Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology

Assessment of personality-related levels of functioning: a pilot study of clinical assessment of the DSM-5 level of personality functioning based on a semi-structured interview

BACKGROUND

The personality disorder categories in the Diagnostic and Statistical Manual of Mental Disorders IV have been extensively criticized, and there is a growing consensus that personality pathology should be represented dimensionally rather than categorically. The aim of this pilot study was to test the Clinical Assessment of the Level of Personality Functioning Scale, a semi-structured clinical interview, designed to assess the Level of Personality Functioning Scale of the DSM-5 (Section III) by applying strategies similar to what characterizes assessments in clinical practice.

METHODS

The inter-rater reliability of the assessment of the four domains and the total impairment in the Level of Personality Functioning Scale were measured in a patient sample that varied in terms of severity and type of pathology. Ratings were done independently by the interviewer and two experts who watched a videotaped Clinical Assessment of the Level of Personality Functioning Scale interview.

RESULTS

Inter-rater reliability coefficients varied between domains and were not sufficient for clinical practice, but may support the use of the interview to assess the dimensions of personality functioning for research purposes.

CONCLUSIONS

While designed to measure the Level of Personality Functioning Scale with a high degree of similarity to clinical practice, the Clinical Assessment of the Level of Personality Functioning Scale had weak reliabilities and a rating based on a single interview should not be considered a stand-alone assessment of areas of functioning for a given patient.

Optimizing Prediction of Psychosocial and Clinical Outcomes With a Transdiagnostic Model of Personality Disorder

Transdiagnostic models hold promise for transforming research and treatment practices for personality disorders (PDs), but widespread acceptance and implementation of such approaches will require persuasive evidence of construct validity and clinical utility. Toward that end, the authors examined the criterion-related validity of a transdiagnostic PD model in relation to psychosocial and clinical outcomes in a high-risk community sample of 700 young adults. Participants and their mothers completed semistructured interviews to assess young adults' PD symptomatology, psychosocial functioning, suicidality, and mental health treatment use. Bifactor modeling revealed an overarching dimension of PD severity-capturing symptoms across all PD categories-that strongly predicted all functional and clinical outcomes in multivariate analyses. Effect sizes for lower-order, specific PD processes were comparatively modest for functional outcomes; however, they provided clinically significant information about suicide risk and treatment use. The authors discuss implications of a transdiagnostic perspective for research on PD etiology, classification, and treatment.

Impairments in Object Relations and Chronicity of Suicidal Behavior in Individuals With Borderline Personality Disorder

While studies have demonstrated connections between impairments in object relations and self-destructive behaviors in individuals with borderline personality disorder (BPD), few have investigated whether these impairments relate to actual suicidal behaviors. The current study utilized the Social Cognition and Object Relations Scale-Global Method to investigate object relational functioning and suicidal behaviors in 131 residential treatment patients. Cognitive but not affective aspects of internalized representations predicted past suicidal behavior in BPD subjects; no relationships were found between quality of object representations and suicide in other-PD subjects. Implications of these findings for research, theory, and treatment of suicidal individuals are discussed.

The Personality Inventory for DSM-5 Brief Form: Evidence for Reliability and Construct Validity in a Sample of Community-Dwelling Italian Adolescents

To assess the reliability and construct validity of the Personality Inventory for DSM-5 Brief Form (PID-5-BF) among adolescents, 877 Italian high school students were administered the PID-5-BF. Participants were administered also the Measure of Disordered Personality Functioning (MDPF) as a criterion measure. In the full sample, Cronbach's alpha values for the PID-5-BF scales ranged from .59 (Detachment) to .77 (Psychoticism); in addition, all PID-5-BF scales showed mean interitem correlation values in the .22 to .40 range. Cronbach's alpha values for the PID-5-BF total score was .83 (mean interitem r = .16). Although 2-month test-retest reliability could be assessed only in a small ( n = 42) subsample of participants, all PID-5-BF scale scores showed adequate temporal stability, as indexed by intraclass r values ranging from .78 (Negative Affectivity) to .97 (Detachment), all ps <.001. Exploratory structural equation modeling analyses provided at least moderate support for the a priori model of PID-5-BF items. Multiple regression analyses showed that PID-5-BF scales predicted a nonnegligible amount of variance in MDPF Non-Cooperativeness, adjusted R² = .17, p < .001, and Non-Coping scales, adjusted R² = .32, p < .001. Similarly, the PID-5-BF total score was a significant predictor of both MDPF Non-Coping, and Non-Cooperativeness scales.

