The Alternative Model of Personality Disorders: Assessment, Convergent and Discriminant Validity, and a Look to the Future

The Alternative Model of Personality Disorders (AMPD) is a dimensional, empirically based diagnostic system developed to overcome the serious limitations of traditional categories. We review the mounting evidence on its convergent and discriminant validity, with an incursion into the less-studied ICD-11 system. In the literature, the AMPD's Pathological Trait Model (Criterion B) shows excellent convergence with normal personality traits, and it could be useful as an organizing framework for mental disorders. In contrast, Personality Functioning (Criterion A) cannot be distinguished from personality traits, lacks both discriminant and incremental validity, and has a shaky theoretical background. We offer some suggestions with a view to the future. These include removing Criterion A, using the real-life consequences of traits as indicators of severity, delving into the dynamic mechanisms underlying traits, and furthering the integration of currently disengaged psychological paradigms that can shape a sounder clinical science.

Narcissistic Trauma: Main Characteristics and Life Impact

ABSTRACT

Narcissistic trauma can lead to disruption of the personality functioning system. Therefore, it is important to study the persons who have it, their traits, the sphere of relationships, and strategies of social adaptation. The research aims to study narcissism indicators among individuals with narcissistic trauma diagnosed during a therapeutic conversation to identify its connection with loneliness, life satisfaction, and communication style. The empirical research involved 32 people who sought psychotherapeutic help. All participants provided written consent to participate in the research. A clinical methodology was used to identify the degree of personal narcissism-the Narcissism Assessment Test. The study of the dominant style of social interaction revealed the dominance of two opposite styles: straightforward-aggressive and responsible-generous. Thus, narcissistic trauma is likely to lead to dysfunction of the self-system, and the ability to enjoy life and communication. The data obtained can be useful for both theoretical psychologists and psychotherapists.

[Effect of Personality and Physical Activity on Bone Mineral Density in College Students: A Cross-sectional Survey]

Objective

To explore the correlation between 5 dimensions of personality, physical activity (PA), and bone mineral density (BMD) among college students.

Methods

A total of 705 undergraduates (329 males and 376 females) from a sports university were recruited. Based on their sports training experience, the participants were divided into 6 major sports groups, including ball sports, skilled sports, competitive sports, track and field, leisure sports, and no sports. Students with professional sports training (ie, athletes) were categorized into ballgame, skilled, competitive, and track and field groups, while the rest (non-athletes) were placed in leisure and no sports groups. Ten-Item Personality Inventory in China (TIPI-C), or the 5-factor model of personality, was used to measure the 5 personality dimensions of openness, conscientiousness, extraversion, agreeableness, and neuroticism of the participants. Their daily level was measured with GT3X+ triaxial accelerometers over 7 continuous days. Then, parameter thresholds were established and the participants' PA was categorized as light (LPA), moderate (MPA), and vigorous (VPA). The bone mineral density (BMD) of arms, legs, and the total body was measured using dual-energy X-ray absorptiometry. The mediation effect of PA and that of the 5-factor model of personality were tested using PROCESS and Sobel tests. The correlation between the 5 personality dimensions, PA, and BMD was explored, with PA and the 5 personality dimensions as mediator variables. A comparison of PA and BMD was conducted across the 6 major sports groups. The correlation between PA of different intensities and BMD was also analyzed using Spearman's correlation.

Results

Although there were 90 potential relationships between PA, the 5 personality dimensions, and BMD, only 3 were significant. When conscientiousness was used as an independent variable and MPA, as a mediating variable, statistically significant differences in PROCESS results were reported (P<0.01), with MPA mediating 17.3% of arm BMD, 19.4% of leg BMD, and 19.1% of total body BMD. Among male students, there was no significant difference in LPA among the 6 groups, but significant differences in MPA and VPA (P<0.05). Among female students, significant differences in LPA, MPA, and VPA were observed in all 6 groups and the differences between MPA and VPA were especially prominent (P<0.05). For both males and females, the differences in arm, leg, and total body BMD across the 6 groups were statistically significant (P<0.05), with these differences being more pronounced in females. There was no correlation between LPA and BMD in either sex. MPA and VPA were positively correlated with BMD, with MPA correlating with arm, leg, and total body BMD (males, Spearman's correlation [rs]: 0.11-0.14, P<0.05; females, rs: 0.20-0.23, P<0.01). VPA correlated with arm, leg, and total body BMD (males, rs: 0.11-0.23, P<0.05; females, rs: 0.26-0.30, P<0.01).

