Identity Impairment as a Central Dimension in Personality Pathology

Identity and Personality Pathology in Adult Forensic Psychiatric Patients and Healthy Controls

Since the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), identity impairment has become a diagnostic criterion for all personality disorders. The current study examined the occurrence of identity dimensions, clinically relevant identity impairments and personality pathology, and associations between these constructs in 92 forensic patients and 139 healthy controls. Patients showed higher levels of almost all identity dimensions, identity impairments, personality disorders, and almost all maladaptive personality traits than controls. Various identity dimensions were associated with consolidated identity as well as identity impairments in both groups. Both patients and controls with high ruminative exploration and identity malfunctioning showed more personality pathology. Different associations between identity functioning and particularly antisocial and borderline personality disorder showed to be stronger in patients than in controls. Our results highlight the importance of identity impairment as a crucial criterion to assess and treat personality pathology in forensic patients.

Clinical profiles of adolescent personality pathology: a latent structure examination of the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) in a help-seeking sample

BACKGROUND

Despite the introduction of dimensional conceptualisations of personality functioning in the latest classification systems, such as Criterion A of the Alternative Model of Personality Disorders in the DSM-5, heterogeneous clinical presentation of personality pathology remains a challenge. Relatedly, the latent structure of personality pathology as assessed by the Semi-Structured Interview for Personality Functioning DSM-5 (STiP-5.1) has not yet been comprehensively examined in adolescents. Therefore, this study aimed to examine the latent structure of the STiP-5.1, and, based on those findings, to describe any unique clinical profiles that might emerge.

METHODS

The final sample comprised 502 participants aged 11-18 years consecutively recruited from a specialised personality disorder outpatient service, as well as general day clinic and inpatient wards at the University Hospital University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University Hospital Bern, Switzerland. Participants were assessed using the STiP-5.1, as well as a battery of other psychological measures by clinical psychologists or trained doctoral students. Variations of Factor Analysis, Latent Class Analysis and Factor Mixture Models (FMM) were applied to the STiP-5.1 to determine the most appropriate structure.

RESULTS

The best fitting model was an FMM comprising four-classes and two factors (corresponding to self- and interpersonal-functioning). The classes differed in both overall severity of personality functioning impairment, and in their scores and clinical relevance on each element of the STiP-5.1. When compared to the overall sample, classes differed in their unique clinical presentation: class 1 had low impairment, class 2 had impairments primarily in self-functioning with high depressivity, class 3 had mixed levels of impairment with emerging problems in identity and empathy, and class 4 had severe overall personality functioning impairment.

CONCLUSIONS

A complex model incorporating both dimensional and categorical components most adequately describes the latent structure of the STiP-5.1 in our adolescent sample. We conclude that Criterion A provides clinically useful information beyond severity (as a dimensional continuum) alone, and that the hybrid model found for personality functioning in our sample warrants further attention. Findings can help to parse out clinical heterogeneity in personality pathology in adolescents, and help to inform early identification and intervention efforts.

How negative self-views may interfere with building positive relationships: An experimental analogue of identity dysfunction in borderline personality disorder

INTRODUCTION

A disturbed, negative sense of self is associated with various interpersonal difficulties and is characteristic of disorders such as borderline personality disorder (BPD). Negative self-views may affect an individuals' ability to build positive relationships, including a therapeutic relationship. However, it is not yet well understood how identity disturbances give rise to interpersonal difficulties. Using an experimental analogue design, we tested whether identity disturbances are associated with interpersonal difficulties.

METHODS

Participants were university students (N = 43, age M = 20.51 (SD = 3.08), women N = 32 (74.4%)) who reported moderate to high levels of BPD features, with 34.9% reporting significant BPD features as measured by the Borderline scale of the Personality Assessment Inventory (PAI-BOR). In a within-subject experimental paradigm using a Social Feedback Task, participants received negative, intermediate, and positive evaluations, supposedly from a panel. Using multilevel models, we tested whether negative self-views were associated with how much the participants liked, trusted, and felt close to each of the three panel members who provided either predominantly negative, intermediate, or positive feedback.

