764 vII. APPLICATIONS  AND  IMPLICATIONS
ing diagnostic overlap have contributed to 
considerable dissatisfaction among clini -
cians with respect to the DSM categories. In -
deed, when clinicians are explicitly surveyed 
with respect to clinical utility, they typically 
prefer a dimensional trait model descrip -
tion over the diagnostic categories (Morey, 
Skodol, & Oldham, 2014; Mullins-  Sweatt 
& Lengel, 2012; Widiger, 2019).
For example, it has been over 20 years 
since the American Psychiatric Association 
began developing treatment guidelines for 
each of the mental disorders included within 
DSM-5 and, to date, guidelines have been 
published for only one personality disorder 
(i.e., BPD). It is understandably difficult to 
develop a uniform treatment program for 
persons who share the same personality 
disorder diagnosis yet do not share many 
of the defining features (Clark, 2007; Wi -
diger & Trull, 2007). The five domains of 
the FFM are much better suited for treat -
ment planning, because they are consider -
ably more distinct and homogeneous. Extra -
version and agreeableness are the domains 
of interpersonal relatedness; neuroticism is 
a domain of emotional instability and dys -
regulation; conscientiousness is a domain 
of work-  related behavior, constraint, and 
responsibility; and openness is a domain of 
cognitive intellect, curiosity, unconvention -
ality, and creativity (Mullins-  Sweatt & Wi -
diger, 2006).
Indeed, Presnall (2013) outlined an initial 
draft of an FFM treatment manual, indi -
cating relatively specific psychotherapeutic 
and pharmacological treatment recommen -
dations for all 10 poles of all five domains. 
Presnall suggested that interpersonal mod -
els of therapy, marital–  family therapy, and 
group therapy might be particularly suitable 
for the two FFM interpersonal domains 
(i.e., extraversion and agreeableness). There 
is currently no pharmacotherapy for this in -
terpersonal dysfunction, which is not actu -
ally a criticism; it is simply an indication of 
the specificity of the treatment implications. 
In contrast to agreeableness and extraver -
sion, neuroticism concerns depressive, anxi -
ety, and emotional dyscontrol, often targets 
for effective pharmacological interventions, 
as well as cognitive, behavioral, and/or psy -
chodynamic interventions. Maladaptively 
high openness implies cognitive–  perceptual aberrations, and so would likely have phar -
macological implications (i.e., neuroleptics) 
that are quite different from the anxiolyt -
ics, antidepressants, and mood stabilizers 
that would be used for neuroticism. There 
might be specific pharmacological treat -
ment implications for low conscientiousness 
(e.g., methylphenidates; Nigg et al., 2002), 
although, as yet, there are none for mal -
adaptively high conscientiousness. Perhaps 
there never will be a pharmacotherapy for 
high conscientiousness, but the point is that 
the structure of the FFM is considerably 
more commensurate with specific treatment 
implications than the heterogeneous and 
overlapping DSM-IV-TR personality syn -
dromes.
Barlow, Sauer-  Zavala, Carl, Bullis, and 
Ellard (2014) have developed an empirically- 
validated Unified Protocol for the treatment 
of neuroticism (Sauer-  Zavala, Wilner, & 
Barlow, 2017). Given the substantial pub -
lic health care implications of neuroticism 
(Lahey, 2009), “the public-  health implica -
tions of directly treating and even prevent -
ing the development of neuroticism would 
be substantial” (Barlow et al., 2014, p. 344). 
Widiger and Trull (2007) and Lahey (2009) 
have indeed suggested mass screening for 
levels of neuroticism, given its considerable 
public health care implications. Magidson, 
Roberts, Collado-  Rodriguez, and Lejuez 
(2014) have made a similar recommenda -
tion for improving persons’ levels of consci -
entiousness, as conscientiousness is a major 
contributor to a wide array of significant life 
outcomes, including occupational success, 
marital stability, academic achievement, and 
even physical health and longevity (Jackson 
& Roberts, 2017). “Efforts to change con -
scientiousness may hold great public health 
significance in enabling changes across key 
outcomes related to health, functioning, 
and quality of life” (Magidson et al., 2014, 
p. 1443).
In addition, to the extent that DSM-5 Sec -
tion II personality disorders are maladaptive 
variants of the domains and facets of the 
FFM, all that has become known about the 
etiology, course, assessment, correlates, and 
outcome of FFM traits (Widiger, 2017) can 
be applied to an understanding of the Amer -
ican Psychiatric Association personality dis -
orders. Indeed, some of the more problemat -