778 Alternative DSM-5 Model for Personality Disorders4—Extreme 
impairmentExperience of a unique self and 
sense of agency/autonomy are 
virtually absent, or are orga-
nized around perceived exter-
nal persecution. Boundaries 
with others are confused or 
lacking.
Has weak or distorted self-image 
easily threatened by interac-
tions with others; significant 
distortions and confusion 
around self-appraisal.
Emotions not congruent with 
context or internal experience. 
Hatred and aggression may be 
dominant affects, although they 
may be disavowed and attrib-
uted to others.Has poor differentiation of 
thoughts from actions, so 
goal-setting ability is 
severely compromised, with 
unrealistic or incoherent 
goals.
Internal standards for behav-
ior are virtually lacking. 
Genuine fulfillment is virtu-
ally inconceivable.
Is profoundly unable to con-
structively reflect on own 
experience. Personal moti-
vations may be unrecog-
nized and/or experienced 
as external to self.Has pronounced inability to 
consider and understand 
others’ experience and 
motivation.
Attention to others’ perspec-
tives is virtually absent 
(attention is hypervigilant, 
focused on need fulfillment 
and harm avoidance).
Social interactions can be 
confusing and disorienting.Desire for affiliation is limited 
because of profound disinterest or 
expectation of harm. Engagement 
with others is detached, disorga-
nized, or consistently negative.
Relationships are conceptualized 
almost exclusively in terms of 
their ability to provide comfort or 
inflict pain and suffering.