The time has come for dimensional personality disorder diagnosis

Development of a Short and ICD-11 Compatible Measure for DSM-5 Maladaptive Personality Traits Using Ant Colony Optimization Algorithms

While Diagnostic and Statistical Manual of Mental Disorders–Fifth edition (DSM-5) Section III and ICD-11 (International Classification of Diseases 11th–Revision) both allow for dimensional assessment of personality pathology, the models differ in the definition of maladaptive traits. In this study, we pursued the goal of developing a short and reliable assessment for maladaptive traits, which is compatible with both models, using the item pool of the Personality Inventory for DSM-5 (PID-5). To this aim, we applied ant colony optimization algorithms in English- and German-speaking samples comprising a total N of 2,927. This procedure yielded a 34-item measure with a hierarchical latent structure including six maladaptive trait domains and 17 trait facets, the “Personality Inventory for DSM-5, Brief Form Plus” (PID5BF+). While latent structure, reliability, and criterion validity were ascertained in the original and in two separate validation samples (n = 849, n = 493) and the measure was able to discriminate personality disorders from other diagnoses in a clinical subsample, results suggest further modifications for capturing ICD-11 Anankastia.

Assessing ICD-11 personality trait domain qualifiers with the MMPI-2-RF

OBJECTIVE

The current study examined the utility of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) in assessing ICD-11 personality psychopathology trait domain qualifiers.

METHOD

Using a community sample (N = 217) weighted for externalizing dysfunction, this study evaluated the convergence between ICD-11 trait domains as measured by the personality inventory for DSM-5 (PID-5) with hypothesized MMPI-2-RF scales. Particular emphasis was placed on evaluating the convergence between the ICD-11 trait domain qualifiers and the MMPI-2-RF personality psychopathology-5 (PSY-5) scales, as the latter are meant to represent broadband domains of personality pathology.

RESULTS

Correlation and regression analyses demonstrated expected associations between ICD-11 domains and conceptually expected MMPI-2-RF scales, with some minor exceptions. Notably, the Anankastia domain showed associations with scales assessing negative affect, but did not show expected negative associations with scales related to disinhibition.

CONCLUSIONS

The findings generally supported the use of the MMPI-2-RF in assessing individual expressions of personality dysfunction from the ICD-11 trait domain qualifier perspective.

Toward an Integrated Model of Pathological Personality Traits: Common Hierarchical Structure of the PID-5 and the DAPP-BQ

A dimensional classification seems to be the next move in the personality disorders field. However, it is not clear whether there is one dimensional model or many, or whether the currently available dimensional instruments measure the same traits. To help clarify these issues, the authors administered the Personality Inventory for DSM-5 (PID-5) and the Dimensional Assessment of Personality Pathology (DAPP-BQ) to 414 psychiatric outpatients. Factor analyses showed that a common hierarchical structure underlies both instruments, even if each one measures slightly different aspects of it. Disattenuated correlations indicated that, at the lower order level, two thirds of the PID-5 and DAPP-BQ facets measure essentially the same traits, although the pairings were not exactly as predicted. Among higher order domains, only PID Negative Affectivity and Detachment converged unambiguously with DAPP Emotional Dysregulation and Inhibition. Overall, the PID-5 and the DAPP-BQ reflect, with small divergences, one and the same structure of pathological personality traits.

Brief Report: Expert Preferences for Categorical, Dimensional, and Mixed/Hybrid Approaches to Personality Disorder Diagnosis

The authors asked 361 personality disorder experts to rank order their preferences for a categorical, dimensional, or mixed/hybrid approach to personality disorder diagnosis in manuals such as the DSM and ICD. Respondents reported a general preference for the mixed/hybrid approach over a purely dimensional approach, and a clear preference against a categorical model. Although there were some statistically significant differences in the rates across training background, age, and gender, this overall pattern of preferences held across these factors. Preferences were notably similar to those reported by Bernstein et al. (2007) prior to the beginnings of deliberations on DSM-5 that ultimately led to a hybrid model. Results are informative for discussions regarding how to classify personality disorders in diagnostic manuals.

Clinical Associations Between Severity of Impulsivity, Psychiatric Morbidity, Dysfunctional Defences and Personality Disorder: A Comparative Study With Axis-I Disorders

OBJECTIVE

Psychiatric morbidity, impulsive behaviour and use of dysfunctional and maladaptive defences are core features of personality disorder (PD). This study aims to evaluate the significance of the strength of the association between these three core dimensions and PD.

METHOD

Using a cross-sectional design, a sample of co-morbid Axis-I & -II disorders, and a sample of Axis-I disorders with no co-morbid PD were recruited at three general psychiatric mental health resource centres and then compared.PD as dependent variable was analysed both as a categorical and as a dimensional entity using the Structured Clinical Interview for DSM-IV. The Symptoms Checklist 90-R general severity index (GSI), the Barratt Impulsivity Scale (BIS) and the Defense Style Questionnaire (DSQ) were used to measure severity of psychiatric morbidity, impulsivity and defensive style, respectively.

RESULTS

BIS was a highly significant predictor of categorical PD (β = .13, SE = .03, p < .001), but not GSI and DSQ. BIS and GSI significantly predicted PD as a dimensional construct (β = 0.32, SE = .08, t = 4.05, p < 0.001; and β = 5.04, SE = 1.54, t = 3.28, p = 0.002, respectively). The diagnostic efficiency statistics found that BIS had greater sensitivity (.82) and specificity (.79), and overall predictive power (.87) of correctly identifying true positive and true negative PD diagnosis compared to the other two measures.

CONCLUSIONS

BIS may be used in routine clinical practice as a screening measure to identify the presence of PD in complex presentations.

