Comparing personality disorder models: cross-method assessment of the FFM and DSM-IV-TR

The clinical utility of the ICD-11 classification of personality disorders and related traits: A preliminary scoping review

OBJECTIVES

A diagnostic system that fails to deliver clinically useful information will not be utilized and consequently will be unable to provide valuable data for health policy and clinical decision making. Therefore, it is imperative to obtain an accurate depiction of the clinical utility of the eleventh revision of the International Classification of Diseases (ICD-11) Personality Disorder (PD) model. The current mixed-methods systematic review aimed to determine the clinical utility of the ICD-11 PD classification system.

METHOD

An electronic screening of six databases was conducted and resulting studies were subjected to specific exclusion criteria, which elicited eight studies of interest. Study characteristics were tabulated and methodological quality was appraised.

RESULTS

Four studies offered strong support for the model's clinical utility, three offered some support accompanied by notable limitations and one study could only offer criticisms.

CONCLUSION

Future investigation of the ICD-11 PD classification system's (a) communicative value between clinicians and their patients, and between clinicians and their patient's families; (b) ease of use; and (c) feasibility in terms of practical application is required to achieve a complete understanding of its clinical utility and ultimately bring clarity to the current ambiguous findings.

A Multi-Method Investigation of Normative and Pathological Personality Across the Spectrum of Gambling Involvement

Pathological Gambling (PG) has been linked to both specific personality traits and personality disorders (PDs). However, previous studies have used a wide variety of research designs that preclude clear conclusions about the personality features that distinguish adults with PG from other groups. The current investigation seeks to advance this research by using a sample including adults who do not gamble, who gamble socially, and who exhibit PG, using self-report, informant-report, and interview-rated measures of personality traits and disorders. A total of 245 adults completed measures of gambling behaviour and problems, as well as normative and pathological personality over two assessment visits. A multivariate ANCOVA was conducted to investigate differences between groups. Analyses supported numerous group differences including differences between all groups on the Neuroticism facet of Impulsivity, and between non-gambling/socially gambling and PG groups on the Conscientiousness facet of Self-Discipline. Adults with PG exhibited more symptoms of Borderline, Paranoid, Schizotypal, Avoidant, and Dependent PDs than adults who gamble socially or not at all. The current investigation provides a comprehensive survey of personality across a wide range of gambling involvement, using a multi-method approach. Our findings help to clarify the most pertinent personality risk factors for PG.

A Bifactor Model of Personality Organization

The aim of this study was to explore the viability of a bifactor model for the Inventory of Personality Organization (IPO), which is a self-report measure of personality functioning based on Kernberg's model of personality organization. A heterogeneous, predominantly clinical sample (N = 616) completed the German 83-item version of the IPO. Confirmatory and Exploratory Factor Analyses were applied to explore the factor structure of the IPO. We were able to establish a bifactor model with a general factor of personality functioning and three specific factors (Aggression, Reality Testing, Moral Values), which represent additional dimensions of personality organization. Virtually all items showed substantial positive loadings on the general factor, explaining roughly 66% of the common variance. Furthermore, we found support for convergent and discriminant validity of general and specific factors with regard to interview-based assessments of personality disorders and personality organization. The results lend support to a bifactor approach to Kernberg's model of personality organization. We also present a 30-item brief form of the IPO that efficiently implements the bifactor approach and may be further validated in future studies.

Self and informant report across the borderline personality disorder spectrum

Individuals with borderline personality disorder (BPD) features may be unaware of or unwilling to report their own personality or maladaptive behaviors, which complicates the assessment of BPD. Informants who know the individuals with BPD features may be uniquely suited to aid in the personality assessment of these individuals. The present study analyzed the comparative ability of individuals (targets) and informants to report BPD features across the continuum of BPD severity. The sample consisted of 1387 targets, ages 55 to 65 (56% women), who were recruited for an epidemiological longitudinal study examining the effects of PDs on health and social functioning. Each target nominated an informant who provided information about the target's personality. Results indicated relatively low levels of agreement between perspectives and that informants reported BPD symptoms with more precision and at lower levels of BPD severity than targets. The benefits of including an informant perspective when measuring the BPD continuum are discussed; these benefits may include gains in reliability and improvement in the prediction of outcomes. (PsycINFO Database Record

Diagnostic Agreement Between Clinicians and Clients: The Convergent and Discriminant Validity of the SWAP-200 and MCMI-III Personality Disorder Scales

