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

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

Personality Functioning, Problems in Living, and Personality Traits

The publication of the Alternative Model of Personality Disorder (AMPD) was a signpost achievement in the personality assessment. However, research on the AMPD has generally not led to either a deeper understanding of personality disorder or personality assessment or new ideas about how to provide better care for people with personality disorder diagnoses. A significant portion of research has focused on narrow issues and appears to be driven in part by ideological differences between scholars who prefer Criterion A (personality functioning) or Criterion B (maladaptive traits). I trace these issues to ambiguity about the concept of personality functioning as defined in the AMPD and its conceptual distinction from personality traits and problems in living. In this paper, I reground these concepts in coherent and distinct definitions, elaborate upon the implications of their differences, and show how these differences can help clarify and reorient AMPD research to focus on generating clinically useful models for personality pathology and personality assessment.

Differentiating Abnormal, Normal, and Ideal Personality Profiles in Multidimensional Spaces

Abstract: Current dimensional taxonomies of personality disorder (PD) establish that intense traits do not suffice to diagnose a disorder, and additional constructs reflecting dysfunction are required. However, traits appear able to predict maladaptation by themselves, which might avoid duplications and simplify diagnosis. On the other hand, if trait-based diagnoses are feasible, it is the whole personality profile that should be considered, rather than individual traits. This takes us into multidimensional spaces, which have their own particular – but poorly understood – logic. The present study examines how profile-level differences between normal and disordered subjects can be used for diagnosis. The Dimensional Assessment of Personality Pathology – Basic Questionnaire (DAPP-BQ) and the Personality Inventory for DSM-5 (PID-5) were administered to a community and a clinical sample each (total n = 1,925 and 3,543 respectively). Intense traits proved to be common in the general population, so empirically-based thresholds are indispensable not to take as abnormal what is at most unideal. Profile-level parameters such as Euclidean and Mahalanobis distances outperformed individual traits in predicting mental problems and equaled the performance of published measures of dysfunction or severity. Personality profiles can play a more central role in identifying disorders than is currently acknowledged, provided that adequate metrics are used.

The evolution of personality disorders: A review of proposals

Personality disorders (PDs) are currently considered dysfunctions. However, personality differences are older than humanity and are ubiquitous in nature, from insects to higher primates. This suggests that a number of evolutionary mechanisms-other than dysfunctions-may be able to maintain stable behavioral variation in the gene pool. First of all, apparently maladaptive traits may actually improve fitness by enabling better survival or successful mating or reproduction, as exemplified by neuroticism, psychopathy, and narcissism. Furthermore, some PDs may harm important biological goals while facilitating others, or may be globally beneficial or detrimental depending on environmental circumstances or body condition. Alternatively, certain traits may form part of life history strategies: Coordinated suites of morphological, physiological and behavioral characters that optimize fitness through alternative routes and respond to selection as a whole. Still others may be vestigial adaptations that are no longer beneficial in present times. Finally, variation may be adaptative in and by itself, as it reduces competition for finite resources. These and other evolutionary mechanisms are reviewed and illustrated through human and non-human examples. Evolutionary theory is the best-substantiated explanatory framework across the life sciences, and may shed light on the question of why harmful personalities exist at all.

Severity in the ICD-11 personality disorder model: Evaluation in a Spanish mixed sample

Severity is the main component of the ICD-11 personality disorder (PD) classification, but pertinent instruments have only recently been developed. We analyzed the psychometric properties of the ICD-11 Personality Disorder Severity scale (PDS-ICD-11) in a mixed sample of 726 community and clinical subjects. We also examined how the different components of the ICD-11 PD system -five trait domains, the borderline pattern specifier, and severity, all of them measured through self-reports- are interconnected and operate together. PDS-ICD-11 properties were adequate and similar to those of the original instrument. However, regressions and factor analyses showed a considerable overlap of severity with the five personality domains and the borderline specifier (72.6%). Bifactor modeling resulted in a general factor of PD (g-PD) that was not equivalent to severity nor improved criterion validity. The whole ICD-11 PD system, i.e., five personality domains, borderline, and severity, explained an average of 43.6% of variance of external measures of well-being, disability, and clinical problems, with severity contributing 4.8%. Suggestions to further improve the ICD-11 PD taxonomy include remodeling the present definition of severity to give more weight to the real-life consequences of traits.

