DSM-5人格障碍的替代模型_Alternative_DSM-5_Model_for_Personality_Disorders

The current approach to personality disorders appears in Section II of DSM-5,

and an alternative model developed for DSM-5 is presented here in Section III. The inclusion of both models in DSM-5 reflects the decision of the APA Board of Trustees to preserve continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders. For example, the typical patient meeting criteria for a specific personality disorder frequently also meets criteria for other personality disorders. Similarly, other specified or unspecified personality disorder is often the correct (but mostly uninformative) diagnosis, in the sense that patients do not tend to present with patterns of symptoms that correspond with one and only one personality disorder.

In the following alternative DSM-5 model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. The specific personality disorder diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. This approach also includes a diagnosis of personality disorder—trait specified (PD-TS) that can be made when a personality disorder is considered present but the criteria for a specific disorder are not met.

目前对人格障碍的方法出现在DSM-5的第II部分，

DSM-5的第III部分提出了一种替代模型。两个模型在DSM-5中的包括反映了APA理事会决定保持与当前临床实践的连续性，同时引入新方法，旨在解决当前人格障碍方法的许多不足。例如，典型的符合特定人格障碍标准的患者经常也符合其他人格障碍的标准。类似地，其他特定或非特定的人格障碍通常是正确（但大多数情况下没有信息）的诊断，因为患者倾向于不仅符合一个人格障碍的症状模式。

在以下替代DSM-5模型中，人格障碍的特征是人格功能障碍和病理人格特征。从这个模型中可能得出的特定人格障碍诊断包括反社会、回避、边缘、自恋、强迫-冲动和精神分裂型人格障碍。此方法还包括一种人格障碍诊断—特定特征（PD-TS），当认为存在人格障碍但未满足特定障碍的标准时可以进行诊断。

General Criteria for Personality Disorder

General Criteria for Personality Disorder

The essential features of a personality disorder are

A. Moderate or greater impairment in personality (self/interpersonal) functioning.

B. One or more pathological personality traits.

C. The impairments in personality functioning and the individual’s personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations.

D. The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood.

E. The impairments in personality functioning and the individual’s personality trait expression are not better explained by another mental disorder.

F. The impairments in personality functioning and the individual’s personality trait expression are not solely attributable to the physiological effects of a substance or another medical condition (e.g., severe head trauma).

G. The impairments in personality functioning and the individual’s personality trait expression are not better understood as normal for an individual’s developmental stage or sociocultural environment.

A diagnosis of a personality disorder requires two determinations: 1) an assessment of the level of impairment in personality functioning, which is needed for Criterion A, and 2) an evaluation of pathological personality traits, which is required for Criterion B. The impairments in personality functioning and personality trait expression are relatively inflexible and pervasive across a broad range of personal and social situations (Criterion C); relatively stable across time, with onsets that can be traced back to at least adolescence or early adulthood (Criterion D); not better explained by another mental disorder (Criterion E); not attributable to the effects of a substance or another medical condition (Criterion F); and not better understood as normal for an individual’s developmental stage or sociocultural environment (Criterion G). All Section III personality disorders described by criteria sets, as well as PD-TS, meet these general criteria, by definition.

Criterion A: Level of Personality Functioning

Disturbances in self and interpersonal functioning constitute the core of personality psychopathology and in this alternative diagnostic model they are evaluated on a continuum. Self functioning involves identity and self-direction; interpersonal functioning involves empathy and intimacy (see Table 1). The Level of Personality Functioning Scale (LPFS; see Table 2, pp. 775–778) uses each of these elements to differentiate five levels of impairment, ranging from little or no impairment (i.e., healthy, adaptive functioning; Level 0) to some (Level 1), moderate (Level 2), severe (Level 3), and extreme (Level 4) impairment.

TABLE 1

Elements of personality functioning

Self:

1. Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range of emotional experience.

2. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively.

Interpersonal:

1. Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding the effects of one’s own behavior on others.

2. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior.

Impairment in personality functioning predicts the presence of a personality disorder, and the severity of impairment predicts whether an individual has more than one personality disorder or one of the more typically severe personality disorders. A moderate level of impairment in personality functioning is required for the diagnosis of a personality disorder; this threshold is based on empirical evidence that the moderate level of impairment maximizes the ability of clinicians to accurately and efficiently identify personality disorder pathology.

Criterion B: Pathological Personality Traits

Pathological personality traits are organized into five broad domains: Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Within the five broad trait domains are 25 specific trait facets that were developed initially from a review of existing trait models and subsequently through iterative research with samples of persons who sought mental health services. The full trait taxonomy is presented in Table 3 (see pp. 779781). The B criteria for the specific personality disorders comprise subsets of the 25 trait facets, based on meta-analytic reviews and empirical data on the relationships of the traits to DSM-IV personality disorder diagnoses.

Criteria C and D: Pervasiveness and Stability

Impairments in personality functioning and pathological personality traits are relatively pervasive across a range of personal and social contexts, as personality is defined as a pattern of perceiving, relating to, and thinking about the environment and oneself. The term relatively reflects the fact that all except the most extremely pathological personalities show some degree of adaptability. The pattern in personality disorders is maladaptive and relatively inflexible, which leads to disabilities in social, occupational, or other important pursuits, as individuals are unable to modify their thinking or behavior, even in the face of evidence that their approach is not working. The impairments in functioning and personality traits are also relatively stable. Personality traits—the dispositions to behave or feel in certain ways—are more stable than the symptomatic expressions of these dispositions, but personality traits can also change. Impairments in personality functioning are more stable than symptoms.

Criteria E, F, and G: Alternative Explanations for Personality Pathology (Differential Diagnosis)

On some occasions, what appears to be a personality disorder may be better explained by another mental disorder, the effects of a substance or another medical condition, or a normal developmental stage (e.g., adolescence, late life) or the individual’s sociocultural environment. When another mental disorder is present, the diagnosis of a personality disorder is not made, if the manifestations of the personality disorder clearly are an expression of the other mental disorder (e.g., if features of schizotypal personality disorder are present only in the context of schizophrenia). On the other hand, personality disorders can be accurately diagnosed in the presence of another mental disorder, such as major depressive disorder, and patients with other mental disorders should be assessed for comorbid personality disorders because personality disorders often impact the course of other mental disorders. Therefore, it is always appropriate to assess personality functioning and pathological personality traits to provide a context for other psychopathology.

中文翻译

人格障碍的一般标准

人格障碍的基本特征包括：

A. 人格（自我/人际）功能中等或更严重的损害。
B. 一种或多种病理人格特质。
C. 人格功能的损害和个体的人格特质表达在广泛的个人和社交情境中相对僵化和普遍。
D. 人格功能的损害和个体的人格特质表达相对稳定，其起始可以追溯到至少青春期或早期成年时期。
E. 人格功能的损害和个体的人格特质表达不会被另一种精神障碍更好地解释。
F. 人格功能的损害和个体的人格特质表达不仅仅归因于物质的生理效应或其他医学状况（例如，严重头部创伤）。
G. 人格功能的损害和个体的人格特质表达不可视为个体发展阶段或社交文化环境的正常现象。

诊断人格障碍需要两个决定因素：1）评估人格功能的损害程度，这是标准A所需的；2）评估病理人格特质，这是标准B所需的。人格功能的损害和人格特质表达相对僵化和普遍（标准C）；相对稳定，其起始可以追溯到至少青春期或早期成年时期（标准D）；不会被另一种精神障碍更好地解释（标准E）；不归因于物质或其他医学状况的效应（标准F）；并且不可视为个体发展阶段或社交文化环境的正常现象（标准G）。所有第三节所描述的人格障碍的标准集，以及PD-TS，都符合这些一般标准的定义。

