Brief Report: Expert Preferences for Categorical, Dimensional, and Mixed/Hybrid Approaches to Personality Disorder Diagnosis

Clinical Staging for Personality Disorders in Older Adults

OBJECTIVE

This scientific research aimed to investigate the feasibility of implementing a clinical staging (CS) model for personality disorders (PDs) in older adults. The CS model could provide valuable insights into the life course of personality pathology, prognosis, and treatment decisions for PDs in older adults.

METHODS/DESIGN

The study employed an international Delphi methodology with three rounds and involved 21 experts.

RESULTS

Consensus was achieved on 12 out of 17 statements, confirming the viability of a CS model for PDs in older adults. The proposed model incorporates the Alternative Model for PDs, criterion A, and integrates life course information, distinguishing between chronic PD, re-emergent PD, late-onset PD, and past PD.

CONCLUSION

The findings suggest that international experts support the implementation of a CS model for PDs in older adults, considering both the severity of personality functioning and the retrospective life course of PD expression.

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.

ICD-11 personality disorder features in the danish general population: Cut-offs and prevalence rates for severity levels

INTRODUCTION

Prevalence rates and correlates of personality disorders (PD) are relevant to health care policy and planning.

OBJECTIVES

To present normative data for self-reported ICD-11 personality disorder (PD) features including tentative cut-off scores and prevalence rates for severity levels along with psychosocial correlates.

METHODS

The Personality Disorder Severity ICD-11 (PDS-ICD-11) scale and criterion measures of impairment were administered to a social-demographically stratified sample of Danish citizens (N = 8,941) of which 3,044 delivered complete data. Item-Response Theory (IRT) was employed to indicate cut-offs based on standard deviations from the latent mean.

RESULTS

The unidimensionality of the PDS-ICD-11 score was supported and IRT analysis suggested norm-based thresholds at latent severity levels. Expected associations with criterion measures were found.

CONCLUSION

The normative data portray ICD-11 PD features in the general population and allow for interpretation of PDS-ICD-11 scores (e.g., scores of 12, 16, and 19 may indicate mild, moderate, and severe dysfunction), which may inform health care policy and planning. A total weighted prevalence of 6.9 % of the Danish general population is estimated to have clinically significant personality dysfunction, proportionally composed of Mild (4.8 %), Moderate (1.2 %), and Severe (0.9 %) levels. Future research should corroborate these findings using relevant clinical samples and methods.

Measuring personality functioning with the 12-item version of the OPD-Structure Questionnaire (OPD-SQS): reliability, factor structure, validity, and measurement invariance in the general population

Background

The assessment of personality functioning is at the core of current dimensional models of personality disorders. A variety of measures from different clinical and research traditions aim to assess basic psychological capacities regarding the self and others. While some instruments have shown reliability and validity in clinical or other selected samples, much less is known about their performance in the general population.

Methods

In three samples representative of the German adult population with a total of 7,256 participants, levels of personality functioning were measured with the short 12-item version of the Operationalized Psychodynamic Diagnosis - Structure Questionnaire (OPD-SQS). We addressed questions of factor structure, reliability, validity, factorial invariance, and provide norm values.

Results

Confirmatory factor analysis indicated a satisfactory to good model fit. OPD-SQS models were mostly unaffected by variables such as gender, age, or measurement time. As expected, personality functioning was associated with general psychopathology as well as indices of occupational functioning.

Conclusion

The OPD-SQS is a viable measure to assess personality functioning in the general population.

Dimensional models of personality disorders: Challenges and opportunities

Categorical models of personality disorders have been beneficial throughout psychiatric history, providing a mechanism for organizing and communicating research and treatment. However, the view that individuals with personality disorders are qualitatively distinct from the general population is no longer tenable. This perspective has amassed steady criticism, ranging from inconsequential to irreconcilable. In response, stronger evidence has been accumulated in support of a dimensional perspective that unifies normal and pathological personality on underlying trait continua. Contemporary nosology has largely shifted toward this dimensional perspective, yet broader adoption within public lexicon and routine clinical practice appears slow. This review focuses on challenges and the related opportunities of moving toward dimensional models in personality disorder research and practice. First, we highlight the need for ongoing development of a broader array of measurement methods, ideally facilitating multimethod assessments that reduce biases associated with any single methodology. These efforts should also include measurement across both poles of each trait, intensive longitudinal studies, and more deeply considering social desirability. Second, wider communication and training in dimensional approaches is needed for individuals working in mental health. This will require clear demonstrations of incremental treatment efficacy and structured public health rebates. Third, we should embrace cultural and geographic diversity, and investigate how unifying humanity may reduce the stigma and shame currently generated by arbitrarily labeling an individual's personality as normal or abnormal. This review aims to organize ongoing research efforts toward broader and routine usage of dimensional perspectives within research and clinical spaces.

Associations of different types of child maltreatment and diabetes in adulthood - the mediating effect of personality functioning: Findings from a population-based representative German sample

PURPOSE

This study aimed to examine the role of personality functioning in the association between various types of child maltreatment (CM) (sexual, physical, and emotional abuse as well as physical and emotional neglect) and diabetes in adulthood.