Positive Self–regard and Claim to Leadership: Two Fundamental Forms of Self–evaluation

The present article examines the common factor structure of various self–evaluative personality constructs. Consistent with previous research, we found considerable redundancy between constructs. Two basic forms of self–evaluation could be distinguished: Positive Self–regard (PSR) reflects people's contentedness with themselves in comparison with their own standards. Constructs such as depression, self–esteem and neuroticism have very high loadings on this factor. In contrast, Claim to Leadership (CTL) reflects the subjective conviction that one is called to take charge and lead others. This conviction is often called ‘narcissism’. PSR mainly reflects an intra–personal kind of self–evaluation, whereas CTL reflects an inter–personal kind. Both forms of self–evaluation independently predict intellectual self–enhancement, but only one of them (PSR) also predicts self–reported mental health. Moreover, the two forms of self–evaluation are differentially associated with self–reported and peer–reported inter–personal traits (Dominance and Affiliation). Finally, the concepts of ‘Grandiosity’ and ‘Vulnerability’ from narcissism research may easily be reframed in terms of CTL and PSR. The two–dimensional framework may help overcome the conceptual confusion that exists around different forms of self–evaluation and streamline the field for future research. Copyright © 2013 European Association of Personality Psychology

The distinction between symptoms and traits in the Hierarchical Taxonomy of Psychopathology (HiTOP)

The Hierarchical Taxonomy of Psychopathology (HiTOP) is an empirically and quantitatively derived dimensional classification system designed to describe the features of psychopathology and, ultimately, to replace categorical nosologies. Among the constructs that HiTOP organizes are "symptom components" and "maladaptive traits," but past HiTOP publications have not fully explicated the distinction between symptoms and traits. We propose working definitions of symptoms and traits and explore challenges, exceptions, and remaining questions. Specifically, we propose that the only systematic difference between symptoms and traits in HiTOP is one of time frame. Maladaptive traits are dispositional constructs that describe persistent tendencies to manifest features of psychopathology, whereas symptoms are features of psychopathology as they are manifest during any specific time period (from moments to days to months). This has the consequence that almost every HiTOP dimension, at any level of the hierarchy, can be assessed as either a trait or a symptom dimension, by adjusting the framing of the assessment. We discuss the implications of these definitions for causal models of the relations between symptoms and traits and for distinctions between psychopathology, normal personality variation, and dysfunction.

Personality Disorders as Emergent Interpersonal Syndromes: Psychopathic Personality as a Case Example

Personality disorders have long been bedeviled by a host of conceptual and methodological quandaries. Starting from the assumption that personality disorders are inherently interpersonal conditions that reflect folk concepts of social impairment, the authors contend that a subset of personality disorders, rather than traditional syndromes, are emergent interpersonal syndromes (EISs): interpersonally malignant configurations (statistical interactions) of distinct personality dimensions that may be only modestly, weakly, or even negatively correlated. Preliminary support for this perspective derives from a surprising source, namely, largely forgotten research on the intercorrelations among the subscales of select MMPI/MMPI-2 clinical scales. Using psychopathic personality as a case example, the authors offer provisional evidence for the EIS hypothesis from four lines of research and delineate its implications for personality disorder theory, research, and classification. Conceptualizing some personality disorders as EISs elucidates long-standing quandaries and controversies in the psychopathology literature and affords fruitful avenues for future investigation.

The General Criteria for Personality Disorders Assessed by Interview: Do They Still Have a Role to Play?

