A critique of the proposed prototype rating system for personality disorders in DSM-5

Genesis, modelling and methodological remedies to autism heterogeneity

Diagnostic criteria used in autism research have undergone a shift towards the inclusion of a larger population, paralleled by increasing, but variable, estimates of autism prevalence across clinical settings and continents. A categorical diagnosis of autism spectrum disorder is now consistent with large variations in language, intelligence, comorbidity, and severity, leading to a heterogeneous sample of individuals, increasingly distant from the initial prototypical descriptions. We review the history of autism diagnosis and subtyping, and the evidence of heterogeneity in autism at the cognitive, neurological, and genetic levels. We describe two strategies to address the problem of heterogeneity: clustering, and truncated-compartmentalized enrollment strategy based on prototype recognition. The advances made using clustering methods have been modest. We present an alternative, new strategy for dissecting autism heterogeneity, emphasizing incorporation of prototypical samples in research cohorts, comparison of subgroups defined by specific ranges of values for the clinical specifiers, and retesting the generality of neurobiological results considered to be acquired from the entire autism spectrum on prototypical cohorts defined by narrow specifiers values.

An Exploratory Study of MMPI-2-RF Personality and Psychopathology Profiles of Adults with Autism Spectrum Disorder without Intellectual Disability

OBJECTIVE

More empirical research is needed to disentangle the phenotypes of autism spectrum disorder (ASD) and cluster C personality symptomatology (CCPD), as both show similarities in their clinical presentation. We explored personality and psychopathology dimensions as conceptualized in contemporary dimensional taxonomies (i.e., hierarchical taxonomy of psychopathology; HiTOP) in adults with ASD without intellectual disability operationalized by the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF).

METHOD

Applying secondary analytic processes using clinical data, we cross-examined the MMPI-2-RF profiles of adults with ASD (n = 28) compared to adults with Cluster C personality disorders (CCPD; n = 28) and a control group (n = 28) by conducting nonparametric tests and assessing effect sizes.

RESULTS

The profiles of the ASD and CCPD groups evidenced to be similar, and both average clinical profiles diverged from the average control group profiles by elevated levels of demoralization, internalizing, and somatization symptomatology. There were small differences between the average profiles of adults with ASD and adults with CCPD. Additional research using dimensional measures of psychopathology could elucidate the dimensional phenotypes of ASD and CCPD.

CONCLUSIONS

Based on the results in this study, the MMPI-2-RF may not meaningfully discriminate between the two clinical presentations, with the exception of various externalizing scales.

Cardiac autonomic functioning and clinical outcome in adolescent borderline personality disorder over two years

The present study aimed to expand on previous findings that pre-treatment autonomic nervous system (ANS) functioning serves as a predictor of clinical outcome in adolescent borderline personality disorder (BPD), while examining whether the relationship between ANS functioning and treatment outcome may vary as a function of early life maltreatment (ELM). ANS stress response was examined considering changes in heart rate (HR) and vagally-mediated heart rate variability (vmHRV) over different conditions of the Montreal Imaging Stress Task (MIST) in a clinical sample of N = 27 adolescents across the spectrum of BPD severity. Participants received in- and/or outpatient treatment, while clinical data was assessed at routine follow-ups. Clinical outcome was defined by change in the number of fulfilled BPD criteria (as measured using the SCID-II), severity of psychopathology (CGI-S), and global level of functioning (GAF), measured 12 and 24 months after baseline assessments. Mixed-effects (random-intercept/random slope) linear regression models were calculated to examine markers of ANS function as potential predictors of clinical outcome. Irrespective of the presence of ELM exposure, both vmHRV resting-state and stress recovery measures were identified as significant predictors of clinical outcome over time. This study adds to the existing literature by replicating and expanding on preliminary findings, considering also physiological reactivity and recovery in addition to resting-state measures of ANS functioning. The present results further highlight the potential of markers of ANS functioning to serve as objective measures in the process of monitoring patient progress and to make predictions regarding treatment outcome in psychiatry research.

Validity and clinical utility of DSM and prototype diagnosis for depressive and anxiety spectrum disorders in predicting adaptive functioning

Prototype matching, which involves comparing a patient clinical presentation with a prototype description of the disorder, addresses some of the clinical limitations of categorical approaches. Most research to-date on prototype matching has been conducted with personality disorders. Here, we examined the validity and clinical utility of prototype diagnosis for mood and anxiety disorders. We compared clinicians prototype diagnosis (based on DSM IV and empirically derived) to categorical diagnosis (based on independent SCID interview) in predicting patient global adaptive functioning rated across the clinician, patient and independent interviewer among N = 80 clinicians and N = 170 patients. Our findings show that prototype diagnosis (both one that is based on DSM criteria and empirically derived) demonstrates some incremental validity over and above the categorical DSM IV, in predicting patient's global adaptive functioning. This is particularly pronounced for mood disorders (MDD and dysthymia) as well as several anxiety disorders (OCD, social phobia) across a range of experience level of diagnosticians. Furthermore, clinicians rated the prototype matching approach as more useful in clinical practice compared with the binary categorical system. Using a dimensional approach, which is based on prototype matching that also preserves the advantages of categorical system offers a valid and efficient approach to psychiatric assessment.