Applying Item Response Theory to the OPD Structure Questionnaire: Identification of a Unidimensional Core Construct and Feasibility of Computer Adaptive Testing

Recent developments in the dimensional assessment of personality functioning have made the implementation of latent measurement models increasingly attractive. In this study, we applied item response theory (IRT) to a well-established personality functioning instrument (the OPD Structure Questionnaire) to identify a unidimensional latent trait and to evaluate the feasibility of computer adaptive testing (CAT). We hypothesized that the use of IRT could reduce the test burden - compared to a fixed short form - while maintaining high precision over a wide range of the latent trait. The OPD-SQ was collected from 1235 patients in a psychosomatic clinic. IRT assumptions were fulfilled. A 9-factor model yielded sufficient fit and unidimensionality in exploratory factor analysis with bifactor rotation. Items were iteratively reduced, and a graded-response IRT model was fitted to the data. Simulations showed that a CAT with approximately 7 items was able to capture an OPD-SQ global severity score with an accuracy similar to that of a fixed 12-item short form. The final item bank and CAT yielded satisfactory content validity. Strong correlations with depression and anxiety replicated previous results on the OPD-SQ. We concluded that IRT applications could be useful to reduce the test burden of personality functioning instruments.

Evaluating Stable and Situational Expressions of Passive-Aggressive Personality Disorder: A Multimethod Experience Sampling Case Study

Passive-aggressive (PA) personality traits have received increasing attention in the research literature and are known to interfere with treatment engagement and recovery. Theoretical disagreements about PA, combined with its omission from the DSM-5, have left open many questions regarding its dynamic structure and temporal stability. Our goal in the present case study was to use a multimethod, experience sampling assessment framework for a single research subject enrolled in long-term residential treatment who exhibited significant PA traits to provide a complex portrait of daily interpersonal behaviors and experiences across a range of contexts. We review data gathered over a year of residential treatment to identify changes in self and interpersonal functioning and to deepen our understanding of the dynamic motivational structure of PA over time. Our findings expand understanding of both PA dynamics and provide support for integrating multimethod assessment into routine clinical practice.

Personalized models of personality disorders: using a temporal network method to understand symptomatology and daily functioning in a clinical sample

BACKGROUND

An ongoing challenge in understanding and treating personality disorders (PDs) is a significant heterogeneity in disorder expression, stemming from variability in underlying dynamic processes. These processes are commonly discussed in clinical settings, but are rarely empirically studied due to their personalized, temporal nature. The goal of the current study was to combine intensive longitudinal data collection with person-specific temporal network models to produce individualized symptom-level structures of personality pathology. These structures were then linked to traditional PD diagnoses and stress (to index daily functioning).

METHODS

Using about 100 daily assessments of internalizing and externalizing domains underlying PDs (i.e. negative affect, detachment, impulsivity, hostility), a temporal network mapping approach (i.e. group iterative multiple model estimation) was used to create person-specific networks of the temporal relations among domains for 91 individuals (62.6% female) with a PD. Network characteristics were then associated with traditional PD symptomatology (controlling for mean domain levels) and with daily variation in clinically-relevant phenomena (i.e. stress).

RESULTS

Features of the person-specific networks predicted paranoid, borderline, narcissistic, and obsessive-PD symptom counts above average levels of the domains, in ways that align with clinical conceptualizations. They also predicted between-person variation in stress across days.

CONCLUSIONS

Relations among behavioral domains thought to underlie heterogeneity in PDs were indeed associated with traditional diagnostic constructs and with daily functioning (i.e. stress) in person-specific networks. Findings highlight the importance of leveraging data and models that capture person-specific, dynamic processes, and suggest that person-specific networks may have implications for precision medicine.

Borderline Personality Disorder: To diagnose or not to diagnose? That is the question

There is considerable controversy around psychiatric diagnosis generally and personality disorders specifically. Since its conception, borderline personality disorder has been controversial because of the stigma associated with the diagnosis and the therapeutic nihilism held by practitioners who encounter people with this high prevalence problem in acute settings. This paper reviews the history of the diagnosis of BPD and summarizes some of the controversy surrounding the categorical nature of diagnosis. Both the DSM 5 and ICD-11 will be discussed; however, for the purposes of this paper, the DSM 5 will take the primary focus due to greater cultural significance. Recent developments in the treatment of borderline personality disorder suggest that it is a highly treatable condition and that full clinical recovery is possible. This paper formulates an argument that despite problems with psychiatric diagnosis that are unlikely to be resolved soon, a diagnosis should be made with an accompanying formulation to enable people to receive timely and effective treatment to enable personal and clinical recovery.

Moving forward: closing the gap between research and practice for young people with BPD

The study of personality disorders has come a long way, and this is characterized by the optimism prevalent within the community dedicated to its study. Outside this community - delays in intervention, ostracism, and ignorance remain common place. With a significant burden of disease and high costs at individual, social, and societal levels there is an urgent need to translate research into practice. Proposed solutions include educating the workforce to improve attitudes and developing more sustainable treatment alternatives. This paper brings forward a user perspective on the need to close the gap between what we know from research and what is done in policy and clinical practice.

A Psychometric Evaluation of a Reduced Version of the PID-5 in Clinical and Non-Clinical Adolescents

Abstract. A dimensional perspective on personality pathology in which trait assessment plays an important role has been proposed in the DSM-5, as represented in the PID-5 measure. In an attempt to increase the feasibility of the personality disorder (PD) assessment process, Maples and colleagues constructed a reduced, 100-item version of the PID-5. This study aimed to replicate and extend previous findings on the psychometric properties of this 100-item PID-5 relying on a non-clinical ( N = 100) and a clinical ( N = 101) sample of mid-adolescents, as well as a non-clinical ( N = 218) and a clinical ( N = 212) sample of late-adolescents. Results indicate that the psychometric properties of the 100-item PID-5 are adequate and similar to the original PID-5 in all samples. Our study provides evidence for extended applicability of the 100-item PID-5 for both clinical and non-clinical adolescents.