A particularly controversial aspect in the field of personality assessment is the use of self-report measures, versus clinicians' evaluations, for diagnosing personality disorder (PD). No studies have systematically documented the agreement between these sources for the entire array of DSM-5 PDs using comprehensive measures and experienced clinicians' judgments. The present work fills this gap by indexing the agreement between patients' self-descriptions and clinicians' judgments, relying on standardized and thorough PD instruments. The Shedler-Westen Assessment Procedure-200 (SWAP-200; Westen & Shedler, 1999a, 1999b) and the Millon Clinical Multiaxial Inventory-III (Millon, Davis, & Millon, 1997) were both completed in a clinical series of 56 adult outpatients. Analyses highlighted moderate correlations between the two measures for the 10 DSM-5 PDs (Mdn = .35). Agreement was highest for psychological features that are more easily observable by the clinicians. Furthermore, results revealed problematic discriminant validity between the two instruments.

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

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

Patient-reported outcomes in borderline personality disorder

Patient-reported outcome (PRO) refers to measures that emphasize the subjective view of patients about their health-related conditions and behaviors. Typically, PROs include self-report questionnaires and clinical interviews. Defining PROs for borderline personality disorder (BPD) is particularly challenging given the disorder's high symptomatic heterogeneity, high comorbidity with other psychiatric conditions, highly fluctuating symptoms, weak correlations between symptoms and functional outcomes, and lack of valid and reliable experimental measures to complement self-report data. Here, we provide an overview of currently used BPD outcome measures and discuss them from clinical, psychometric, experimental, and patient perspectives. In addition, we review the most promising leads to improve BPD PROs, including the DSM-5 Section III, the Recovery Approach, Ecological Momentary Assessments, and novel experimental measures of social functioning that are associated with functional and social outcomes.

Dimensional models of personality: the five-factor model and the DSM-5

It is evident that the classification of personality disorder is shifting toward a dimensional trait model and, more specifically, the five-factor model (FFM). The purpose of this paper is to provide an overview of the FFM of personality disorder. It will begin with a description of this dimensional model of normal and abnormal personality functioning, followed by a comparison with a proposal for future revisions to DSM-5 and a discussion of its potential advantages as an integrative hierarchical model of normal and abnormal personality structure.

Factorial Invariance of the Five-Factor Model Rating Form Across Gender

The Five-Factor Model Rating Form (FFMRF) provides a brief, one-page assessment of the Five-Factor Model. An important and unique aspect of the FFMRF is that it is the only brief measure that includes scales for the 30 facets proposed by Costa and McCrae. The current study builds on existing validity support for the FFMRF by evaluating its factorial invariance across gender within a sample of 699 undergraduate students. Consistent with other measures of the Five-Factor Model, men scored lower than women on the domains of neuroticism, extraversion, agreeableness, and conscientiousness but slightly higher on openness. The novel contribution of the current study is the use of exploratory structural equation modeling to determine that the FFMRF displayed a five-factor structure that demonstrated strong measurement invariance across gender. This factorial invariance adds important support for the validity of the FFMRF as a self-report measure as it indicates that the scores assess the same latent constructs in men and women. Although future work is needed to clarify some facet-level findings and evaluate for potential predictive biases, the present results add to the increasing body of research supporting the validity of the FFMRF as a self-report measure of personality.

Convergent and Discriminant Validity of the Five Factor Form

The current study tests the convergent and discriminant validity of a modified version of the Five Factor Model Rating Form (FFMRF), a one-page, brief measure of the five-factor model. The Five Factor Form (FFF) explicitly identifies maladaptive variants for both poles of each of the 30 facets of the FFMRF. The purpose of the current study was to test empirically whether this modified version still provides a valid assessment of the FFM, as well as to compare its validity as a measure of the FFM to other brief FFM measures. Two independent samples of 510 and 330 community adults were sampled, one third of whom had a history of some form of mental health treatment. The FFF was compared with three abbreviated and/or brief measures of the FFM (i.e., the FFMRF, the Ten Item Personality Inventory, and the Big Five Inventory), a more extended measure (i.e., International Personality Item Pool-NEO), an alternative measure of general personality (i.e., the HEXACO-Personality Inventory-Revised), and a measure of maladaptive personality functioning (i.e., the Personality Inventory for Diagnostic and Statistical Manual of Mental Disorders, 5th edition). The results of the current study demonstrated convergent and discriminant validity, even at the single-item facet level.