Reliability of DSM and empirically derived prototype diagnosis for mood, anxiety and personality disorders

BACKGROUND

Prominent psychiatric diagnostic systems such as the DSM-IV and ICD-10 have shown low reliability in clinical practice. An alternative approach to classification of psychiatric disorders is prototype matching. In the current study, we examined reliability of assessing mood, anxiety and personality disorders using a multi-method multi informant approach. More specifically, we examined diagnosis made by treating clinician and independent expert clinical interviewer, using three different diagnostic systems (DSM symptom count, DSM-IV prototype diagnosis and empirically derived prototype diagnosis).

METHODS

A convenience sample of clinicians (N = 80) and patients (N = 170) from eight community mental health clinics in Israel participated in the study.

RESULTS

Our findings show fair to excellent interrater reliability for prototype dimensional diagnostic systems (ranged from 0.40 to 0.79) for most mood and anxiety disorders examined. Overall, dimensional diagnostic systems, yielded better interrater reliability for mood, anxiety and personality disorders, as compared with categorical diagnosis. There were no significant differences between dimensional systems.

CONCLUSIONS

Our findings provide further support to the advantages of dimensional over categorical models in increasing reliability.

An Investigation of Adherence to Diagnostic Criteria, Revisited: Clinical Diagnosis of the DSM-IV/DSM-5 Section II Personality Disorders

In an initial investigation by Morey and Ochoa (1989), adherence to DSM-III personality disorder diagnostic criteria was examined as an agreement rate between clinician (global) diagnoses and diagnoses algorithmically generated from DSM-III criteria rules. Morey and Ochoa (1989) findings suggested significant clinician-criterion diagnostic incongruity, a result that cross-validated in a DSM-III-R replication performed by Blashfield and Herkov (1996). The current study examined such adherence, utilizing DSM-IV decision rules, in a national sample of 337 clinicians and their target patients. The results of the current study are largely consistent with the earlier findings, with clinician-criterion agreement rates comparable to those commonly reported for interdiagnostician reliability. Ramifications for the future of personality disorder diagnostic classification are discussed.

Psychopathy and the DSM

Psychopathy is one of the more well-established personality disorders. However, its relationship with the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has been controversial. The purpose of this article is to trace and discuss the history of this relationship from the very first edition of the DSM to the current fifth edition. Emphasized in particular is the problematic relationship of DSM antisocial personality disorder with the diagnosis of psychopathy by Cleckley (1941, 1976) and the Psychopathy Checklist- Revised (Hare, 2003), as well as with the more recently developed models of psychopathy by Lilienfeld and Widows (2005), Lynam et al. (2011), and Patrick, Fowles, and Krueger (2009).

New directions for an old construct: Depressive personality research in the DSM-5 era

The DSM-5 Personality and Personality Disorders Work Group has suggested that the DSM-IV depressive personality disorder (DPD) construct be assessed within a proposed set of trait domains, which include anxiousness, depressivity, and anhedonia, and that the diagnostic category itself be removed from the DSM-5. A review of studies on DPD has demonstrated many challenges and limitations to DPD research, despite strong evidence of its validity and clinical utility. Nevertheless, there remains much interest in how a depressive personality construct fits into a dimensionalized framework of assessing psychopathology. In this paper, I offer three major research directions that can help advance our understanding of the depressive personality construct. These directions can inform researchers and clinicians how depressive personality fits within broad trait dimensions of classification, as well as the internal psychological processes, dynamics and content that characterize this type of psychopathology.

Is dimensional scoring important only for subthreshold levels of severity in personality disorders other than borderline?

Research assessing the utility of dimensional and categorical models of personality disorders (PDs) overwhelmingly supports the use of continuous over categorical models. Using borderline PD as an example, recent studies from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project suggested that continuous (criteria count) scoring of PDs is most informative for "subthreshold" levels of pathology, but is less important once a patient meets the diagnostic threshold. Using PD criteria count, the current study compared 7 indices of psychosocial morbidity for patients above and below diagnostic threshold for 3 additional PDs: paranoid, avoidant, and obsessive-compulsive. Results showed that for all tested PDs, only number of current Axis I disorders was more correlated with PD criteria in the sub-threshold group as compared to those who met criteria for the disorder. Results for the remaining 6 indices of psychosocial morbidity varied by PD tested.

