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

Comparing the new concept of impairment in personality functioning with borderline personality disorder: differential psychosocial and psychopathological correlates in a clinical adolescent sample

Borderline personality disorder (BPD) is an established diagnosis in adolescence with high comorbidity and psychosocial impairment. With the introduction of the alternative model for personality disorders in DSM-5 (AMPD), personality functioning is operationalized using the Level of Personality Functioning Scale (LPFS), which has been shown to be associated with severity of personality pathology. The present study aimed at examining differential psychopathological and psychosocial correlates of LPFS and BPD. A total of 526 adolescent in- and outpatients were interviewed with the STiP-5.1 (LPFS) and the SCID-II. Mixed linear regression was used to investigate the associations between the two interviews with measures of psychopathology and psychosocial impairment. 11.4% met the diagnostic threshold of both interviews, 16.1% only of the LPFS, and 64.1% were below the diagnostic threshold in both interviews (no PD). The BPD only group was larger than expected-8.4% of patients who met criteria for BPD did not fulfill criteria for significant impairment in the LPFS. The highest burden was found in individuals concurrently showing significant impairment in LPFS and fulfilling BPD diagnosis (LPFS + BPD). Differences between the LPFS only group and the BPD only group were found in risk behavior and traumatic experiences, with higher prevalence in the BPD group. Findings confirm the high psychopathological burden and psychosocial impairment associated with both BPD and LPFS. Those exceeding the diagnostic threshold of LPFS in combination with a BPD diagnosis are characterized by greatest disability. Not all adolescents fulfilling formal BPD diagnosis showed a clinically significant impairment in LPFS, which may refer to a distinct diagnostic group.

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.

Personality systems interactions theory: an integrative framework complementing the study of the motivational and volitional dynamics underlying adjustment to chronic pain

In the endeavor to advance our understanding of interindividual differences in dealing with chronic pain, numerous motivational theories have been invoked in the past decade. As they focus on relevant, yet different aspects of the dynamic, multilevel processes involved in human voluntary action control, research findings seem fragmented and inconsistent. Here we present Personality Systems Interactions theory as an integrative meta-framework elucidating how different motivational and volitional processes work in concert under varying contextual conditions. PSI theory explains experience and behavior by the relative activation of four cognitive systems that take over different psychological functions during goal pursuit. In this way, it may complement existing content-related explanations of clinical phenomena by introducing a functional, third-person perspective on flexible goal management, pain acceptance and goal maintenance despite pain. In line with emerging evidence on the central role of emotion regulation in chronic pain, PSI theory delineates how the self-regulation of positive and negative affect impacts whether behavior is determined by rigid stimulus-response associations (i.e., habits) or by more abstract motives and values which afford more behavioral flexibility. Along with testable hypotheses, multimodal interventions expected to address intuitive emotion regulation as a central process mediating successful adaptation to chronic pain are discussed.

Establishing Levels of Personality Functioning Using the Structured Interview of Personality Organization (STIPO-R): a Latent Profile Analysis

Both the new ICD-11 and the latest Alternative DSM-5 Model for Personality Disorders focus on self and interpersonal functioning as the central feature of personality pathology, also acknowledging that personality disorders are organized along a dimensional continuum of severity. This revised understanding is in line with long-standing psychodynamic conceptualisations of personality pathology, in particular Kernberg's object relations model of personality organization. Despite existing evidence for the clinical utility of the derived Structured Interview of Personality Organization (STIPO-R), empirical support for the identification of clear cut-points between the different levels of personality functioning is missing. For this purpose, a total of 764 adult participants were recruited across two clinical (outpatient and inpatient) settings (n = 250) and two non-clinical (university students and general community) samples (n = 514). Results from the mixture modeling suggested the existence of five groups across the clinical and non-clinical samples that covered: healthy personality functioning, maladaptive personality rigidity, and mild, moderate, and severe levels of personality pathology. All five indicators of personality organization were found to be reliable predictors of personality pathology. Of the five STIPO-R indicators, Aggression and Moral Values had the most discriminative power for differentiating between the Mild, Moderate, and Severe personality disorder groups. Implications of these findings are discussed.

Personality disorders: the impact of severity on societal costs

Personality disorders (PDs) are associated with high levels of societal costs. However, previous research has found limited or no evidence of unique contributions of individual PD categories on the overall level of societal costs. Recent research supports the validity of PD as a dimensional construct, and PD severity may be a better predictor of societal costs than specific PD categories. The aim of this study was to explore if PD severity could predict the level of societal costs among treatment-seeking patients with PDs, while controlling for the impact of comorbid mental health and substance use disorders. Four different severity indicators were explored: the number of PDs, the total number of PD criteria, the number of BPD criteria, and the Level of Personality Functioning Scale (LPFS) from the alternative model in DSM-5. Participants (n = 798/794) were retrieved from the quality register of the Norwegian Network for Personality Disorders for the period 2017-2020. Societal costs were assessed using a structured interview covering the six-month period prior to assessment. Diagnoses and diagnostic criteria were determined using a semi-structured diagnostic interview (SCID-5-PD and M.I.N.I), and the LPFS was assessed by the LPFS-Brief Form 2.0 (LPFS-BF 2.0) questionnaire. Statistics included multiple regression analyses. None of the severity indicators were significant predictors of overall societal costs among treatment-seeking patients, and effect sizes were small.

