been developed
for only one personality disorder: borderline (APA, 2001). One
explanation is that the DSM-IV-TR PDs are generally not well suited
for treatment manuals because each PD involves an array of maladaptive personality traits, behaviors, and other indicators of these
traits. Furthermore, there is great heterogeneity within diagnoses
(e.g., patients diagnosed with the same PD may share few of the same
traits), and traits may cut across different PD categories (e.g., impulsivity for both borderline PD and antisocial PD).
In contrast, the FFM appears much better suited to develop specific treatment plans and guidelines. First, because the model was
developed iteratively, the FFM is a more conceptually (as well as
empirically) coherent personality structure. For example, by definition, personality disorders are diagnosed when the maladaptive
personality traits result in “clinical significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2000, p. 689). The FFM model assesses traits relevant
to emotional dysregulation/distress (e.g., Neuroticism traits), to
social/interpersonal (e.g., Extraversion and Agreeableness traits), to
work-oriented behavior and responsibility (e.g., Conscientiousness
traits), and to cognitive (e.g., Openness traits) domains of functioning. Further, Miller, Pilkonis, and Mulvey (2006) demonstrated
that FFM traits provided unique information about treatment
utilization and satisfaction above and beyond what could be
accounted for by general distress and by the DSM-IV-TR PDs
themselves.
FFM traits may also have implications for treatment choices as
well as within-treatment behavior. Extraversion and Agreeableness
are relevant to relationship quality both within and outside the consultation room. Interpersonal models of therapy, marital and family
therapy, and group therapy might be suggested by maladaptive variants of Extraversion and Agreeableness traits. Neuroticism traits are
relevant to mood, anxiety, and emotional dyscontrol, and problems
here might suggest pharmacologic interventions (e.g., mood stabilizers) or cognitive interventions targeting these dysfunctions. In the
case of Conscientiousness, maladaptively high levels might suggest
Five-Factor Model of Personality Disorder and DSM-5
1715
treatments that target obsessionality or compulsivity (e.g., exposure
plus response prevention or SSRIs). In contrast, low levels might
suggest treatments for attention deficit, hyperactivity, and impulsivity (e.g., ADHD stimulant medication). Finally, maladaptively high
Openness could indicate cognitive-perceptual aberrations and problems with reality testing, conditions that might be amenable to pharmacologic treatment (e.g., low-dose antipsychotic medication).
These examples are offered to show the treatment implications of
an FFM of personality disorder, and that these are substantially
more distinct and specific than those for the DSM-IV-TR personality
disorders. However, an important question is whether clinicians
actually find FFM information useful in their clinical formulations.
Several studies have provided encouraging findings. For example,
Samuel and Widiger (2006) provided practicing psychologists with
detailed descriptions of actual persons with maladaptive personality
traits (e.g., Ted Bundy). When asked to describe the person with
respect to the FFM and, alternatively, with the DSM-IV-TR personality disorders, clinicians indicated that an FFM dimensional rating
was more useful than the DSM-IV-TR with respect to providing a
global description of the individual’s personality, communicating
information to clients, encompassing all of the individual’s important personality difficulties, and even assisting in formulating effective treatment interventions.
Another concern raised regarding the FFMPD is that it is cumbersome and not user-friendly. However, as detailed above, an
FFMPD evaluation can proceed in logical steps, and evaluating
individuals’ standing on 30 trait facets is much easier and more
time-efficient than assessing almost 100 DSM-IV-TR PD criteria or
than assessing the 25 DSM-5 traits, six PD types, and four variants
of personality functioning called for in the current DSM-5 Work
Group proposal (Trull & Widiger, 1997; Widiger & Coker, 2002;
Widiger & Lowe, 2007).
CONCLUSION
For years, researchers have called for a switch to a dimensional
model of personality disorders (Clark, 2007; Livesley, 2007; Widiger
& Frances, 1985; Widiger & Trull, 2007), and there have even been
references to dimensional models within the text of the DSM-IV-TR
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(APA, 2000), the most recent diagnostic manual. The time seemed
ripe for making this change, but, regrettably, the DSM-5 Work
Group’s proposal for a trait-based PD system falls flat for several
reasons (Widiger, 2011). First, the Work Group had the opportunity
to integrate normal personality trait models researched within psychology with the personality disorders of psychiatry. Instead, they
decided to construct a “new” five-dimensional model of personality
disorder. This five-dimensional model excludes normal personality
traits, does not incorporate years of research on personality and
personality pathology, and is operationalized in ways so as to miss
important areas of personality functioning.
The DSM-5 Personality and Personality Disorders Work Group’s
proposal includes 25 maladaptive personality traits that differentially saturate major domains of personality, that are unipolar in
nature, and that overlap excessively with each other. As noted
earlier, the failure to recognize the bipolarity of personality structure
contributes to a number of problems for the DSM-5 proposal,
including the failure to include some important traits and the misplacement of others. Furthermore, as discussed, this 25-trait model
does not adequately cover the personality pathology that is assessed
in the proposed six PD types as well as that of the excluded PDs from
DSM-IV-TR (the latter which can purportedly be accounted for by
this model).
In the end, the FFMPD seems better suited for the task of representing personality and personality disorder than the DSM-5 Work
Group 25-trait model. The FFMPD has a strong conceptual and
empirical base, its relationship to PD diagnoses has been demonstrated, and it can also point to areas of personality dysfunction that
are not currently represented in diagnostic systems (e.g., racism,
alexithymia; Bell, 2004, 2006; Luminet et al., 1999; Taylor & Bagby,
2004; Trull, 2005). In addition, the FFMPD holds promise in its
ability to inform and guide treatment, as well as in other areas of
clinical utility.
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