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

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.

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.

Do PID-5 Trait Scores Predict Symptom Disorders? A Meta-analytic Review

The Personality Inventory for DSM-5 (PID-5) has become influential in the dimensional assessment of personality dysfunction. Though most studies have examined links between PID-5 trait domains and personality pathology, a number of investigations have assessed relationships between PID-5 scores and symptom disorders (e.g., depression, anxiety). We employed meta-analytic techniques to synthesize findings in this area, identifying 26 publications assessing associations between PID-5 scores and symptom disorders (N of effect sizes across the five trait domains = 260). PID-5 domain score effect sizes (rs) ranged from 0.20 for Antagonism to 0.35 for Negative Affect (all ps < .00001). Relationships between PID-5 scores and specific forms of psychopathology were generally consistent with expectations, with some unanticipated relationships as well. Findings confirm that the pathological personality traits assessed by the PID-5 predict symptom disorders as well as personality dysfunction, extending the heuristic value and clinical utility of the measure.

Using the Personality Assessment Inventory to Assess the Alternative Model for Personality Disorders: Criterion Validity in a Clinical Sample

The Personality Assessment Inventory (PAI) is a broadband measure of psychopathology that is widely used in applied settings. Researchers developed regression-based estimates that use the PAI to measure constructs of the Alternative Model for Personality Disorders (AMPD) - a hybrid dimensional and categorical approach to conceptualizing personality disorders. Although prior work has linked these estimates to formal measures of the AMPD, there is little work investigating the clinical correlates of this scoring approach of the PAI. The current study examines associations between these PAI-based AMPD estimates and life data in a large, archival dataset of psychiatric outpatients and inpatients. We found general support for the criterion validity of AMPD estimate scores, such that a theoretically consistent pattern of associations emerged with indicators such as prior academic achievement, antisocial behavior, psychiatric history, and substance abuse. These results provide preliminary support to this scoring approach for use in clinical samples.

The effectiveness of individual schema therapy in older adults with borderline personality disorder: A multiple-baseline case series design

OBJECTIVE

The aim of this study was to explore the effectiveness of schema therapy (ST) in older adults with borderline personality disorder (BPD).

METHODS

Multiple baseline case series design with five BPD patients, with a mean age of 66. After a baseline phase with random length, patients received weekly ST sessions for a year, followed by follow-up sessions during 6 months. Participants rated the credibility of negative core beliefs weekly; various secondary outcome measures were assessed every 6 months (severity of BPD, early maladaptive schemas, schema modes, personality functioning, maladaptive personality traits, psychological distress and quality of life), and BPD diagnosis was assessed before baseline and after follow-up. Data were analysed with mixed regression analyses and paired t-tests.

RESULTS

Results revealed that ST led to a significant decrease in credibility of negative core beliefs, with high effect sizes. All participants remitted from their BPD diagnosis.

CONCLUSION

This is the first study exploring the effectiveness of ST for BPD in older adults, and it suggests that ST can be a powerful intervention for this group of patients.

The predictive validity of the DSM-5 alternative model for borderline personality disorder: Associations with coping strategies, general distress, rumination, and suicidal ideation across one year

The DSM-5 Alternative Model for Personality Disorders (AMPD) characterizes borderline personality disorder (BPD) in part as a constellation of maladaptive personality trait facets including emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, risk-taking, and hostility. Previous studies have supported the construct validity of AMPD-BPD; however, research examining its predictive validity in relation to theoretically and clinically relevant constructs remains needed. The present study investigates the longitudinal relationships between AMPD-BPD and general distress, rumination, and suicidal ideation, as well as adaptive and maladaptive coping targeted in Dialectical Behavior Therapy (DBT) in a sample of participants with elevated BPD symptomology. We also examined if dysfunctional coping skill use at 9-month follow-up explained the relationship between baseline BPD traits and outcomes at 1-year. There were significant correlations between baseline trait BPD with dysfunctional coping skill use at 9-month follow-up and psychological distress and rumination at 1-year follow-up. Dysfunctional skill use exhibited a significant indirect effect in the association between trait BPD and rumination after 1 year. The findings of this study support the construct validity of AMPD-BPD that can inform treatment and research.