Evaluating the Psychometric Properties of the German Self and Interpersonal Functioning Scale (SIFS)

The Self and Interpersonal Functioning Scale (SIFS) is a 24-item self-report questionnaire assessing personality functioning according to the alternative DSM-5 model for personality disorders. We evaluated the German SIFS version in a total sample of 886 participants from Germany and Switzerland. Its factor structure was investigated with confirmatory factor analysis comparing bifactor models with two specific factors (self- and interpersonal functioning) and four specific factors (identity, self-direction, empathy, and intimacy). The SIFS sum and domain scores were tested for reliability and convergent validity with self-report questionnaires and interviews for personality functioning, -organization, -traits, -disorder categories, and well-being. None of the bifactor models yielded good model fit, even after excluding two items with low factor loadings and including a method factor for reverse-keyed items. Based on a shortened 22-item SIFS version, models suggested that the g-factor explained 52.9-59.6% of the common variance and that the SIFS sum score measured the g-factor with a reliability of .68-.81. Even though the SIFS sum score showed large test-retest reliability and correlated strongly with well-established self-report questionnaires and interviews, the lack of structural validity appears to be a serious disadvantage of the SIFS compared to existing self-reports questionnaires of personality functioning.

Investigation of the role of personality traits and emotion regulation on personality functioning in patients with depression/anxiety disorder

The relationship between the dimensional assessment of personality and difficulties in emotion regulation has yet to be made clear. The present study aimed to investigate the role of personality traits and emotion regulation on personality functioning. Difficulties in Emotion Regulation Scale (DERS), Beck Anxiety Inventory, Beck Depression Inventory, Personality Inventory for DSM-5 (PID-5) and Level of Personality Functioning Scale (LPFS) were rated for 220 patients with depression and/or anxiety disorder diagnosis and 100 healthy controls. Stepwise regression analyses (SRA) were used to find potential predictors of personality functioning, and generalized linear analyses (GLA) were used to find mediators between the traits and personality functioning. SRA results in the clinical group showed that higher depression, antagonism, difficulties in impulse control and difficulties in awareness predicted higher levels of dysfunction in personality. According to GLA results in the clinical group, the impulse subscale of DERS partially mediated the relationship between antagonism and level of impairment in personality functioning. Our results indicate that certain emotion regulation styles and personality traits play an important role in predicting personality functioning in the clinical sample of depression and anxiety patients. Future studies should focus on specific emotion dysregulation strategies and broaden the dimensional personality literature in different samples.

Personality and mentalization: A latent profile analysis of mentalizing problematics in adult patients

BACKGROUND

The aim of this study was to investigate the relationship between patients' mentalizing problematics and their personality; specifically, it aimed to identify clusters of individuals characterized by specific patterns of mentalizing imbalances and to analyze the relationship between these and diagnosis of personality disorder (PD), nonmentalizing modes, emotion dysregulation, and interpersonal reactivity.

METHODS

Four hundred therapeutic dyads were recruited. A part of these (n = 183) only completed clinician-report measures, Mentalization Imbalances Scale, and Modes of Mentalization Scale, while others (n = 217) also completed patients' self-report measures, which were Reflective Functioning Questionnaire, Difficulties in Emotion Regulation Scale, and Interpersonal Reactivity Index.

RESULTS

A latent profile analysis enlightened the presence of four clusters with problematics in the dimensions of mentalization, indicated by cluster names: (1) Affective-self-automatic profile (ASA-P) (with higher percentage of PDs); (2) External profile (E-P) (with lower percentage of PDs); (3) Others-automatic-affective profile (OAA-P); (4) Cognitive-self-automatic profile (CSA-P). Multivariate analysis of variances confirmed that the four clusters differed in relation to the quality of mentalization, emotional dysregulation and interpersonal reactivity, with higher levels of nonmentalization modes, uncertainty about mental states and emotion dysregulation in ASA-P, higher levels of good mentalization in E-P, lower impulsivity in CSA-P, and greater empathic concern in OAA-P.

Moderately Eccentric: Evidence for Dimensionality in the Latent Structure of Schizotypal Personality Features

The authors investigated the latent structure of schizotypal personality features using taxometric analysis in a large sample of individuals from clinical and nonclinical populations. A total of 7,072 community adults and 270 psychiatric patients participated in the study by responding to the eccentricity, distrust, and isolation scales from the Dimensional Clinical Personality Inventory (IDCP). Data were analyzed using three different taxometric techniques, MAMBAC, MAXEIG, and L-Mode. The indicators proved valid for the taxometric analysis (d ≥ 1.25). The comparison curve fit index (CCFI) coefficients from the three methods used were close to zero, and the average CCFI was lower than .40, clearly indicating a dimensional structure for schizotypal personality features. These findings suggest that schizotypal personality traits occur in levels, with no evidence of any natural boundary between clinical and nonclinical manifestations. Results from other studies that were consistent with a categorical structure may be due to methodological weaknesses.

A meta-structure for DSM-5 and ICD-11 pathological traits and the differentiation of personality functioning at different trait levels in older adults

OBJECTIVES

Categorical criteria are not well suited to inform personality disorder (PD) diagnoses in older adults. More promising are the ICD-11 and DSM-5 alternative models. Both conceptualize PD by level of severity and maladaptive traits. Severity is conditional for making a PD diagnosis. Trait levels portray stylistic differences in PD expression. Yet, in older adults the hierarchical trait structure is unknown. Neither is the differentiation of the severity criterion from maladaptive traits confirmed.