On the path to developing dimensional models of personality disorder (PD), we are at risk of leaving key diagnostic aspects behind. The general criteria for PD may be important ones because they reflect the defining aspects of personality pathology: long duration, independence from psychopathological states, and harmfulness. We assessed these criteria by interview in a sample of 362 psychiatric outpatients after administering the Personality Diagnostic Questionnaire-4+. The result was a 42.5% fall in self-reported endorsements, due to misinterpretations (11.5%), short duration of traits or contamination by state psychopathology (9.8%), and traits being non-harmful (21.2%). However, not all personality traits and disorders underwent correction to the same extent, and ultimately, the interview did not improve the prediction of clinical variables. These findings raise doubts about the practical relevance of the general criteria for PD and support the role of self-report questionnaires for diagnostic purposes.

Substance and Evaluation in Personality Disorder Diagnoses

Like person judgments in everyday life, diagnoses of personality disorders (PDs) reflect at least two influences: first, the actual characteristics of the target person (substance), and second, the more positive or negative view that the perceiver has of the target person (evaluation). In this article, we present a systematic account of substance and evaluation in PD diagnoses, using a modified version of Brunswik's (1956) lens model. An empirical study shows that the items of the alternative DSM-5 model for personality disorders (AMPD) are in fact saturated with evaluation, that this evaluation is largely the same as "social desirability," and that the two mandatory components of the AMPD (criterion A and B) are not easily distinguishable from one another in that regard. We provide concrete recommendations as to how the conceptual clarity of PD diagnostics may be improved, by distinguishing people's personality dispositions from their (likely) long-term consequences.

Application of the DSM-5 Level of Personality Functioning Scale by Lay Raters

One concern that has been expressed with the Alternative Model for Personality Disorders (AMPD) presented in DSM-5 is that the description of characteristic impairments in personality function uses concepts requiring considerable experience and clinical inference to apply. To examine this question, the individual indicators included in the AMPD's Level of Personality Functioning Scale (LPFS) that describes these core impairments were abstracted as individual items, and then rated on a target acquaintance by 194 undergraduate college students with minimal training in personality disorder and no training in the AMPD. Results indicated that the LPFS indicators were highly internally consistent as rated in this sample, and that the degree of discrimination between groups corresponded very well with the putative level of severity represented for each indicator in the LPFS. These findings support the contention that using the LPFS might not require any particular clinical experience or training.

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

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.

Validation of an Adapted French Form of the Structured Interview for the Five-Factor Model (SIFFM) in a Swiss Sample

Abstract. We analyzed the psychometric properties of the Structured Interview for the Five-Factor Model (SIFFM) in a French-speaking Swiss sample and compared the French version to the original English version. A community-based sample of 260 participants (183 women and 77 men, aged 20 to 88 years, Mage = 46.23, SDage = 16.37) were assessed using the SIFFM and the NEO-FFI-R. Forty of the participants agreed to be filmed or to be assessed by two investigators simultaneously. The internal consistency coefficients of the five dimensions of SIFFM ranged from .63 to .84. An exploratory factor analysis within the confirmatory factor analysis framework showed that the structure of the French version of the SIFFM was in line with the structure suggested by the Five-Factor Model. Except for the modesty and dutifulness subscales, each facet scale had its highest factor loading on the factor representing the targeted domain. Moreover, a principal axis joint factor analysis of the SIFFM and NEO-FFI-R domains suggested that the convergent validity between the two instruments was adequate. Furthermore, the interrater reliability coefficients for the SIFFM scores were high. The French version of the SIFFM shows acceptable psychometric properties, comparable to those of the English version, and may be an informative assessment method and an alternative to self-report measures.