RESULTS

People with more negative self-views reported lower mood in response to positive feedback. In addition, where people with more positive self-views felt better when receiving feedback that was congruent with their self-views, people with more negative self-views did not report a better mood. Importantly, people with negative self-views felt lower desire to affiliate with the member who provided predominantly positive feedback. Affiliation was not affected when feedback was given by the negative member and intermediate member to those with negative self-views.

CONCLUSIONS

The findings validated that those with more negative self-views anticipated and expected more negative responses from others. Negative self-views, as relevant for BPD, may explain how people relate differently to those giving different types of feedback. Pervasive negative self-views may interfere with building new relationships including the therapeutic alliance. It may be helpful for clinicians to be aware of the potential challenges around creating a supportive therapeutic relationship for patients with negative self-views. Overly positive affirmations made by clinicians may inadvertently lower the patient's mood and may impede alliance formation.

The Self-Concept and Identity Measure in Patients with Personality Disorders: A Psychometric Evaluation and Associations With Identity Processes, Core Domains of Self-Functioning, and Personality Disorder Symptoms

As developmental and clinical research on identity has largely developed in disconnect, scholars recommend adopting a developmental psychopathology perspective on identity, which considers adaptive and pathological identity functioning. Such a perspective has also been introduced in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) Alternative Model for Personality Disorders (AMPD), which suggests that all personality disorders (PDs) are marked by moderate to extreme deficits in self-functioning (i.e., identity and self-direction). The present study aims to validate the Dutch Self-Concept and Identity Measure (SCIM), a 27-item self-report questionnaire that assesses consolidated identity, disturbed identity, and lack of identity, in 153 psychiatric inpatients with PDs (75.2% female; Mage = 31.73). We investigated the factor structure and reliability of the SCIM, and examined associations of SCIM scales with typical identity processes, AMPD domains of self-functioning, and symptoms of all PDs. Results indicated that a 23-item Dutch SCIM produced valid and reliable scores among patients with PDs. Furthermore, SCIM scales were significantly and differentially related to identity commitment processes, ruminative identity exploration, domains of self-functioning, and symptoms of all PDs. Moreover, findings indicated that PDs varied regarding the severity of identity impairment.

A validation of the Swedish self-concept and Identity Measure (SCIM) and its association with mental health problems

Pathological disturbance to one's identity is closely linked with mental illness and in particular personality disorders. Current measures of identity pathology within clinical research are nevertheless inconsistently used and present with substantial limitations such as disproportionate focus on adolescence. The Self-Concept and Identity Measure (SCIM) identifies pathological and non-pathological identity disturbance by implementing a measurement for clinical components of identity, as well as introducing the Lack of Identity concept. This study thus explores the psychometric properties (factor structure, internal consistency, and criterion validity) of the Swedish SCIM in a large sample of Swedish university students (N = 1500). Model fit indices for the three-dimension model of identity pathology consisting of consolidated-, disturbed-, and lack of identity subscales were deemed acceptable and the Swedish SCIM scores correlated with measures of psychopathology in the expected direction, together concluding that the Swedish SCIM was satisfactorily valid and reliable. The results further reveal a significant positive correlation between identity pathology and non-suicidal self-injury, two concepts that co-occur in psychopathologies, such as borderline personality disorder, but have not yet been studied in a Western population with this tool. The potential clinical use of this translated dimensional tool needs to be tested in a Swedish clinical population, however, we conclude that it already offers insight into the complexities of identity functioning and correlations with clinical symptoms.

Identity - A critical but neglected construct in cognitive-behaviour therapy

In cognitive-behaviour therapy attention paid to the self and identity has primarily involved self-representations (the Me-Self) rather than how the self is experienced (the I-Self). Within the I-Self experiences vary on a continuum from pre-reflective consciousness (raw experienced perceptions and states of being) to self-awareness (permitting reflection on and evaluation of subjective experience). There is considerable evidence that the I-Self is affected in many if not all disorders, and I review illustrative studies of OCD, eating disorders, body dysmorphic disorder, PTSD, and personality disorder. These indicate that patients often experience themselves as being defective in various ways, or as having an unstable or contradictory I-Self. Recognition of this neglected aspect of patients' experience has major implications for assessment and treatment. For example, acknowledgment that their sense of self may fluctuate dramatically from moment to moment, may be fragmented, or may consist of a sense of emptiness, may help to build a more empathic therapeutic relationship. If frightening or distressing pre-reflective experiences are the cause of avoidance or other maladaptive coping strategies, conscious attention paid to them in therapy may help to better integrate the I-Self and Me-Self, restoring a sense of predictability and control.