标准A：人格功能水平

自我和人际功能的障碍构成了人格心理病理的核心，而在这种替代诊断模型中，它们是在连续体上进行评估的。自我功能涉及身份和自我指导；人际功能涉及同理心和亲密关系（见表1）。人格功能水平量表（LPFS；见表2，第775-778页）使用这些元素来区分五个损害水平，从少量或无损害（即健康、适应功能；水平0）到一些（水平1）、中等（水平2）、严重（水平3）和极端（水平4）损害。

表1

人格功能元素

自我:

1. 身份：作为独特的自我体验，自我与他人之间有明确的界限；自尊的稳定性和自我评估的准确性；情感体验的容量和调节能力。
2. 自我指导：追求连贯和有意义的短期和人生目标；采用建设性和有益社会的内在行为标准；能够有益地自省。

人际:

1. 同理心：理解和欣赏他人的经历和动机；对不同观点的容忍；理解自己行为对他人的影响。
2. 亲密关系：与他人的连接的深度和持续时间；亲近的愿望和能力；人际行为中的相互尊重。

人格功能的损害预示着人格障碍的存在，损害的严重程度预示着个体是否具有多种人格障碍或更典型的严重人格障碍。人格功能的中等损害是诊断人格障碍所需的；这一门槛是基于实证证据的，即中等损害水平最大化了临床医生准确和有效地识别人格障碍病理的能力。

标准B：病理人格特质

病理人格特质被组织成五个广泛的领域：负面情感、疏离、对抗、失抑制和精神病性。在这五个广泛的特质领域中，有25个特定的特质方面，最初是通过审查现有的特质模型开发的，随后是通过与寻求精神卫生服务的人的样本进行迭代研究的。完整的特质分类法在表3中呈现（见第779-781页）。特定人格障碍的B标准由25个特质方面的子集组成，基于对特质与DSM-IV人格障碍诊断关系的荟萃分析和实证数据。

标准C和D：普遍性和稳定性

人格功能的损害和病理人格特质在广泛的个人和社交背景中相对普遍，因为人格被定义为一种感知、关联和思考环境和自己的模式。相对一词反映了除了最极端的

病理性人格外，所有人格都表现出一定程度的适应性。人格障碍的模式是不适应的和相对僵化的，这导致了社交、职业或其他重要追求的障碍，因为个体无法修改他们的思维或行为，即使面对证据表明他们的方法不起作用。功能障碍和人格特质也相对稳定。人格特质——以某种方式行为或感觉的倾向——比这些倾向的症状表现更稳定，但人格特质也可以改变。人格功能的损害比症状更稳定。

标准E、F和G：人格病理的替代解释（鉴别诊断）

有时，看似人格障碍的情况可能更好地由另一种精神障碍、物质的效应或另一种医学状况、或正常的发展阶段（例如，青春期、晚年）或个体的社交文化环境来解释。当另一种精神障碍存在时，如果人格障碍的表现明显是另一种精神障碍的表现（例如，如果分裂型人格障碍的特征仅出现在精神分裂症的背景下），则不会诊断人格障碍。另一方面，即使存在另一种精神障碍，例如重性抑郁障碍，也可以准确诊断人格障碍，并且应该评估患有其他精神障碍的患者是否患有共病人格障碍，因为人格障碍通常会影响其他精神障碍的进程。因此，始终有必要评估人格功能和病理人格特质，以为其他心理病理提供背景。

Specific Personality Disorders

Section III includes diagnostic criteria for antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders. Each personality disorder is defined by typical impairments in personality functioning (Criterion A) and characteristic pathological personality traits (Criterion B):

• Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking.

• Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment.

• Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility.

• Typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity.

• Typical features of obsessive-compulsive personality disorder are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression.

• Typical features of schizotypal personality disorder are impairments in the capacity for social and close relationships, and eccentricities in cognition, perception, and behavior that are associated with distorted self-image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression.

The A and B criteria for the six specific personality disorders and for PD-TS follow. All personality disorders also meet criteria C through G of the General Criteria for Personality Disorder.

特定人格障碍

第三节包括反社会、回避、边缘型、自恋、强迫型和分裂型人格障碍的诊断标准。每种人格障碍都由典型的人格功能障碍（标准A）和特征性的病理人格特质（标准B）来定义：

• 反社会人格障碍的典型特征是不遵守合法和道德行为，以及以欺骗、不负责任、操纵和/或冒险为伴的自我中心、冷酷的对他人漠不关心。
• 回避人格障碍的典型特征是由于感觉无能和不足、对负面评价和拒绝的焦虑性关注以及对被嘲笑或尴尬的恐惧而回避社交情境和人际关系的抑制。
• 边缘型人格障碍的典型特征是自我形象、个人目标、人际关系和情感的不稳定性，伴随着冲动、冒险和/或敌意。
• 自恋人格障碍的典型特征是变化和脆弱的自尊心，试图通过寻求关注和认可来调节，并伴有公开或隐秘的自大。
• 强迫型人格障碍的典型特征是在建立和维持亲密关系方面的困难，与僵化的完美主义、不灵活和情感表达受限有关。
• 分裂型人格障碍的典型特征是社交和亲密关系能力的损害，以及与扭曲的自我形象和不连贯的个人目标有关，并伴随着怀疑和情感表达受限的认知、感知和行为的古怪之处。

以下是六种特定人格障碍和PD-TS的A和B标准。所有人格障碍还符合人格障碍的一般标准的C至G标准。

Antisocial Personality Disorder

Typical features of antisocial personality disorder are a failure to conform to lawful and ethical behavior, and an egocentric, callous lack of concern for others, accompanied by deceitfulness, irresponsibility, manipulativeness, and/or risk taking. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Antagonism and Disinhibition.

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

1. Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure.

2. Self-direction: Goal setting based on personal gratification; absence of prosocial internal standards, associated with failure to conform to lawful or culturally normative ethical behavior.

3. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.

4. Intimacy: 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.

B. Six or more of the following seven pathological personality traits:

1. Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends.

2. Callousness (an aspect of Antagonism): 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.

3. Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.

4. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior.

5. Risk taking (an aspect of Disinhibition): 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.

6. Impulsivity (an aspect of Disinhibition): 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.

7. Irresponsibility (an aspect of Disinhibition): Disregard for—and failure to honorfinancial and other obligations or commitments; lack of respect for—and lack of follow-through on—agreements and promises.

Note. The individual is at least 18 years of age. Specify if:

With psychopathic features.

Specifiers. A distinct variant often termed psychopathy (or “primary” psychopathy) is marked by a lack of anxiety or fear and by a bold interpersonal style that may mask maladaptive behaviors (e.g., fraudulence). This psychopathic variant is characterized by low levels of anxiousness (Negative Affectivity domain) and withdrawal (Detachment domain) and high levels of attention seeking (Antagonism domain). High attention seeking and low withdrawal capture the social potency (assertive/dominant) component of psychopathy, whereas low anxiousness captures the stress immunity (emotional stability/resilience) component.

In addition to psychopathic features, trait and personality functioning specifiers may be used to record other personality features that may be present in antisocial personality disorder but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g., anxiousness), are not diagnostic criteria for antisocial personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of antisocial personality disorder (Criterion A), the level of personality functioning can also be specified.