Relational Aggression and Narcissistic Traits: How Youth Personality Pathology Informs Aggressive Behavior

Low agreeableness features centrally in personality profiles of Cluster B personality disorder (PD) diagnoses, and it has been associated with relational aggression (RAgg; intentionally damaging others' social relationships). Researchers have hypothesized that RAgg may be a potential developmental precursor for Cluster B PDs. However, a dimensional approach to personality dysfunction is preferable to the categorical system found in the current diagnostic manual. To build a bridge between two disjointed literatures (categorical PDs and RAgg), the aim of this project is to detail how RAgg in youth is situated in the trait space represented by disagreeableness in a dimensional model of personality pathology. Caregivers of 911 youth (ages 6-18) reported on youth's RAgg and disagreeableness. We found that RAgg was most strongly related to three facets: Narcissistic traits, Hyperexpressive traits, and Dominance-Egocentrism traits. Overall, these findings provide support for RAgg as an early manifestation of personality pathology, particularly for narcissistic traits.

Unresolved Attachment Mediates the Relationship Between Childhood Trauma and Impaired Personality Functioning in Adolescence

The present study investigates the mediating effect of attachment trauma on the relationship between childhood maltreatment and personality functioning in 199 adolescents (12-18 years) using a novel approach of an in-depth analysis of attachment-related traumatic contents during an attachment interview (AAP). Our findings demonstrate that adolescents with a high amount of traumatic attachment-related material show a lower resilience when facing traumatic childhood experiences, resulting in a greater severity of personality dysfunction. In particular, the associations between emotional abuse and neglect and the domains of identity, empathy, self-direction, and intimacy were mediated by the severity of attachment trauma. These results advance our understanding of the different nuances of attachment-related traumatic material and how they might shape personality structure in an adolescent age group.

The Relationship between Maternal Personality Disorder and Early Birth Outcomes: A Systematic Review and Meta-Analysis

(1) Background: Women with personality disorder are at risk of social and emotional problems which impact deleteriously on everyday functioning. Moreover, a personality disorder diagnosis has been established to have an adverse impact upon pregnancy outcomes and child health. Understanding this impact is critical to improving both maternal and child outcomes. This systematic review and meta-analysis will evaluate the contemporary evidence regarding these relationships. (2) Methods: Prospero and Cochrane were searched for any systematic reviews already completed on this topic. Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES, PsycINFO via the EBSCO host, and the Web of Science Core Collection were searched to include research articles published between 1980 and 2019. A total of 158 records were identified; 105 records were screened by reviewing the abstract; 99 records were excluded; 6 full text articles were assessed for eligibility; 5 records were included in the review. (3) Results: All the included studies reported on preterm birth. The meta-analysis indicates significant risk of preterm birth in women with personality disorder (overall odds ratio (OR) 2.62; CI 2.24–3.06; p < 0.01). Three studies reported on low birth weight, with the meta-analysis indicating a raised risk of low birth weight of the babies born to women with personality disorder (overall OR 2.00 CI 1.12–3.57 (p = 0.02)). Three studies reported on appearance, pulse, grimace, activity, and respiration (APGAR) score, with the meta-analysis of OR’s indicating a risk of low APGAR score in women with personality disorder (overall OR 2.31; CI 1.17–4.55; p = 0.02). (4) Conclusions: The infants of women with personality disorder are at elevated risk of preterm birth, low birth weight and low APGAR score.

Elucidating the relationship between borderline personality disorder and intimate partner violence

This study examined the established association between borderline personality disorder (BPD) and intimate partner violence (IPV). More specifically, it compared the DSM-5 traditional categorical personality disorder (PD) model with the DSM-5 Alternative Model of PD (AMPD) operationalizations of BPD in their relative associations with IPV. The effects of gender, as well as the associations between BPD and different forms of IPV were also considered. Additionally, we investigated the specific BPD-relevant AMPD personality traits that influence the BPD-IPV association. The study sample were 250 community-dwelling men and women recruited through an established crowdsourcing platform. Results revealed that both the 'traditional' and AMPD operationalizations of BPD were approximately equally associated with IPV perpetration, although the traditional BPD operationalization demonstrated some minor advantages in this regard. The AMPD trait facets of hostility (negative affectivity), suspiciousness (negative affectivity) and risk taking (disinhibition) were most strongly associated with IPV perpetration for the total sample, and additional negative affectivity trait facets were also associated with IPV for men only. Implications for these findings are discussed. © 2020 John Wiley & Sons, Ltd.

Arabic Version of the Personality Inventory for the DSM-5 (PID-5) in a Community Sample of United Arab Emirates Nationals

Background:

Section III of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) proposes a model for conceptualizing personality disorders in which they are characterized by impairments in personality functioning and maladaptive personality traits. The Personality Inventory for DSM-5 (PID-5) is a self-report measure that assesses the presence and severity of these maladaptive personality traits.

Objective:

The current study examined the reliability and validity of the Arabic version of the Personality Inventory for DSM-5 (PID-5) to measure maladaptive personality traits in the Emirati population of the United Arab Emirates.

Methods:

The Arabic version of the PID-5 was administered to a community sample of 1,090 United Arab Emirates nationals (89.5% female and 10.5% male, mean age = 22.44 years old). The descriptive measures, internal consistency, test-retest reliability, convergent validity with NEO – Five Factor Inventory, as well as PID-5’s factor structure, were all addressed.

Results:

The PID-5facets and domains mean scores were higher in the Emirati sample compared to the original US sample. Internal consistency of the PID-5 scales was acceptable to high and test-retest coefficients ranged from 0.84 (facets) to 0.87 (domains). As expected, the five domains of the Arabic version of the PID-5 correlated significantly with all Five-Factor Model domains of personality. Additionally, the Arabic version of the PID-5 confirmed a five-factor structure that resembles the PID-5 domains.

Conclusion:

The findings of this study provided initial support for the use of the Arabic version of the PID-5 to assess maladaptive personality traits in the Emirati population of the United Arab Emirates.

Maternal personality traits, antenatal depressive symptoms and the postpartum mother-infant relationship: a prospective observational study

PURPOSE

Maternal depression has been associated with bonding difficulties and lower maternal sensitivity in observed mother-infant interactions. However, little research has examined the impact of disordered personality traits in mothers on these outcomes. We investigated the association between disordered personality traits in mothers measured during pregnancy and postnatal (a) self-reported bonding with infant; (b) observational mother-infant interactions.