METHODS

A series of exploratory factor analyses with progressively greater numbers of factors were conducted to examine the hierarchical trait structure in 293 community dwelling older adults. The on average differentiation of a single higher order personality functioning factor from trait factors at succeeding levels of the hierarchy was estimated with Cohen q effect size.

RESULTS

Six meaningful trait levels were identified. From the fourth trait level on the general personality functioning factor shared less than 15% variance on average with the trait factors. Trait factors at the sixth level corresponded to both DSM-5 and ICD-11 pathological traits.

CONCLUSION

A future nosology integrating DSM-5 and ICD-11 trait proposals would be applicable in older adults. Personality functioning can be differentiated from traits, so separate assessment of traits and severity is worthwhile.

Examining the Structure and Validity of Self-Report Measures of DSM-5 Alternative Model for Personality Disorders Criterion A

The Level of Personality Functioning Scale (LPFS) operationalizes Criterion A of the DSM-5 Alternative Model for Personality Disorders. Despite progress in LPFS measurement development and validation, there is a lack of research, and some disagreement, concerning structural, convergent, and incremental validity of LPFS self-report measures. The present study aimed to compare the LPFS Self-Report, LPFS Self-Report of Criterion A, and LPFS Brief Form. Internal structure was assessed through principal component analyses, factor analyses, and bifactor analyses of unidimensionality. Associations with both pathological and basic personality characteristics among the LPFS measures were explored. Incremental validity of LPFS severity in predicting pathological personality outcomes controlling for basic personality traits, and the reverse, were examined. Results suggest a unidimensional structure robustly associated with other pathological personality assessments. LPFS severity and basic personality traits mutually offered unique explanatory power. We discuss the implications of assessing personality pathology using LPFS self-report measures.

Associations Between MMPI-3 Scale Scores and the DSM-5 AMPD and ICD-11 Dimensional Personality Traits

The current study aimed to examine the associations between Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scales and the dimensional personality traits contained within the ICD-11 Personality Disorder diagnosis and DSM-5 Alternative Model for Personality Disorders (AMPD) models. The sample consisted of 489 undergraduate students, with dimensional personality traits operationalized via the Comprehensive Assessment of Traits relevant to Personality Disorder (CAT-PD). A priori hypotheses were generated for which MMPI-3 scales would be most associated with each personality trait domain, as well as individual CAT-PD scales. Zero-order correlations and regression analyses were used to examine associations between a set of hypothesized MMPI-3 scale scores and CAT-PD scale scores. The results showed a pattern of meaningful correlations supporting the majority of hypotheses. Moreover, most hypothesized scales also incremented one another in regression models predicting hypothesized PD scale scores. These findings indicate that the MMPI-3 is well situated to aid clinicians in the assessment of personality trait dysfunction from a dimensional perspective.

Somatization and Somatic Symptom Disorder and its overlap with dimensionally measured personality pathology: A systematic review

OBJECTIVE

Difficulties in the assessments of Somatoform Disorders (SD) and Personality Disorders (PD) regarding operationalization, arbitrary thresholds, and reliability led to a shift from categorical to dimensional models in the DSM-5. Empirical research data postulates a continuous level of severity in both groups of diseases. The aim of this systematic review was to investigate the overlap between somatization and personality pathology.

METHODS

Until July 2020, we conducted a systematic literature search with PubMed, Web of Science and SCOPUS. We specifically reviewed current empirical data on the Alternative Model of Personality Disorders (AMPD) and Somatic Symptom Disorder (SSD) and SD. Data was drawn out using predefined data panels. Results were reflected in the context of the Hierarchical Taxonomy of Psychopathology (HiTOP) model. Risk of bias was assessed due to blinding, randomization, selective reporting, incomplete data, and attribution bias.

RESULTS

A total of eight studies (N = 2979) met the inclusion criteria. Whereas categorical measures revealed mixed results, positive correlations between SD/SSD and dimensionally measured personality functioning were present in four studies (N = 1741). In three studies (N = 2025) correlations between SD/SSD and neuroticism/negative affectivity (d = 0.22-1.041) were present. Moreover, harm avoidant (d = 0.526 - 0.826) and self-defeating traits (d = 0.892) revealed significant associations with somatization.

CONCLUSIONS

Dimensional personality assessments are highly neglected in patients with SSD and warrant further research. However, in line with the HiTOP model, there is tentative evidence that somatization can be described as an independent personality trait, which shows most striking overlaps with self-pathologies (Criterion A) and the trait of negative affectivity (Criterion B).

Associations between MMPI-3 scale scores and the DSM-5 personality disorders

OBJECTIVE

The current study examined associations between Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scales and self-reported DSM-5 Section II personality disorder (PD) symptoms. A priori hypotheses were generated for which MMPI-3 scales would be most highly associated with each PD.

METHODS

We used a large sample (n = 489) of university students, who completed the MMPI-3 and two established self-report measures of personality disorders.

RESULTS

The results were generally consistent with theoretical expectations and previous research utilizing the MMPI-2-RF. Specifically, most hypothesized MMPI-3 scales exhibited meaningful associations with relevant PD variables, although there were some notable exceptions. The regression models revealed significant predictors for each PD which were generally consistent with expectations and previous research.

CONCLUSIONS

Overall, the MMPI-3 appears well situated to cover a range of DSM-5 Section II PD-related psychopathology, and three of the new MMPI-3 scales appear to have added utility for assessing personality pathology.

Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization

PURPOSE OF REVIEW

The concept of personality functioning (Alternative DSM-5 Model of Personality Disorders) has led to increased interest in dimensional personality disorder diagnosis. While differing markedly from the current categorical classification, it is closely related to the psychodynamic concepts of personality structure and personality organization. In this review, the three dimensional approaches, their underlying models, and common instruments are introduced, and empirical studies on similarities and differences between the concepts and the categorical classification are summarized. Additionally, a case example illustrates the clinical application.

RECENT FINDINGS

Numerous studies demonstrate the broad empirical basis, validated assessment instruments and clinical usefulness of the dimensional concepts. Their advantages compared to the categorical approach, but also the respective differences, have been demonstrated empirically, in line with clinical observations. Evidence supports the three dimensional concepts, which share conceptual overlap, but also entail unique aspects of personality pathology, respectively.

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.

DSM-5 Level of Personality Functioning: Refocusing Personality Disorder on What It Means to Be Human

Level of Personality Functioning (LPF) represents the entry criterion (Criterion A) of the Alternative Model for Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is defined as a dimensional general severity criterion common to all personality disorders and conceptually independent of personality types or traits, and it represents maladaptive self (identity and self-direction) and interpersonal (empathy and intimacy) functioning. We review the history, measurement, and significance of LPF. We show that the inclusion of LPF in the AMPD is well justified if it is defined as a general adaptive failure of a subjective intrapsychic system needed to fulfill adult life tasks. If so defined, LPF distinguishes itself from maladaptive traits (Criterion B of the AMPD) and captures the contribution humans make as agentic authors to the interpretation and management of the self. While Criterion B maladaptive traits provide important descriptive nuance to manifestations of personality pathology, maladaptive LPF is conditional to the diagnosis of personality disorder.

The Inter-Rater Reliability and Validity of the Italian Translation of the Structured Clinical Interview for DSM-5 Alternative Model for Personality Disorders Module I and Module II: A Preliminary Report on Consecutively Admitted Psychotherapy Outpatients

To evaluate the reliability and convergent validity of the Structured Clinical Interview for DSM-5 Alternative Model for Personality Disorders (SCID-5-AMPD) Module I and Module II, 88 adult psychotherapy participants were administered the Italian translations of the SCID-5-AMPD Module I and Module II, Level of Personality Functioning Scale-Brief Form (LPFS-BF), Level of Personality Functioning Scale-Self Report (LPFS-SF), Personality Inventory for DSM-5 (PID-5), Personality Diagnostic Questionnaire-4+ (PDQ-4+), and Structured Clinical Interview for DSM-5 Personality Disorders (SCID-5-PD) relying on a Williams crossover design. SCID-5-AMPD Module I and Module II showed excellent inter-rater reliability. In terms of convergent validity, meaningful associations were observed between SCID-5-AMPD Module I scores and self-report measures of Criterion A; similarly, SCID-5-AMPD Module II trait scores were meaningfully related to PID-5 trait scores. As a whole, our preliminary findings supported the clinical utility of DSM-5 AMPD.

The Structure of Psychopathology in a Sample of Clinically Referred, Emotionally Dysregulated Early Adolescents

This investigation answers and amplifies calls to model the transdiagnostic structure of psychopathology in clinical samples of early adolescents and using stringent psychometric criteria. In 162 clinically referred, clinically evaluated 11-13-year-olds, we compared a correlated two-factor model, containing latent internalizing and externalizing factors, to a bifactor model, which added a transdiagnostic general factor. We also evaluated the bifactor model psychometrically, including criterion validity with broad indicators of psychosocial functioning. In doing so, we compared alternative approaches to defining and interpreting criterion validity: a recently proposed incremental definition based on amounts of variance in criterion factors explained, and the more typical definition based on the presence of conceptually meaningful relationships. While traditional fit statistics favored the bifactor model as expected, psychometric analyses added important nuance. Despite moderate reliability, the general factor was not fully transdiagnostic (i.e., was not informed by several externalizing scores), and was partially redundant with internalizing scores. Approaches to criterion validity yielded opposing results. Compared to the correlated two-factor model, the bifactor model redistributed, without incrementally increasing, the total variance explained in criterion indicators of psychosocial functioning. Yet, the bifactor model did improve the precision of clinically important relationships to psychosocial functioning, raising questions about meaningful tests of bifactor psychopathology models.

Assessment of Criterion A

The diagnostic concept of Personality Disorder (PD) is changing. A dimensional PD concept that focuses on severity of impairment of personality functioning was introduced in the DSM 5 Section III in 2013 and is adopted by the upcoming ICD-11 in a similar manner. Several reliable, valid and useful instruments to assess personality functioning (Criterion A) either as self-report, expert rating or clinical interview were developed in the past years. This article gives a latest state-of-the-art overview of these measures. It underlines the importance of multi-informant multi-method assessment of, and a longitudinal perspective on PD pathology and the importance of standardized inclusion of PD individuals in studies to increase the significance of research findings.

Global personality dysfunction and the relationship of pathological and normal trait domains in the DSM-5 alternative model for personality disorders

OBJECTIVE

The DSM-5 Alternative Model of Personality Disorders distinguishes core personality dysfunction common to all personality pathology from maladaptive traits that delineate specific variants of disorder. Previous research shows the convergence between maladaptive and normal range trait domains as well as substantial correlations between maladaptive traits and core dysfunctions, leading some to conclude that personality traits and dysfunction are redundant. This study sought to examine the potential utility of the concept of core dysfunctions as a means of clarifying the nature of the relationship between maladaptive and normal-range traits.

