Personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [1] have the same criteria as those in the DSM-IV-TR (4th edition, text revision). With any ongoing review process, especially one with this degree of complexity, different points of view emerge, and an effort was made to accommodate them. Thus, PDs are included in both section II (diagnostic criteria and codes) and section III (emerging measures and models). This preserves continuity with current clinical practice, while also introducing a new approach that aims to address the numerous shortcomings of the current approach to PDs.

The material in section II represents an update of the text with the same criteria as those found in the DSM-IV-TR, whereas section III includes the proposed research model for PD diagnosis and conceptualization developed by the DSM-5 work group. For example, the typical patient criteria to be met for a specific PD frequently overlap with criteria for other PDs. Similarly, other specified or unspecified PDs are often the correct (but mostly uninformative) diagnosis, in the sense that patients do not tend to present with patterns of symptoms that correspond with only one PD [1].

In the alternative DSM-5 model, PDs are characterized by impairments in personality functioning and pathological personality traits. The specific PD diagnoses that may be derived from this model include antisocial, avoidant, borderline, narcissistic, obsessive compulsive, and schizotypal PDs. This approach also includes a diagnosis of PD trait specified that can be made when a PD is considered present, but the criteria for a specific disorder are not met [1].

A diagnosis of a PD requires two determinations: an assessment of the level of impairment in personality functioning and an evaluation of pathological traits. These criteria are relatively inflexible and pervasive across a broad range of personal and social situations that are relatively stable over time, with onsets that can be traced back to at least adolescence or early adulthood, that are not better explained by another mental health disorder, that are not attributable to the effects of a substance or another medical condition, and that are not better understood as normal for an individual’s developmental stage or sociocultural environment.

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 (the experience of oneself as unique, with clear boundaries between oneself and others; the stability of self-esteem and accuracy of self-appraisal; the capacity for, and ability to regulate, a range of emotional experience) and self-direction (the pursuit of coherent and meaningful short-term and life goals; utilization of constructive and pro-social internal standards of behavior; ability to self-reflect productively).

Interpersonal functioning involves empathy (comprehension and appreciation of others’ experiences and motivations; tolerance of differing perspectives; understanding the effects of one’s own behavior on others) and 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 PD, and the severity of impairment predicts whether an individual has more than one PD or one of the more typically severe PDs.

In the alternative DSM-5 model for PD, histrionic PD is left out of the classification. The clinical utility of the DSM-5 section III personality trait model (organized into five broad domains: negative, affectivity, detachment, antagonism, disinhibition, and psychoticism) domains adds value to the others 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 [1].

Gender differences are variations that result from biological sex as well as an individual’s self-representation that includes the psychological, behavioral, and social consequences of one’s perceived gender. Gender bias with regard to criteria for PDs has been controversial and widely debated [2, 3].

Judgments about personality functioning must take into account the individual’s ethnic, cultural, and social background. PDs should not be confused with problems associated with acculturation following immigration or with the expression of habits, customs or religious and political values professed by the individual’s culture of origin. It is useful for the clinician, especially when evaluating someone from a different background, to obtain additional information from informants who are familiar with the person’s cultural background [1].

Gender differences are variations that result from biological as well as the individual’s self-representations, the social, behavioral, and social consequences of one’s perceived gender. The term gender difference is used more commonly in research than sex differences.

The DSM-IV-TR does suggest that some PDs might be more common in men: antisocial, narcissistic, obsessive–compulsive, paranoid, schizotypal, and schizoid. They also suggest that borderline, histrionic, and dependent PDs might be more frequent in women [4]. Avoidant PD seems to be similar in both genders (and this also may be the case for schizotypal PD). Borderline PD (BPD) is diagnosed predominantly (about 75 %) in women according to the DSM-5 [1].

In clinical settings, histrionic PD has been diagnosed more frequently in women. In contrast, some studies using structured assessments report similar prevalence rates among men and women [1].

Norms for interpersonal behavior, personal appearance, and emotional expressiveness vary widely across cultures, genders, and age groups. Before considering the various traits (e.g., emotion, seductiveness, dramatic interpersonal style, novelty seeking, sociability, charm, impressionability, a tendency to somatization) to be evidence of histrionic PD, it is important to evaluate whether they cause clinically significant impairment or distress [1].

Other PDs may be confused with histrionic PD because they have certain features in common. It is therefore important to distinguish among these disorders based on differences in their characteristic features. However, if an individual has personality features that meet criteria for one or more PDs in addition to histrionic PD, all can be diagnosed.

Many individuals may display histrionic personality traits. Only when these traits are inflexible, maladaptive, persistent, and cause significant functional impairment or subjective distress do they constitute a PD.

Certain PDs are diagnosed more frequently in men. Others (e.g., borderline, histrionic, and dependent PDs) are diagnosed more frequently in women. Although these differences in prevalence probably reflect real gender differences in the presence of such patterns, clinicians must be cautious not to overdiagnose or underdiagnose certain PDs in women or in men because of social stereotypes of gender roles and behaviors. However, many studies have been carried out to try to be more accurate and to search for gender biases in these results. Also, some authors have tried to explain why these biases occur.

Ford and Widiger [5] tried to investigate whether the differences found in antisocial PD (more frequent in men) and histrionic PD (more frequent in women) represent actual differences between men and women, or the influence of stereotyping and sex biases on clinical diagnosis. They proved that there is a tendency for therapists to perceive men as antisocial personalities and women as hysterical personalities even when the patients have identical features. They interviewed 354 psychologists, giving them case histories or individual behaviors, either informing them if the case was a woman or a man, or not informing about this characteristic at all. Using this method they found that subjects failed more often to diagnose histrionic PD in male than in female patients; and for the antisocial PD, subjects failed more often to make a correct diagnosis in female than in male patients and, even more remarkable, even antisocial female patients were significantly more likely to be diagnosed with histrionic PD than with antisocial PD. Another interesting clue they gave us is that these biases have a higher influence on the global PD diagnosis than on each individual criterion, which were more accurately diagnosed correctly.