METHODS

Five hundred fifty-six women were recruited during early pregnancy and subsequently followed up at mid-pregnancy (approximately 28 weeks' gestation) and when infants were aged approximately 3 months (n = 459). During early pregnancy, data were collected on disordered personality traits (using the Standardised Assessment of Personality Abbreviated Scale) and depressive symptoms (using the Edinburgh Postnatal Depression Scale). At 3 months postpartum, self-reported perceived bonding (using the Postpartum Bonding Questionnaire) were collected. A sub-sample of women additionally provided observational mother-infant interaction data (n = 206) (coded using the Child-Adult Relationship Experimental Index).

RESULTS

Higher disordered personality traits was not associated with maternal perceptions of bonding impairment, but was associated with reduced maternal sensitivity during observational mother-infant interactions [adjusted for age, education, having older children, substance misuse prior to pregnancy, infant sex and gestational age: coefficient = - 0.28, 95% CI = - 0.56 to - 0.00, p < 0.05]. After adjusting for depressive symptoms, the association was attenuated [coefficient = - 0.19, 95% CI = - 0.48 to 0.11, p = 0.217].

CONCLUSIONS

Mothers with disordered personality traits did not perceive themselves as having bonding impairments with their infants but were less sensitive during observed interactions, though depressive symptoms attenuated this relationship. Both depression and disordered personality traits need to be addressed to optimize mother-infant interactions.

Die Relevanz eines kohärenten forensischen Beurteilungs- und Behandlungsprozesses

Das Ziel einer therapeutischen Maßnahme bei Straftätern ist gemäß Gesetzesgrundlage die Reduktion der Gefahr erneuter „erheblicher rechtswidriger Taten“ (§§ 63 und 64 StGB, Deutschland) bzw. mit dem „Zustand des Täters in Zusammenhang stehender Taten“ (Art. 59 und 63 bzw. Art. 60 für Abhängigkeiten StGB, Schweiz). Um dieses Ziel zu erreichen, ist ein kohärenter Prozess notwendig, der die Fallkonzeption (inkl. Diagnostik und Hypothese zum Deliktmechanismus), Behandlungsplanung und -Behandlungsevaluation umfasst. Im Rahmen des ersten Schrittes muss herausgearbeitet werden, ob überhaupt eine Behandlungsbedürftigkeit des Straftäters vorliegt. Diese ergibt sich aus dem Risiko für erneute schwerwiegende Taten sowie aus den Behandlungsmöglichkeiten der damit zusammenhängenden forensisch relevanten Auffälligkeiten des Straftäters. Aus einer breiten wissenschaftlichen Befundlage geht hervor, dass solch eine Behandlungsbedürftigkeit mitnichten nur im allgemeinpsychiatrischen Sinne psychisch Kranke und schon gar nicht ausschließlich schuldunfähige Straftäter aufweisen. Vielmehr können weitere deliktrelevante persönlichkeitsnahe Risikofaktoren, die einer wirksamen Behandlung grundsätzlich zugänglich sind, kausal im Zusammenhang mit Delinquenz und Rückfälligkeit stehen.

In der aktuellen Rechtsprechung in Deutschland und der Schweiz spiegelt sich diese Erkenntnis nicht wider. Im Gegenteil: Voraussetzung für die Anordnung einer therapeutischen Maßnahme ist das Vorliegen einer „schweren psychischen Störung“ gemäß ICD/DSM und in Deutschland zusätzlich die verminderte Schuldfähigkeit oder Schuldunfähigkeit.

Diese Eingrenzung blendet die Behandlungsbedürftigkeit eines bedeutsamen Teils der Straftäterpopulation aus und untergräbt damit, was die Forensik zu leisten im Stande wäre: differenziert deliktorientiert zu therapieren. Verfahren wie das Forensische Operationalisierte Therapie-Risiko-Evaluationssystem (FOTRES 3) können gegenüber allgemeinpsychiatrischen Kriterienkatalogen einen inkrementellen Beitrag zur dafür notwendigen forensischen Diagnostik liefern. Erste empirische Befunde dazu werden im Artikel vorgestellt.

Understanding the association between borderline personality disorder and alcohol-related problems: An examination of drinking motives, impulsivity, and affective instability

Borderline personality disorder (BPD) and alcohol use disorder frequently co-occur, yet we know relatively little about risk processes underlying this association. Previous research with nonclinical samples has highlighted how drinking motives may link personality characteristics with heavy alcohol use and problems. The present study substantively extends previous research by examining if drinkers with BPD had higher levels of alcohol use problems compared with drinkers without BPD and similar levels of alcohol use involvement. Multiple domains of impulsivity and affective instability were examined as dimensional markers of risk that may increase alcohol problems for individuals with BPD. Furthermore, multiple domains of drinking motives were examined as potential mediators accounting for the association between BPD and alcohol-related problems. Participants were 81 current drinkers (n = 39 with a current diagnosis of BPD). Results indicated that those with BPD endorsed more alcohol problems compared with non-BPD drinkers, F(1, 77) = 22.26, p < .001. These findings remained after accounting for multiple domains of impulsivity and affective instability. The indirect effects of coping and conformity-related drinking motives partially accounted for the relation between BPD and alcohol problems. Research examining differential response to alcohol for individuals with BPD is needed to directly test if acute alcohol consumption is particularly effective at reducing negative affect for adults with BPD. Offering alternative methods of managing uncomfortable or painful states and/or fitting in with others socially may represent particularly important targets for intervention efforts that decrease these reasons for drinking. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review

Despite the importance of psychotherapists' subjective experiencse working with patients with mental issues, little is known about the relationship between therapists' emotional reactions and patients' personality problems. The present study is a systematic review of quantitative research on the association between patients' personality pathology and psychotherapists' emotional, cognitive and behavioural reactions in individual psychotherapy setting. A systematic database search (from January 1980 to August 2019) supplemented by manual searches of references and citations identified seven relevant studies. Significant and consistent relationships were found between therapist reactions and specific personality traits or disorders. In general, odd and eccentric patients tend to evoke feelings of distance and disconnection; emotionally dysregulated patients tend to evoke anxiety and incompetence, and anxious and withdrawn patients tend to evoke sympathy and concern. However, the relatively small sample of studies and methodological inconsistencies across studies limit firm conclusions and suggest the need for more systematic research. Findings from this review indicate that patients who share the same personality disorder or symptoms tend to evoke specific and similar cognitive, emotional and behavioural reactions in their therapists. This suggests that therapists overall reactions toward patients may be source of valuable diagnostic information.