METHOD

Three nonclinical samples (n = 178, 307, and 1,008) were evaluated for personality dysfunction, maladaptive traits, and normal-range traits using different measures.

RESULTS

Results indicated that: (1) normal trait domains and core dysfunction contribute independently to understanding maladaptive traits; (2) the correlation of a normal trait domain with its putative maladaptive equivalent is consistently accounted for in part by core dysfunction; and (3) the multitrait multimethod matrices of normal and maladaptive personality trait domains demonstrate appreciable discriminant validity problems that are clarified by a consideration of core dysfunction.

CONCLUSION

These results suggest that maladaptive traits reflect the distinguishable contributions of core personality dysfunction (problems) and normal-range personality traits (person).

Interdiagnostician Reliability of the DSM-5 Section II and Section III Alternative Model Criteria for Borderline Personality Disorder

This study examined the interdiagnostician reliability and potential gender bias of the DSM-IV/DSM-5 Section II and DSM-5 Alternative Model definitions of borderline personality disorder. A national sample of 123 mental health professionals provided diagnostic judgments on 12 case vignettes selected to represent a range of personality pathology. Two versions of each case were included, one identified as male and the other as female, but which were otherwise identical. Analyses examined the intraclass correlation between clinicians and also examined rates of diagnostic assignments as a function of case gender. Reliability of diagnosis of borderline personality did not differ across the two diagnostic approaches, and concordance of diagnoses across the two systems was significant. The dimensional components of the DSM-5 Alternative Model demonstrated significantly more diagnostic reliability than the DSM-IV categorical diagnoses. The DSM-5 Alternative Model conceptualization of borderline personality can be diagnosed with comparable or greater reliability than the extant DSM-IV definition.

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.

Psychosis and Schizophrenia-Spectrum Personality Disorders Require Early Detection on Different Symptom Dimensions

Psychotic disorders and schizophrenia-spectrum personality disorders (PD) with psychotic/psychotic-like symptoms are considerably linked both historically and phenomenologically. In particular with regard to schizotypal and schizotypal personality disorder (SPD), this is evidenced by their placement in a joint diagnostic category of non-affective psychoses in the InternationaI Classification of Diseases 10th Revision, (CD-10) and, half-heartedly, the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, (DSM-5). Historically, this close link resulted from observations of peculiarities that resembled subthreshold features of psychosis in the (premorbid) personality of schizophrenia patients and their biological relatives. These personality organizations were therefore called "borderline (schizophrenia)" in the first half of the 20th century. In the 1970s, they were renamed to "schizotypal" and separated from psychotic disorders on axis-I and from other PD on axis-II, including modern borderline PD, in the DSM. The phenomenological and historical overlap, however, has led to the common assumption that the main difference between psychotic disorders and SPD in particular was mainly one of severity or trajectory, with SPD representing a latent form of schizophrenia and/or a precursor of psychosis. Thus, psychosis proneness and schizotypy are often assessed using SPD questionnaires. In this perspective-piece, we revisit these assumptions in light of recent evidence. We conclude that schizotypy, SPD (and other schizophrenia-spectrum PD) and psychotic disorder are not merely states of different severity on one common but on qualitatively different dimensions, with the negative dimension being predictive of SPD and the positive of psychosis. Consequently, in light of the merits of early diagnosis, the differential early detection of incipient psychosis and schizophrenia-spectrum PD should be guided by the assessment of different schizotypy dimensions.

Detecting the Presence of a Personality Disorder Using Interpersonal and Self-Dysfunction

Calls have increased to place interpersonal and self-disturbance as defining features of personality disorders (PDs). Findings from a methodologically diverse set of studies suggest that a common factor undergirds all PDs. The nature of this core of PDs, however, is not clear. In the current study, interviews were completed for DSM-IV PD diagnosis and interpersonal dysfunction independently with 272 individuals (PD = 191, no-PD = 91). Specifically, we evaluated interpersonal dysfunction across social domains. In addition, we empirically assessed the structure of self-dysfunction in PDs. We found dysfunction in work and romantic domains, and unstable identity uniquely predicted variance in the presence of a PD. Using receiver operating characteristic analysis, we found that the interpersonal dysfunction and self-dysfunction scales each predicted PDs with high accuracy. In combination, the scales resulted in excellent sensitivity (.90) and specificity (.88). The results support interpersonal and self-dysfunction as general factors of PD.

The Level of Personality Functioning Scale-Brief Form 2.0: Update of a brief instrument for assessing level of personality functioning

Section III of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) introduced the alternative model of personality disorders that includes assessing levels of personality functioning. Here, we describe the development, preliminary psychometric evaluation and sensitivity to change of a revised brief self-report questionnaire, the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0). Patients (N = 201) referred to a specialized centre for the assessment and treatment of personality disorders completed the LPFS-BF 2.0, the Brief Symptom Inventory and the Severity Indices of Personality Problems Short Form and were administered the Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders. Internal structure and aspects of construct validity were examined. A subsample of 39 patients also completed the questionnaires after 3 months of inpatient treatment. Confirmatory factor analyses demonstrated better fit for a two-factor solution (interpretable as self-functioning and interpersonal functioning) than for a unidimensional model, though acceptable model fit was evident only after two post hoc modifications. The LPFS-BF 2.0 demonstrated satisfactory internal consistency and promising construct validity. Sensitivity to change after 3 months of treatment was high. The LPFS-BF 2.0 constitutes a short, user-friendly instrument that provides a quick impression of the severity of personality pathology. © 2018 John Wiley & Sons, Ltd.