Key insights from studies on the stability of personality disorders in different age groups

While for decades, temporal stability has been conceived as a defining feature of personality disorders (PDs), cumulative findings appear to question the stability of PDs and PD symptoms over time. However, stability itself is a complex notion and findings are highly heterogenous. Building upon a literature search from a systematic review and meta-analysis, this narrative review aims to capture key findings in order to provide critical implications, both for clinical practice and future research. Taken together, this narrative review revealed that unlike previous assumptions, stability estimates in adolescence are comparable to stability estimates in adulthood and PDs and PD symptoms are not that stable. The extent of stability itself depends yet on various conceptual, methodological, environmental, and genetic factors. While findings were thus highly heterogenous, they all seem to converge in a notable trend towards symptomatic remission, except for high-risk-samples. This challenges the current understanding of PDs in terms of disorders and symptoms and argues instead in favor of the AMPD and ICD-11 reintroducing the idea of self and interpersonal functioning as the core feature of PDs.

Attitudes, Clinical Practices, and Perceived Advocacy Needs of Professionals With Interests in Personality Disorders

Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the International Society for the Study of Personality Disorders surveyed 248 professionals with interests in PDs about their attitudes toward different diagnostic systems for adults and adolescents, their PD-related clinical practices, and perceived advocacy needs in their area. Results suggested that dimensional diagnostic systems are preferable to categorical and that skepticism about personality pathology in adolescents may not be warranted. The most pressing advocacy need was the increased availability of PD-related services, but many other needs were identified. Results provide a blueprint for advocacy and suggest ways that professional societies can collaborate with public health bodies to expand the reach of PD expertise and services.

The prognostic utility of personality traits versus past psychiatric diagnoses: Predicting future mental health and functioning

Past psychiatric diagnoses are central to patient case formulation and prognosis. Recently, alternative classification models such as the Hierarchical Taxonomy of Psychopathology (HiTOP) proposed to assess traits to predict clinically-relevant outcomes. The current study directly compared personality traits and past diagnoses as predictors of future mental health and functioning in three independent, prospective samples. Regression analyses found that personality traits significantly predicted future first onsets of psychiatric disorders (ΔR2=06-.15), symptom chronicity (ΔR2=.03-.06), and functioning (ΔR2=.02-.07), beyond past and current psychiatric diagnoses. Conversely, past psychiatric diagnoses did not provide an incremental prediction of outcomes when personality traits and other concurrent predictors were already included in the model. Overall, personality traits predicted a variety of outcomes in diverse settings, beyond diagnoses. Past diagnoses were generally not informative about future outcomes when personality was considered. Together, these findings support the added value of personality traits assessment in case formulation, consistent with HiTOP model.

Feasibility of the Cognitive Model for Behavioral Interventions in Older Adults with Behavioral and Psychological Symptoms of Dementia

Objectives: The purpose of this study was to develop an individually tailored, non-pharmacological treatment model, the Cognitive Model for Behavioral Interventions (CoMBI), for patients with Behavioral and Psychological Symptoms of Dementia (BPSD) and comorbid maladaptive personality traits (CMPT), and to explore its feasibility and effectiveness.Methods: CoMBI was developed and implemented in two geriatric psychiatric inpatient wards in the Netherlands. In this single-group pretest-posttest, feasibility study, 40 patients with BPSD and CMPT (M = 73.8, SD = 8.5) were treated with CoMBI. BPSD and CMPT were assessed using informant-based questionnaires. Wilcoxon signed-rank tests and effect size calculations were conducted to determine differences.Results: Wilcoxon signed-rank tests demonstrated a significant decrease of BPSD with medium (r = 0.45) to large (r = 0.56) effect sizes. CoMBI demonstrated high acceptability and compliance by health-care professionals and family members.Conclusions: CoMBI is a feasible treatment model for challenging behavior in patients with BPSD and CMPT. CoMBI is associated with a significant decrease in challenging behaviors regardless of etiology.Clinical implications: Focusing on personality and associated core needs could have a key role in the non-pharmacological treatment of the elderly with BPSD.

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.