Conclusion

MPA is associated with BMD in college students scoring high in the conscientiousness dimension of personality. In addition, there is a weak positive correlation between both MPA and VPA and BMD levels, with these associations being more pronounced in females.

Narcissistic dimensions and depressive symptoms in patients across mental disorders in cognitive behavioural therapy and in psychoanalytic interactional therapy in Germany: a prospective cohort study

BACKGROUND

Narcissistic personality traits have been theorised to negatively affect depressive symptoms, therapeutic alliance, and treatment outcome, even in the absence of narcissistic personality disorder. We aimed to examine how the dimensional narcissistic facets of admiration and rivalry affect depressive symptoms across treatment modalities in two transdiagnostic samples.

METHODS

We did a naturalistic, observational prospective cohort study in two independent adult samples in Germany: one sample pooled from an inpatient psychiatric clinic and an outpatient treatment service offering cognitive behavioural treatment (CBT), and one sample from an inpatient clinic providing psychoanalytic interactional therapy (PIT). Inpatients treated with CBT had an affective or psychotic disorder. For the other two sites, data from all service users were collected. We examined the effect of core narcissism and its facets admiration and rivalry, measured by Narcissistic Admiration and Rivalry Questionnaire-short version, on depressive symptoms, measured by Beck's Depression Inventory and Patient Health Questionnaire-Depression Scale, at baseline and after treatment in patients treated with CBT and PIT. Primary analyses were regression models, predicting baseline and post-treatment depression severity from core narcissism and its facets. Mediation analysis was done in the outpatient CBT group for the effect of the therapeutic alliance on the association between narcissism and depression severity after treatment.

FINDINGS

The sample included 2371 patients (1423 [60·0%] female and 948 [40·0%] male; mean age 33·13 years [SD 13·19; range 18-81), with 517 inpatients and 1052 outpatients in the CBT group, and 802 inpatients in the PIT group. Ethnicity data were not collected. Mean treatment duration was 300 days (SD 319) for CBT and 67 days (SD 26) for PIT. Core narcissism did not predict depression severity before treatment in either group, but narcissistic rivalry was associated with higher depressive symptom load at baseline (β 2·47 [95% CI 1·78 to 3·12] for CBT and 1·05 [0·54 to 1·55] for PIT) and narcissistic admiration showed the opposite effect (-2·02 [-2·62 to -1·41] for CBT and -0·64 [-1·11 to -0·17] for PIT). Poorer treatment response was predicted by core narcissism (β 0·79 [0·10 to 1·47]) and narcissistic rivalry (0·89 [0·19 to 1·58]) in CBT, whereas admiration showed no effect. No effect of narcissism on treatment outcome was discernible in PIT. Therapeutic alliance mediated the effect of narcissism on post-treatment depression severity in the outpatient CBT sample.

INTERPRETATION

As narcissism affects depression severity before and after treatment with CBT across psychiatric disorders, even in the absence of narcissistic personality disorder, the inclusion of dimensional assessments of narcissism should be considered in future research and clinical routines. The relevance of the therapeutic alliance and therapeutic strategy could be used to guide treatment approaches.

FUNDING

IZKF Münster.

TRANSLATION

For the German translation of the abstract see Supplementary Materials section.

What is a psychopathology dimension?

Coherence in the science and practice of mental health assessment depends upon a tight connection between psychopathology concepts that are used and the way those concepts are operationalized and defined. In contrast, the use of the same word to mean more than one thing contributes to incoherence, inefficiency, and confusion. In this paper, we review three possible meanings of the word "dimension" as it relates to the assessment of psychopathology and describe how the indiscriminate use of this word has caused confusion in the general context of the transition to a more evidence-based approach to mental health diagnosis. We attempt to disambiguate the term "dimension" by demarcating three concepts that can be distinguished based on different empirical standards: continuous variables, unidimensional dimensions, and distinct dimensions.