Maladaptive beliefs as mediators of the relationship between personality traits and Borderline Personality Disorder symptoms

Abstract The present study analyzes the relationship between maladaptive beliefs, personality traits, and Borderline Personality Disorder symptoms by focusing in the mediating role of beliefs in the prediction between personality and psychiatric disorders. The sample consisted of 823 adults aged between 18 and 39 years (M = 24.09, SD = 4.71), who answered a questionnaire of symptoms and beliefs for Borderline Personality Disorder and Big Five Personality Inventory. The predictive model that fit better to the data indicates Neuroticism and Conscientiousness as predictors of Borderline Personality Disorder symptoms, mediated by maladaptive belief patterns. In this sense, it is possible to conclude that both personality traits and maladaptive beliefs are important for the understanding of Borderline Personality Disorder. The theoretical implications of this result and the limitations of the study are discussed.

Schema therapy conceptualization of personality functioning and traits in ICD-11 and DSM-5

PURPOSE OF REVIEW

Schema therapy conceptualizes personality disorders in terms of modes and underlying schemas. This article reviews the literature on schema therapy conceptualization of personality disorder functioning and traits, and proposes how these findings apply to novel personality disorder classification in ICD-11 and the DSM-5 Alternative Model of Personality Disorders (AMPD).

RECENT FINDINGS

Maladaptive schemas and modes are generally associated with personality dysfunction and traits in conceptually coherent ways. The healthy adult mode, a transdiagnostic core concept in schema therapy, corresponds to the ICD-11 and DSM-5-AMPD features of core personality functioning. Modes and underlying schemas substantially overlap with specific ICD-11 and DSM-5-AMPD traits, which denote individual themes and styles of personality dysfunction.

SUMMARY

The dimensional personality disorder framework in ICD-11 and DSM-5-AMPD is largely compatible with the schema therapy model. The ICD-11 and DSM-5-AMPD provide a scientifically derived and theory-free framework for all practitioners, which may be connected to clinical theory of schema therapy in a coherent manner. Level of personality functioning can be conceptualized as healthy adult functioning (e.g. sense of identity, self-worth, emotion regulation, intimacy, and fulfillment), which inform intensity of treatment. Trait qualifiers can be conceptualized by associated modes (e.g., compliant surrender) and underlying schemas (e.g. abandonment), which inform focus and style of treatment.

What Does Personality Mean in the Context of Mental Health? A Topic Modeling Approach Based on Abstracts Published in Pubmed Over the Last 5 Years

Personality disorders (PDs) are one of the major problems for the organization of public health systems. Deepening the link between personality traits and psychopathological drifts, it seems increasingly essential for the often dramatic repercussions that PDs have on social contexts. Some of these disorders, such as borderline PD, antisocial PD, in their most tragic expression, are the basis of problems related to crime, sexual violence, abuse, and mistreatment of minors. Many authors propose a dimensional classification of personality pathology, which has received empirical support from numerous studies over the last 20 years based on more robust theoretical principles than those applied to current nosography. The present study investigates the nature of the research carried out in the last years on the personality in the clinical field exploring the contents of current research on personality relapses, evaluating, on the one hand, the emerging areas of greatest interest and others, those that they stopped generating sufficient motivations in scholars. This study evaluates text patterns regarding how the terms "personality" and "mental health" are used in titles and abstracts published in PubMed in the last 5 years. We use a topic analysis: Latent Dirichlet Allocation that expresses every report as a probabilistic distribution of latent topics that are represented as a probabilistic distribution of words. A total of 7,572 abstracts (from 2012 to 2017) were retrieved from PubMed for the query on "mental health" and "personality." The study found 30 topics organized in eight hierarchical clusters that describe the type of current research carried out on personality and its clinical relapse. The hierarchical clusters latent themes were the following: social dimensions, clinical aspects, biological issues, clinical history of PD, internalization and externalization symptoms, impulsive behaviors, comorbidities, criminal behaviors. The results indicate that the concept of personality is associated with a wide range of conditions. The study of personality and mental health still proceeds, mainly, according to a practical-clinical approach; too little moves, however, according to an innovative research approach, but the work shows the common commitment of scholars to a new way of dealing with the study of personality.

A Bayesian Account of Psychopathy: A Model of Lacks Remorse and Self-Aggrandizing

This article proposes a formal model that integrates cognitive and psychodynamic psychotherapeutic models of psychopathy to show how two major psychopathic traits called lacks remorse and self-aggrandizing can be understood as a form of abnormal Bayesian inference about the self. This model draws on the predictive coding (i.e., active inference) framework, a neurobiologically plausible explanatory framework for message passing in the brain that is formalized in terms of hierarchical Bayesian inference. In summary, this model proposes that these two cardinal psychopathic traits reflect entrenched maladaptive Bayesian inferences about the self, which defend against the experience of deep-seated, self-related negative emotions, specifically shame and worthlessness. Support for the model in extant research on the neurobiology of psychopathy and quantitative simulations are provided. Finally, we offer a preliminary overview of a novel treatment for psychopathy that rests on our Bayesian formulation.