Measurement and mental health disparities: Psychopathology classification and identity assessment

Mental health disparities research compares groups of individuals with regard to their mental health status, and numerous studies have reported significant and burdensome disparities across populations. This literature is based almost entirely on traditional mental disorder constructs (e.g. major depressive disorder and borderline personality disorder) as defined by official nosologies, but these disorders are associated with numerous problems of reliability and validity. Advances in psychopathology classification research have converged on an alternative conceptualization of mental disorder structure, which comprises a set of transdiagnostic dimensions that cut across traditional diagnostic boundaries and overcome the limitations of traditional diagnoses. The application of these dimensions, particularly those of the hierarchical taxonomy of psychopathology model, holds great promise for mental health disparities research. Measurement considerations associated with these transdiagnostic dimensions, as well as participants' intersecting identities, are discussed. Incorporation of these measurement advances with statistical advances allows for the generation and testing of unique hypotheses related to minority stressors that may give rise to observed disparities. © 2019 John Wiley & Sons, Ltd.

Integrating Structure and Function in Conceptualizing and Assessing Pathological Traits

The Diagnostic and Statistical Manual of Mental Disorders' (5th Edition) Alternative Model of Personality Disorders includes a dimensional trait model to describe individual differences in the manifestation of personality pathology. Empirically derived quantitative trait models of psychopathology address many of the structural problems of classical diagnostic schemes (e.g., nonbinary distributions, excessive comorbidity, and diagnostic heterogeneity). However, they are largely based on the structure of individual differences in the manifestation of psychopathology. In contrast, clinical theories of personality disorder, which are the foundation of intervention efforts, are based on the function of maladaptive behavior. This distinction is akin to the difference between morphology and physiology in the broader biological sciences. A structure-function divide in the focus of empirical and clinical work contributes to a lack of integration and difficulties with translation. Here we discuss this tension and argue for the need to bridge this divide and adopt research efforts that integrate structure and function of personality traits. Specifically, we suggest that between-person structure identifies the principal domains of functioning, but to understand dysfunction personality must be conceptualized and studied as an ensemble of contextualized dynamic processes.

Dispositional Disinhibition and Alcohol Use Disorders: Personality, Risk Appraisal and Problematic Alcohol Consumption

Background: The relationship between psychopathic personality and problematic alcohol consumption could be important for understanding risk and potential interventions. This existing work on psychopathy and alcohol abuse is typically conducted in criminal and hospitalized populations and little attention has been paid to investigating the general populations' psychopathic personality and problematic consumption of alcohol. The psychopathy-focused Triarchic Psychopathy Measure (TriPM) and the more general Reinforcement Sensitivity Theory of personality (RST) focus on individual differences related to low self-control and sensation seeking, and could relate to problematic alcohol consumption in non-forensic samples. The current study brings together RST and psychopathic personality traits to predict alcohol use disorders. We hypothesize that impulsivity and anxiety predict problematic alcohol consumption and related risk appraisal. Methods: We analyzed data from a sample of 349 general population participants who had completed measures of the TriPM, RST, alcohol use disorders (AUDIT), and their perceived negative outcomes of high risk behavior with the Cognitive Appraisal of Risky Events (CARE) measure. Results: We find some evidence that TriPM's disinhibition and RST's anxious personality traits relate to AUDIT scores. We find limited evidence that personality traits predict the negative appraisal of risky events, but alcohol use was related to increased perceptions of the negative outcomes of alcohol consumption. Conclusions: Overall this study shows that individual differences do relate to problematic alcohol consumption but not the appraisal of risks related to alcohol consumption. This has implications for the structuring of intervention for those at-risk of problematic consumption of alcohol.

From categorical diagnosis to dimensional assessment of borderline personality

Recent research suggested that personality disorders could be diagnosed as a continuous phenomenon. Therefore, in our study we examined whether the dimensional model of pathological personality traits could be applied to the assessment of borderline personality1. For this purpose, we modified an existing measure of borderline personality, the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD), and scrutinized its psychometric properties (i.e., reliability, factorial structure, criterion validity). To assess criterion validity we calculated correlations with pathological personality traits. Our sample comprised 354 participants (67.8% women). Confirmatory factor analysis revealed that the modified MSI-BPD measures borderline per-sonality as a global construct, giving one-factor structure. The reliability of the measurement was excellent (α = .90). Moreover, we found positive associations between borderline personality and all five pathological person-ality traits, which supports the validity of the continuous assessment of borderline personality. Our findings sug-gest that the DSM-5 dimensional model may be applied in the assessment of borderline personality.

Alcohol Use Disorder and Antisocial and Borderline Personality Disorders

Alcohol use disorder (AUD) frequently co-occurs with other psychiatric disorders, including personality disorders, which are pervasive, persistent, and impairing. Personality disorders are associated with myriad serious outcomes, have a high degree of co-occurrence with substance use disorders, including AUD, and incur significant health care costs. This literature review focuses on co-occurring AUD and personality disorders characterized by impulsivity and affective dysregulation, specifically antisocial personality disorders and borderline personality disorders. Prevalence rates, potential explanations and causal models of co-occurrence, prognoses, and the status of existing treatment research are summarized. Several important future research considerations are relevant to these complex, co-occurring conditions. Research assessing mechanisms responsible for co-occurring AUD and antisocial personality disorder or borderline personality disorder will further delineate the underlying developmental processes and improve understanding of onset and courses. In addition, increased focus on the efficacy and effectiveness of treatments targeting underlying traits or common factors in these disorders will inform future prevention and treatment efforts, as interventions targeting these co-occurring conditions have relatively little empirical support.