The DSM-5 Levels of Personality Functioning and Severity of Iranian Patients With Antisocial and Borderline Personality Disorders

BACKGROUND

Fundamental problems with Personality Disorders (PD) diagnostic system in the previous version of DSM, led to the revision of DSM. Therefore, a multidimensional system has been proposed for diagnosis of personality disorder features in DSM-5. In the dimensional approach of DSM-5, personality disorders diagnosis is based on levels of personality functioning (Criteria A) and personality trait domains (Criteria B).

OBJECTIVES

The purpose of this study was firstly, to examine the DSM-5 levels of personality functioning in antisocial and borderline personality disorders, and second, to explore which levels of personality functioning in patients with antisocial and borderline personality disorders can better predicted severity than others.

PATIENTS AND METHODS

This study had a cross sectional design. The participants consisted of 252 individuals with antisocial (n = 122) and borderline personality disorders (n = 130). They were recruited from Tehran prisoners, and clinical psychology and psychiatry centers of Razi and Taleghani Hospitals, Tehran, Iran. The sample was selected based on judgmental sampling. The SCID-II-PQ, SCID-II and DSM-5 levels of personality functioning were used to diagnose and assess personality disorders. The data were analyzed by correlation and multiple regression analysis. All statistical analyses were performed using the SPSS 16 software.

RESULTS

Firstly, it was found that DSM-5 levels of personality functioning have a strong correlation with antisocial and borderline personality symptoms, specially intimacy and self-directedness (P < 0.001). Secondly, the findings showed that identity, intimacy and self-directedness significantly predicted antisocial personality disorder severity (P < 0.0001). The results showed that intimacy and empathy were good predictors of borderline personality disorder severity, as well (P < 0.0001).

CONCLUSIONS

Overall, our findings showed that levels of personality functioning are a significant predictor of personality disorders severity. The results partially confirm existing studies.

The Role of Metaperception in Personality Disorders: Do People with Personality Problems Know How Others Experience Their Personality?

Do people with personality problems have insight into how others experience them? In a large community sample of adults (N = 641), the authors examined whether people with personality disorder (PD) symptoms were aware of how a close acquaintance (i.e., a romantic partner, family member, or friend) perceived them by measuring participants' metaperceptions and self-perceptions as well as their acquaintance's impression of them on Five-Factor Model traits. Compared to people with fewer PD symptoms, people with more PD symptoms tended to be less accurate and tended to overestimate the negativity of the impressions they made on their acquaintance, especially for the traits of extraversion, agreeableness, and conscientiousness. Interestingly, these individuals did not necessarily assume that their acquaintance perceived them as they perceived themselves; instead, poor insight was likely due to their inability to detect or utilize information other than their self-perceptions. Implications for the conceptualization, measurement, and treatment of PDs are discussed.

Severity of personality disorders and domains of general personality dysfunction related to attachment

This is the first study to link attachment to both severity of total DSM-IV personality disorder (PD) traits and domains of general personality dysfunction, using a sample of 72 inpatients from New York City. We assessed a measure of global PD severity and the core domains of personality functioning using the severity indices of personality problems (SIPP-118). Attachment was measured with the experience in close relationships-revised (ECR-R) and the relationship style questionnaire (RSQ). Global PD severity correlated most strongly with attachment anxiety (r = 0.65). Regression of the SIPP-118 domains on attachment produced models that accounted for a substantial proportion of variance in those scales (R(2) ranging from 28.2 to 54.2%). SIPP-118 relational capacities were the strongest predictor of ECR-R avoidance (β = -0.88) and anxiety (β = -0.58), as well as RSQ secure (β = 0.53) and fearful (β = -0.65). In conclusion, insecure attachment strongly related to the severity of global PD traits and specifically to relational capacities, which are a higher-order domain of general personality dysfunction. These findings provide further evidence that interpersonal problems are at the core of PDs and that attachment could constitute an important mediator of the social dysfunction in persons with personality pathology.

Dimensional assessment of self- and interpersonal functioning in adolescents: implications for DSM-5's general definition of personality disorder