反社会人格障碍

反社会人格障碍的典型特征是无法符合合法和道德行为，以及伴随着欺骗、不负责任、操纵和/或冒险的自我中心、冷酷的对他人漠不关心。这些特征在身份、自我指导、同理心和/或亲密关系方面的困难中显而易见，下面将详细描述，还包括敌对和失控领域的特定适应不良特征。

提出的诊断标准

A. 人格功能中等或更严重的障碍，表现为以下四个方面中的两个或更多方面的特征困难：

1. 身份：自我中心；自尊源于个人收益、权力或快乐。
2. 自我指导：基于个人满足的目标设定；缺乏与不遵循合法或文化规范的道德行为相一致的亲社交内部标准。
3. 同理心：对他人的感受、需求或痛苦缺乏关心；伤害或虐待他人后缺乏悔意。
4. 亲密关系：无法建立相互亲密的关系，因为利用是与他人建立关系的主要手段，包括通过欺骗和强迫；使用支配或恐吓来控制他人。

B. 以下七个病理人格特质中的六个或更多：

1. 操纵（敌对的一种表现）：经常使用诡计来影响或控制他人；使用诱惑、魅力、油腔滑调或讨好来达到自己的目的。
2. 冷漠（敌对的一种表现）：对他人的感受或问题缺乏关心；对自己对他人的负面或有害影响缺乏内疚或悔意；攻击；虐待。
3. 欺诈（敌对的一种表现）：不诚实和欺诈；自我歪曲；在叙述事件时夸大或捏造。
4. 敌意（敌对的一种表现）：持续或频繁的愤怒感受；对小的冒犯和侮辱的愤怒或易怒反应；卑鄙、恶毒或报复性行为。
5. 冒险（失控的一种表现）：参与危险、冒险和可能自我伤害的活动，不必要且不顾后果；容易厌倦并轻率开始活动以对抗厌倦；对自己的局限和个人危险的现实缺乏关心。
6. 冲动（失控的一种表现）：对即时刺激的即刻反应；没有计划或考虑结果的瞬时基础行为；建立和遵循计划的困难。
7. 不负责任（失控的一种表现）：对财务和其他义务或承诺的漠视和不履行；对协议和承诺的尊重和未完成的缺乏。

注意：个体至少18岁。如果有，需注明：
具有精神病特征。

Avoidant Personality Disorder

Typical features of avoidant personality disorder are avoidance of social situations and inhibition in interpersonal relationships related to feelings of ineptitude and inadequacy, anxious preoccupation with negative evaluation and rejection, and fears of ridicule or embarrassment. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Negative Affectivity and Detachment.

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in two or more of the following four areas:

1. Identity: Low self-esteem associated with self-appraisal as socially inept, personally unappealing, or inferior; excessive feelings of shame.

2. Self-direction: Unrealistic standards for behavior associated with reluctance to pursue goals, take personal risks, or engage in new activities involving interpersonal contact.

3. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated with distorted inference of others’ perspectives as negative.

4. Intimacy: Reluctance to get involved with people unless being certain of being liked; diminished mutuality within intimate relationships because of fear of being shamed or ridiculed.

B. Three or more of the following four pathological personality traits, one of which must be (1) Anxiousness:

1. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to social situations; worry about the negative effects of past unpleasant experiences and future negative possibilities;feeling fearful, apprehensive, or threatened by uncertainty; fears of embarrassment.

2. Withdrawal (an aspect of Detachment): Reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.

3. Anhedonia (an aspect of Detachment): Lack of enjoyment from, engagement in, or energy for life’s experiences; deficits in the capacity to feel pleasure or take interest in things.

4. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

Specifiers. Considerable heterogeneity in the form of additional personality traits is found among individuals diagnosed with avoidant personality disorder. Trait and level of personality functioning specifiers can be used to record additional personality features that may be present in avoidant personality disorder. For example, other Negative Affectivity traits (e.g., depressivity, separation insecurity, submissiveness, suspiciousness, hostility) are not diagnostic criteria for avoidant personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of avoidant personality disorder (Criterion A), the level of personality functioning also can be specified.

回避型人格障碍

回避型人格障碍的典型特征是由于感觉无能和不足，避免社交场合和人际关系的抑制，对负面评价和拒绝的焦虑型关注，以及对嘲笑或尴尬的恐惧。如下所述，这些特征在身份、自我指导、同理心和/或亲密关系方面的困难中显而易见，还包括消极情感和疏远领域的特定适应不良特征。

提出的诊断标准

A. 人格功能中等或更严重的障碍，表现为以下四个方面中的两个或更多方面的特征困难：

1. 身份：与自我评价为社交无能、个人无吸引力或劣等有关的低自尊；过度的羞耻感。
2. 自我指导：与不愿追求目标、冒险或从事涉及人际交往的新活动有关的行为的不切实际标准。
3. 同理心：对批评或拒绝的关注和敏感，与将他人的观点歪曲为消极有关。
4. 亲密关系：除非确定别人喜欢，否则不愿与人交往；由于害怕被羞辱或嘲笑，亲密关系中的相互关系减弱。

B. 以下四个病理人格特质中的三个或更多，其中之一必须是（1）焦虑：

1. 焦虑（消极情感的一种方面）：对社交情境的剧烈的紧张、紧张或恐慌感；担心过去不愉快经历和未来负面可能性的负面影响；对不确定性感到害怕、担心或受到威胁；害怕尴尬。
2. 退缩（疏远的一种方面）：社交场合中的沉默寡言；避免社交接触和活动；缺乏社交联系的主动性。
3. 无欢乐感（疏远的一种方面）：对生活经历的缺乏享受、参与或活力；感受快乐或对事物感兴趣的能力不足。
4. 回避亲密关系（疏远的一种方面）：避免亲近或浪漫的关系、人际依附和亲密的性关系。

Borderline Personality Disorder

Typical features of borderline personality disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition.

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

1. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.

2. Self-direction: Instability in goals, aspirations, values, or career plans.

3. 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.

4. 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 of idealization and devaluation and alternating between overinvolvement and withdrawal.

B. Four or more of the following seven pathological personality traits, at least one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:

1. Emotional lability (an aspect of Negative Affectivity): Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and circumstances.

2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of nervousness, tenseness, or panic, often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibili-ties; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.

3. Separation insecurity (an aspect of Negative Affectivity): Fears of rejection byand/or separation from—significant others, associated with fears of excessive dependency and complete loss of autonomy.

4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feelings of inferior self-worth; thoughts of suicide and suicidal behavior.

5. Impulsivity (an aspect of Disinhibition): 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 or following plans; a sense of urgency and self-harming behavior under emotional distress.

6. Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger.

7. Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

Specifiers. Trait and level of personality functioning specifiers may be used to record additional personality features that may be present in borderline personality disorder but are not required for the diagnosis. For example, traits of Psychoticism (e.g., cognitive and perceptual dysregulation) are not diagnostic criteria for borderline personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of borderline personality disorder (Criterion A), the level of personality functioning can also be specified.

边缘型人格障碍

边缘型人格障碍的典型特征是自我形象、个人目标、人际关系和情感的不稳定，伴随着冲动、冒险和/或敌意。以下所述的特性困难在身份、自我指导、同理心和/或亲密关系方面显而易见，还包括消极情感领域的特定适应不良特质，以及对抗和/或无抑制。

提出的诊断标准

A. 人格功能中等或更严重的障碍，表现为以下四个方面中的两个或更多方面的特征困难：

1. 身份：显著贫乏、发育不良或不稳定的自我形象，常与过度的自我批评有关；持续的空虚感；在压力下的解离状态。
2. 自我指导：目标、愿望、价值观或职业计划的不稳定。
3. 同理心：与人际过敏相结合的对他人感受和需求的识别能力受损（即，容易感到被冒犯或侮辱）；对他人的看法有选择地偏向负面属性或弱点。
4. 亲密关系：激烈、不稳定和冲突的亲密关系，以不信任、需求和对真实或想象的抛弃的焦虑型关注为特征；亲密关系通常在理想化和贬低之间极端看法，交替在过度投入和撤退之间。