Toward a Shared Understanding of Important Consequences of Personality

The assumption that personality makes a difference in people's everyday lives is probably the main reason why investigating personality seems worthwhile at all. Although the number of empirical studies addressing the everyday consequences of personality is considerable, an overarching conceptual framework is missing. We present such a framework, using a version of the SORKC model from cognitive-behavioral therapy. Our version of the model incorporates a full account of how personality may influence the ways in which people perceive and respond to situations, which may ultimately have important consequences for them and others. However, not everything that formally qualifies as a consequence of personality is equally relevant. In choosing criterion variables for their own research, researchers interested in personality consequences seem to have strongly relied on implicit assumptions regarding a “good life.” We review a sample of recent studies from the personality literature, using our own conceptualization of important personality consequences to assess the current state of the field, and deduce recommendations for future research.

How temperament and character affect our career, relationships, and mental health

BACKGROUND

On the way toward an agreed dimensional taxonomy for personality disorders (PD), several pivotal questions remain unresolved. We need to know which dimensions produce problems and in what domains of life; whether impairment can be found at one or both extremes of each dimension; and whether, as is increasingly advocated, some dimensions measure personality functioning whereas others reflect style.

METHOD

To gain this understanding, we administered the Temperament and Character Inventory to a sample of 862 consecutively attended outpatients, mainly with PDs (61.2%). Using regression analysis, we examined the ability of personality to predict 39 variables from the Life Outcome Questionnaire concerning career, relationships, and mental health.

RESULTS

Persistence stood out as the most important dimension regarding career success, with 24.2% of explained variance on average. Self-directedness was the best predictor of social functioning (21.1%), and harm avoidance regarding clinical problems (34.2%). Interpersonal dimensions such as reward dependence and cooperativeness were mostly inconsequential. In general, dimensions were detrimental only in one of their poles.

CONCLUSIONS

Although personality explains 9.4% of life problems overall, dimensions believed to measure functioning (character) were not better predictors than those measuring style (temperament). The notion that PD diagnoses can be built upon the concept of "personality functioning" is unsupported.

Connecting Personality Structure and Dynamics: Towards a More Evidence-Based and Clinically Useful Diagnostic Scheme

The purpose of this special issue of the Journal of Personality Disorders is to promote the integration of personality structure and dynamics towards more evidence-based and clinically useful conceptualizations of personality pathology. In this article, we describe a contemporary model of personality structure that is useful for distinguishing patients from one another and the connections between this structure and within-person dynamics that occur across different levels of an individual personality, across situations, and within situations. In so doing, we connect the personality trait tradition that has tended to emphasize stable individual differences with traditions that have tended to focus on the more dynamic aspects of interpersonal behavior and emotional experience. We then introduce the empirical articles in this special issue within this integrative context, in order to demonstrate the value in connecting personality structure to dynamics for research and practice.

Pathological Personality Traits and Intimacy Processes within Roommate Relationships

Problems with intimacy constitute an important area of interpersonal dysfunction in those with personality pathology. Drawing on the interpersonal process model of intimacy, the present research used a longitudinal dyadic design of same–sex roommate pairs (n = 103) to address how certain pathological personality traits (i.e. Negative Affect, Detachment, and Antagonism) relate to the development of disclosure, perceived responsiveness, and closeness. We expected that participants’ pathological traits would be linked to both their own and their roommate's intimacy development, and that the mechanisms underlying these links would include the endorsement of interpersonal values and/or the dispositional expression of interpersonal behaviour in the roommate relationship. Our findings demonstrate that interpersonal motives and/or behaviours primarily help to explain how individuals with higher levels of Detachment manifest difficulty with intimacy. Implications of our findings for research on personality pathology, normative traits, and intimacy are discussed. Copyright © 2015 European Association of Personality Psychology

The structure and correlates of self-reported DSM-5 maladaptive personality traits: findings from two German-speaking samples

The authors investigated the structure and correlates of DSM-5 maladaptive personality traits in two samples of 577 students and 212 inpatients using the German self-report form of the Personality Inventory for DSM-5. They found that (a) the factor structure of DSM-5 trait facets is largely in line with the proposed trait domains of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism; (b) all DSM-5 trait domains except Psychoticism are highly related to the respective domains of the Five-Factor Model of personality; (c) the trait facets are positively associated with a self-report measure of general personality dysfunction; and (d) the DSM-5 trait facets show differential associations with a range of self-reported DSM-IV Axis I disorders. These findings give further support to the new DSM-5 trait model and suggest that it may generalize to other languages and cultures.