Central to the proposed DSM-5 general definition of personality disorder (PD) are features of self- and interpersonal functioning. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G) is a coding system that assesses eight dimensions of self- and relational experience that can be applied to narrative data or used by clinically experienced observers to quantify observations of patients in ongoing psychotherapy. This study aims to evaluate the relationship of SCORS-G dimensions to personality pathology in adolescents and their incremental validity for predicting multiple domains of adaptive functioning. A total of 294 randomly sampled doctoral-level clinical psychologists and psychiatrists described an adolescent patient in their care based on all available data. Individual SCORS-G variables demonstrated medium-to-large effect size differences for PD versus non-PD identified adolescents (d = .49-1.05). A summary SCORS-Composite rating was significantly related to composite measurements of global adaptive functioning (r = .66), school functioning (r = .47), externalizing behavior (r = -.49), and prior psychiatric history (r = -.31). The SCORS-Composite significantly predicted variance in domains of adaptive functioning above and beyond age and DSM-IV PD diagnosis (ΔR(2)s = .07-.32). As applied to adolescents, the SCORS-G offers a framework for a clinically meaningful and empirically sound dimensional assessment of self- and other representations and interpersonal functioning capacities. Our findings support the inclusion of self- and interpersonal capacities in the DSM-5 general definition of personality disorder as an improvement to existing PD diagnosis for capturing varied domains of adaptive functioning and psychopathology.

Personality disorders in DSM-5: emerging research on the alternative model

The current categorical classification of personality disorders, originally introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), has been found to suffer from numerous shortcomings that hamper its usefulness for research and for clinical application. The Personality and Personality Disorders Work Group for DSM-5 was charged with developing an alternative model that would address many of these concerns. The developed model involved a hybrid dimensional/categorical model that represented personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. The Board of Trustees of the American Psychiatric Association did not accept the Task Force recommendation to implement this novel approach, and thus this alternative model was included in Sect. III of the DSM-5 among concepts requiring additional study. This review provides an overview of the emerging research on this alternative model, addressing each of the primary components of the model.

The Brave New World of Personality Disorder-Trait Specified: Effects of Additional Definitions on Coverage, Prevalence, and Comorbidity

The alternative dimensional model for personality disorder (PD) in DSM-5, Section III (DSM-5-III) includes two main criteria: (A) personality-functioning impairment, and (B) personality-trait pathology; provides specific functioning-and-trait criteria for six PD-type diagnoses; and introduces PD-trait specified (PD-TS), which requires meeting the general PD criteria and not meeting criteria for any specific PD type. We termed this Simple PD-TS and developed two additional definitions: Mixed PD-TS, meeting criteria for one or two PD types and having five or more additional pathological traits; and Complex PD-TS, meeting criteria for three or more PD types. In a mixed sample of 165 outpatients and 215 community adults screened to be at high-risk for PD, we investigated the effect of these additional definitions on prevalence, coverage, comorbidity, and within-diagnosis heterogeneity, and conclude that eliminating the PD-type diagnoses and thus having PD-TS as the only PD diagnosis would be both more parsimonious and more useful clinically.

Transitioning to a dimensional model of personality disorder in DSM 5.1 and beyond

PURPOSE OF REVIEW

To propose options for gradually transitioning to a thoroughgoing dimensional model of personality disorder.

RECENT FINDINGS

The American Psychiatric Association was less willing to implement a dimensional approach to the diagnosis of personality disorder than the leadership of the DSM-5 anticipated. The next opportunity to implement such an approach will be in the ICD-11 and the DSM 5.1.

SUMMARY

Instead of seeking a revolutionary change, attempting a more gradual transition that leads to something significantly better in the long run is likely to be more successful. For the long run, in addition to clinical utility and scientific validity, new diagnostic models must possess user acceptability. Professionals will be more likely to accept a new model if they believe it will allow them to do good work. Competent use of a dimensional model is not only a matter of increased familiarity with personality trait profiles, it requires a different kind of clinical expertise.

Clinical utility of the DSM-5 alternative model of personality disorders: six cases from practice

In Section III, Emerging Measures and Models, DSM-5 presents an Alternative Model of Personality Disorders, which is an empirically based model of personality pathology measured with the Level of Personality Functioning Scale (LPFS) and the Personality Inventory for DSM-5 (PID-5). These novel instruments assess level of personality impairment and pathological traits. Objective. A number of studies have supported the psychometric qualities of the LPFS and the PID-5, but the utility of these instruments in clinical assessment and treatment has not been extensively evaluated. The goal of this study was to evaluate the clinical utility of this alternative model of personality disorders. Method. We administered the LPFS and the PID-5 to psychiatric outpatients diagnosed with personality disorders and other nonpsychotic disorders. The personality profiles of six characteristic patients were inspected (involving a comparison of presenting problems, history, and diagnoses) and used to formulate treatment considerations. We also considered 6 specific personality disorder types that could be derived from the profiles as defined in the DSM-5 Section III criteria. Results. Using the LPFS and PID-5, we were able to characterize the 6 cases in a meaningful and useful manner with regard to understanding and treatment of the individual patient and to match the cases with 6 relevant personality disorder types. Implications for ease of use, communication, and psychotherapy are discussed. Conclusion. Our evaluation generally supported the utility for clinical purposes of the Alternative Model for Personality Disorders in Section III of the DSM-5, although it also identified some areas for refinement. (Journal of Psychiatric Practice 2015;21:3-25).