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.

A perspective on the current issues in the DSM-5 classification of personality disorders

David Kupfer chaired the DSM-5 Task Force, and Andrew Skodol the working group, on personality disorders. Various initial propositions were posted on the Internet in 2010 for comment and discussion: new general definition, new criteria, new diagnostic procedures, reduction in the number of categories, and dimensional representation. Following numerous criticisms, the Task Force's final decisions were made public on December 1, 2012. Personality disorders now figure alongside other mental disorders, because of the deletion of Axis II. The methodology concerning personality traits is in a third section to promote new studies. The new proposed hybrid system has not, to date, proven better than the categories of the DSM-IV. These various decisions are commented upon.

Five-Factor Model personality disorder prototypes: a review of their development, validity, and comparison to alternative approaches

In this article, the development of Five-Factor Model (FFM) personality disorder (PD) prototypes for the assessment of DSM-IV PDs are reviewed, as well as subsequent procedures for scoring individuals' FFM data with regard to these PD prototypes, including similarity scores and simple additive counts that are based on a quantitative prototype matching methodology. Both techniques, which result in very strongly correlated scores, demonstrate convergent and discriminant validity, and provide clinically useful information with regard to various forms of functioning. The techniques described here for use with FFM data are quite different from the prototype matching methods used elsewhere.

Structure of the DSM-IV personality disorders as revealed in clinician ratings

The revisions proposed for the DSM-5 would greatly alter how personality pathology is conceptualized, assessed, and diagnosed. One aspect of the proposed changes, elimination of four current personality disorders, has raised considerable controversy. The present study attempts to inform this debate by exploring clinicians' views of the structure of Personality Disorders using the current diagnostic system, the DSM-IV. An exploratory factor analysis was conducted on the DSM-IV Personality Disorder criteria using clinician ratings for 280 patients. The factor analysis revealed eight clear and meaningful factors. The eight factors contained all six personality disorders proposed for retention in DSM-5 but also contained clear representations of two disorders (Paranoid and Schizoid) identified for removal from the system. These conditions appear to have clinical utility and their removal may have unintended negative consequences in clinical practice. Dependent and Avoidant criteria also merged to form a new construct with interesting clinical implications. These findings provide new insights into the complex typologies clinicians employ when applying the DSM-IV system to personality disordered patients. Lastly we argue that successful refinement of clinically significant constructs, like diagnostic systems, requires a balanced appraisal of evidence for clinical utility as well as external and internal validity.

Is dimensional scoring of borderline personality disorder important only for subthreshold levels of severity?

Studies comparing dimensional and categorical representations of personality disorders (PDs) have consistently found that PD dimensions are more reliable and valid. While comparisons of dimensional and categorical scoring approaches have consistently favored the dimension model, two reports from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project have raised questions as to when dimensional scoring is important. In the first study, Asnaani, Chelminski, Young, and Zimmerman (2007) found that once the diagnostic threshold for borderline PD was reached the number of criteria met was not significantly associated with indices of psychosocial morbidity. In the second study, Zimmerman, Chelminski, Young, Dalrymple, and Martinez (2012) found that patients with 1 criterion of borderline PD had significantly more psychosocial morbidity than patients with 0 criteria. The findings of these two studies suggest that dimensional ratings of borderline PD may be more strongly associated with indicators of illness severity for patients who do not versus do meet the DSM-IV criteria for borderline PD. In this third report from the MIDAS project, we tested this hypothesis in a study of 3,069 psychiatric outpatients evaluated with semi-structured diagnostic interviews. In the patients without borderline PD the number of borderline features was significantly associated with each of 6 indicators of illness severity, whereas in the patients with borderline PD 3 of the 6 correlations were significant. The mean correlation between the number of borderline PD criteria and the indicators of illness severity was nearly three times higher in the patients without borderline PD than the patients with borderline PD (0.23 versus 0.08), and 4 of the 6 correlation coefficients were significantly higher in the patients without borderline PD. These findings suggest that dimensional scoring of borderline PD is more important for subthreshold levels of pathology and are less critical once a patient meets the diagnostic threshold. The implications of these findings for DSM-5 are discussed.