B. 以下七个病理人格特质中的四个或更多，其中至少一个必须是（5）冲动、（6）冒险或（7）敌意：

1. 情感不稳定（消极情感的一方面）：不稳定的情感体验和频繁的情绪变化；情感容易激发，强烈，和/或与事件和环境不成比例。
2. 焦虑（消极情感的一方面）：对人际压力的反应中的紧张、紧张或恐慌的强烈感觉；担心过去不愉快经历和未来负面可能性的负面影响；对不确定性感到害怕、担心或受到威胁；害怕崩溃或失去控制的恐惧。
3. 分离不安（消极情感的一方面）：与显著他人拒绝和/或分离有关的恐惧，与过度依赖和完全失去自主的恐惧有关。
4. 抑郁（消极情感的一方面）：经常感到沮丧、痛苦和/或绝望；从这样的情绪中恢复的困难；对未来的悲观；普遍的羞耻；自卑的感觉；自杀的想法和自杀行为。
5. 冲动（无抑制的一方面）：对即时刺激的反应而在刹那间行动；在没有计划或考虑后果的情况下临时行动；建立或遵循计划的困难；在情感压力下的紧迫感和自我伤害行为。
6. 冒险（无抑制的一方面）：参与危险、冒险和潜在自我伤害的活动，没有必要且不考虑后果；对自己的局限性和个人危险现实

的漠不关心。
7. 敌意（对抗的一方面）：持续或频繁的愤怒感受；对小冒犯和侮辱的愤怒或易怒反应。

回答指南

1. 找到对这个问题理解最深入的一位专家：一位专门研究和治疗人格障碍的精神病学家或临床心理学家。
2. 模拟他给出最底层的详细解释：
   • 原理或理论：边缘型人格障碍的核心特征是情感不稳定和对人际关系的极端反应。这可能与遗传、大脑功能和早期环境因素有关。
   • 常见误解：人们可能将边缘型人格障碍误解为纯粹的情绪波动或情感控制问题，而忽略了其复杂的心理结构和人际交往问题。
3. 结合实例和细节：例如，边缘型人格障碍患者可能会在短时间内经历情感的剧烈波动，从极度兴奋变为深深的沮丧。
4. 从反面考虑这个问题：不了解边缘型人格障碍的人可能会将患者的行为视为故意的或控制的，而不是一种严重的心理难题。
5. 最后一步额外给出更高层次的问题并回答：例如，如何治疗边缘型人格障碍？答案可能包括边缘型人格障碍专门的治疗方法，如边缘线治疗（DBT），以及心理治疗、药物治疗和社交技能培训等组合。

Narcissistic Personality Disorder

Typical features of narcissistic personality disorder are variable and vulnerable self-esteem, with attempts at regulation through attention and approval seeking, and either overt or covert grandiosity. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Antagonism.

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

1. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal inflated or deflated, or vacillating between extremes; emotional regulation mirrors fluctuations in self-esteem.

2. Self-direction: Goal setting based on gaining approval from others; personal standards unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.

3. Empathy: 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.

4. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others’ experiences and predominance of a need for personal gain.

B. Both of the following pathological personality traits:

1. Grandiosity (an aspect of Antagonism): Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescension toward others.

2. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

Specifiers. Trait and personality functioning specifiers may be used to record additional personality features that may be present in narcissistic personality disorder but are not required for the diagnosis. For example, other traits of Antagonism (e.g., manipulativeness, deceitfulness, callousness) are not diagnostic criteria for narcissistic personality disorder (see Criterion B) but can be specified when more pervasive antagonistic features (e.g., “malignant narcissism”) are present. Other traits of Negative Affectivity (e.g., depressivity, anxiousness) can be specified to record more “vulnerable” presentations. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of narcissistic personality disorder (Criterion A), the level of personality functioning can also be specified.

中文翻译

自恋型人格障碍

自恋型人格障碍的典型特点是可变和脆弱的自尊，通过寻求注意和批准来调节，并表现为明显或隐秘的自大。在身份、自我指导、同理心和/或亲密关系方面有明显的特征困难，如下所述，以及在对抗领域的特定适应不良特质。

建议的诊断标准

A. 人格功能中等或更严重的损害，表现为以下四个领域中的两个或更多领域的典型困难：

1. 身份：过度依赖他人来定义自我和调节自尊；夸大的自我评价，膨胀或缩小，或在极端之间摇摆；情感调节反映自尊的波动。
2. 自我指导：基于获得他人批准的目标设定；个人标准过高，以便将自己视为卓越，或过低，基于权利感；常常对自己的动机一无所知。
3. 同理心：难以识别或与他人的感受和需求产生共鸣；过度关注他人的反应，但只有当感知与自我有关时才如此；高估或低估自己对他人的影响。
4. 亲密关系：关系大多肤浅，存在于服务自尊调节；由于对他人经历的真实兴趣很少和对个人利益的优势，相互关系受到限制。

B. 下列两个病理人格特质：

1. 自大（对抗的一方面）：权利感，无论是公开还是隐秘的；自我为中心；坚定地相信自己优于他人；对他人居高临下。
2. 寻求注意（对抗的一方面）：过度尝试吸引并成为他人注意的焦点；寻求钦佩。

特指。特质和人格功能水平的特指标准可用于记录自恋型人格障碍中可能存在的额外人格特征，但不是诊断所需的。例如，对抗的其他特质（例如，操纵、欺诈、冷酷）不是自恋型人格障碍的诊断标准（见标准B），但当存在更广泛的对抗性特质（例如，“恶性自恋”）时可以指定。还可以指定负面情感的其他特质（例如，沮丧、焦虑），以记录更“脆弱”的表现。此外，虽然人格功能中等或更严重的损害是诊断自恋型人格障碍的要求（标准A），但也可以指定人格功能的水平。

Obsessive-Compulsive Personality Disorder

Typical features of obsessive-compulsive personality disorder are difficulties in establishing and sustaining close relationships, associated with rigid perfectionism, inflexibility, and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domains of Negative Affectivity and/or Detachment.

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

1. Identity: Sense of self derived predominantly from work or productivity; constricted experience and expression of strong emotions.

2. Self-direction: Difficulty completing tasks and realizing goals, associated with rigid and unreasonably high and inflexible internal standards of behavior; overly conscientious and moralistic attitudes.

3. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behaviors of others.

4. Intimacy: Relationships seen as secondary to work and productivity; rigidity and stubbornness negatively affect relationships with others.

B. Three or more of the following four pathological personality traits, one of which must be (1) Rigid perfectionism:

1. Rigid perfectionism (an aspect of extreme Conscientiousness [the opposite pole of Disinhibition]): Rigid insistence on everything being flawless, perfect, and without errors or faults, including one’s own and others’ performance; sacrificing of timeliness to ensure correctness in every detail; believing that there is only one right way to do things; difficulty changing ideas and/or viewpoint; preoccupation with details, organization, and order.

2. Perseveration (an aspect of Negative Affectivity): Persistence at tasks long after the behavior has ceased to be functional or effective; continuance of the same behavior despite repeated failures.

3. Intimacy avoidance (an aspect of Detachment): Avoidance of close or romantic relationships, interpersonal attachments, and intimate sexual relationships.

4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.

Specifiers. Trait and personality functioning specifiers may be used to record additional personality features that may be present in obsessive-compulsive personality disorder but are not required for the diagnosis. For example, other traits of Negative Affectivity (e.g., anxiousness) are not diagnostic criteria for obsessive-compulsive personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of obsessive-compulsive personality disorder (Criterion A), the level of personality functioning can also be specified.