Functional impairment and the DSM-5 dimensional system for personality disorder

The DSM-5 has included for further research a new dimensional measure of personality disorder, operationalized in the Personality Inventory for DSM-5 (PID5). It is important to investigate if extreme variants of these traits are associated with functional impairment, because functional impairment is a key aspect of the definition of personality disorder. The current study investigated this relationship in 989 college students and 91 clinical patients. The PID5 facets were meaningfully associated with measures of functional impairment in both samples, although the clinical sample evidenced more pathological levels of most traits, as might be expected. Overall, the PID5 appears to be a useful measure for the new DSM-5 system of personality disorder diagnosis.

An integrative examination of general personality dysfunction in a large community sample

Recently, the severity of general personality dysfunction has gained broad interest in personality disorder (PD) research. We analysed data of 511 participants aged 20-41 years from a comprehensive psychiatric survey in the general population of Zurich, Switzerland. We added the trait-scores from all DSM-IV PDs, as assessed by a self-report questionnaire, to provide a measure of general personality dysfunction. Adjusting for the Big Five personality domains as a proxy for stylistic PD elements, this composite PD score exhibited strong associations with neuroticism and schizotypy. General personality dysfunction additionally revealed a moderate detrimental association with psychosocial functioning and a strong effect on coping resources, on heavy drinking and drug use and on most psychopathological syndromes. Of particular interest is the strong association with total psychopathological distress and co-occurrence of multiple disorders, suggesting that increasing PD severity relates to the degree of global impairment independent of specific PD traits. Discussed herein are implications for public mental health policies, classification, conceptualization and treatment of PDs.

Personality disorder classification: stuck in neutral, how to move forward?

An "Alternative DSM-5 Model for Personality Disorders" was published in Sect. III of DSM-5, while the identical categories and criteria from DSM-IV for the personality disorders (PDs) are in Sect. II. Given strong shifts from categorical diagnoses toward dimensional representations in psychiatry, how did the PDs end up "stuck in neutral," with the flawed DSM-IV model perpetuated? This article reviews factors that influenced the development of the new model and data to encourage and facilitate its use by clinicians. These include recognizing 1) a dimensional structure for psychopathology for which personality may be foundational; 2) a consensus on the structure of normal and abnormal personality; 3) the clinical significance of personality; 4) PD-specific severity required to establish disorder; 5) disruption, discontinuity, and perceived clinical utility of the Alternative Model may not be problems; and 6) a way forward involving collaborative research on neurobiological and psychosocial processes, treatment planning, and outcomes.

Personality organization in borderline patients with a history of suicide attempts

Suicide attempts (SA) are common in patients with Borderline Personality Disorder (BPD). Recent studies focus on aspects of personality associated with risk for SA such as deficits in affect regulation including impulse control and aggression. The current study examines associations of dysfunctional personality organization, psychiatric comorbidities as well as non-suicidal self-injury (NSSI) with SA in a sample of 68 BPD outpatients. Patients with a history of SA yielded higher scores in personality domains of aggression, especially self-directed aggression. Further, a history of SA was associated with a worse general level of personality organization and a higher prevalence rate of NSSI and substance abuse disorder. The results demonstrate that SA in BPD patients might be regarded as a manifestation of impaired personality functioning rather than mere state variables and symptoms. Moreover, these findings might have implications for indication, treatment, and prognosis of Borderline Personality Disorder.

Dimensions of personality structure among patients with substance use disorders and co-occurring personality disorders: a comparison with psychiatric outpatients and healthy controls

BACKGROUND

Although dual diagnosis has been a topic of great scientific interest for a long time, few studies have investigated the personality traits that characterize patients suffering from substance use disorders and co-occurring personality disorders through a dimensional approach. The present study aimed to evaluate structural personality profiles among dual-diagnosis inpatients to identify specific personality impairments associated with dual diagnosis.

METHODS

The present study involved 97 participants divided into three groups: 37 dual-diagnosis inpatients, 30 psychiatric outpatients and 30 nonclinical controls. Dimensions of personality functioning were assessed and differences between groups were tested using Kernberg's dimensional model of personality.

RESULTS

Results showed that dual diagnosis was associated with the presence of difficulties in three main dimensions of personality functioning. Dual-diagnosis inpatients reported a poorly integrated identity with difficulties in the capacity to invest, poorly integrated moral values, and high levels of self-direct and other-direct aggression.