Identity and Personality Pathology: A Convergence Across the DSM-5 Personality Disorder Model and the Alternative Model for Personality Disorders

Long-standing theory regarding personality pathology as well as the recently proposed DSM-5 Alternative Model for Personality Disorders (AMPD) posit that self/identity problems are a hallmark feature cutting across forms of personality pathology. With emergence of the AMPD, researchers have started to focus empirical investigations on identity pathology as a transdiagnostic factor across personality pathology. The current study investigated identity pathology across indicators of personality pathology from both the current categorical perspective (DSM-5 PD) and the dimensional perspective in the AMPD. Identity diffusion and low self-concept clarity were correlated with all PD feature scales and all maladaptive personality dimension scales. Regression analyses revealed most indicators of personality pathology were significant correlates of identity diffusion and low self-concept clarity. Borderline and Avoidant PD feature scales and Negative Affectivity and Detachment maladaptive personality dimension scales emerged as the strongest correlates of identity pathology. The role that identity pathology plays in personality pathology is highlighted.

Associations between symptoms of borderline personality disorder and suicidality in inpatient adolescents: The significance of identity disturbance

Several studies report that borderline personality disorder (BPD) is a risk factor for suicidality in adults. However, this issue requires further research in adolescents, as it is not clear which individual BPD symptoms are significant correlates of suicidality in this age group. The main aim of the current study was to test which symptoms of BPD are associated with suicidality in adolescent inpatients, even when controlling for age, gender, and depressive symptoms. Inpatient adolescents (N = 339) aged 12-17 years completed the Childhood Interview for DSM-IV Borderline Personality Disorder, the Beck Depression Inventory-II, the Modified Scale for Suicidal Ideation, and reported their number of lifetime suicide attempts. Multivariable regression analyses showed that, after controlling for confounding variables, overall BPD symptom severity was positively related to suicidal ideation and suicide attempts. Of the individual BPD symptoms, identity disturbance, chronic emptiness, avoid abandonment, and transient paranoia were the most robust correlates of suicidal ideation intensity, and only identity disturbance was associated with the number of lifetime suicide attempts. To assess the risk of suicidality in youth, it is essential to assess for BPD symptoms; it is important to focus on adolescents' subjective feelings to assess the severity of identity disturbance and chronic emptiness.

Are We Thinking about the Same Disorder? A Trifactor Model Approach to Understand Parents' and Their Adolescents' Reports of Borderline Personality Pathology

Multiple informant assessment is the norm when evaluating borderline personality pathology (BPP) in adolescence, especially by including reports from both parents and adolescents. However, these reports tend to be discrepant, and it is unclear how to integrate. The current study used a trifactor model to isolate sources of variance in parents' and adolescents' reports of BPP due to their shared and unique perspectives in a sample of 652 inpatient adolescents (63% female; M_age = 15.31, SD = 1.45) and their parents (81% mothers). Consensus/agreement was characterized by the externalizing features of BPP whereas idiosyncratic views of adolescent BPP covered the full latent BPP construct, suggesting that simple aggregation of parent and adolescent reports is inappropriate. Measurement invariance suggested that unique perspectives were characterized by slightly different operationalizations of BPP and response biases for specific features of BPP. Attachment security and parents' interpersonal problems predicted shared and unique perspectives differently for female and male adolescents. Lastly, we found that shared and unique perspectives differentially predicted interview based BPP, length of stay, and adolescent mentalizing. In sum, findings replicate previous evidence of parent-child informant discrepancy in youth psychopathology, broadly, and provide insights specific to BPP. Discussion includes practical recommendations for assessment and interpretation of BPP assessment.