中文翻译

强迫型人格障碍

强迫型人格障碍的典型特点是在建立和维持亲密关系方面存在困难，与严格的完美主义、僵化和受限的情感表达有关。在身份、自我指导、同理心和/或亲密关系方面有明显的困难，如下所述，以及在负面情感和/或疏离领域的特定适应不良特质。

建议的诊断标准

A. 人格功能中等或更严重的损害，表现为以下四个领域中的两个或更多领域的典型困难：

1. 身份：自我感主要源于工作或生产力；对强烈情感的经历和表达受限。
2. 自我指导：与僵化和不合理的高、僵化的行为内部标准有关的任务完成和目标实现困难；过分认真和道德态度。
3. 同理心：理解和欣赏他人的想法、感受或行为方面存在困难。
4. 亲密关系：将人际关系视为工作和生产力的次要方面；僵化和固执对与他人的关系产生负面影响。

B. 下列四个病理人格特质中的三个或更多，其中必须包括（1）严格的完美主义：

1. 严格的完美主义（极端责任心的一方面[抑制的反面极端]）：对一切都必须完美无缺、没有错误或缺陷的僵化坚持，包括自己和他人的表现；为确保每个细节的正确性而牺牲及时性；相信只有一种正确的做事方式；难以改变观点和/或观点；对细节、组织和秩序的过分关注。
2. 坚持不懈（负面情感的一方面）：在行为不再有功能或有效后，仍坚持任务；尽管屡次失败，仍继续相同的行为。
3. 亲密关系回避（疏离的一方面）：回避亲密或浪漫关系、人际依恋和亲密性行为。
4. 受限的情感反应（疏离的一方面）：对情感激发情境反应甚微；受限的情感体验和表达；冷漠或冷淡。

特指。特质和人格功能水平的特指标准可用于记录强迫型人格障碍中可能存在的额外人格特征，但不是诊断所需的。例如，负面情感的其他特质（例如，焦虑）不是强迫型人格障碍的诊断标准（见标准B），但在适当时可以指定。此外，虽然人格功能中等或更严重的损害是诊断强迫型人格障碍的要求（标准A），但也可以指定人格功能的水平。

Schizotypal Personality Disorder

Typical features of schizotypal personality disorder are impairments in the capacity for social and close relationships and eccentricities in cognition, perception, and behavior that are associated with distorted self-image and incoherent personal goals and accompanied by suspiciousness and restricted emotional expression. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, along with specific maladaptive traits in the domains of Psychoticism and Detachment.

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by characteristic difficulties in two or more of the following four areas:

1. Identity: Confused boundaries between self and others; distorted self-concept; emotional expression often not congruent with context or internal experience.

2. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.

3. Empathy: Pronounced difficulty understanding impact of own behaviors on others; frequent misinterpretations of others’ motivations and behaviors.

4. Intimacy: Marked impairments in developing close relationships, associated with mistrust and anxiety.

B. Four or more of the following six pathological personality traits:

1. Cognitive and perceptual dysregulation (an aspect of Psychoticism): Odd or unusual thought processes; vague, circumstantial, metaphorical, overelaborate, or stereotyped thought or speech; odd sensations in various sensory modalities.

2. Unusual beliefs and experiences (an aspect of Psychoticism): Thought content and views of reality that are viewed by others as bizarre or idiosyncratic; unusual experiences of reality.

3. Eccentricity (an aspect of Psychoticism): Odd, unusual, or bizarre behavior or appearance; saying unusual or inappropriate things.

4. Restricted affectivity (an aspect of Detachment): Little reaction to emotionally arousing situations; constricted emotional experience and expression; indifference or coldness.

5. Withdrawal (an aspect of Detachment): Preference for being alone to being with others; reticence in social situations; avoidance of social contacts and activity; lack of initiation of social contact.

6. Suspiciousness (an aspect of Detachment): Expectations of—and heightened sensitivity to—signs of interpersonal ill-intent or harm; doubts about loyalty and fidelity of others; feelings of persecution.

Specifiers. Trait and personality functioning specifiers may be used to record additional personality features that may be present in schizotypal personality disorder but are not required for the diagnosis. For example, traits of Negative Affectivity (e.g., depressivity, anxiousness) are not diagnostic criteria for schizotypal personality disorder (see Criterion B) but can be specified when appropriate. Furthermore, although moderate or greater impairment in personality functioning is required for the diagnosis of schizotypal personality disorder (Criterion A), the level of personality functioning can also be specified.

中文翻译

分裂型人格障碍

分裂型人格障碍的典型特征是在建立社交和亲密关系的能力上存在障碍，以及与扭曲的自我形象和不连贯的个人目标有关的认知、感知和行为的古怪性，伴随着多疑和受限的情感表达。在身份、自我指导、同理心和/或亲密关系方面有明显的困难，以及在精神病性和疏离领域的特定适应不良特质。

建议的诊断标准

A. 人格功能中等或更严重的损害，表现为以下四个领域中的两个或更多领域的典型困难：

1. 身份：自我与他人之间界限混淆；扭曲的自我概念；情感表达常与背景或内部经历不一致。
2. 自我指导：不切实际或不连贯的目标；没有明确的内部标准。
3. 同理心：明显难以理解自身行为对他人的影响；经常误解他人的动机和行为。
4. 亲密关系：在建立亲密关系方面的显著障碍，与不信任和焦虑有关。

B. 下列六个病理人格特质中的四个或更多：

1. 认知和感知失调（精神病性的一方面）：奇怪或不寻常的思维过程；含糊、迂回、隐喻、过分详细或刻板的思考或言语；各种感官方式的奇怪感觉。
2. 不寻常的信念和经历（精神病性的一方面）：被他人视为古怪或特异的思想内容和现实观；不寻常的现实经历。
3. 古怪性（精神病性的一方面）：奇怪、不寻常或古怪的行为或外貌；说不寻常或不合适的话。
4. 受限的情感反应（疏离的一方面）：对情感激发情境反应甚微；受限的情感体验和表达；冷漠或冷淡。
5. 回避（疏离的一方面）：喜欢独处而不是与他人在一起；在社交场合中的沉默寡言；避免社交接触和活动；不主动进行社交接触。
6. 多疑（疏离的一方面）：对人际恶意或伤害的迹象的期望和过度敏感；对他人的忠诚和忠实的怀疑；迫害感。

特指。特质和人格功能水平的特指标准可用于记录分裂型人格障碍中可能存在的额外人格特征，但不是诊断所需的。例如，负面情感的其他特质（例如，沮丧、焦虑）不是分裂型人格障碍的诊断标准（见标准B），但在适当时可以指定。此外，虽然人格功能中等或更严重的损害是诊断分裂型人格障碍的要求（标准A），但也可以指定人格功能的水平。

Personality Disorder—Trait Specified

Proposed Diagnostic Criteria

A. Moderate or greater impairment in personality functioning, manifested by difficulties in two or more of the following four areas:

1. Identity

2. Self-direction

3. Empathy

4. Intimacy

B. One or more pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains:

1. Negative Affectivity (vs. Emotional Stability): Frequent and intense experiences of high levels of a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, anger), and their behavioral (e.g., self-harm) and interpersonal (e.g., dependency) manifestations.

2. Detachment (vs. Extraversion): Avoidance of socioemotional experience, including both withdrawal from interpersonal interactions, ranging from casual, daily interactions to friendships to intimate relationships, as well as restricted affective experience and expression, particularly limited hedonic capacity.

3. Antagonism (vs. Agreeableness): Behaviors that put the individual at odds with other people, including an exaggerated sense of self-importance and a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self-enhancement.

4. Disinhibition (vs. Conscientiousness): Orientation toward immediate gratification, leading to impulsive behavior driven by current thoughts, feelings, and external stimuli, without regard for past learning or consideration of future consequences.

5. Psychoticism (vs. Lucidity): Exhibiting a wide range of culturally incongruent odd, eccentric, or unusual behaviors and cognitions, including both process (e.g., perception, dissociation) and content (e.g., beliefs).

Subtypes. Because personality features vary continuously along multiple trait dimensions, a comprehensive set of potential expressions of PD-TS can be represented by DSM5’s dimensional model of maladaptive personality trait variants (see Table 3, pp. 779–781). Thus, subtypes are unnecessary for PD-TS, and instead, the descriptive elements that constitute personality are provided, arranged in an empirically based model. This arrangement allows clinicians to tailor the description of each individual’s personality disorder profile, considering all five broad domains of personality trait variation and drawing on the descriptive features of these domains as needed to characterize the individual.

Specifiers. The specific personality features of individuals are always recorded in evaluating Criterion B, so the combination of personality features characterizing an individual directly constitutes the specifiers in each case. For example, two individuals who are both characterized by emotional lability, hostility, and depressivity may differ such that the first individual is characterized additionally by callousness, whereas the second is not.