A Hierarchical Integration of Normal and Abnormal Personality Dimensions: Structure and Predictive Validity in a Heterogeneous Sample of Psychiatric Outpatients

Hierarchical, quantitative models of psychopathology focus primarily on higher-order constructs, whereas less is known about the structure and content comprising lower-order dimensions of psychopathology. Here, we address this gap in the literature by using targeted factor analysis to integrate the 25 maladaptive facet-level traits of the Personality Inventory for Diagnostic and Statistical Manual of Mental Disorder-Fifth edition and the 10 aspect-level traits of the normal personality hierarchy within a sample of 198 psychiatric outpatients. A 10-factor solution replicated previous work, with each of the 10 aspects primarily characterizing only one factor. In addition, the 10 factors differentially predicted a range of diagnoses, including alcohol use disorder, major depression, panic disorder, social anxiety, and borderline and avoidant personality disorders. Our results suggest that research on the development, causes, and structure of lower-order traits within the normal personality hierarchy may serve as an important guide to research on the causes and structure of maladaptive personality.

Romantic attachment style and borderline personality pathology: A meta-analysis

Borderline Personality Disorder (BPD) implies profound impairment in interpersonal relationships, particularly romantic relationships (Daley, Burge, & Hammen, 2000). Insecure attachment bears striking resemblance to BPD traits in both empirical and theoretical work (Levy, Johnson, Clouthier, Scala, & Temes, 2015) and may be particularly suited for understanding the BPD-related deficits in romantic functioning. Despite several qualitative reviews concluding that secure attachment is disrupted in those with BPD traits, no consensus has emerged regarding the form of this disruption (Levy et al., 2015), with most reviews focusing on whether BPD is best captured as high levels of attachment anxiety or attachment avoidance. The purpose of the current review is to provide a quantitative synthesis of the strength and direction of the associations between attachment insecurity and BPD traits. Searches on PsycINFO and Pubmed resulted in 27 effect sizes that measured BPD and adult romantic attachment on the two primary dimensions of anxiety and avoidance (Fraley, Waller, & Brennan, 2000). Results demonstrated that attachment anxiety correlates most strongly with BPD traits (r = 0.48); however, attachment avoidance also evinced a significant effect (r = 0.30). Findings from regression analyses indicate that attachment anxiety and avoidance interact, suggesting a particularly strong relationship between attachment disorganization and BPD traits.

Measuring Personality Problems in Patients With Substance Use Disorders: A Cross-Sample Validation

Objective: Co-occurrence of substance use disorder and personality disorder (PD) is associated with greater functional impairment and mutual deterioration of the prognosis. More information is needed about the extent of personality problems in substance use disorder patients and when these problems can be assessed in a reliable way. The aim of this study was to compare the levels and scale reliability of (mal)adaptive personality functioning in four different samples and to discuss the possible clinical implications. Methods: Personality problems were assessed using the self-report Severity Indices of Personality Problems (SIPP) questionnaire in four samples: (a) 136 patients in the detoxification phase, (b) 187 patients with substance use disorder in long-term inpatient treatment, (c) 1,399 patients with PD in day and outpatient treatment, and (d) a community population of 935 respondents. Scale reliability of the SIPP facets was computed for each sample and levels of personality problems were compared among samples. Results: The scale reliability was acceptable for most of the SIPP facets in both substance use disorder samples. The substance use disorder samples had scores on SIPP that reflected greater personality dysfunction compared with the general community population and at a level similar to the PD population. Conclusions: SIPP appears to be a promising instrument for assessing personality pathology in substance use disorder treatment. The finding of high levels of maladaptive personality functioning in substance use disorder populations challenges the clinical management of the substance use disorder patient group and supports the development of integrated treatment approaches.

Untangling Intelligence, Psychopathy, Antisocial Personality Disorder, and Conduct Problems: A Meta–Analytic Review

Substantial research has investigated the association between intelligence and psychopathic traits. The findings to date have been inconsistent and have not always considered the multidimensional nature of psychopathic traits. Moreover, there has been a tendency to confuse psychopathy with other closely related, clinically significant disorders. The current study represents a meta–analysis conducted to evaluate the direction and magnitude of the association of intelligence with global psychopathy, as well as its factors and facets, and related disorders (i.e. antisocial personality disorder, conduct disorder, and oppositional defiant disorder). Our analyses revealed a small, significant, negative relationship between intelligence and total psychopathy ( r = −.07, p = .001). Analysis of factors and facets found differential associations, including both significant positive (e.g. interpersonal facet) and negative (e.g. affective facet) associations, further affirming that psychopathy is a multidimensional construct. Additionally, intelligence was negatively associated with antisocial personality disorder ( r = −.13, p = .001) and conduct disorder ( r = −.13, p = .001) but positively with oppositional defiant disorder ( r = .06, p = .001). There was significant heterogeneity across studies for most effects, but the results of moderator analyses were inconsistent. Finally, bias analyses did not find significant evidence for publication bias or outsized effects of outliers. © 2019 European Association of Personality Psychology

A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders

PURPOSE OF REVIEW

Both the Alternative DSM-5 Model for Personality Disorders (AMPD) and the chapter on personality disorders (PD) in the recent version of ICD-11 embody a shift from a categorical to a dimensional paradigm for the classification of PD. We describe these new models, summarize available measures, and provide a comprehensive review of research on the AMPD.

RECENT FINDINGS

A total of 237 publications on severity (criterion A) and maladaptive traits (criterion B) of the AMPD indicate (a) acceptable interrater reliability, (b) largely consistent latent structures, (c) substantial convergence with a range of theoretically and clinically relevant external measures, and (d) some evidence for incremental validity when controlling for categorical PD diagnoses. However, measures of criterion A and B are highly correlated, which poses conceptual challenges. The AMPD has stimulated extensive research with promising findings. We highlight open questions and provide recommendations for future research.