CONCLUSIONS

The present study highlighted that a dimensional approach to the study of dual diagnosis may clarify the personality functioning of patients suffering from this pathological condition. The use of the dimensional approach could help to advance research on dual diagnosis, and it could have important implications on clinical treatment programs for dual-diagnosis inpatients.

Clinical validity of a dimensional assessment of self- and interpersonal functioning in adolescent inpatients

The Social Cognition and Object Relations Scale-Global Version (SCORS-G) is a clinical rating system assessing 8 domains of self- and interpersonal relational experience that can be applied to narrative response data (e.g., Thematic Apperception Test [TAT; Murray, 1943], early memories narratives) or oral data (e.g., psychotherapy narratives, relationship anecdotal paradigms). In this study, 72 psychiatrically hospitalized adolescents consented and were rated by their individual and group therapist using the SCORS-G. Clinicians also rated therapy engagement, personality functioning, quality of peer relationships, school functioning, global assessment of functioning (GAF), history of eating-disordered behavior, and history of nonsuicidal self-injury. SCORS-G composite ratings achieved an acceptable level of interrater reliability and were associated with theoretically predicted variables (e.g., engagement in therapy, history of nonsuicidal self-injury). SCORS-G ratings also incrementally improved the prediction of therapy engagement and global functioning beyond what was accounted for by GAF scores. This study further demonstrates the clinical utility of the SCORS-G with adolescents.

Facial emotion recognition in adolescents with personality pathology

It has been argued that a heightened emotional sensitivity interferes with the cognitive processing of facial emotion recognition and may explain the intensified emotional reactions to external emotional stimuli of adults with personality pathology, such as borderline personality disorder (BPD). This study examines if and how deviations in facial emotion recognition also occur in adolescents with personality pathology. Forty-two adolescents with personality pathology, 111 healthy adolescents and 28 psychiatric adolescents without personality pathology completed the Emotion Recognition Task, measuring their accuracy and sensitivity in recognizing positive and negative emotion expressions presented in several, morphed, expression intensities. Adolescents with personality pathology showed an enhanced recognition accuracy of facial emotion expressions compared to healthy adolescents and clients with various Axis-I psychiatric diagnoses. They were also more sensitive to less intensive expressions of emotions than clients with various Axis-I psychiatric diagnoses, but not more than healthy adolescents. As has been shown in research on adults with BPD, adolescents with personality pathology show enhanced facial emotion recognition.

The essential features of personality disorder in DSM-5: the relationship between criteria A and B

The essential features of the general criteria for personality disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are based on impairments in self and interpersonal functioning (criterion A) and pathological personality traits (criterion B). The current study investigated the relationship between criteria A and B in a German psychiatric sample (N = 149). Criterion A was measured by the General Assessment of Personality Disorder (GAPD); criterion B, by the Dimensional Assessment of Personality Pathology (DAPP) and the Revised NEO Personality Inventory (NEO-PI-R). There was a significant relationship between the GAPD, the DAPP, and the NEO-PI-R. The DAPP and NEO-PI-R domains increased the predictive validity of the GAPD (by 7.5% and 14.6%, respectively). The GAPD increased the variance explained by the DAPP by 1.5% and by the NEO-PI-R by 6.5%. The results suggest a substantial relationship between criteria A and B. Criterion B shows incremental validity over criterion A but criterion A only in part over criterion B. Future research should investigate whether it is possible to assess functional impairment apart from personality traits.

The joint structure of normal and pathological personality: further evidence for a dimensional model

OBJECTIVE

The literature proposes a joint structure of normal and pathological personality with higher-order factors mainly based on the five-factor model of personality (FFM). The purpose of the present study was to examine the joint structure of the FFM and the DSM-IV personality disorders (PDs) and to discuss this structure with regard to higher-order domains commonly reported in the literature.

METHODS

We applied a canonical correlation analysis, a series of principal component analyses with oblique Promax rotation and a bi-factor analysis with Geomin rotation on 511 subjects of the general population of Zurich, Switzerland, using data from the ZInEP Epidemiology Survey.

RESULTS

The 5 FFM traits and the 10 DSM-IV PD dimensions shared 77% of total variance. Component extraction tests pointed towards a two- and three-component solution. The two-component solution comprised a first component with strong positive loadings on neuroticism and all 10 PD dimensions and a second component with strong negative loadings on extraversion and openness and positive loadings on schizoid and avoidant PDs. The three-component solution added a third component with strong positive loadings on conscientiousness and agreeableness and a negative loading on antisocial PD. The bi-factor model provided evidence for 1 general personality dysfunction factor related to neuroticism and 5 group factors, although the interpretability of the latter was limited.