Exploring the Alternative Model for Personality Disorders Using SCORS-G Ratings on Thematic Apperception Test Narratives

The Alternative Model for Personality Disorders (AMPD) in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) conceptualizes personality pathology as a combination of impairment (Criterion A) and traits (Criterion B). One measure used to develop Criterion A was the Social Cognition and Object Relations Scale - Global Rating Method (SCORS-G), which is a multidimensional, object-relational clinician-rated measure of personality functioning. Although there are conceptual links between the AMPD and SCORS-G dimensions, there exists no research examining the relationship. To address this, we examined associations between the SCORS-G dimensions and measures of the AMPD constructs in a large, archival dataset of outpatients and inpatients. More pathological scores on SCORS-G dimensions reflecting self- and interpersonal functioning were associated with greater pathological traits and impairment. Overall, results support further investigation into SCORS-G as a useful measure in AMPD research and assessment.

Trading Patients: Applying the Alternative Model for Personality Disorders to Two Cases of DSM-5 Borderline Personality Disorder Over Time and Across Therapists

The DSM-5 Alternative Model for Personality Disorders (AMPD) dimensionally defines personality pathology using severity of dysfunction and maladaptive style. As the empirical literature on the clinical utility of the AMPD grows, there is a need to examine changes in diagnostic profiles and personality expression in treatment over time. Assessing these changes in individuals diagnosed with borderline personality disorder (BPD) is complicated by the tendency for patients to cycle through multiple therapists over the course of treatment leaving the potential for muddled diagnostic clarity and disjointed case conceptualizations. Following patient trajectories across therapists offers a unique opportunity to examine the AMPD’s sensitivity to and utility for capturing personality stability and change over time for patients with BPD. This article demonstrates the utility of the AMPD for two clinical cases in three distinct ways: (i) highlighting heterogeneity in BPD between patients, (ii) comparing improvements in personality severity and style over time, and (iii) elucidating profile change across therapist ratings. We present two patients diagnosed with DSM-5 Section II BPD, crossing between two therapists over the course of 3 years of psychodynamic psychotherapy. Treating clinicians rated patients for their respective treatment phases using the Level of Personality Functioning Scale (LPFS), capturing severity, and the Personality Inventory for the DSM-5 (PID-5), capturing style. AMPD diagnostic profiles differentiated patients with BPD in both severity and style, and captured within-patient change beyond within-therapist response bias. Results indicated greater improvements in personality severity while personality style remained more stable. Implications for the patients’ treatment progress and associated challenges are discussed, as are considerations for the utility of the AMPD in therapy.

Adult ADHD and emerging models of maladaptive personality: a meta-analytic review

BACKGROUND

ADHD is a highly consequential disorder that is estimated to affect 2.5% of the adult population. Emerging models of psychopathology posit that disorders like ADHD can be usefully situated within general models of individual differences in personality, such as those recently implemented in the DSM and ICD for the diagnosis of personality disorder. Previous research and systematic reviews have linked adult ADHD to the personality traits Conscientious Inhibition and Negative Emotionality. However, there have been some inconsistencies in the literature and research embedding ADHD-personality connections in the DSM-5 and ICD-11 personality disorder models has been limited. The goal of this paper was to systematically review associations between adult ADHD and personality traits, organized within a maladaptive five factor framework.

METHOD

A comprehensive literature search yielded 13 papers whose effects were meta-analyzed.

RESULTS

Results supported associations between ADHD and low Conscientious Inhibition and high Negative Emotionality. However, interesting patterns of variability were observed, potentially related to issues such as instrumentation and facet variation.

CONCLUSION

Results support the clinical application of personality assessment for suggesting risk for ADHD symptoms, and point to important directions for further research.

Resilient, undercontrolled, and overcontrolled personality types based upon DSM-5 maladaptive personality traits

We explored the clinical relevance of resilient, overcontrolled and undercontrolled personality types based upon DSM-5 maladaptive personality traits. We examined if these prototypes could be differentiated in terms of personality functioning, and internalizing and externalizing pathology. Self-report questionnaires and structured interviews were administered to 192 adult patients referred to a mental health care center specialized in assessment and treatment of personality disorders. Through cluster analysis we identified a resilient type with no elevation on maladaptive trait domains and showing better personality functioning and less pathology than the overcontrolled and undercontrolled types. Furthermore, the overcontrolled type had elevated Negative Affectivity and a higher prevalence of mood disorders, whereas the undercontrolled type had elevations on all maladaptive traits, with the exception of Disinhibition, and higher rates of narcissistic and borderline personality disorders. Given the differences in psychopathology between the types, identifying these types may inform treatment focus. Also, in line with a stepped care model, compared to overcontrollers, resilient types may need less intensive treatment and undercontrollers may need more intensive treatment.