Personality testing and the Americans With Disabilities Act: Cause for concern as normal and abnormal personality models are integrated

Applied psychologists commonly use personality tests in employee selection systems because of their advantages regarding incremental criterion-related validity and less adverse impact relative to cognitive ability tests. Although personality tests have seen limited legal challenges in the past, we posit that the use of personality tests might see increased challenges under the Americans with Disabilities Act (ADA) and the ADA Amendments Act (ADAAA) due to emerging evidence that normative personality and personality disorders belong to common continua. This article aims to begin a discussion and offer initial insight regarding the possible implications of this research for personality testing under the ADA. We review past case law, scholarship in employment law, Equal Employment Opportunity Commission (EEOC) guidance regarding “medical examinations,” and recent literature from various psychology disciplines—including clinical, neuropsychology, and applied personality psychology—regarding the relationship between normative personality and personality disorders. More importantly, we review suggestions proposing the five-factor model (FFM) be used to diagnose personality disorders (PDs) and recent changes in theDiagnostic and Statistical Manual of Mental Disorders(DSM). Our review suggests that as scientific understanding of personality progresses, practitioners will need to exercise evermore caution when choosing personality measures for use in selection systems. We conclude with six recommendations for applied psychologists when developing or choosing personality measures.

Mental health professionals' perceived clinical utility of the ICD-10 vs. ICD-11 classification of personality disorders

AIM

The ICD-11 classification of personality disorders (PDs) has adopted a dimensional approach which includes three levels of severity (mild, moderate and severe) with the option of specifying five trait qualifiers (negative affectivity, detachment, dissociality, disinhibition and anankastia) and one borderline pattern qualifier. This study examined mental health professionals' perceived clinical utility of the ICD-11 PD framework compared with the ICD-10 categorical PD framework.

METHOD

A sample of 163 mental health professionals (primarily psychologists, nurses and medical doctors) completed a survey in which they were asked to apply the ICD-10 and ICD-11 PD classifications on one of their patients followed by judgement of their clinical utility.

RESULTS

The ICD-11 PD framework was generally rated as being slightly more useful than the ICD-10 framework even when accounting for educational background and years of experience. This advantage particularly involved the utility for treatment planning, communicating with patients, comprehensiveness and ease of use. The two frameworks showed no significant differences with respect to utility for communicating with other professionals and describing global personality.

CONCLUSION

This study provided initial evidence that mental health professionals perceive the ICD-11 PD classification as slightly more useful for clinical practice than the ICD-10 classification. © 2019 John Wiley & Sons, Ltd.

Evaluation of DSM-5 and ICD-11 personality traits using the Personality Inventory for DSM-5 (PID-5) in a Brazilian sample of psychiatric inpatients

OBJECTIVE

The objective of this study was to test if the Personality Inventory for DSM-5 (PID-5) is an adequate instrument to evaluate psychiatric inpatients' pathological personality traits.

METHODS

Inpatients (n = 130; mean age: 38.5 years; 62.3% female; 63.9% single) answered the PID-5 after clinical improvement of their psychiatric symptoms. The mean scores of the DSM-5 personality domains, facets and profiles, and ICD-11 domain traits were compared with the mean scores of a Brazilian normative sample (n = 656). We investigated the diagnostic performance of the scales to identify individuals with and without psychopathology.

RESULTS

The final sample included mainly diagnoses of mood disorders. Except for Antagonism and Disinhibition, all DSM-5 personality domains and most facets as well as almost all DSM-5 personality disorder profiles (except Narcissist) and ICD-11 trait domains (except Detachment and Dissociality) of the inpatients presented high differences compared with the normative sample. In general, the PID-5 scales presented a high negative predictive value and a low positive predictive value to identify individuals with severe psychopathology.

DISCUSSION

This study found high scores of pathological personality traits in a sample of Brazilian psychiatric inpatients. The PID-5 may be a promising instrument to measure pathological personality traits among psychiatric inpatients. Methodological and sample size limitations may have influenced the results. © 2018 John Wiley & Sons, Ltd.

The Development of the ICD-11 Classification of Personality Disorders: An Amalgam of Science, Pragmatism, and Politics

The nomenclature of personality disorders in the 11th revision of the International Classification of Diseases and Related Health Problems represents the most radical change in the classification history of personality disorders. A dimensional structure now replaces categorical description. It was argued by the Working Group that only a dimensional system was consistent with the empirical evidence and, in the spirit of clinical utility, the new system is based on two steps. The first step is to assign one of five levels of severity, and the second step is to assign up to five prominent domain traits. There was resistance to this structure from those who feel that categorical diagnosis, particularly of borderline personality disorder, should be retained. After lengthy discussion, described in detail here, there is now an option for a borderline pattern descriptor to be selected as a diagnostic option after severity has been determined.

Diagnosis and classification of personality disorders: novel approaches

PURPOSE OF REVIEW

To provide an update of the recent studies, which have evaluated the radical changes in personality disorder classification in DSM-5 and ICD-11.

RECENT FINDINGS

Although the DSM-5 Committee rejected the personality disorders Work Group proposal for personality disorder classification, the model was published in DSM-5 Section III. This Alternative Model of Personality Disorders (AMPD) has been widely adopted by the research community resulting in multiple studies evaluating its reliability and clinical utility. The ICD-11 Personality Classification has recently been accepted by the WHO and is also receiving increasing study. Both models emphasize personality disorder severity, which most studies report is consistently linked to impairment and outcome. Both models propose five descriptive domains, which appear to capture most of the current personality disorder diagnoses, and can also be linked to disease extremes of normal personality such as the Five Factor Model.

SUMMARY

The changes in DSM-5 AMPD and ICD-11 represent a significant paradigm shift in the diagnosis of personality disorders. Early research suggests that the changes may be beneficial for clinicians and researchers. The models more closely align with the large body of literature supporting dimensional models of normal personality. The severity dimensions are consistent with the large body of evidence that personality disorder severity is a strong determinant of impairment and outcome. It remains to be seen if clinicians will use the classification to plan and predict treatment for a wide range of mental disorders.

Borderline personality disorder diagnosis in a new key

BACKGROUND

Conceptualizations of personality disorders (PD) are increasingly moving towards dimensional approaches. The definition and assessment of borderline personality disorder (BPD) in regard to changes in nosology are of great importance to theory and practice as well as consumers. We studied empirical connections between the traditional DSM-5 diagnostic criteria for BPD and Criteria A and B of the Alternative Model for Personality Disorders (AMPD).