In search of hidden threats: A scoping review on paranoid presentations in personality disorders

Recent diagnostic developments suggest that paranoia is a transdiagnostic characteristic common to several personality disorders rather than a personality disorder per se. Nonetheless, empirical literature fails to provide comprehensive and univocal findings on whether and how paranoid presentations relate to different personality disorders. In the present scoping review, we map the empirical literature on paranoid presentations in personality disorders, considering the entire spectrum of paranoid manifestations (i.e., the paranoia hierarchy). In selecting original quantitative studies on paranoid presentations in personality-disordered patients, we screened 4,433 records in PsycArticles, PsycInfo and PUBMED. We eventually included 47 eligible studies in the review. Our synthesis indicates consistent empirical evidence of a wide range of paranoid presentations in Paranoid, Schizotypal and Borderline personality disorders. Conversely, little empirical literature exists on paranoid presentations in other personality disorders. Preliminary findings suggest broad-severity paranoid presentations, ranging from milder to severe forms, in Paranoid, Schizotypal and Borderline personality disorders. There is also some evidence of milder forms of paranoia in Avoidant, Antisocial and Narcissistic personality disorders. Conversely, there is poor evidence of paranoid presentations in Schizoid, Histrionic, Dependent or Obsessive-compulsive personality disorders. Research gaps and recommendations for improving empirical research on paranoid presentations in personality disorders are discussed.

Connecting DSM-5 and ICD-11 trait domains with schema therapy and dialectical behavior therapy constructs

The DSM-5 Section III alternative model of personality disorder (AMPD) and the International Classification of Diseases - 11th Edition's (ICD-11) personality disorder classification allow clinicians to identify individual trait domains in which people score highly. However, how these domains relate to constructs associated with efficacious treatment approaches is unclear. The current study aimed to determine whether constructs from two evidence-based treatments (schema therapy [ST] and dialectical behavior therapy [DBT]) were associated with maladaptive personality traits in a way consistent with underlying theories. We examined associations between ST constructs, DBT skill use and maladaptive coping styles, and personality traits in a sample of 525 adults. Bivariate intercorrelations and a series of multiple regression analyses were conducted to investigate the associations. As hypothesized, maladaptive coping was strongly associated with all trait domains. Surprisingly, poor DBT-skill use was only associated with negative affectivity, detachment, and disinhibition trait domains. Specific schema domains were associated with each personality trait domain, supporting trait domain-schema domain specificity. The current study highlights the potential clinical utility of the AMPD and ICD-11 trait models and ultimately contributes to the dearth of evidence on their likely usefulness for treatment selection, planning, and applications.

Exploring Guilt Differences in Grandiose Narcissism, Vulnerable Narcissism, and Malignant Self-Regard

Narcissistic personality disorder is a heterogeneous and complex pathology which manifests itself very differently in individuals. The aim of the present study was to analyze differences and similarities in morality and sensitivity to feelings of guilt among grandiose narcissism (GN), vulnerable narcissism (VN), and malignant self-regard (MSR). We expected that MSR and VN would be most sensitive to deontological and altruistic guilt, and that MSR and VN would have higher levels of moral standards than GN. A nonclinical sample of 752 participants was evaluated. Results showed a significant association among MSR, VN, and GN. According to our hypothesis, GN turned out to be the one with the lowest association values to guilt measures. Our results demonstrated that MSR is strongly associated with all types of guilt, GN is associated with a substantial lack of guilt, and VN is associated with deontological guilt and self-hate, but not altruistic guilt. Results confirm the relevance of considering and understanding guilt when differentiating GN, VN, and MSR.

A Consumer Perspective on Personality Diagnostic Systems: One Size Does Not Fit All

Although providers and patients may largely agree on what is essential to clinically useful assessment and diagnosis, patients have a unique voice and contribute additional information to our conceptualization of clinical utility. The current study evaluated the clinical utility of three diagnostic models (Section II categorial, Section III hybrid, and the original ICD-11 dimensional) from the consumer/user perspective. Participants included 703 undergraduate students and 154 family members or individuals with borderline personality disorder. Participants rated mock diagnostic reports on six indices of clinical utility. Results indicated that undergraduates favored categorical reports over the original ICD-11 dimensional reports on three of six indices but rated categorical and hybrid reports as essentially equivalent. In the patient/family sample, participants favored the hybrid or categorical model on all indices. Our findings speak to the value of a clear diagnostic label and suggest that future iterations of the DSM adopting a hybrid or dimensional model should have a continued focus on simplicity in communication.