Differences between ICD-11 PTSD and complex PTSD on DSM-5 section III personality traits

Background: The formulations of post-traumatic stress disorder (PTSD) and the newly included disorder complex PTSD (CPTSD) in the 11th edition of the International Classification of Diseases (ICD-11) have not been evaluated on a broad range of maladaptive personality traits. Objective: The aim of this study was to evaluate ICD-11 PTSD and CPTSD on maladaptive personality traits. Method: In a cross-sectional study of 106 Danish outpatients with ICD-10 PTSD, we used the International Trauma Questionnaire (ITQ) to identify patients with either ICD-11 PTSD or CPTSD (N = 84). We utilized the Personality Inventory for DSM-5 (PID-5) from the alternative model of personality disorders in DSM-5, section III, to evaluate personality trait differences between ICD-11 PTSD and CPTSD. Furthermore, PID-5 was also used to investigate relationships between personality traits and ICD-11 PTSD/CPTSD symptom clusters. The Life Event Checklist was used to assess traumatic experiences, and the MINI International Neuropsychiatric Interview was applied to assess comorbidity. Results: Patients with ICD-11 PTSD or CPTSD had elevated scores on personality traits indicative of internalizing psychopathology. However, higher impairment levels of the trait domains Negative Affectivity (d= 0.75) and Psychoticism (d = 0.80) discriminated patients with ICD-11 CPTSD from patients with PTSD. The PID-5 trait domain Detachment was moderately positively correlated to most of the ITQ symptom clusters and, the ITQ Negative Self-concept symptom cluster showed a relatively high number of significant correlations across all the PID-5 trait domains and facets. The PID-5 domain Negative Affectivity and almost all the encompassing facets were significantly correlated with DSO symptom clusters. Conclusions: The findings demonstrate the relevance of applying dimensional assessment of personality features to study the psychopathology of ICD-11 PTSD and CPTSD and potential differences. The results suggest that CPTSD is a more debilitating disorder than PTSD considering the severity of the personality features.

Psychometric Properties of the Independent 36-Item PID5BF+M for ICD-11 in the Czech-Speaking Community Sample

Background: Empirical soundness and international robustness of the PID5BF+M, a shortened version of the PID-5 developed for simultaneous evaluation of maladaptive personality traits in the DSM-5 AMPD and ICD-11 models for personality disorders, was recently confirmed in 16 samples from different countries. Because the modified PID5BF+ scale (36 items) was extracted from the complete 220-item PID-5, an independent evaluation of psychometric properties of a stand-alone PID5BF+M is still missing. Objectives: The present study evaluated the validity and reliability of the 36-item PID5BF+M in comparison with the extracted version from the original PID-5. It also assessed associations between the Borderline Pattern qualifier and trait domain qualifiers. Methods: Two non-clinical samples meeting the inclusion criteria were employed in the study. Sample 1 (n = 614) completed the 220-item PID-5; Sample 2 (n = 1,040) completed the independent 36-item PID5BF+M. Participants were from all 14 regions of the Czech Republic. The Borderline Pattern qualifier was evaluated using a shortened IPDEQ screener. Results: The proposed latent structure of the independent PID5BF+M was confirmed, with an exception of the Disinhibition domain. The results confirmed good internal consistency and test-retest reliability of the measure, as well as some support for the measurement invariance of the independent PID5BF+M in comparison with the extracted version from the original PID-5. Significant associations between the Negative affectivity, Disinhibition, and Psychoticism qualifiers and the IPDEQ items for the emotionally unstable personality disorder of both impulsive and borderline types confirmed good predictive validity of the PID5BF+M in pursuing borderline psychopathology within the ICD-11 model. Conclusions: The independent PID5BF+M was found to be a valid and reliable tool for evaluation of the ICD-11 trait model. However, the Disinhibition domain deserves further investigation in clinical samples as well as in international community samples.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity

PURPOSE OF REVIEW

The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders.

RECENT FINDINGS

Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust.