The convergence of personality disorder diagnoses across different methods among monolingual (Spanish-speaking only) Hispanic patients in substance use treatment

Methods for diagnosing personality disorders (PDs) within clinical settings typically diverge from those used in treatment research. Treatment groups in research studies are routinely diagnosed using semistructured interviews or self-report questionnaires, yet these methods show poor agreement with clinical diagnoses recorded in medical charts or assigned by treating clinicians, reducing the potential for evidence-based practice. Furthermore, existing research has been limited by focusing on primarily White and English-speaking participants. Our study extended prior research by comparing 4 independent methods of PD diagnosis, including self-report questionnaire, semistructured interview, chart diagnoses, and ratings by treating clinicians, within a clinical series of 130 monolingual (Spanish only) Hispanic persons (69% male; M age 37.4), in treatment for substance use. The authors examined the convergence of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) PD diagnoses across these methods. PD diagnoses appeared infrequently within medical charts but were diagnosed at higher levels by independent treating clinicians, self-report questionnaires, and semistructured interviews. Nonetheless, diagnostic concordance between clinical diagnoses and the other methods were poor (κ < .20). Convergence of PD diagnoses across diagnostic methods for Spanish-speaking Hispanic persons are comparable to other groups allaying concerns about cross-cultural application of PD diagnoses. Additionally, the results of this study echo previous research in suggesting that clinicians' PD diagnoses overlap little with self-report questionnaires or semistructured diagnostic interviews and suggest that PDs are underdiagnosed using standard diagnostic approaches. Implications for the clinical application of empirically supported research are discussed.

Self-other knowledge asymmetries in personality pathology

OBJECTIVE

Self-reports of personality provide valid information about personality disorders (PDs). However, informant reports provide information about PDs that self-reports alone do not provide. The current article examines whether and when one perspective is more valid than the other in identifying PDs.

METHOD

Using a representative sample of adults 55 to 65 years of age (N = 991; 45% males), we compared the validity of self- and informant (e.g., spouse, family, or friend) reports of the Five-Factor Model traits in predicting PD scores (i.e., composite of interviewer, self-, and informant reports of PDs).

RESULTS

Self-reports (particularly of Neuroticism) were more valid than informant reports for most internalizing PDs (i.e., PDs defined by high Neuroticism). Informant reports (particularly of Agreeableness and Conscientiousness) were more valid than self-reports for externalizing and/or antagonistic PDs (i.e., PDs defined by low Agreeableness and Conscientiousness). Neither report was consistently more valid for thought disorder PDs (i.e., PDs defined by low Extraversion). However, informant reports (particularly of Agreeableness) were more valid than self-reports for PDs that were both internalizing and externalizing (i.e., PDs defined by high Neuroticism and low Agreeableness).

CONCLUSIONS

The intrapersonal and interpersonal manifestations of PDs differ, and these differences influence who knows more about pathology.

Convergent and incremental predictive validity of clinician, self-report, and structured interview diagnoses for personality disorders over 5 years

OBJECTIVE

Research has demonstrated poor agreement between clinician-assigned personality disorder (PD) diagnoses and those generated by self-report questionnaires and semistructured diagnostic interviews. No research has compared prospectively the predictive validity of these methods. We investigated the convergence of these 3 diagnostic methods and tested their relative and incremental validity in predicting independent, multimethod assessments of psychosocial functioning performed prospectively over 5 years.

METHOD

Participants were 320 patients in the Collaborative Longitudinal Personality Disorders Study diagnosed with PDs by therapist, self-report, and semistructured interview at baseline. We examined the relative incremental validity of therapists' naturalistic ratings relative to these other diagnostic methods for predicting psychosocial functioning at 5-year follow-up.

RESULTS

Hierarchical linear regression analyses revealed that both the self-report questionnaire and semistructured interview PD diagnoses had significant incremental predictive validity over the PD diagnoses assigned by a treating clinician. Although, in some cases, the clinicians' ratings for individual PDs did have validity for predicting subsequent functioning, they did not generally provide incremental prediction beyond the other methods. These findings remained robust in a series of analyses restricted to a subsample of therapist ratings based on clinical contact of 1 year or greater.