人格障碍——特征指定

提出的诊断标准

A. 人格功能中等或更严重的障碍，表现为以下四个方面中的两个或更多方面的困难：

1. 身份
2. 自我指导
3. 同理心
4. 亲密关系

B. 一个或多个病理人格特质领域或领域内的特定特质方面，考虑以下所有领域：

1. 消极情感（对比情感稳定）：频繁和强烈的体验各种负面情感（例如，焦虑、抑郁、内疚/羞耻、担忧、愤怒）的高水平，及其行为（例如，自我伤害）和人际（例如，依赖）表现。
2. 疏离（对比外向）：避免社交情感体验，包括从日常互动到友谊到亲密关系的人际互动的撤退，以及情感体验和表达的限制，特别是有限的享乐能力。
3. 对抗（对比随和）：使个体与他人对立的行为，包括夸大的自我重要感和特殊待遇的期望，以及对他人的冷酷反感，包括对他人需求和感受的不知情，以及准备利用他人以提升自我。
4. 无抑制（对比责任心）：朝向即时满足的取向，导致由当前的思想、感受和外部刺激驱动的冲动行为，不考虑过去的学习或未来后果。
5. 精神病性（对比清晰）：展示一系列与文化不符的奇怪、古怪或不寻常的行为和认知，包括过程（例如，感知、解离）和内容（例如，信念）。

子类型

由于人格特征沿着多个特征维度连续变化，因此DSM5的适应不良人格特征变体的维度模型（见表3，第779–781页）可以代表PD-TS的全面潜在表达集合。因此，PD-TS不需要子类型，而是提供了构成人格的描述元素，按照以经验为基础的模型排列。这种安排允许临床医生根据每个人的人格障碍轮廓量身定制描述，考虑所有五个广泛的人格特质变化领域，并在需要时借助这些领域的描述特征来描述个体。

指定符

在评估标准B时，总是记录个人的具体人格特征，因此每个情况下个人的人格特征组合直接构成了指定符。例如，两个都以情感不稳定、敌意和抑郁为特征的个体可能有所不同，其中第一个个体还以冷酷为特征，而第二个则没有。

Personality Disorder Scoring Algorithms

The requirement for any two of the four A criteria for each of the six personality disorders was based on maximizing the relationship of these criteria to their corresponding personality disorder. Diagnostic thresholds for the B criteria were also set empirically to minimize change in prevalence of the disorders from DSM-IV and overlap with other personality disorders, and to maximize relationships with functional impairment. The resulting diagnostic criteria sets represent clinically useful personality disorders with high fidelity, in terms of core impairments in personality functioning of varying degrees of severity and constellations of pathological personality traits.

Personality Disorder Diagnosis

Individuals who have a pattern of impairment in personality functioning and maladaptive traits that matches one of the six defined personality disorders should be diagnosed with that personality disorder. If an individual also has one or even several prominent traits that may have clinical relevance in addition to those required for the diagnosis (e.g., see narcissistic personality disorder), the option exists for these to be noted as specifiers. Individuals whose personality functioning or trait pattern is substantially different from that of any of the six specific personality disorders should be diagnosed with PD-TS. The individual may not meet the required number of A or B criteria and, thus, have a subthreshold presentation of a personality disorder. The individual may have a mix of features of personality disorder types or some features that are less characteristic of a type and more accurately considered a mixed or atypical presentation. The specific level of impairment in personality functioning and the pathological personality traits that characterize the individual’s personality can be specified for PD-TS, using the Level of Personality Functioning Scale (Table 2) and the pathological trait taxonomy (Table 3). The current diagnoses of paranoid, schizoid, histrionic, and dependent personality disorders are represented also by the diagnosis of PD-TS; these are defined by moderate or greater impairment in personality functioning and can be specified by the relevant pathological personality trait combinations.

Level of Personality Functioning

Like most human tendencies, personality functioning is distributed on a continuum. Central to functioning and adaptation are individuals’ characteristic ways of thinking about and understanding themselves and their interactions with others. An optimally functioning individual has a complex, fully elaborated, and well-integrated psychological world that includes a mostly positive, volitional, and adaptive self-concept; a rich, broad, and appropriately regulated emotional life; and the capacity to behave as a productive member of society with reciprocal and fulfilling interpersonal relationships. At the opposite end of the continuum, an individual with severe personality pathology has an impoverished, disorganized, and/or conflicted psychological world that includes a weak, unclear, and maladaptive self-concept; a propensity to negative, dysregulated emotions; and a deficient capacity for adaptive interpersonal functioning and social behavior.

人格障碍评分算法

对于每一种人格障碍，需要任何两个四个A标准的要求是基于最大化这些标准与相应人格障碍的关系。B标准的诊断阈值也是实证设置的，以最小化DSM-IV的障碍患病率变化和与其他人格障碍的重叠，并最大化与功能障碍的关系。由此产生的诊断标准集代表了在不同程度的严重性和病理人格特质的星座方面具有高保真度的临床有用的人格障碍。

人格障碍诊断

具有与六个定义的人格障碍之一相匹配的人格功能障碍和适应不良特质的个体应被诊断为人格障碍。如果个体还具有除诊断所需特质之外可能具有临床相关性的一个或甚至几个突出特质（例如，请参见自恋型人格障碍），则可以选择将其记录为指定符。人格功能或特质模式与六个特定人格障碍中的任何一个截然不同的个体应被诊断为PD-TS。个体可能不满足所需的A或B标准的数量，因此，可能存在人格障碍的次阈值表现。个体可能具有人格障碍类型的特征混合或一些较不具有类型特征的特征，并且更准确地被视为混合或非典型表现。可以使用人格功能水平量表（表2）和病理特征分类（表3）来指定PD-TS的人格功能障碍的具体水平和表征个体人格的病理人格特质。偏执型、分裂型、表演型和依赖型人格障碍的当前诊断也由PD-TS的诊断表示；这些由中度或更严重的人格功能障碍定义，并可以通过相关的病理人格特质组合来指定。

人格功能水平

与大多数人类倾向一样，人格功能分布在一个连续体上。功能和适应的核心是个体对自己和与他人互动的思考和理解的特征方式。一个功能最佳的个体拥有一个复杂、完全阐述和完全整合的心理世界，其中包括一个主要积极、自愿和适应的自我概念；丰富、广泛和适当调节的情感生活；以及作为社会有生产力成员的能力，与人际关系相互满足和充实。在连续体的另一端，具有严重人格病理的个体具有一个贫乏、混乱和/或冲突的心理世界，其中包括一个薄弱、模糊和适应不良的自我概念；倾向于消极、失调的情感；以及适应人际功能和社交行为的能力不足。

Self- and Interpersonal Functioning Dimensional Definition

Generalized severity may be the most important single predictor of concurrent and prospective dysfunction in assessing personality psychopathology. Personality disorders are optimally characterized by a generalized personality severity continuum with additional specification of stylistic elements, derived from personality disorder symptom constellations and personality traits. At the same time, the core of personality psychopathology is impairment in ideas and feelings regarding self and interpersonal relationships; this notion is consistent with multiple theories of personality disorder and their research bases. The components of the Level of Personality Functioning Scale—identity, self-direction, empathy, and intimacy (see Table 1)—are particularly central in describing a personality functioning continuum.

Mental representations of the self and interpersonal relationships are reciprocally influential and inextricably tied, affect the nature of interaction with mental health professionals, and can have a significant impact on both treatment efficacy and outcome, underscoring the importance of assessing an individual’s characteristic self-concept as well as views of other people and relationships. Although the degree of disturbance in the self and interpersonal functioning is continuously distributed, it is useful to consider the level of impairment in functioning for clinical characterization and for treatment planning and prognosis.