Dimensional models of personality disorders: Challenges and opportunities

Categorical models of personality disorders have been beneficial throughout psychiatric history, providing a mechanism for organizing and communicating research and treatment. However, the view that individuals with personality disorders are qualitatively distinct from the general population is no longer tenable. This perspective has amassed steady criticism, ranging from inconsequential to irreconcilable. In response, stronger evidence has been accumulated in support of a dimensional perspective that unifies normal and pathological personality on underlying trait continua. Contemporary nosology has largely shifted toward this dimensional perspective, yet broader adoption within public lexicon and routine clinical practice appears slow. This review focuses on challenges and the related opportunities of moving toward dimensional models in personality disorder research and practice. First, we highlight the need for ongoing development of a broader array of measurement methods, ideally facilitating multimethod assessments that reduce biases associated with any single methodology. These efforts should also include measurement across both poles of each trait, intensive longitudinal studies, and more deeply considering social desirability. Second, wider communication and training in dimensional approaches is needed for individuals working in mental health. This will require clear demonstrations of incremental treatment efficacy and structured public health rebates. Third, we should embrace cultural and geographic diversity, and investigate how unifying humanity may reduce the stigma and shame currently generated by arbitrarily labeling an individual's personality as normal or abnormal. This review aims to organize ongoing research efforts toward broader and routine usage of dimensional perspectives within research and clinical spaces.

Cross-walking personality disorder types to ICD-11 trait domains: An overview of current findings

The ICD-11 has adopted a classification of Personality Disorders (PD) that abolishes the established categorical PD types in favor of global severity classification with specification of individual trait domains. To facilitate and guide this profound transition, an overview of current research on empirical associations between established PD types and ICD-11 trait domains seems warranted. We identified a total of 9 relevant studies from 2018 to 2022, which were based on both clinical and community samples from U.S., China, Brazil, Denmark, Spain, Korea, and Canada. The patterns of associations with ICD-11 trait domains were systematically synthesized and portrayed for each PD type. Findings overall showed expected and conceptually meaningful associations between categorical PD types and ICD-11 trait domains, with only few deviations. Based on these findings, we propose a cross-walk for translating categorical PD types into ICD-11 trait domains. More research is needed in order to further guide continuity and translation between ICD-10 and ICD-11 PD classification in mental healthcare, including facet-level ICD-11 trait information. Moreover, the nine reviewed studies only relied on self-reported ICD-11 trait domains, which should be expanded with clinician-rated trait domains in future research. Finally, future research should also take ICD-11's essential PD severity classification into account.

Clinical Implications of ICD-11 for Diagnosing and Treating Personality Disorders

PURPOSE OF REVIEW

The International Classification of Diseases 11th revision (ICD-11) introduced a new approach to personality disorders and related traits. This paper reviews recent literature on the assessment of ICD-11 personality disorders and implications for clinical diagnosis, decision-making, and treatment.

RECENT FINDINGS

We reviewed findings on two measures developed for the ICD-11 model of personality dysfunction and six inventories for the ICD-11 trait specifiers. The psychometric qualities of these tools are promising, and they allow for both rapid screening and fine-grained assessment. Implications for clinical diagnosis and treatment of personality disorders are reviewed including utility for forensic practice. Based on evidence and our experience, we provide some recommendations for severity- and trait-informed interventions. Initial evidence supports the available instruments for assessing ICD-11 personality disorders. More research is needed including development of clinician-rating forms and diagnostic interviews as well as treatment protocols and trials based on the new ICD-11 classification.

Efficacy and tolerability of pharmacotherapy for obsessive-compulsive personality disorder: a systematic review of randomized controlled trials

INTRODUCTION

Although obsessive-compulsive personality disorder (OCPD) is one of the most prevalent personality disorders, it is one of the least studied. There is debate as to whether pharmacotherapy is efficacious for OCPD. We aimed to systematically evaluate the efficacy and tolerability of pharmacotherapy for OCPD.

AREAS COVERED

This systematic review found two randomized controlled trials investigating pharmacotherapy of OCPD. In a study of major depression (n = 308) with comorbid OCPD (n = 71), citalopram was more effective for OCPD than sertraline with fewer drop-outs from treatment. In a small study of OCPD (n = 24), fluvoxamine was more effective than placebo, and there was a low drop-out rate. Risk of bias and quality assessment of these studies was not possible, and findings have very low levels of certainty.

EXPERT OPINION

Two studies provide preliminary evidence in support of citalopram and fluvoxamine for OCPD. Further randomized controlled trials are required before firm conclusions can be drawn regarding efficacy of pharmacotherapy for OCPD.