CONCLUSIONS

Normal and pathological personality domains are not isomorphic or superposable, although they share a substantial proportion of variance. The two and three higher-order domains extracted in the present study correspond well to equivalent factor-solutions reported in the literature. Moreover, these superordinate factors can consistently be integrated within a hierarchical structure of alternative four- and five-factor models. The top of the hierarchy presumably constitutes a general personality dysfunction factor which is closely related to neuroticism.

Assessment of personality functioning: validity of the operationalized psychodynamic diagnosis axis IV (structure)

BACKGROUND

The assessment of personality functioning has recently become a focus of psychiatric diagnostics. The interview-based Operationalized Psychodynamic Diagnosis (OPD-2) provides a 'structure axis' for the assessment of personality functioning.

METHODS

One hundred twenty-four psychiatric patients were diagnosed by means of the Structured Clinical Interviews for DSM-IV (SCID-I and SCID-II), underwent OPD-2 interviews, and completed 9 questionnaires.

RESULTS

The OPD-2 structure axis shows good interrater reliability (intraclass correlation = 0.793). Correlations between the OPD-2 structure axis domains and a priori selected questionnaire scales were of medium size and significant. Patients with a personality disorder (PD) showed significantly worse personality functioning than those without. In cluster B PD, personality functioning was more severely impaired than in cluster C PD.

DISCUSSION

The OPD-2 structure axis shows good reliability as well as concurrent and discriminant validity and can be recommended for clinical use and research purposes.

Introducing the Short Dark Triad (SD3)

Three socially aversive traits—Machiavellianism, narcissism, and psychopathy—have been studied as an overlapping constellation known as the Dark Triad. Here, we develop and validate the Short Dark Triad (SD3), a brief proxy measure. Four studies (total N = 1,063) examined the structure, reliability, and validity of the subscales in both community and student samples. In Studies 1 and 2, structural analyses yielded three factors with the final 27 items loading appropriately on their respective factors. Study 3 confirmed that the resulting SD3 subscales map well onto the longer standard measures. Study 4 validated the SD3 subscales against informant ratings. Together, these studies indicate that the SD3 provides efficient, reliable, and valid measures of the Dark Triad of personalities.

The role of the DSM-5 personality trait model in moving toward a quantitative and empirically based approach to classifying personality and psychopathology

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) represents a watershed moment in the history of official psychopathology classification systems because it is the first DSM to feature an empirically based model of maladaptive personality traits. Attributes of patients with personality disorders were discussed by the DSM-5 Personality and Personality Disorders Work Group and then operationalized and refined in the course of an empirical project that eventuated in the construction of the Personality Inventory for DSM-5 (PID-5). We review research to date on the DSM-5 trait model, with a primary aim of discussing how this kind of research could serve to better tether the DSM to data as it continues to evolve. For example, studies to date suggest that the DSM-5 trait model provides reasonable coverage of personality pathology but also suggest areas for continued refinement. This kind of research provides a way of evolving psychopathology classification on the basis of research evidence as opposed to clinical authority.

Examination of the Section III DSM-5 diagnostic system for personality disorders in an outpatient clinical sample

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013), includes a novel approach to the diagnosis of personality disorders (PDs) in Section III, to stimulate further research with the possibility that this proposal will be included more formally in future DSM iterations. This study provides the 1st test of this proposal in a clinical sample by simultaneously examining its 2 primary components: a system for rating personality impairment and a newly developed dimensional model of pathological personality traits. Participants were community adults currently receiving outpatient mental health treatment who completed a semistructured interview for DSM-IV PDs and were then rated in terms of personality impairment and pathological traits. Data on the pathological traits were also collected through self-reports using the Personality Inventory for DSM-5 (PID-5). Both sets of trait scores were compared with self-report measures of general personality traits, internalizing symptoms, and externalizing behaviors. Interrater reliabilities for the clinicians' ratings of impairment and the pathological traits were fair. The impairment ratings manifested substantial correlations with symptoms of depression and anxiety, DSM-5 PDs, and DSM-5 pathological traits. The clinician and self-reported personality trait scores demonstrated good convergence with one another, both accounted for substantial variance in DSM-IV PD constructs, and both manifested expected relations with the external criteria. The traits but not the impairment ratings demonstrated incremental validity in the prediction of the DSM-IV PDs. Overall, these results support the general validity of several of the components of this new PD diagnostic system and point to areas that may require further modification.