Rating Level of Personality Functioning

To use the Level of Personality Functioning Scale (LPFS), the clinician selects the level that most closely captures the individual’s current overall level of impairment in personality functioning. The rating is necessary for the diagnosis of a personality disorder (moderate or greater impairment) and can be used to specify the severity of impairment present for an individual with any personality disorder at a given point in time. The LPFS may also be used as a global indicator of personality functioning without specification of a personality disorder diagnosis, or in the event that personality impairment is subthreshold for a disorder diagnosis.

自我和人际功能维度定义

一般化的严重程度可能是评估人格心理病理学中同时和预期功能障碍的最重要的单一预测因素。人格障碍通过一般化的人格严重程度连续体以及从人格障碍症状星座和人格特质派生的风格元素的额外指定来最佳地描述。与此同时，人格心理病理学的核心是关于自我和人际关系的观念和感受的损害；这一观念与人格障碍的多个理论及其研究基础相一致。人格功能水平量表的组成部分——身份、自我方向、同理心和亲密（见表1）在描述人格功能连续体方面尤为关键。

关于自我和人际关系的心理表征是相互影响并且密不可分的，影响与心理健康专业人员的互动性质，并可能对治疗效能和结果产生重大影响，强调了评估个体的特征自我概念以及对其他人和关系的观点的重要性。尽管自我和人际功能中的干扰程度是连续分布的，但考虑功能障碍水平对于临床特征描述以及治疗计划和预后是有用的。

评估人格功能水平

要使用人格功能水平量表（LPFS），临床医生选择最能捕捉个体当前人格功能障碍总体水平的水平。对于人格障碍的诊断（中度或更严重的障碍）该评分是必需的，并且可以用于指定某个时间点上患有任何人格障碍的个体存在的障碍严重程度。LPFS还可以用作人格功能的全球指标，而无需指定人格障碍诊断，或者在人格障碍处于障碍诊断的次阈值的情况下。

Personality Traits

Definition and Description

Criterion B in the alternative model involves assessments of personality traits that are grouped into five domains. A personality trait is a tendency to feel, perceive, behave, and think in relatively consistent ways across time and across situations in which the trait may manifest. For example, individuals with a high level of the personality trait of anxiousness would tend to feel anxious readily, including in circumstances in which most people would be calm and relaxed. Individuals high in trait anxiousness also would perceive situations to be anxiety-provoking more frequently than would individuals with lower levels of this trait, and those high in the trait would tend to behave so as to avoid situations that they think would make them anxious. They would thereby tend to think about the world as more anxiety provoking than other people.

Importantly, individuals high in trait anxiousness would not necessarily be anxious at all times and in all situations. Individuals’ trait levels also can and do change throughout life. Some changes are very general and reflect maturation (e.g., teenagers generally are higher on trait impulsivity than are older adults), whereas other changes reflect individuals’ life experiences.

Dimensionality of personality traits. All individuals can be located on the spectrum of trait dimensions; that is, personality traits apply to everyone in different degrees rather than being present versus absent. Moreover, personality traits, including those identified specifically in the Section III model, exist on a spectrum with two opposing poles. For example, the opposite of the trait of callousness is the tendency to be empathic and kindhearted, even in circumstances in which most persons would not feel that way. Hence, although in Section III this trait is labeled callousness, because that pole of the dimension is the primary focus, it could be described in full as callousness versus kind-heartedness. Moreover, its opposite pole can be recognized and may not be adaptive in all circumstances (e.g., individuals who, due to extreme kind-heartedness, repeatedly allow themselves to be taken advantage of by unscrupulous others).

Hierarchical structure of personality. Some trait terms are quite specific (e.g., “talkative”) and describe a narrow range of behaviors, whereas others are quite broad (e.g., Detachment) and characterize a wide range of behavioral propensities. Broad trait dimensions are called domains, and specific trait dimensions are called facets. Personality trait domains comprise a spectrum of more specific personality facets that tend to occur together. For example, withdrawal and anhedonia are specific trait facets in the trait domain of Detachment. Despite some cross-cultural variation in personality trait facets, the broad domains they collectively comprise are relatively consistent across cultures.

The Personality Trait Model

The Section III personality trait system includes five broad domains of personality trait variation—Negative Affectivity (vs. Emotional Stability), Detachment (vs. Extraversion), Antagonism (vs. Agreeableness), Disinhibition (vs. Conscientiousness), and Psychoticism (vs. Lucidity)—comprising 25 specific personality trait facets. Table 3 provides definitions of all personality domains and facets. These five broad domains are maladaptive variants of the five domains of the extensively validated and replicated personality model known as the “Big Five”, or Five Factor Model of personality (FFM), and are also similar to the domains of the Personality Psychopathology Five (PSY-5). The specific 25 facets represent a list of personality facets chosen for their clinical relevance.

Although the Trait Model focuses on personality traits associated with psychopathology, there are healthy, adaptive, and resilient personality traits identified as the polar opposites of these traits, as noted in the parentheses above (i.e., Emotional Stability, Extraversion, Agreeableness, Conscientiousness, and Lucidity). Their presence can greatly mitigate the effects of mental disorders and facilitate coping and recovery from traumatic injuries and other medical illness.

人格特质

定义和描述

替代模型中的标准B涉及分为五个领域的人格特质的评估。人格特质是在时间和可能表现出特质的情境之间以相对一致的方式感受、感知、行为和思考的倾向。例如，具有焦虑特质高水平的人倾向于容易感到焦虑，包括在大多数人保持冷静和放松的情况下。具有这一特质较低水平的人焦虑特质高的人也会更频繁地感知情境具有引发焦虑的作用，而具有这一特质高水平的人倾向于行为上避免他们认为会使自己感到焦虑的情境。因此，他们倾向于将世界看作比其他人更引发焦虑。

重要的是，具有焦虑特质高水平的人不一定在所有时间和所有情境中都感到焦虑。个体的特质水平也会并且确实会在一生中发生变化。一些变化非常普遍并反映成熟（例如，青少年通常在特质冲动性方面高于老年人），而其他变化则反映了个体的生活经历。

人格特质的维度。所有人都可以定位在特质维度的谱系上；也就是说，人格特质适用于不同程度的每个人，而不是存在与不存在。此外，人格特质，包括在第三节模型中特别识别的那些，都存在于具有两个相反极点的谱系上。例如，冷酷特质的相反是倾向于在大多数人不会有这种感觉的情况下富有同情心和善良。因此，尽管在第三节中这一特质被标记为冷酷，因为该维度的极点是主要焦点，但它可以完整地描述为冷酷与善良。此外，它的相反极点可以被认出，并且可能在所有情况下都不具有适应性（例如，由于极端的善良，反复让自己被不择手段的人利用的个体）。

人格的层次结构。一些特质术语相当具体（例如，“健谈”）并描述了狭窄的行为范围，而其他一些则相当广泛（例如，脱离）并描述了广泛的行为倾向。广泛的特质维度称为领域，特定的特质维度称为方面。人格特质领域包括一系列更具体的人格方面，这些方面倾向于一起出现。例如，撤退和无乐趣是脱离特质领域的具体特质方面。尽管人格特质方面存在一些跨文化变化，但它们共同构成的广泛领域在文化之间相对一致。

人格特质模型

第三节人格特质系统包括五个广泛的人格特质变化领域——消极情感性（与情感稳定性相反）、脱离（与外向相反）、敌对（与宜人相反）、失控（与责任心相反）和精神病性（与清晰相反）——包括25个具体的人格特质方面。表3提供了所有人格领域和方面的定义。这五个广泛的领

域是广泛验证和复制的人格模型“大五”或人格的五因素模型（FFM）的五个领域的不适应变体，并且与人格心理病理学五（PSY-5）的领域也相似。具体的25个方面代表了由于其临床相关性而选择的人格方面的列表。

尽管特质模型专注于与心理病理学有关的人格特质，但是还确定了这些特质的健康、适应和有弹性的人格特质，如上述括号中所述（即情感稳定、外向、宜人、责任心和清晰）。它们的存在可以大大减轻精神障碍的影响，并有助于应对和从创伤性伤害和其他医学疾病中康复。

Distinguishing Traits, Symptoms, and Specific Behaviors

Although traits are by no means immutable and do change throughout the life span, they show relative consistency compared with symptoms and specific behaviors. For example, a person may behave impulsively at a specific time for a specific reason (e.g., a person who is rarely impulsive suddenly decides to spend a great deal of money on a particular item because of an unusual opportunity to purchase something of unique value), but it is only when behaviors aggregate across time and circumstance, such that a pattern of behavior distinguishes between individuals, that they reflect traits. Nevertheless, it is important to recognize, for example, that even people who are impulsive are not acting impulsively all of the time. A trait is a tendency or disposition toward specific behaviors; a specific behavior is an instance or manifestation of a trait.