Identity Development and Maladaptive Personality Traits in Young Refugees and First- and Second-Generation Migrants

Refugees are often exposed to a variety of stressors and traumatic events, posing a significant risk for the development of mental disorders. Young refugees may be particularly at risk because adverse life events affect identity formation, a developmental task that is typically expected in adolescence and emerging adulthood. Trauma and cultural changes may alter identity development, potentially leading to identity diffusion, a core concept of personality disorders. However, previous research on personality pathology among refugees is scarce. In this study, we examine identity development and maladaptive personality traits in young refugees and migrants. Refugees from 22 countries of origin were recruited in a German reception center (n = 120) and a group of adults with a migration background in first- or second generation was obtained via web-based recruitment (n = 281). Identity development was measured using the Assessment of Identity Development in Adolescence - Short Form. Maladaptive personality traits were assessed with the Personality Inventory for DSM-5-Brief Form. Group differences between refugees and migrants regarding identity development and trait expression were investigated using t-tests. The relationship between the two measures and their corresponding subscales was examined by means of correlation analyses. Refugees reported significantly higher levels of identity diffusion, negative affectivity, detachment, antagonism, and disinhibition compared to migrants. No significant differences were found for psychoticism. Correlation analyses revealed low to moderate positive associations between identity diffusion and maladaptive trait expression. Possible implications for early phase of resettlement, preventive psychiatric care and further research questions are discussed.

An Evaluation of Age-Group Latent Mean Differences in Maladaptive Identity in Adolescence

Little is known about the differences between age groups in maladaptive personality function as denoted in Criterion A of the Alternative Model for Personality Disorder (AMPD) in the DSM-5, which is the entry criterion for diagnosing personality disorder in the upcoming ICD-11. The current study aimed to address this gap by evaluating latent mean age group differences in maladaptive identity, which is one aspect that has been identified as an important feature of maladaptive, general personality function as represented in the DSM-5 and ICD-11. We were also interested whether mean differences would track with mean differences in borderline personality disorder (BPD) features given prior data suggesting that general personality function overlap with the construct of BPD. A community sample of N = 2,381 adolescents, representing a mix of different socio-economic and educational backgrounds, ages 12-18 (M = 14.92, SD = 1.94; 46% male) completed a measure of maladaptive identity. A subset (n = 1,165) completed a measure of borderline personality features. Latent variable modeling was used to evaluate latent mean differences across seven age bands. Results suggested a normative increase in maladaptive identity after age 12, which remained consistent until age 17 when it dropped back to levels observed in 12-year-olds. Maladaptive identity was significantly associated with mean-level increases in borderline personality features, with these constructs becoming more closely associated with increasing age.

Exploring Identity Disturbance and Psychotic Spectrum Symptoms as Predictors of Borderline and Schizotypal Personality Disorders

INTRODUCTION

Borderline personality disorder (BPD) and schizotypal personality disorder (SPD) were introduced in DSM-III and retained in DSM-5 Section II. They often co-occur and some aspects of the clinical differentiation between the 2 diagnoses remain unclear (e.g., psychotic-like features and identity disturbance).

METHODS

The present study explored if self-reported identity disturbance and psychosis proneness could discriminate between the BPD and SPD DSM-5 diagnoses. All patients were interviewed with the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders, and administered the Inventory of Personality Organization, Self-Concept and Identity Measure, Schizotypal Personality Questionnaire, Perceptual Aberration Scale, and the Magical Ideation Scale.

RESULTS

A total of 105 patients were initially assessed, 26 were excluded, and the final sample (N = 79) was composed of 34 BPD patients, 25 SPD patients, and 20 patients with co-occurring SPD and BPD. The BPD group (n = 34) was first compared with the pure SPD group (n = 25), and secondly with the total group of patients diagnosed with SPD (n = 25 + 20). Logistic regression analyses indicated that primitive defenses and disorganization best differentiated the BPD and the pure SPD group, while primitive defenses and interpersonal factor along with perceptual aberrations best differentiated the BPD and the total SPD group.

CONCLUSION

Identity disturbance did not predict the diagnostic groups, but BPD patients were characterized by primitive defenses, which are closely related to identity disturbance. Pure SPD was characterized by oddness/eccentricity, while the lack of specificity for cognitive-perceptual symptoms suggests that the positive symptoms do not differentiate BPD from SPD.