Since the release of DSM-III-R in 1980, the categorical approach to diagnosing personality disorders (which has been retained in DSM-5 Section II) has been widely criticized for substantial shortcomings in terms of poor scientific validity and clinical utility. As a response to this, Young & Gluhoski (1996) proposed a dimensional schema-based model as an alternative approach to diagnosing, understanding, and treating personality disorders. Now, two decades after this proposal, an official dimensional system has been included in Section III of the DSM-5, and it largely aligns with the schema therapy model.

In this blog post, Bo Bach suggests that schema therapists may take advantage of the DSM-5 Section III personality dimensions in regard to case-formulation and targets of treatment. He explored the associations between the Young Schema Questionnaire 3 – Short Form (YSQ-S3), The Schema Mode Inventory (SMI), and The Personality Inventory for DSM-5 (PID-5) in a sample of 662 participants. Results indicate that the majority of DSM-5 trait dimensions were strongly associated with conceptually relevant schemas and modes. Thus, problems related to schemas and modes are now better communicated by means of an official diagnostic system than ever before.

Bo Bach

Clinical Psychologist and Research Associate

Psychiatric Research Unit – Region Zealand

Psychiatric Clinic Slagelse

Denmark

The Alternative DSM-5 Model for Personality Disorders

Section III of the Diagnostic and Statistical Manual of Mental Disorders – 5^th Edition (DSM-5) offers an alternative model for personality disorders intended to address the scientific problems of the categorical system (currently preserved in Section II), including within-diagnosis heterogeneity, excessive overlap with other diagnoses, and arbitrary categories that were developed from diverse traditions and clinical observations. For example, two different patients may both meet the categorical criteria for borderline personality disorder (5 of 9 criteria) but only have one symptom in common. Beyond describing overall personality functioning (Criterion A; severity), the alternative personality disorder model measures a range of scientifically based trait dimensions (Criterion B; style), which are the topic in this blog post. Similar to schemas and modes, all individuals can be located on spectra of trait dimensions. Accordingly, it is always valuable to know a person’s difficulties, implying that assessment of pathological trait dimensions may be relevant whether an individual has a personality disorder or not. Clinicians have free access to use the English version of the Personality Inventory for DSM-5 (see psychiatry.org), and to date the instrument is validated in Dutch, German, Italian, Danish, French, Spanish, and Norwegian translations. Soon a complete clinician-rated SCID-AMPD interview will be available to assess the complete Alternative Model for Personality Disorders.

 

What can the DSM-5 Section III dimensions do for schema therapists?

Since the trait dimensions are atheoretical in origin, they should be applicable across different frameworks of psychotherapy, including schema therapy, as would be expected from an official diagnostic system. Personality traits are commonly considered as descriptors of thoughts, feelings, and behavior, which in turn are viewed as manifestations of underlying processes. Therefore, we set out to investigate the alignment between the DSM-5 section III trait dimensions (25 traits) and schema therapy constructs (18 schemas and 14 modes). We proposed that uncovering such associations likely implies the clinical utility of the trait dimensions for developing case formulations with reference to related schemas and modes as treatment targets. 

 

Associations between schema therapy constructs and the DSM-5 Section III dimensions were investigated in a mixed sample of 662 adults, including 312 psychiatric outpatients. All constructs were self-reported using the Danish validated versions of the Young Schema Questionnaire 3 – Short Form (YSQ-S3), The Schema Mode Inventory (SMI), and The Personality Inventory for DSM-5 (PID-5). Associations were examined in terms of factor loadings and regression coefficients in relation to five higher-order domains, followed by specific correlations among all constructs. 

We demonstrated that the majority of trait dimensions are strongly associated with conceptually relevant schemas and modes. For example, the trait Submissiveness was substantially associated with the Subjugation schema, and likewise the trait Impulsivity was substantially associated with the Impulsive Child mode (see Table 1). Overall, we found that DSM-5 Personality Traits explained 89.4% of the variance of Schema Therapy constructs. This suggests that psychotherapists may be able to interpret and utilize DSM-5 traits as if they reflect schemas or modes. In addition, this may also add clinical understanding and utility to the DSM-5 trait model.  Moreover, DSM-5 trait dimensions also add features such as eccentricity, perceptual dysregulation (dissociation), unusual beliefs and experiences, deceitfulness, and manipulativeness to individualized case-formulations, which are not covered by schema therapy constructs. Taken together, our findings supported the ability of specific facets to account for specific schemas and modes, which is explicitly useful for schema therapists who potentially could take advantage of this. In other words, schema therapists may be better placed for adopting a dimensional trait model in a future DSM-5.1 when the current personality disorder categories expectantly are omitted.

Table 1. Examples of specific associations

References

Bach, B., Lee, C., Mortensen, E. L., & Simonsen, E. (2015). How Do DSM-5 Personality Traits Align with Schema Therapy Constructs? Journal of Personality Disorders. doi:10.1521/pedi_2015_29_212

Bach, B., Markon, K., Simonsen, E., & Krueger, R. F. (2015). Clinical Utility of the Alternative DSM-5 Model of Personality Disorders: Six Cases from Practice. Journal of Psychiatric Practice, 21(1), 3–25.

Bach, B., Simonsen, E., Christoffersen, P., & Kriston, L. (2015). The Young Schema Questionnaire 3 Short Form (YSQ-S3): Psychometric Properties and Association With Personality Disorders in a Danish Mixed Sample. European Journal of Psychological Assessment, doi: 10.1027/1015-5759/a000272

Bernstein, D. P., Iscan, C., & Maser, J. (2007). Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system. Journal of Personality Disorders, 21, 536–551.

Bo, S., Bach, B., Mortensen, E. L., & Simonsen, E. (2015). Reliability and Hierarchichal Structure of DSM-5 Pathological Traits in a Danish Mixed Sample. Journal of Personality Disorders, doi: 10.1521/pedi_2015_29_187

Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., & Skodol, A. E. (2012). Initial construction of a maladaptive personality trait model and inventory for DSM-5. Psychological Medicine, 42(9), 1879–90.

Reiss, N., Krampen, D., Christoffersen, P., & Bach, B. (2015). Reliability and Validity of the Danish Version of the Schema Mode Inventory (SMI). Psychological Assesment. doi: 10.1037/pas0000154

Young, J. E., & Gluhoski, V. L. (1996). Schema-Focused Diagnosis for Personality Disorders. In F. W. Kaslow (Ed.), Handbook of Relational Diagnosis and Dysfunctional Famility Patterns (pp. 300–321). John Wiley & Sons, Inc.