SUMMARY

The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

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

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

Scripting the DSM-5 Alternative Model for Personality Disorders assessment procedure: A clinically feasible multi-informant multi-method approach

Published case studies on the DSM-5 (section III) Alternative Model for Personality Disorders (AMPD) generally utilized unstandardized assessment procedures or mono-method approaches. We present a case from clinical practice to illustrate a standardized, clinically feasible procedure for assessing personality pathology according to the full AMPD model, using a multi-method approach. We aim to present a procedure that can guide and inspire clinicians that are going to work with dimensional models as presented in DSM-5 and ICD-11. Specifically, we show how questionnaire and interview data from multiple sources (i.e. patient and family) can be combined. The clinical case also illustrates how Criterion A (i.e. functioning) and B (i.e. traits) are interrelated, suggesting that the joint assessment of both Criterion A and B is necessary for a comprehensive and clinically relevant case formulation. It also highlights how multi-method information can enhance diagnostic formulations. Finally, we show how the AMPD model can serve treatment planning and provide suggestions for how patient feedback might be delivered. © 2020 John Wiley & Sons, Ltd.

Clinical Utility of Assessing Changes of Personality Functioning During Substance Misuse Treatment

Dimensional models for classifying personality have received extensive empirical support in the treatment of substance misuse. However, we do not currently understand whether and which dimensions of personality functioning are amenable to change. The aim was to examine whether there are clinically significant changes between pre- and during-treatment and assess whether these differ between those completing or dropping out of treatment. From the 200 participants from the outpatient and 340 from the inpatient treatment, a purposeful selection was utilised of 75 cases that participated in both phases and had complete datasets of the assessment battery. A quantitative multi-site individual follow-up design allowed the examination of the potential effects of treatment in personality functioning as well as the degree of clinical significant change of personality functioning. We use Jacob and Truax's formula of reliable and clinically significant change. Five independent mixed between-within subject analyses of variance were performed. All personality adaptations changed towards higher-functioning levels, except Social Concordance, which remained stable. Compared to those dropping out, completers had significantly more changes towards functional characteristic adaptations and higher clinical improvement. The persistence of maladaptive characteristic adaptations may be an important risk marker for poor treatment outcomes, requiring therapeutic attention.

International Assessment of DSM-5 and ICD-11 Personality Disorder Traits: Toward a Common Nosology in DSM-5.1

INTRODUCTION

The DSM-5 Alternative Model of Personality Disorders (AMPD) and the ICD-11 classification of personality disorders (PD) are largely commensurate and, when combined, they delineate 6 trait domains: negative affectivity, detachment, antagonism/dissociality, disinhibition, anankastia, and psychoticism.

OBJECTIVE

The present study evaluated the international validity of a brief 36-item patient-report measure that portrays all 6 domains simultaneously including 18 primary subfacets.

METHODS

We developed and employed a modified version of the Personality Inventory for DSM-5 - Brief Form Plus (PID5BF+). A total of 16,327 individuals were included, 2,347 of whom were patients. The expected 6-factor structure of facets was initially investigated in samples from Denmark (n = 584), Germany (n = 1,271), and the USA (n = 605) and subsequently replicated in both patient- and community samples from Italy, France, Switzerland, Belgium, Norway, Portugal, Spain, Poland, Czech Republic, the USA, and Brazil. Associations with interview-rated DSM-5 PD categories were also investigated.

RESULTS

Findings generally supported the empirical soundness and international robustness of the 6 domains including meaningful associations with familiar interview-rated PD types.

CONCLUSIONS

The modified PID5BF+ may be employed internationally by clinicians and researchers for brief and reliable assessment of the 6 combined DSM-5 and ICD-11 domains, including 18 primary subfacets. This 6-domain framework may inform a future nosology for DSM-5.1 that is more reasonably aligned with the authoritative ICD-11 codes than the current DSM-5 AMPD model. The 36-item modified PID5BF+ scoring key is provided in online supplementary Appendix A see www.karger.com/doi/10.1159/000507589 (for all online suppl. material).

Introduction to the Special Series on the Personality Functioning Component of the Alternative DSM-5 Model for Personality Disorders

The Alternative DSM-5 Model for Personality Disorders (AMPD; American Psychiatric Association, 2013 ) was created to remedy the previously well-explicated limitations of the categorical DSM-IV personality disorders. The AMPD combines dimensional assessments of personality functioning (Criterion A) and traits (Criterion B), which can be used independently or together, and serve as the basis for defining six categorical disorder options. The Criterion A Level of Personality Functioning Scale (LPFS) defines a continuum characterized by the four elements of identity, self-direction, empathy, and intimacy. Empirical work related to the LPFS has been growing, and this Journal of Personality Assessment special series features reports from a variety of research groups around the world. These studies provide contributions for better understanding the reliability, validity, and utility of the LPFS, as well as describing new measures that have been created to investigate personality functioning.