Interpersonal Dynamics in Personality and Personality Disorders

Clinical and basic personality psychologists interact less than they should, given their similar interests. In clinical personality psychology, available evidence supports a transition from the current categorical system to a hierarchical trait scheme for diagnosing the stable features of personality disorder. However, trait models do not capture the dynamic aspects of personality disorders as they have been described in the clinical literature, and thus miss a clinically critical feature of personality pathology. In contrast, basic personality psychologists have coalesced around a consensual structure of individual differences and become increasingly interested in the dynamic processes that underlie and contextualize traits. But trait psychology models are not sufficiently specific to characterize dynamic personality processes. In this paper, I filter clinical descriptions of personality disorders through the lens of interpersonal theory to specify a recursive within–situation interpersonal pattern of motives, affects, behaviours, and perceptions that could contribute to the stable between–situation patterns of maladaptive behaviour of historical interest to both basic and clinical personality psychologists. I suggest that this interpersonal model adds specificity to recent proposals regarding processes in the basic personality literature and has significant potential to advance research on personality dynamics. © 2018 European Association of Personality Psychology

ICD-11 and DSM-5 personality trait domains capture categorical personality disorders: Finding a common ground

OBJECTIVE

The five personality disorder trait domains in the proposed International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition are comparable in terms of Negative Affectivity, Detachment, Antagonism/Dissociality and Disinhibition. However, the International Classification of Diseases, 11th edition model includes a separate domain of Anankastia, whereas the Diagnostic and Statistical Manual of Mental Disorders, 5th edition model includes an additional domain of Psychoticism. This study examined associations of International Classification of Diseases, 11th edition and Diagnostic and Statistical Manual of Mental Disorders, 5th edition trait domains, simultaneously, with categorical personality disorders.

METHOD

Psychiatric outpatients ( N = 226) were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders Interview and the Personality Inventory for DSM-5. International Classification of Diseases, 11th edition and Diagnostic and Statistical Manual of Mental Disorders, 5th edition trait domain scores were obtained using pertinent scoring algorithms for the Personality Inventory for DSM-5. Associations between categorical personality disorders and trait domains were examined using correlation and multiple regression analyses.

RESULTS

Both the International Classification of Diseases, 11th edition and the Diagnostic and Statistical Manual of Mental Disorders, 5th edition domain models showed relevant continuity with categorical personality disorders and captured a substantial amount of their information. As expected, the International Classification of Diseases, 11th edition model was superior in capturing obsessive-compulsive personality disorder, whereas the Diagnostic and Statistical Manual of Mental Disorders, 5th edition model was superior in capturing schizotypal personality disorder.

CONCLUSION

These preliminary findings suggest that little information is 'lost' in a transition to trait domain models and potentially adds to narrowing the gap between Diagnostic and Statistical Manual of Mental Disorders, 5th edition and the proposed International Classification of Diseases, 11th edition model. Accordingly, the International Classification of Diseases, 11th edition and Diagnostic and Statistical Manual of Mental Disorders, 5th edition domain models may be used to delineate one another as well as features of familiar categorical personality disorder types. A preliminary category-to-domain 'cross walk' is provided in the article.

Using the Structured Interview of Personality Organization for DSM-5 Level of Personality Functioning Rating Performed by Inexperienced Raters

We argue that clinical information related to an object-relations model of personality pathology can be used by untrained and clinically inexperienced students to rate personality-disordered patients on the Level of Personality Functioning Scale (LPFS). To do so, 73 clinically inexperienced undergraduate students were asked to assess personality functioning of 10 female inpatients using the LPFS from audio recordings of the Structured Interview of Personality Organization (STIPO). LPFS ratings showed acceptable interrater reliability. Moreover, LPFS ratings were significantly associated with external measures of severity of personality pathology (number of DSM-IV-TR personality disorders) as assessed by experienced clinicians. Finally, the students' ratings were also associated with the level of personality organization as measured by experienced clinicians using the STIPO. Our findings confirm that untrained raters can reliably assess personality pathology by rating the LPFS based on material from the STIPO. Implications related to the use of the STIPO as a tool for the assessment of personality pathology according to the DSM-5 Alternative model are discussed.

Age-Neutrality of a Brief Assessment of the Section III Alternative Model for Personality Disorders in Older Adults

The alternative model for personality disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5) is considered an important step toward a possibly better conceptualization of personality pathology in older adulthood, by the introduction of levels of personality functioning (Criterion A) and trait dimensions (Criterion B). Our main aim was to examine age-neutrality of the Short Form of the Severity Indices of Personality Problems (SIPP-SF; Criterion A) and Personality Inventory for DSM-5-Brief Form (PID-5-BF; Criterion B). Differential item functioning (DIF) analyses and more specifically the impact on scale level through differential test functioning (DTF) analyses made clear that the SIPP-SF was more age-neutral (6% DIF, only one of four domains showed DTF) than the PID-5-BF (25% DIF, all four tested domains had DTF) in a community sample of older and younger adults. Age differences in convergent validity also point in the direction of differences in underlying constructs. Concurrent and criterion validity in geriatric psychiatry inpatients suggest that both the SIPP-SF scales measuring levels of personality functioning (especially self-functioning) and the PID-5-BF might be useful screening measures in older adults despite age-neutrality not being confirmed.