Similarly, traits are distinguished from most symptoms because symptoms tend to wax and wane, whereas traits are relatively more stable. For example, individuals with higher levels of depressivity have a greater likelihood of experiencing discrete episodes of a depressive disorder and of showing the symptoms of these disorders, such difficulty concentrating. However, even patients who have a trait propensity to depressivity typically cycle through distinguishable episodes of mood disturbance, and specific symptoms such as difficulty concentrating tend to wax and wane in concert with specific episodes, so they do not form part of the trait definition. Importantly, however, symptoms and traits are both amenable to intervention, and many interventions targeted at symptoms can affect the longer term patterns of personality functioning that are captured by personality traits.

Assessment of the DSM-5 Section III Personality Trait Model

The clinical utility of the Section III multidimensional personality trait model lies in its ability to focus attention on multiple relevant areas of personality variation in each individual patient. Rather than focusing attention on the identification of one and only one optimal diagnostic label, clinical application of the Section III personality trait model involves reviewing all five broad personality domains portrayed in Table 3. The clinical approach to personality is similar to the well-known review of systems in clinical medicine. For example, an individual’s presenting complaint may focus on a specific neurological symptom, yet during an initial evaluation clinicians still systematically review functioning in all relevant systems (e.g., cardiovascular, respiratory, gastrointestinal), lest an important area of diminished functioning and corresponding opportunity for effective intervention be missed.

Clinical use of the Section III personality trait model proceeds similarly. An initial inquiry reviews all five broad domains of personality. This systematic review is facilitated by the use of formal psychometric instruments designed to measure specific facets and domains of personality. For example, the personality trait model is operationalized in the Personality Inventory for DSM-5 (PID-5), which can be completed in its self-report form by patients and in its informant-report form by those who know the patient well (e.g., a spouse). A detailed clinical assessment would involve collection of both patient- and informant-report data on all 25 facets of the personality trait model. However, if this is not possible, due to time or other constraints, assessment focused at the five-domain level is an acceptable clinical option when only a general (vs. detailed) portrait of a patient’s personality is needed (see Criterion B of PD-TS). However, if personality-based problems are the focus of treatment, then it will be important to assess individuals’ trait facets as well as domains.

Because personality traits are continuously distributed in the population, an approach to making the judgment that a specific trait is elevated (and therefore is present for diagnostic purposes) could involve comparing individuals’ personality trait levels with population norms and/or clinical judgment. If a trait is elevated—that is, formal psychometric testing and/or interview data support the clinical judgment of elevation—then it is considered as contributing to meeting Criterion B of Section III personality disorders.

Clinical Utility of the Multidimensional Personality Functioning and Trait Model

Disorder and trait constructs each add value to the other in predicting important antecedent (e.g., family history, history of child abuse), concurrent (e.g., functional impairment, medication use), and predictive (e.g., hospitalization, suicide attempts) variables. DSM-5 impairments in personality functioning and pathological personality traits each contribute independently to clinical decisions about degree of disability; risks for self-harm, violence, and criminality; recommended treatment type and intensity; and prognosis—all important aspects of the utility of psychiatric diagnoses. Notably, knowing the level of an individual’s personality functioning and his or her pathological trait profile also provides the clinician with a rich base of information and is valuable in treatment planning and in predicting the course and outcome of many mental disorders in addition to personality disorders. Therefore, assessment of personality functioning and pathological personality traits may be relevant whether an individual has a personality disorder or not.

区分特质、症状和特定行为

尽管特质绝非不可改变，并且在一生中确实会发生变化，但与症状和特定行为相比，它们表现出相对一致性。例如，一个人可能在特定时间因特定原因表现出冲动行为（例如，一个很少冲动的人突然决定在某个特殊物品上花费大量金钱，因为有一个独特价值的不同寻常的购买机会），但只有当行为在时间和情境中聚集，从而在个体之间区分出一种行为模式时，它们才反映出特质。然而，重要的是要认识到，例如，即使是冲动的人也不是一直都在冲动地行动。特质是朝特定行为的倾向或性情；特定的行为是特质的实例或表现。

同样，特质与大多数症状有所不同，因为症状倾向于增减，而特质相对更稳定。例如，具有较高抑郁性水平的个体更有可能经历抑郁障碍的离散发作，并表现出这些障碍的症状，如注意力集中困难。然而，即使是具有抑郁性倾向的患者通常也会经历可区分的情绪障碍发作，并且随着特定发作的出现，例如注意力集中困难等特定症状倾向于增减，因此它们不构成特质定义的一部分。然而重要的是，症状和特质都可接受干预，许多针对症状的干预可以影响人格特质捕捉到的人格功能的长期模式。

DSM-5第三节人格特质模型的评估

第三节多维人格特质模型的临床效用在于其能够集中注意力在每个个体患者的多个相关人格变化领域上。临床应用第三节人格特质模型不是将注意力集中在识别一个且只有一个最佳诊断标签上，而是涉及审查表3中描绘的所有五个广泛的人格领域。人格的临床方法类似于临床医学中众所周知的系统审查。例如，个体的主诉可能集中在特定的神经症状上，然而在初步评估期间，临床医生仍然会系统地审查所有相关系统（例如，心血管、呼吸、消化系统）的功能，以免遗漏重要的减弱功能和相应的有效干预机会。

第三节人格特质模型的临床使用也是如此。最初的询问审查了人格的所有五个广泛领域。这种系统审查通过使用旨在测量人格特定方面和领域的正式心理测量工具来促进。例如，人格特质模型在DSM-5的人格库存（PID-5）中得到实现，患者可以用其自报表格完成，那些了解患者的人（例如配偶）可以用其知情人报告表格完成。详细的临床评估将涉及收集有关人格特质模型的所有25个方面的患者和知情人报告数据。然而，如果由于时间或其他限制无法做到这一点，当

只需要患者人格的一般（而非详细）画像时，可以接受以五个领域层面为重点的评估作为临床选择（见PD-TS的标准B）。然而，如果以人格为基础的问题是治疗的焦点，则评估个体的特质方面以及领域将是重要的。

因为人格特质在人群中连续分布，做出特定特质突出（因此用于诊断目的是存在的）的判断的方法可能涉及将个体的人格特质水平与人口标准和/或临床判断进行比较。如果特质被提高——即正式的心理测量测试和/或面试数据支持临床判断的提高——那么它被认为有助于满足第三节人格障碍的标准B。

多维人格功能和特质模型的临床效用

障碍和特质结构在预测重要的先行变量（例如家庭史、儿童虐待史）、并发变量（例如功能障碍、药物使用）和预测变量（例如住院、自杀企图）方面相互增值。DSM-5中的人格功能障碍和病理人格特质各自独立地有助于有关残疾程度的临床决策；自残、暴力和犯罪风险；推荐的治療类型和强度；以及预后——这些都是精神病诊断的效用的重要方面。值得注意的是，了解个体的人格功能水平和他或她的病理特质概况还为临床医生提供了丰富的信息基础，并在治療规划以及预测许多精神障碍（除人格障碍外）的病程和结果方面具有价值。因此，无论个体是否患有人格障碍，评估人格功能和病理人格特质都可能是相关的。