Malignant Self-Regard: Overview and Future Directions

Malignant self-regard (MSR) is a self-representation that encompasses the shared features of depressive personality disorder, masochistic/self-defeating personality disorder, depressive-masochistic personality, and vulnerable narcissism. In this review we begin by describing the construct's historical precursors, which begin in early psychoanalytic/dynamic theory, and then trace its development across iterations of the Diagnostic and Statistical Manual of Mental Disorders. Special attention is paid to differentiating MSR from vulnerable narcissism. We then consider MSR's place within transdiagnostic, transtheoretical, and dimensional models of personality pathology. We focus heavily on MSR's impact on various personality systems (e.g., thought and affect systems) and also on overall personality functioning. The empirical research on MSR in relation to these systems is thoroughly reviewed and largely supports its psychometric properties and clinical significance. We suggest that MSR may map onto the distress subfactor in the hierarchical taxonomy of psychopathology (HiTOP) and that MSR seems to occupy the shared internalizing space across the neurotic and borderline level of personality organization in Kernberg's model of personality disorders. We also identify four major directions for future research: the possible benefits of self-defeating tendencies that involve pathological narcissism and self-esteem; MSR's relationship to overall health and well-being; depressive states and MSR severity; and how MSR fits within the Alternative Model for Personality Disorders and the personality disorder framework of the International Classification of Diseases.

The clinical utility of the ICD-11 classification of personality disorders and related traits: A preliminary scoping review

OBJECTIVES

A diagnostic system that fails to deliver clinically useful information will not be utilized and consequently will be unable to provide valuable data for health policy and clinical decision making. Therefore, it is imperative to obtain an accurate depiction of the clinical utility of the eleventh revision of the International Classification of Diseases (ICD-11) Personality Disorder (PD) model. The current mixed-methods systematic review aimed to determine the clinical utility of the ICD-11 PD classification system.

METHOD

An electronic screening of six databases was conducted and resulting studies were subjected to specific exclusion criteria, which elicited eight studies of interest. Study characteristics were tabulated and methodological quality was appraised.

RESULTS

Four studies offered strong support for the model's clinical utility, three offered some support accompanied by notable limitations and one study could only offer criticisms.

CONCLUSION

Future investigation of the ICD-11 PD classification system's (a) communicative value between clinicians and their patients, and between clinicians and their patient's families; (b) ease of use; and (c) feasibility in terms of practical application is required to achieve a complete understanding of its clinical utility and ultimately bring clarity to the current ambiguous findings.

Semi-structured interview for personality functioning DSM-5 (STiP-5.1): Psychometric evaluation of the Czech version

The DSM-5 Alternative Model for Personality Disorders introduced a dimensional perspective on personality disorders and their assessment by measuring personality functioning in the following domains: Identity, Self-Direction, Empathy, and Intimacy. This study provides a replication of the psychometric evaluation of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) within a mixed clinical sample and a community sample. The sample consisted of 188 adults: 86 participants from the general population and 102 people from a mixed clinical sample. All participants completed the STiP-5.1 and Level of Personality Functioning Scale-Brief Form (LPFS-BF 2.0). Results showed good internal consistency (McDonald's ω = 0.89-0.94) and promising convergent validity (correlations with LPFS-BF 2.0 above 0.6) of the STiP-5.1. Its scores differentiated participants within the community sample from those in the mixed clinical sample with large effect sizes (r_rb = 0.77-0.88). Moreover, the impairment in personality functioning was more pronounced in people with personality disorders than in other psychiatric disorders (medium effect size, r_rb = 0.46-0.57), supporting the notion of a continuum of personality functioning impairment. The STiP-5.1 therefore offers an instrument with satisfactory psychometric properties for the assessment of personality functioning both for research and clinical practice.

ICD-11 Personality Disorders: A Psychodynamic Perspective on Personality Functioning

The new ICD-11 introduces a fully dimensional classification of personality disorders representing a fundamental change in personality disorder diagnosis with major implications for clinical practice and research. The new system centers on the evaluation of the severity of impairment in the areas of self and interpersonal functioning. This focus on personality functioning converges with long-standing psychoanalytic/psychodynamic conceptualizations of personality pathology. In a detailed conceptual analysis and review of existing empirical data, points of convergence and notable differences between major exponents of the psychodynamic tradition-object relations theory as developed by Kernberg et al. and the Operationalized Psychodynamic Diagnosis-and the ICD-11 system are critically discussed. Personality functioning can be considered to be the current "common ground" for the assessment of personality disorders and constitutes a considerable step forward in making personality disorder diagnosis both clinically meaningful and suitable for research purposes.