The DSM-5 personality disorder proposal and future directions in the diagnostic classification of personality disorder

BACKGROUND

The compilation of DSM-5 presented a substantial opportunity to develop a coherent, evidence-based classification of personality disorder. The irremediable problems with DSM-IV are widely recognized, the field seemed ready for change, and the data and methods for constructing a scientific classification are readily available. Rather than seize this opportunity, DSM-5 advanced an incoherent proposal lacking in evidential support and too poorly organized for clinical use.

METHODS

This article examines the problems with the proposal based on a consideration of the basic requirements of a satisfactory classification. It is suggested that an adequate system should have an explicit and coherent conceptual structure, be based on the best available scientific evidence, possess clinical utility, and be as parsimonious as possible.

RESULTS

The DSM-5 proposal fails to meet these criteria. Problems with the product and process suggest the need for a radical reconsideration of how personality disorders are classified and how classifications are compiled.

CONCLUSIONS

The article proposes that greater emphasis be placed on developing a classification that provides the diagnostic information clinicians need to treat personality disorder and that future classifications should be constructed through an explicit process that is open to public scrutiny.

Validierung einer deutschsprachigen 16-Item-Version des Inventars der Persönlichkeitsorganisation (IPO-16)

In diesem Artikel wird eine deutschsprachige Kurzskala des Inventars der Persönlichkeitsorganisation (IPO-16) vorgestellt und in drei klinischen Stichproben mit insgesamt 1300 Personen validiert. Das IPO ist ein international verbreitetes Selbsteinschätzungsinstrument, das in mehreren Versionen vorliegt und zur Erfassung von struktureller Beeinträchtigung in den Bereichen Identität, Abwehr und Realitätsprüfung eingesetzt wird. Die Kurzskala basiert auf 16 versionsübergreifenden IPO-Items und misst den Schweregrad der strukturellen Beeinträchtigung. In den Studien konnte gezeigt werden, dass das IPO-16 (1) intern konsistent ist, (2) eine modellkonforme Faktorenstruktur hat, (3) eine sehr hohe Überlappung zur IPO-Vollversion aufweist, (4) in der Selbsteinschätzung über konvergente und diskriminante Validität verfügt, (5) den Schweregrad der Persönlichkeitsstörung aus Expertensicht unabhängig vom aktuellen Leidensdruck vorhersagt und (6) eine diagnostische Effizienz erreicht, die mit anderen Screening-Instrumenten im Bereich der Persönlichkeitsstörungsdiagnostik vergleichbar ist. Mit dem IPO-16 liegt für den deutschsprachigen Raum erstmals ein ökonomisches und gut validiertes Selbsteinschätzungsinstrument zur Erfassung von struktureller Beeinträchtigung vor.

Assessing the level of structural integration using operationalized psychodynamic diagnosis (OPD): implications for DSM-5

A key ingredient in the current proposal of the DSM-5 Work Group on Personality and Personality Disorders is the assessment of overall severity of impairment in personality functioning: the Levels of Personality Functioning Scale (LPFS). The aim of this article is to contribute a conceptual and empirical discussion of the LPFS from the perspective of the Operationalized Psychodynamic Diagnosis (OPD) system (OPD Task Force, 2008 ). First, we introduce the OPD Levels of Structural Integration Axis (OPD-LSIA), a measure of individual differences in severity of personality dysfunction that is rooted in psychodynamic theory. We show that the OPD-LSIA is reliable, valid, and highly associated with observer ratings of personality disorders. In the second part, we present results from an OPD expert consensus study exploring potential limitations of the current LPFS item set from the perspective of the OPD-LSIA. We conclude with highlighting implications for future revisions of the DSM-5 proposal.