CONCLUSIONS

These results from a large clinical sample echo previous research documenting limited agreement between clinicians' naturalistic PD diagnoses and those from self-report and semistructured interview methods. They extend prior work by providing the first evidence about the relative predictive validity of these different methods. Our findings challenge the validity of naturalistic PD diagnoses and suggest the use of structured diagnostic instruments.

Dimensional models of personality: the five-factor model and the DSM-5

It is evident that the classification of personality disorder is shifting toward a dimensional trait model and, more specifically, the five-factor model (FFM). The purpose of this paper is to provide an overview of the FFM of personality disorder. It will begin with a description of this dimensional model of normal and abnormal personality functioning, followed by a comparison with a proposal for future revisions to DSM-5 and a discussion of its potential advantages as an integrative hierarchical model of normal and abnormal personality structure.

Integrating normal and abnormal personality structure: the Five-Factor Model

It is evident that the conceptualization, diagnosis, and classification of personality disorder (PD) is shifting toward a dimensional model. The purpose of this special issue of Journal of Personality is to indicate how the Five-Factor Model (FFM) can provide a useful and meaningful basis for an integration of the description and classification of both normal and abnormal personality functioning. This introductory article discusses its empirical support and the potential advantages of understanding personality disorders, including those included within the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders and likely future PDs from the dimensional perspective of the FFM.

Identifying individuals with antisocial personality disorder using resting-state FMRI

Antisocial personality disorder (ASPD) is closely connected to criminal behavior. A better understanding of functional connectivity in the brains of ASPD patients will help to explain abnormal behavioral syndromes and to perform objective diagnoses of ASPD. In this study we designed an exploratory data-driven classifier based on machine learning to investigate changes in functional connectivity in the brains of patients with ASPD using resting state functional magnetic resonance imaging (fMRI) data in 32 subjects with ASPD and 35 controls. The results showed that the classifier achieved satisfactory performance (86.57% accuracy, 77.14% sensitivity and 96.88% specificity) and could extract stabile information regarding functional connectivity that could be used to discriminate ASPD individuals from normal controls. More importantly, we found that the greatest change in the ASPD subjects was uncoupling between the default mode network and the attention network. Moreover, the precuneus, superior parietal gyrus and cerebellum exhibited high discriminative power in classification. A voxel-based morphometry analysis was performed and showed that the gray matter volumes in the parietal lobule and white matter volumes in the precuneus were abnormal in ASPD compared to controls. To our knowledge, this study was the first to use resting-state fMRI to identify abnormal functional connectivity in ASPD patients. These results not only demonstrated good performance of the proposed classifier, which can be used to improve the diagnosis of ASPD, but also elucidate the pathological mechanism of ASPD from a resting-state functional integration viewpoint.

Clinical application of the five-factor model

The Five-Factor Model (FFM) has become the predominant dimensional model of general personality structure. The purpose of this paper is to suggest a clinical application. A substantial body of research indicates that the personality disorders included within the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) can be understood as extreme and/or maladaptive variants of the FFM (the acronym "DSM" refers to any particular edition of the APA DSM). In addition, the current proposal for the forthcoming fifth edition of the DSM (i.e., DSM-5) is shifting closely toward an FFM dimensional trait model of personality disorder. Advantages of this shifting conceptualization are discussed, including treatment planning.

An Investigation of the Factor Structure and Convergent and Discriminant Validity of the Five-Factor Model Rating Form

The Five-Factor Model Rating Form (FFMRF) is a one-page measure designed to provide an efficient assessment of the higher order domains of the Five Factor Model (FFM) as well as the more specific, lower order facets proposed by McCrae and Costa. Although previous research has suggested that the FFMRF’s assessment of the lower order facets converge reasonably with other FFM measures, the structural validity of the domain-level assessment has not yet been evaluated. The current study employed an exploratory structural equation modeling framework to investigate the fit of a five-factor solution within a combined sample of 757 participants. This was a novel analysis using a combined sample drawn from three previously published studies and was composed primarily of undergraduates but also included a smaller clinical subsample. Results indicated that the FFMRF is well accommodated within a five-factor solution. Furthermore, the FFMRF domain scores evinced large correlations with domain scores from the NEO Personality Inventory–Revised. The results suggest that the FFMRF might hold promise as a choice for those seeking a brief measure that provides a valid assessment of both the broad and specific traits of the FFM.