Why is an evidence-based classification of personality disorder so elusive?

Despite recent revisions, the classification of personality disorder remains a matter of dispute, and there is little evidence of consistent progress toward an evidence-based system. This essay examines four issues impeding taxonomic progress and explores how they might be addressed. First, the phenomenological and aetiological complexity of personality disorder poses a formidable challenge to traditional taxonomic methods. Second, current classifications incorporate assumptions such as a stringent version of medical model and an essentialist philosophy that are inconsistent with empirical evidence. Third, despite the claims of trait psychology, a viable alternative to categorical diagnosis is not available. Contemporary trait models have not gained widespread clinical acceptance and substantial conceptual and methodological limitations compromise their clinical value. Finally, the processes used to revise official classifications are biased toward conservative revisions and difficult to shield from non-scientific influences. It is suggested that rather making further attempts to develop a general monolithic classification that meets all needs, consideration be given to developing a more flexible and multifaceted framework that combines diagnosis and assessment. © 2020 John Wiley & Sons, Ltd.

Integration of the ICD-11 and DSM-5 Dimensional Systems for Personality Disorders Into a Unified Taxonomy With Non-overlapping Traits

The promise of replacing the diagnostic categories of personality disorder with a better-grounded system has been only partially met. We still need to understand whether our main dimensional taxonomies, those of the International Classification of Diseases, 11th Revision (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are the same or different, and elucidate whether a unified structure is possible. We also need truly independent pathological domains, as they have shown unacceptable overlap so far. To inquire into these points, the Personality Inventory for DSM-5 (PID-5) and the Personality Inventory for ICD-11 (PiCD) were administered to 677 outpatients. Disattenuated correlation coefficients between 0.84 and 0.93 revealed that both systems share four analogous traits: negative affectivity, detachment, dissociality/antagonism, and disinhibition. These traits proved scalar equivalence too, such that scores in the two questionnaires are roughly interchangeable. These four domains plus psychoticism formed a theoretically consistent and well-fitted five-factor structure, but they overlapped considerably, thereby reducing discriminant validity. Only after the extraction of a general personality disorder factor (g-PD) through bifactor analysis, we could attain a comprehensive model bearing mutually independent traits.

Obsessive-Compulsive (Anankastic) Personality Disorder in the ICD-11: A Scoping Review

Introduction: With the shift from a categorical to a dimensional model, ICD-11 has made substantial changes to the diagnosis of personality disorders (PDs), including obsessive-compulsive (anankastic) personality disorder (OCPD). The ICD-11 PD model proposes a single diagnosis of PD with specifications regarding severity and domains. However, a systematic overview of ICD-11 anankastia is lacking. In this review we address the reformulation of the OCPD diagnosis in the ICD-11, and draw comparisons with the DSM-5, with a particular focus on diagnostic validity and clinical utility. We hypothesized that the ICD-11 PD model provides a diagnostically valid and clinically useful approach to OCPD, with specific emphasis on the anankastia domain as the primary trait qualifier. Methods: Literature published from 2010 to 2020 was systematically searched using the PubMed/MEDLINE, PsychInfo, Cochrane, and Web of Sciences search engines, in order to find all articles that addressed ICD-11 anankastia. Relevant articles were collated, and themes of these articles subsequently extracted. Results: Out of the 264 publications identified, 19 articles were included in this review. Four themes were identified, namely (a) overlap of DSM-5 OCPD with the ICD-11 PD model, (b) the factorial structure of the ICD-11 PD model with respect to the anankastia domain, (c) the clinical utility of the ICD-11 PD model, and (d) comparison of the ICD-11 PD model of anankastia with the DSM-5 alternative model for OCPD. Conclusions: The ICD-11 anankastia domain overlaps with DSM-5 OCPD traits, and the factor analyses of the ICD-11 PD model further support the diagnostic validity of this domain. There is some support for the clinical utility of the ICD-11 PD model of anankastia but further studies are needed, including of its relationship to obsessive-compulsive and related disorders.