Retention or deletion of personality disorder diagnoses for DSM-5: an expert consensus approach

One of the official proposals for the fifth edition of the American Psychiatric Association's (APA) diagnostic manual (DSM-5) is to delete half of the existing personality disorders (i.e., dependent, histrionic, narcissistic, paranoid, and schizoid). Within the APA guidelines for DSM-5 decisions, it is stated that there should be expert consensus agreement for the deletion of a diagnostic category. Additionally, categories to be deleted should have low clinical utility and/or minimal evidence for validity. The current study surveyed members of two personality disorder associations (n = 146) with respect to the utility, validity, and status of each DSM-IV-TR personality disorder diagnosis. Findings indicated that the proposal to delete five of the personality disorders lacks consensus support within the personality disorder community.

Personality disorders in DSM-5

A substantive revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) last occurred in 1994; therefore, the mental health field should anticipate significant changes to the classification of mental disorders in the fifth edition. Since DSM-5 Work Groups have recently proposed revisions for the major diagnostic classes of mental disorders, an article on the current status of the personality disorders (PDs) is timely. This article reviews scientific principles that have influenced the development of proposed changes for the assessment and diagnosis of personality psychopathology in DSM-5, presents the proposed model as of the summer of 2011, summarizes rationales for the changes, and discusses critiques of the model. Scientific principles were articulated for DSM-5 more than a decade ago; their application to the process has not been straightforward, however. Work Group members have labored to improve the DSM-5 approach to personality and PDs to make the classification more valid and more clinically useful. The current model continues to be a work in progress.

An Integrative Conceptual Framework for Assessing Personality and Personality Pathology

As a contribution to the ongoing debate over the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, we present a framework for jointly conceptualizing personality and personality pathology. The key element is an explicit distinction between personality description (which is the realm of basic personality psychology) and personality evaluation (which is the realm of clinical personality psychology). Previous diagnostic systems did not acknowledge this crucial distinction. We created a sample diagnostic system, to illustrate how a practical application of our conceptual framework may look like. The system comprises two ingredients: First, a list of personality dispositions that may become problematic. These are described at a “basic level” of abstraction (i.e., the level at which patients and clinicians intuitively communicate about personality problems). Second, a list of negative consequences that are used to evaluate the extent to which a patient's personality pattern is “problematic.” A sample of therapists used the system for describing actual patients and found it to be better than the International Classification of Diseases (ICD)-10 and DSM–IV. Based on our conceptual deliberations, we analyze the DSM-5 proposal for personality and personality disorders. The proposal contains three different sets of “higher-order concepts” (personality traits, personality types, and levels of personality functioning). Only the first of these is sufficiently supported by empirical evidence, including analyses of our own set of personality dispositions.

Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders provides the authoritative list of what are considered to be mental disorders. This list has a tremendous impact on research, funding, and treatment, as well as a variety of civil and forensic decisions. The development of this diagnostic manual is an enormous responsibility. Provided herein are lessons learned during the course of the development of the fourth edition. Noted in particular is the importance of obtaining and publishing critical reviews, restraining the unbridled creativity of experts, conducting field trials that address key issues and concerns, and conducting forthright risk-benefit analyses. It is suggested that future editions of the diagnostic manual be developed under the auspices of the Institute of Medicine. The goal would be broad representation, an evidence-based approach, disinterested recommendations, and a careful attention to the risks and benefits of each suggestion for change to the individual patient, to public policy, and to forensic applications.

A (re)-evaluation of the symptom structure of borderline personality disorder

OBJECTIVE

Despite evidence of significant symptom heterogeneity and excessive diagnostic comorbidity, many contend that borderline personality disorder (BPD) is unidimensional, an assumption that rests primarily on results from factor analytic investigations of BPD symptom criteria. We note several limitations in the literature and argue that the symptom structure of BPD can be best clarified by using both factor analytic techniques and examining the BPD symptom dimensions in relation to external criteria (that is, personality traits). Our goals were to: examine if the symptoms of BPD are best conceptualized as unidimensional or multidimensional, and determine the extent to which personality traits account for any symptom dimensions that underlie BPD.

METHOD

All published structural models of the BPD symptom criteria were identified and tested for statistical fit using confirmatory factor analysis in a sample of 373 patients who had completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-Axis II Personality Questionnaire BPD scale. Dimensions from the best fitting model were examined in relation to traits from the Five-Factor Model (FFM) and the Personality Psychopathology Five (PSY-5) using correlational and regression analyses.

RESULTS

Sanislow's 3-factor model, containing affect dysregulation, behavioural dysregulation, and disturbed relations symptom dimensions, provided the best fit; the unidimensional model produced the worst. The symptom dimensions of the 3-factor model were differentiable from one another and had unique associations with the FFM and PSY-5 personality traits.

CONCLUSION

BPD is a multidimensional construct.