Phenotypic expression of schizotypal traits in an adolescent population

The main goal of the present study was to examine the influence of gender and age in the phenotypic expression of schizotypal traits in a community sample of adolescents. The sample was composed of a total of 1,618 participants, 776 (48%) males, with a mean age of 15.9 years (SD = 1.2). The ESQUIZO-Q: Oviedo Schizotypy Assessment Questionnaire was used for the assessment of schizotypal traits, a measure specifically developed for its use in adolescents. The results showed that gender and age were two sociodemographical variables that influenced the expression of schizotypal features. The males in the study obtained higher mean scores than the females in the Negative dimension (Physical and Social Anhedonia); however, the females obtained higher mean scores in Magical Thinking, Lack of Close Friends, and Social Disorganization. With regard to age, the younger adolescents had lower scores in Odd Thinking and Language, Lack of Close Friends, Excessive Social Anxiety, and Social Disorganization compared to the older adolescents. This differential pattern is similar to the one found in patients with schizophrenia and in nonclinical young adults, and these findings improve our understanding about the phenotypic expression of schizotypy during adolescence.

Five factor model prototype matching scores: convergence within alternative methods

The Five Factor Model of Personality (FFM) has been proposed as a potential alternative to the current DSM-IV-TR model, which conceptualizes personality disorders (PDs) as categorical constructs. While an extensive literature has pointed out the flaws of the diagnostic categories, they are quite familiar to clinicians and there may still be instances when identifying these constructs for clinical purposes, such as for rapidly communicating information about a patient, is warranted. From the perspective of the FFM, the PDs represent specific constellations of personality traits and research has demonstrated that the PDs can be recovered by assessing the degree to which an FFM profile matches the FFM description of a prototypic PD case. The current study builds upon that research by assessing the convergent and discriminant validity of prototype scores and DSM-IV PD measures using self-report, informant report, semi-structured interview, and clinician descriptions. The results suggest that the prototype matching scores are largely valid across these methods for all PDs, with perhaps the exception of obsessive-compulsive. These findings are related to previous research and the clinical implications of these findings are discussed.

Clinicians' Use of Personality Disorder Models within a Particular Treatment Setting: A Longitudinal Comparison of Temporal Consistency and Clinical Utility

An active line of current investigation is how the five-factor model (FFM) of personality disorder might be applied by clinicians and particularly, how clinically useful this model is in comparison to the existing nomenclature. The current study is the first to investigate the temporal consistency of clinicians' application of the FFM and the DSM-IV-TR to their own patients. Results indicated that FFM ratings were relatively stable over six-months of treatment, supporting their use by clinicians, but also indexed potentially important clinical changes. Additionally, ratings of utility provided by the clinicians suggested that the FFM was more useful for clinical decision making than was the DSM-IV-TR model. We understand the clinical utility findings within the context of previous research indicating that the FFM is most useful among patients who are not prototypic for a personality disorder.

The impact of NEO PI-R gender norms on the assessment of personality disorder profiles

Many personality assessment inventories provide gender-specific norms to allow comparison of an individual's standing relative to others of the same gender. In some cases, this means that an identical raw score produces standardized scores that differ notably depending on whether the respondent is male or female. Thus, an important question is whether unisex-normed scores or gender-normed scores more validly assess personality. Gender-normed and unisex-normed scores from the NEO Personality Inventory--Revised (P. T. Costa & R. R. McCrae, 1992) were examined in a large clinical sample, using 2 measures of personality disorder as validating criteria. Gender-normed scores did not obtain significantly higher correlations. In fact, for 2 personality disorders (antisocial and narcissistic), gender-normed scores yielded significantly lower correlations, suggesting that personality disorder pathology relates most closely to one's absolute level of a personality trait, rather than one's standing relative to others of the same gender. Ramifications of this finding for personality research and clinical assessment are discussed.

A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: a facet level analysis

Theory and research have suggested that the personality disorders contained within the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) can be understood as maladaptive variants of the personality traits included within the five-factor model (FFM). The current meta-analysis of FFM personality disorder research both replicated and extended the 2004 work of Saulsman and Page (The five-factor model and personality disorder empirical literature: A meta-analytic review. Clinical Psychology Review, 23, 1055-1085) through a facet level analysis that provides a more specific and nuanced description of each DSM-IV-TR personality disorder. The empirical FFM profiles generated for each personality disorder were generally congruent at the facet level with hypothesized FFM translations of the DSM-IV-TR personality disorders. However, notable exceptions to the hypotheses did occur and even some findings that were consistent with FFM theory could be said to be instrument specific.