Examining the Interpersonal Profiles and Nomological Network Associated with Narcissistic Grandiosity and Narcissistic Vulnerability

Theory and research have consistently shown that pathological narcissism can best be described by 2 phenotypic expressions, narcissistic grandiosity and narcissistic vulnerability. The current study sought to examine the specific types of interpersonal problems reported by those high in narcissistic grandiosity and high in narcissistic vulnerability as well as examine the nomological network associated with these 2 manifestations of narcissism. In a sample of university students who completed self-report measures of pathological narcissism, interpersonal problems, depression, self-esteem, malignant self-regard, self-defeating personality disorder symptoms, and anger, we found that narcissistic grandiosity (n = 108) was associated with one distinct interpersonal profile, for example, being overly intrusive in relationships with others, while narcissistic vulnerability (n = 88) was associated with a wider range of interpersonal problems on the interpersonal circumplex. Using cluster analysis, we found 3 interpersonal subtypes associated with narcissistic vulnerability, an intrusive subtype, a cold subtype, and a socially avoidant subtype. Further examination of group differences showed that the 3 interpersonal subtypes associated with narcissistic vulnerability could also be distinguished based on their experience and expression of anger. This suggests the importance of assessing profiles of interpersonal functioning and anger in narcissistic vulnerability. The clinical implications of our results are discussed.

Klinische Stadienmodelle in der Früherkennung und -behandlung der Borderline-Persönlichkeitsstörung

Hintergrund

Die Borderline-Persönlichkeitsstörung (BPS) ist eine schwere psychische Störung, die typischerweise erstmals in der Adoleszenz auftritt und mit einem hohen Leidensdruck, schweren psychosozialen Defiziten bei Betroffenen sowie hohen Kosten für die Gesellschaft verbunden ist. Die Früherkennung und -intervention der BPS haben zum Ziel, die negativen Auswirkungen der Störung frühzeitig zu reduzieren oder zu verhindern und dadurch die Lebensläufe der betroffenen Jugendlichen positiv zu beeinflussen. Klinische Stadienmodelle bieten Orientierung bei der Auswahl einer geeigneten Intervention entsprechend dem aktuellen Krankheitsstadium.

Ziel der Arbeit

In der vorliegenden Arbeit wird das Rationale klinischer Stadienmodelle erläutert. Bestehende Stadienmodelle der BPS werden vorgestellt und diskutiert.

Material und Methoden

Kritische Reflexion vorhandener Forschungsliteratur.

Ergebnisse

Bisher wurden 2 Stadienmodelle der BPS vorgeschlagen, das erste Modell aus dem Jahr 2016 gemeinsam für die BPS und die affektiven Störungen, das neuere, darauf aufbauende Modell aus dem Jahr 2019 mit höherer Spezifität und Fokus auf die Entwicklung von Persönlichkeitsstörungen und sich daraus ergebenden Schwierigkeiten.

Diskussion

Die vorgestellten klinischen Stadienmodelle der BPS bieten Orientierung bei der Beschreibung des typischen Krankheitsverlaufs sowie der Auswahl einer geeigneten Intervention, insbesondere in frühen Krankheitsstadien, da sie dabei helfen können, frühe, unspezifische Anzeichen einer sich entwickelnden Störung wahrzunehmen und eine geeignete Behandlung einzuleiten. Mit weiteren Erkenntnissen über die Entwicklung der BPS und effektive Interventionen können Stadienmodelle in der Zukunft weiter verbessert werden.

Scripting the DSM-5 Alternative Model for Personality Disorders assessment procedure: A clinically feasible multi-informant multi-method approach

Published case studies on the DSM-5 (section III) Alternative Model for Personality Disorders (AMPD) generally utilized unstandardized assessment procedures or mono-method approaches. We present a case from clinical practice to illustrate a standardized, clinically feasible procedure for assessing personality pathology according to the full AMPD model, using a multi-method approach. We aim to present a procedure that can guide and inspire clinicians that are going to work with dimensional models as presented in DSM-5 and ICD-11. Specifically, we show how questionnaire and interview data from multiple sources (i.e. patient and family) can be combined. The clinical case also illustrates how Criterion A (i.e. functioning) and B (i.e. traits) are interrelated, suggesting that the joint assessment of both Criterion A and B is necessary for a comprehensive and clinically relevant case formulation. It also highlights how multi-method information can enhance diagnostic formulations. Finally, we show how the AMPD model can serve treatment planning and provide suggestions for how patient feedback might be delivered. © 2020 John Wiley & Sons, Ltd.