Mixture modeling methods for the assessment of normal and abnormal personality, part I: cross-sectional models

Over the past 75 years, the study of personality and personality disorders has been informed considerably by an impressive array of psychometric instruments. Many of these tests draw on the perspective that personality features can be conceptualized in terms of latent traits that vary dimensionally across the population. A purely trait-oriented approach to personality, however, might overlook heterogeneity that is related to similarities among subgroups of people. This article describes how factor mixture modeling (FMM), which incorporates both categories and dimensions, can be used to represent person-oriented and trait-oriented variability in the latent structure of personality. We provide an overview of different forms of FMM that vary in the degree to which they emphasize trait- versus person-oriented variability. We also provide practical guidelines for applying FMM to personality data, and we illustrate model fitting and interpretation using an empirical analysis of general personality dysfunction.

Validating the proposed diagnostic and statistical manual of mental disorders, 5th edition, severity indicator for personality disorder

The authors sought to determine whether a 5-point global rating of personality dysfunction on the Level of Personality Functioning Scale proposed as a severity index for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), would be related to DSM-IV personality disorder diagnosis as well as to other key clinical judgments. Data were collected from a national sample of 337 mental health clinicians who provided complete diagnostic information relevant to DSM-IV and proposed DSM-5 personality disorder diagnoses, as well as demographic information and other clinical judgments, on one of their patients. Of the 337 patients described, 248 met criteria for 1 of the 10 specific DSM-IV personality disorders. A "moderate" or greater rating of impairment in personality functioning on the Level Scale demonstrated 84.6% sensitivity and 72.7% specificity for identifying patients meeting criteria for a specific DSM-IV personality disorder. The Level of Personality Functioning Scale had significant and substantial validity correlations with other measures of personality pathology and with clinical judgments regarding functioning, risk, prognosis, and optimal treatment intensity. Furthermore, the single-item Level of Personality Functioning rating was viewed as being as clinically useful as the 10 DSM-IV categories for treatment planning and patient description and was a better predictor of clinician ratings of broad psychosocial functioning than were the 10 DSM-IV categories combined. These results confirm hypotheses that the single-item Level of Personality Functioning Scale rating provides an indication of severity of personality pathology that predicts both assignment of personality disorder diagnosis and clinician appraisals of functioning, risk, prognosis, and needed treatment intensity.

Preoccupied attachment and emotional dysregulation: specific aspects of borderline personality disorder or general dimensions of personality pathology?

Emotional dysregulation and impaired attachment are seen by many clinical researchers as central aspects of borderline personality disorder (BPD). Alternatively, these constructs may represent general impairments in personality that are nonspecific to BPD. Using multitraitmultimethod models, the authors examined the strength of associations among preoccupied attachment, difficulties with emotion regulation, BPD features, and features of two other personality disorders (i.e., antisocial and avoidant) in a combined psychiatric outpatient and community sample of adults. Results suggested that preoccupied attachment and difficulties with emotion regulation shared strong positive associations with each other and with each of the selected personality disorders. However, preoccupied attachment and emotional dysregulation were more strongly related to BPD features than to features of other personality disorders. Findings suggest that although impairments in relational and emotional domains may underlie personality pathology in general, preoccupied attachment and emotional dysregulation also have specificity for understanding core difficulties in those with BPD.

The interpersonal core of personality pathology

The purpose of this article is to demonstrate that personality pathology is, at its core, fundamentally interpersonal. The authors review the proposed DSM-5 Section 3 redefinition of personality pathology involving self and interpersonal dysfunction, which they regard as a substantial improvement over the DSM-IV (and Section 2) definition. They note similarities between the proposed scheme and contemporary interpersonal theory and interpret the Section 3 definition using the underlying assumptions and evidence base of the interpersonal paradigm in clinical psychology. The authors describe how grounding the proposed Section 3 definition in interpersonal theory, and in particular a focus on the "interpersonal situation," adds to its theoretical texture, empirical support, and clinical utility. They provide a clinical example that demonstrates the ability of contemporary interpersonal theory to augment the definition of personality pathology. The authors conclude with directions for further research that could clarify the core of personality pathology, and how interpersonal theory can inform research aimed at enhancing the Section 3 proposal and ultimately justify its migration to Section 2.

Differentiating normal and disordered personality using the General Assessment of Personality Disorder (GAPD)

Criteria to differentiate personality disorder from extremes of normal personality variations are important given growing interest in dimensional classification because an extreme level of a personality dimension does not necessarily indicate disorder. The DSM-5 proposed classification of personality disorder offers a definition of general personality disorder based on chronic interpersonal and self/identity pathology. The ability of this approach to differentiate personality disorder from other mental disorders was evaluated using a self-report questionnaire, the General Assessment of Personality Disorder (GAPD). This measure was administered to a sample of psychiatric patients (N = 149) from different clinical sub-sites. Patients were divided into personality disordered and non-personality disordered groups on the basis of the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II). The results showed a hit rate of 82% correct identified patients and a good accuracy of the predicted model. There was a substantial agreement between SCID-II interview and GAPD personality disorder diagnoses. The GAPD appears to predict personality disorder in general, which provides support of the DSM-5 general diagnostic criteria of personality disorder.