METHOD

Raters of varied professional backgrounds possessing substantial knowledge of PDs (N = 20) characterized BPD criteria with the four domains of the Level of Personality Functioning Scale (LPFS) and 25 pathological personality trait facets. Mean AMPD values of each BPD criterion were used to support a nosological cross-walk of the individual BPD criteria and study various combinations of BPD criteria in their AMPD translation. The grand mean AMPD profile generated from the experts was compared to published BPD prototypes that used AMPD trait ratings and the DSM-5-III hybrid categorical-dimensional algorithm for BPD. Divergent comparisons with DSM-5-III algorithms for other PDs and other published PD prototypes were also examined.

RESULTS

Inter-rater reliability analyses showed generally robust agreement. The AMPD profile for BPD criteria rated by individual BPD criteria was not isomorphic with whole-person ratings of BPD, although they were highly correlated. Various AMPD profiles for BPD were generated from theoretically relevant but differing configurations of BPD criteria. These AMPD profiles were highly correlated and showed meaningful divergence from non-BPD DSM-5-III algorithms and other PD prototypes.

CONCLUSIONS

Results show that traditional DSM BPD diagnosis reflects a common core of PD severity, largely composed of LPFS and the pathological traits of anxiousness, depressively, emotional lability, and impulsivity. Results confirm the traditional DSM criterion-based BPD diagnosis can be reliably cross-walked with the full AMPD scheme, and both approaches share substantial construct overlap. This relative equivalence suggests the vast clinical and research literatures associated with BPD may be brought forward with DSM-5-III diagnosis of BPD.

Changes in Personality Functioning After Inpatient Psychodynamic Therapy: A Dimensional Approach to Personality Disorders

OBJECTIVE

Patients with mental disorders do not only show specific symptoms but also impairments in personality functioning, especially those with personality disorders. Recent developments in DSM-5 and ICD-11 suggest a dimensional approach to personality disorders. Few studies, however, have examined changes in personality functioning.

METHODS

In a large sample of 2,596 patients treated by inpatient psychodynamic therapy, changes in personality functioning were studied. Two patient groups were examined, one with (N = 1152, BPO) and one without a presumptive diagnosis of a borderline personality organization (N = 1444, NBPO). For the assessment of personality functioning, the Borderline-Personality Inventory (BPI) was used. The BPI taps personality functioning as defined by Kernberg's structural criteria of personality organization. Symptom distress and interpersonal problems were examined with the Symptom Checklist SCL-90-R and the Inventory of Interpersonal Problems (IIP). Patients were assessed at admission and discharge.

RESULTS

In the BPO sample significant and substantial pre-post effect sizes in overall personality functioning, identity integration, and defense mechanisms/object relations were found (d = 0.68, 0.60, 0.78). In addition, large improvements in symptoms (SCL-90-R) were achieved (d = 0.97). For interpersonal problems effect sizes were medium (0.56). At discharge 36% of the BPO patients scored below the BPI-Cut-Off score for a BPO (remission). Pre-post effect sizes in the NPBO sample (N = 1444) were significant but small for changes in personality functioning (d = 0.31-0.46) and substantial for improvements in symptoms (d = 0.77).

CONCLUSIONS

Both personality functioning and symptom distress can be substantially improved by inpatient psychodynamic therapy. Future research is recommended to study both improvements in symptoms and personality functioning.

Conceptual Models of Borderline Personality Disorder, Part 1: Overview of Prevailing and Emergent Models

Borderline personality disorder (BPD) is a debilitating condition with significant personal and societal costs. Throughout the history of the conceptualization of borderline pathology as a form of psychopathology, there has been debate concerning the essential attributes of this disorder, which has significant implications for its assessment and treatment. The first of this 2-part review evaluates the major approaches to conceptualizing BPD, from the traditional DSM diagnosis through the more recent Alternative Model in DSM-5, Section III, and the research domain criteria initiative of the National Institute of Mental Health that was articulated largely in response to limitations of the DSM.

Moving beyond categories and dimensions in personality pathology assessment and diagnosis

It has been suggested that a dimensional model of personality pathology should be adopted for the development and refinement of personality disorder classification. In this article, the advantages and challenges of moving toward a dimensional model are briefly reviewed. However, it is suggested that although categories and dimensions are valuable frameworks for personality pathology diagnosis, an expansion beyond categories and dimensions is needed to improve the shortcoming seen in current diagnostic systems. Ideas and examples are offered for how this might occur.Declaration of interestNone.

An Object-Relations Based Model for the Assessment of Borderline Psychopathology

The authors describe an object-relations based model drawing on the work of Kernberg and colleagues for the assessment of borderline pathology. The substrate of internal object relations that constitutes borderline pathology internally or structurally is described and a model for assessing such pathology in a clinical interview format focusing on identity, defensive style, and quality of object relations is presented. Two clinical examples illustrate how these data can be compiled for purposes of psychodynamic case formulation and decisions about psychodynamic treatment.

Unique and shared features of narcissistic and antisocial personality disorders: Implications for assessing and modeling externalizing traits

OBJECTIVES

We aimed to determine which, if any, features distinguish antisocial and narcissistic personality disorders (ASPD and NPD), two overlapping externalizing disorders.

METHODS

A large sample of outpatients (N = 2,149) completed interview measures assessing personality pathology, other psychopathology, and impairment. The structure of antisocial and narcissistic traits was examined using both exploratory bifactor and traditional exploratory factor analytic approaches, and we examined relations for our emergent factors.

RESULTS

Factor analytic results indicated that most narcissistic and antisocial traits were strongly overlapping, although some features emerged as relatively distinct (e.g., arrogance defining NPD). Factors modeling our specific bifactor dimensions showed very weak psychopathology and impairment relations.

CONCLUSIONS

The structure of ASPD and NPD traits does not align neatly with Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Section II conceptualizations, Regardless of the factor analytic approach used. Our findings also indicate that specific dimensions defining these PDs show modest predictive power after accounting for a general externalizing dimension.