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.

The effectiveness of individual schema therapy in older adults with borderline personality disorder: Protocol of a multiple-baseline study

BACKGROUND

The treatment of borderline personality disorder (BPD) has been examined extensively in adults up to the age of fifty in the past quarter of a century, but there is still a world to discover in treating BPD in older adults. The aim of the study is to investigate the effectiveness of schema therapy in older adults with BPD.

METHODS/DESIGN

A multiple baseline design is used in which participants are randomly assigned to baseline length. The primary outcome measure is assessed weekly and consists of the credibility of negative core beliefs. Secondary outcome measures are quality of life, psychological distress, early maladaptive schemas, schema modes, severity of BPD symptoms and meeting the criteria for BPD. Ten older adults (age > 60 years) with BPD are treated with schema therapy, with weekly sessions during one year. This treatment phase is preceded by a baseline phase varying from 4 to 8 weeks. After treatment, there is a 6-month follow-up phase with monthly booster sessions.

DISCUSSION

To our knowledge, this is the first empirical study of the effectiveness of psychotherapeutic treatment for BPD in older adults. Because of the different manifestation of BPD in later life, besides section II DSM-5 criteria, the alternative, dimensional model for personality disorders of DSM-5 is used to assess BPD in older adults.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR7107. Registered 11 March 2018.

Item Response Theory Analyses, Factor Structure, and External Correlates of the Italian Translation of the Personality Inventory for DSM-5 Short Form in Community-Dwelling Adults and Clinical Adults

To assess the psychometric properties of the Italian translation of the 100-item short form of the Personality Inventory for DSM-5 (PID-5-SF), 2,143 community-dwelling adults (59.6% female), and 706 adult clinical participants (52.4% female) were administered the Italian translation of the PID-5. Clinical participants were also administered the Structured Clinical Interview for DSM-IV (SCID-II), and the Personality Diagnostic Questionnaire-4+ (PDQ-4+). Item response theory analysis showed that all proposed PID-5-SF items showed adequate item discrimination parameters in both community-dwelling adults and clinical adults. All PID-5-SF trait scales showed satisfactory internal consistency estimates. PID-5-SF five-factor structure closely matched the factor structure of the PID-5 in both community-dwelling participants and clinical participants and was invariant across the two samples that participated in this study. Moreover, the factor structure of the PID-5-SF closely replicated the factor of the PID-5-SF that was originally reported in Maples et al.'s study. In our clinical sample, dominance analysis results showed that PID-5-SF scales explained a nonnegligible and significant amount of variance in both SCID-II and PDQ-4+ ratings of selected DSM-5 Section II personality disorder, and the use of the PID-5-SF did not result in a substantial loss of information as compared with the original PID-5.

A framework for treating DSM-5 alternative model for personality disorder features

Despite its demonstrated empirical superiority over the DSM-5 Section 2 categorical model of personality disorders for organizing the features of personality pathology, limitations remain with regard to the translation of the DSM-5 Section 3 alternative model of personality disorders (AMPD) to clinical practice. The goal of this paper is to outline a general and preliminary framework for approaching treatment from the perspective of the AMPD. Specific techniques are discussed for the assessment and treatment of both Criterion A personality dysfunction and Criterion B maladaptive traits. A concise and step-by-step model is presented for clinical decision making with the AMPD, in the hopes of offering clinicians a framework for treating personality pathology and promoting further research on the clinical utility of the AMPD. Copyright © 2018 John Wiley & Sons, Ltd.

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.

Integrating developmental aspects in current thinking about personality pathology

The current review outlines some recent highlights from the developmental literature on personality pathology with regard to its conceptualization, development, assessment and clinical utility. Notable parallels with adult evidence are described, but also unique and age-specific issues are discussed. Finally, suggestions for future research that may stimulate a life-span and integrative perspective on personality pathology from childhood onwards are proposed.

