Is there adequate empirical justification for radically revising the personality disorders section for DSM-5?

The DSM-5 Personality and Personality Disorders (PDs) Work Group has recommended a reformulation of the PD section. In the present review I examined the empirical support for the Work Group's criticisms of the DSM-IV approach that were central to the justification for radically changing the diagnostic criteria. The Work Group indicated that comorbidity among the DSM-IV PDs is excessive, and to reduce comorbidity they recommended deleting five PDs. The studies they cited demonstrating high levels of comorbidity were of samples of psychiatric patients. A review of the epidemiological literature shows that comorbidity rates are much lower than in patient samples, and this challenges the proposition that high comorbidity is due to the diagnostic criteria. Moreover, the empirical support for the exclusion of some disorders over others is lacking. The Work Group noted that the diagnostic stability of the PDs is modest. However, modest levels of diagnostic stability may be largely attributable to methodological factors such test-retest unreliability, state effects, regression to the mean, and measurement error due to repeated assessments, rather than a reflection of inadequacies of the diagnostic system. Thus, modest stability is likely to be found in any approach toward diagnosing PDs. The present review therefore suggests that several of the core problems linked to the DSM-IV approach toward diagnosing PDs are more likely due to methodological factors than inadequacies of the criteria themselves. The Work Group's recommendation to delete five PDs is inconsistent with the explicit guidelines established for making revisions for DSM-5 which specify that for a disorder to be deleted there should be a thorough review of that disorder's clinical utility and validity.