Convergence between DSM-IV-TR and DSM-5 diagnostic models for personality disorder: evaluation of strategies for establishing diagnostic thresholds

The Personality and Personality Disorders Work Group for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) recommended substantial revisions to the personality disorders (PDs) section of DSM-IV-TR, proposing a hybrid categorical-dimensional model that represented PDs as combinations of core personality dysfunctions and various configurations of maladaptive personality traits. Although the DSM-5 Task Force endorsed the proposal, the Board of Trustees of the American Psychiatric Association (APA) did not, placing the Work Group's model in DSM-5 Section III ("Emerging Measures and Models") with other concepts thought to be in need of additional research. This paper documents the impact of using this alternative model in a national sample of 337 patients as described by clinicians familiar with their cases. In particular, the analyses focus on alternative strategies considered by the Work Group for deriving decision rules, or diagnostic thresholds, with which to assign categorical diagnoses. Results demonstrate that diagnostic rules could be derived that yielded appreciable correspondence between DSM-IV-TR and proposed DSM-5 PD diagnoses-correspondence greater than that observed in the transition between DSM-III and DSM-III-R PDs. The approach also represents the most comprehensive attempt to date to provide conceptual and empirical justification for diagnostic thresholds utilized within the DSM PDs.

Issues regarding the proposed DSM-5 personality disorders in geriatric psychology and psychiatry

The official introduction of the psychiatric diagnosis of personality disorders (PDs) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) began in 1952 with the publication of the first edition (American Psychiatric Association, 1952). DSM-I contained 12 main types of PDs with a total description for all types in only two paragraphs. In the following DSM-II (American Psychiatric Association, 1968), just 10 specific types of PDs were described, including a very brief general definition of PDs. The DSM-III (American Psychiatric Association, 1980) included a significant paradigm shift from the medical model by incorporating the design of a multi-axial approach, in which the combinations of symptoms of more than five primary axes were used to describe the pathological state and formulate the diagnosis. Notably, the PDs were placed on a separate axis (Axis II) to distinguish their long-standing nature from the more episodic clinical disorders placed on Axis I. PDs were recognized as important formal diagnoses and included a more comprehensive listing of polythetic diagnostic criteria for each specific PD.

Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods

Personality disorders are associated with fundamental disturbances of self and interpersonal relations, problems that vary in severity within and across disorders. This review surveyed clinician-rated measures of personality psychopathology that focus on self-other dimensions to explore the feasibility and utility of constructing a scale of severity of impairment in personality functioning for DSM-5. Robust elements of the instruments were considered in creating a continuum of personality functioning based on aspects of identity, self-direction, empathy, and intimacy. Building on preliminary findings (Morey et al., 2011 /this issue), the proposed Levels of Personality Functioning will be subjected to extensive empirical testing in the DSM-5 field trials and elsewhere. The resulting version of this severity measure is expected to have clinical utility in identifying personality psychopathology, planning treatment, building the therapeutic alliance, and studying treatment course and outcome.

Introduction to the special issue on personality assessment in the DSM-5

The DSM-5 is poised to dramatically reshape the way clinicians and researchers assess personality by reconfiguring the conceptualization of DSM-IV personality disorders. This special issue brings together leading scholars in personality pathology, including members of the DSM-5 Personality and Personality Pathology Work Group, as well as personality assessors operating from a variety of theoretical perspectives, to describe various facets of these changes and their potential impacts and in some cases to propose alternative solutions. As we describe in this brief introductory article, the articles in this special issue highlight several important and controversial issues in the transition to DSM-5 personality assessment.

Pathological narcissism and interpersonal behavior in daily life

The cognitive-affective processing system (CAPS) has been proposed as a useful metaframework for integrating contextual differences in situations with individual differences in personality pathology. In this article, we evaluated the potential of combining the CAPS metaframework and contemporary interpersonal theory to investigate how individual differences in pathological narcissism influenced interpersonal functioning in daily life. University students (N = 184) completed event-contingent reports about interpersonal interactions across a 7-day diary study. Using multilevel regression models, we found that combinations of narcissistic expression (grandiosity, vulnerability) were associated with different interpersonal behavior patterns reflective of interpersonal dysfunction. These results are among the first to empirically demonstrate the usefulness of the CAPS model to conceptualize personality pathology through the patterning of if-then interpersonal processes.