An Overview of the DSM-5 Alternative Model of Personality Disorders

Authoritative classification systems for psychopathology such as the DSM and ICD are shifting toward more dimensional approaches in the field of personality disorders (PDs). In this paper, we provide a brief overview of the dimensionally oriented DSM-5 alternative model of PDs (AMPD). Since its publication in 2013, the AMPD has inspired a substantial number of studies, underlining its generative influence on the field. Generally speaking, this literature illustrates both the reliability and validity of the constructs delineated in the AMPD. The literature also illustrates empirical challenges to the conceptual clarity of the AMPD, such as evidence of substantial correlations between indices of personality functioning (criterion A in the AMPD) and maladaptive personality traits (criterion B in the AMPD). Key future directions pertain to linking the AMPD literature with applied efforts to improve the lives of persons who suffer from PDs, and surmounting challenges germane to the evolution of the DSM itself.

Personality Disorders in the ICD-11: Opportunities and Challenges for Advancing the Diagnosis of Personality Pathology

PURPOSE OF REVIEW

The International Classification of Diseases-11th edition (ICD-11) is poised to make a dramatic change in the diagnosis of personality disorders by introducing a fully dimensionalized framework. In this paper, the history of this process is reviewed, along with international efforts taken to address some underlying concerns with this transition. Recent studies of this framework are also reviewed.

RECENT FINDINGS

Studies have concluded that the ICD-11 proposal is supported; however, there are a number of methodological limitations to these studies, including the utilization of measures that are not directly derived from the ICD-11 description of levels of personality severity and trait domains. There is a clear need for additional studies with measures that directly reflect the ICD-11 description of personality disorders. While there are some potentially positive effects of moving toward the dimensional model, there are a number of concerns remaining about the clinical utility of moving in this way.

How can transference-focused psychotherapy (TFP) help general psychiatrists working with patients with borderline personality disorder?

Transference-focused psychotherapy concepts and techniques have much to offer experienced psychiatrists and psychiatrists in training in their work with patients with borderline personality disorder and, as a consequence, help address the stigmatisation of this group of patients and improve their clinical care.

DECLARATION OF INTEREST

W.B.-J. is chair of the Specialty Advisory Committee of the Faculty of Medical Psychotherapy, RCPsych, with governance for the content and delivery of the curriculum for psychotherapy training of trainee psychiatrists in the UK.

Personality-driven depression: The case for malignant self-regard (and depressive personalities)

Many patients with chronic depression are not well-treated. In part, this is due to the underlying personality dynamics that maintain the depressive experience are ignored. In this paper, I describe the concept of malignant self-regard, a derivative of the depressive personality. I describe briefly its origins in the clinical and empirical literature and focus upon the presentation of a case of a patient who displays a prototypic manifestation of malignant self-regard. I offer some ideas for how to manage such patients, with a focus on countertransference experiences that can be used to inform treatment.

Application of the ICD-11 classification of personality disorders

BACKGROUND

The ICD-11 classification of Personality Disorders focuses on core personality dysfunction, while allowing the practitioner to classify three levels of severity (Mild Personality Disorder, Moderate Personality Disorder, and Severe Personality Disorder) and the option of specifying one or more prominent trait domain qualifiers (Negative Affectivity, Detachment, Disinhibition, Dissociality, and Anankastia). Additionally, the practitioner is also allowed to specify a Borderline Pattern qualifier. This article presents how the ICD-11 Personality Disorder classification may be applied in clinical practice using five brief cases.

CASE PRESENTATION

(1) a 29-year-old woman with Severe Personality Disorder, Borderline Pattern, and prominent traits of Negative Affectivity, Disinhibition, and Dissociality; (2) a 36-year-old man with Mild Personality Disorder, and prominent traits of Negative Affectivity and Detachment; (3) a 26-year-old man with Severe Personality Disorder, and prominent traits of Dissociality, Disinhibition, and Detachment; (4) a 19-year-old woman with Personality Difficulty, and prominent traits of Negative Affectivity and Anankastia; (5) a 53-year-old man with Moderate Personality Disorder, and prominent traits of Anankastia and Dissociality.

CONCLUSIONS

The ICD-11 Personality Disorder classification was applicable to five clinical cases, which were classified according to Personaity Disorder severity and trait domain qualifiers. We propose that the classification of severity may help inform clinical prognosis and intensity of treatment, whereas the coding of trait qualifiers may help inform the focus and style of treatment. Empirical investigation of such important aspects of clinical utility are warranted.