The Challenge of Transforming the Diagnostic System of Personality Disorders

While the DSM-5 alternative model of personality disorder (PD) diagnosis allows the field to systematically compare categorical and dimensional classifications, the ICD-11 proposal suggests a radical change by restricting the classification of PDs to one category, deleting all specific types, basing clinical service provision exclusively upon a severity dimension, and restricting trait domains to secondary qualifiers without defining cutoff points. This article reflects broad international agreement about the state of PD diagnosis. It is argued that diagnosis according to the ICD-11 proposal is based on broad, potentially stigmatizing descriptions of impaired functioning and ignores much of the impressive body of research and treatment guidelines that have advanced the care of adults and adolescents with borderline and other PDs. Before radically changing classification, which highly impacts the provision of health care, head-to-head field trials coupled with the views of patients as well as thorough debate among scientists are urgently needed.

Deriving ICD-11 personality disorder domains from dsm-5 traits: initial attempt to harmonize two diagnostic systems

OBJECTIVE

The personality disorder domains proposed for the ICD-11 comprise Negative Affectivity, Detachment, Dissociality, Disinhibition, and Anankastia, which are reasonably concordant with the higher-order trait domains in the Alternative DSM-5 Model for Personality Disorders.

METHOD

We examined (i) whether designated DSM-5 trait facets can be used to describe the proposed ICD-11 trait domains, and (ii) how these ICD-11 trait features are hierarchically organized. A mixed Danish derivation sample (N = 1541) of 615 psychiatric out-patients and 925 community participants along with a US replication sample (N = 637) completed the Personality Inventory for DSM-5 (PID-5). Sixteen PID-5 traits were designated to cover features of the ICD-11 trait domains.

RESULTS

Exploratory structural equation modeling (ESEM) analyzes showed that the designated traits were meaningfully organized in the proposed ICD-11 five-domain structure as well as other recognizable higher-order models of personality and psychopathology. Model fits revealed that the five proposed ICD-11 personality disorder domains were satisfactorily resembled, and replicated in the independent US sample.

CONCLUSION

The proposed ICD-11 personality disorder domains can be accurately described using designated traits from the DSM-5 personality trait system. A scoring algorithm for the ICD-11 personality disorder domains is provided in appendix.

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.

How Do DSM-5 Personality Traits Align With Schema Therapy Constructs?

DSM-5 offers an alternative model of personality pathology that includes 25 traits. Although personality disorders are mostly treated with psychotherapy, the correspondence between DSM-5 traits and concepts in evidence-based psychotherapy has not yet been evaluated adequately. Suitably, schema therapy was developed for treating personality disorders, and it has achieved promising evidence. The authors examined associations between DSM-5 traits and schema therapy constructs in a mixed sample of 662 adults, including 312 clinical participants. Associations were investigated in terms of factor loadings and regression coefficients in relation to five domains, followed by specific correlations among all constructs. The results indicated conceptually coherent associations, and 15 of 25 traits were strongly related to relevant schema therapy constructs. Conclusively, DSM-5 traits may be considered expressions of schema therapy constructs, which psychotherapists might take advantage of in terms of case formulation and targets of treatment. In turn, schema therapy constructs add theoretical understanding to DSM-5 traits.

Convergent and Discriminant Validity of the Five Factor Form and the Sliderbar Inventory

Existing measures of the five factor model (FFM) of personality are generally, if not exclusively, unipolar in their assessment of maladaptive variants of the FFM domains. However, two recently developed measures, the Five Factor Form (FFF) and the Sliderbar Inventory (SI), include items that assess for maladaptive variants at both poles of each item. This structure is unique among existing measures of personality and personality disorder, although there is a historical, infrequently used Stone Personality Trait Schema (SPTS) that had also included this item structure. To facilitate an exploration of their convergent and discriminant validity, the SI and SPTS items were reorganized into FFM scales. The convergent and discriminant validity of the FFF, SI-FFM, and SPTS-FFM scales was considered in a sample of 450 adults with current or a history of mental health treatment. The FFF, SI-FFM, and SPTS-FFM were also compared with respect to their relationship with FFM domains. Finally, the FFF items and SI-FFM scales were tested with respect to their relationship with measures of maladaptive variants of both high and low agreeableness and conscientiousness. The implications of the results are discussed with respect to the assessment of maladaptive personality functioning, and suggestions for future research are provided.

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.