Clinical utility of the DSM-5 alternative model for borderline personality disorder: Differential diagnostic accuracy of the BFI, SCID-II-PQ, and PID-5

BACKGROUND

With the publication of DSM 5 alternative model for personality disorders it is critical to assess the components of the model against evidence-based models such as the five factor model and the DSM-IV-TR categorical model. This study explored the relative clinical utility of these models in screening for borderline personality disorder (BPD).

METHODS

Receiver operator characteristics and diagnostic efficiency statistics were calculated for three personality measures to ascertain the relative diagnostic efficiency of each measure. A total of 1653 adult inpatients at a specialist psychiatric hospital completed SCID-II interviews. Sample 1 (n=653) completed the SCID-II interviews, SCID-II Questionnaire (SCID-II-PQ) and the Big Five Inventory (BFI), while Sample 2 (n=1,000) completed the SCID-II interviews, Personality Inventory for DSM5 (PID-5) and the BFI.

RESULTS

BFI measure evidenced moderate accuracy for two composites: High Neuroticism+ low agreeableness composite (AUC=0.72, SE=0.01, p<0.001) and High Neuroticism+ Low+Low Conscientiousness (AUC=0.73, SE=0.01, p<0.0001). The SCID-II-PQ evidenced moderate-to-excellent accuracy (AUC=0.86, SE=0.02, p<0.0001) with a good balance of specificity (SP=0.80) and sensitivity (SN=0.78). The PID-5 BPD algorithm (consisting of elevated emotional lability, anxiousness, separation insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy (AUC=0.87, SE=0.01, p<0.0001) with a good balance of specificity (SP=0.76) and sensitivity (SN=0.81).

CONCLUSIONS

Findings generally support the use of SCID-II-PQ and PID-5 BPD algorithm for screening purposes. Furthermore, findings support the accuracy of the DSM 5 alternative model Criteria B trait constellation for diagnosing BPD. Limitations of the study include the single inpatient setting and use of two discrete samples to assess PID-5 and SCID-II-PQ.

DSM models of personality disorders

Personality disorders have been included in every edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. Diagnostic terms and revisions from the initial DSM to the current one (DSM-5) are described, and the continuing controversies regarding categorical versus dimensional models are reviewed, including a summary of the new Alternative Model for DSM-5 Personality Disorders, in Section III of DSM-5.

Psychological Assessment with the DSM-5 Alternative Model for Personality Disorders: Tradition and Innovation

The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) Section III Alternative Model for Personality Disorders (AMPD; APA, 2013) represents an innovative system for simultaneous psychiatric classification and psychological assessment of personality disorders (PD). The AMPD combines major paradigms of personality assessment and provides an original, heuristic, flexible, and practical framework that enriches clinical thinking and practice. Origins, emerging research, and clinical application of the AMPD for diagnosis and psychological assessment are reviewed. The AMPD integrates assessment and research traditions, facilitates case conceptualization, is easy to learn and use, and assists in providing patient feedback. New as well as existing tests and psychometric methods may be used to operationalize the AMPD for clinical assessments.

The Personality Inventory for DSM-5 Short Form (PID-5-SF): psychometric properties and association with big five traits and pathological beliefs in a Norwegian population

BACKGROUND

With the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an alternative model for personality disorders based on personality dysfunction and pathological personality traits was introduced. The Personality Inventory for DSM-5 (PID-5) is a 220-item self-report inventory designed to assess the personality traits of this model. Recently, a short 100-item version of the PID-5 (PID-5-SF) has been developed. The aim of this study was to investigate the score reliability and structure of the Norwegian PID-5-SF. Further, criterion validity with the five factor model of personality (FFM) and pathological personality beliefs was examined.

METHODS

A derivation sample of university students (N = 503) completed the PID-5, the Big Five Inventory (BFI), and the Personality Beliefs Questionnaire - Short Form (PBQ-SF), whereas a replication sample of 127 students completed the PID-5-SF along with the aforementioned measures.

RESULTS

The short PID-5 showed overall good score reliability and structural validity. The associations with FFM traits and pathological personality beliefs were conceptually coherent and similar for the two forms of the PID-5.

CONCLUSIONS

The results suggest that the Norwegian PID-5 short form is a reliable and efficient measure of the trait criterion of the alternative model for personality disorders in DSM-5.

Borderline Personality Disorder and Personality Inventory for DSM-5 (PID-5): Dimensional personality assessment with DSM-5

INTRODUCTION

Borderline personality disorder (BPD) diagnosis has been considered highly controversial. The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) proposes an alternative hybrid diagnostic model for personality disorders (PD), and the Personality Inventory for DSM-5 (PID-5) has adequate psychometric properties and has been widely used for the assessment of the dimensional component.

METHODS

Our aim was to analyze the utility of the personality traits presented in Section III of the DSM-5 for BPD diagnosis in an outpatient clinical sample, using the Spanish version of the PID-5. Two clinical samples were studied: BPD sample (n=84) and non-BPD sample (n=45). Between-sample differences in PID-5 scores were analyzed.

RESULTS

The BPD sample obtained significantly higher scores in most PID-5 trait facets and domains. Specifically and after regression logistic analyses, in BPD patients, the domains of Negative Affectivity and Disinhibition, and the trait facets of emotional lability, [lack of] restricted affectivity, and impulsivity were more significantly associated with BPD.

CONCLUSIONS

Although our findings are only partially consistent with the algorithm proposed by DSM-5, we consider that the combination of the PID-5 trait domains and facets could be useful for BPD dimensional diagnosis, and could further our understanding of BPD diagnosis complexity.