METHODS

Analyses are based on representative data of the German population (N = 5,041) from 2016 to 2019. Self-report questionnaires assessed diagnosis of diabetes, child maltreatment (CTQ), personality functioning (OPD-SQS), and symptoms of depression/anxiety (PHQ-4). Odd ratios were calculated to examine the association between CM and diabetes, and mediation analyses including PHQ-4 as covariate were conducted to examine the role of personality functioning.

RESULTS

All CM types significantly elevated the odds of having diabetes in adulthood. Personality functioning mediated the association between abuse and diabetes (sexual: b = 0.012, 95% CI [.002, 0.022], P_M = 25.0%, physical: b = 0.009, 95% CI [.001, 0.017], P_M = 12.0%, and emotional: b = 0.013, 95% CI [.002, 0.024], P_M = 59.8%), but not between neglect and diabetes.

CONCLUSIONS

CM is associated with an increased risk of diabetes, with personality functioning being a relevant mediator for CM abuse types. Hence, by focusing on CM prevention and considering impaired personality functioning in diabetes treatment, diabetes self-management and health behavior could be improved.

Epistemic trust and personality functioning mediate the association between adverse childhood experiences and posttraumatic stress disorder and complex posttraumatic stress disorder in adulthood

Background

Adverse childhood experiences (ACEs) are associated with posttraumatic and complex posttraumatic stress disorder symptoms in adulthood (PTSD/cPTSD), as well as reduced epistemic trust (trust in the authenticity and personal relevance of interpersonally transmitted information) and impaired personality functioning. The present work aims to investigate the predictive value of epistemic trust-the capacity for social learning-on the mediating effect of personality functioning in the association of ACEs and PTSD/cPTSD.

Methods

We conducted structural equation modeling (SEM) based on representative data of the German population (N = 2,004). Personality functioning (OPD-SQS) was applied as a mediator between ACEs and PTSD/cPTSD (ITQ), while epistemic trust (ETMCQ) was added as predictor for OPD-SQS. TLI, CFI, and RMSEA (95%-CI) determined the models' fit.

Results

N = 477 (23.8%) participants reported at least one ACE and n = 218 (10.9%) reported ≥4 ACEs. Fit indices were good for both PTSD (TLI = 0.96; CFI = 0.99; RMSEA = 0.06; 95%CI: 0.041-0.078) and cPTSD (TLI = 0.96; CFI = 0.99; RMSEA = 0.06; 95%CI: 0.043-0.081). ACEs were significantly associated with cPTSD (β = 0.44, p < 0.001) and PTSD (β = 0.29, p < 0.001), explaining 20 and 8% of its variance. Adding personality functioning as a mediator increased the explained variance of cPTSD and PTSD to 47 and 19% while the direct association between ACEs and cPTSD/PTSD decreased (β = 0.21/β = 0.17), thus, indicating a partial mediation. Including epistemic trust substantially increased the explained variance for personality functioning (41%) compared to ACEs as a single predictor (16%).

Conclusion

We add to previous research emphasizing the association between ACEs and PTSD/cPTSD symptoms. Offering insights on underlying mechanisms, we show that epistemic trust and personality functioning are relevant mediators. Since both are modifiable by psychotherapy, knowledge about the role of these constructs can inform research on psychotherapeutic interventions and prevention.

Study Protocol for an Ecological Momentary Assessment Study: TempRes "Temporal Variability of Risk and Resilience Factors for Suicidal Ideation"

Suicide prevention is an important public mental health issue that can be significantly brought forward by recent advances in psychological research methods and assessment. The project "TempRes" aims to harness the power of Ecological Momentary Assessment (EMA) to investigate the transdiagnostic risk and resilience factors associated with suicidal ideation drawn from the most recent research in suicide prevention and personality assessment. Participants will comprise the general population (planned: N = 100) and a risk group (patients currently in psychosomatic or psychiatric treatment) (planned: N = 50). After a comprehensive baseline assessment, they will complete up to ten short assessments per day over the course of 10 days at roughly equidistant intervals. In detail, the project examines the interplay of biography (previous suicidal behavior, experiences of childhood maltreatment), individual differences (level of personality functioning), and time-varying factors (entrapment, loneliness, mood) with respect to the emergence and fluctuation of suicidal ideation. There are two main research foci: First, the project will provide an operationalization and empirical verification of a core assumption of the integrated motivational-volitional model of suicide (IMV model). It will test whether the interaction of the time-varying predictors entrapment with loneliness (as a motivational moderator) explains reports of suicidal ideation over time. Second, it will be the first to examine personality functioning (a transdiagnostic, psychodynamically grounded conceptualization of vulnerability to psychological crises over the life span) as a time-invariant predictor of suicidal ideation assessed within an intensive longitudinal study design. The main analyses will be built on linear mixed models. The overarching aim of the project is to gain a better understanding of the psychological dynamics underlying suicidal ideation in different populations by bringing together concepts from different theoretical traditions. This will inform prevention efforts geared toward the general public as well as intervention in clinical populations.

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.

Schema modes mediate the effect of emotional abuse in childhood on the differential expression of personality disorders

BACKGROUND

There is sound evidence that childhood maltreatment increases the likelihood of developing personality disorders (PDs). However, research on the possible mechanisms involved in the relationship between childhood maltreatment and PDs is scarce. One potential mediator of the maltreatment-PD relationship are schema modes, reflecting dynamic states of cognition, emotion, and behaviour.

AIMS

The current study aimed to explore the mediating effect of schema modes on the association between childhood maltreatment and the expression of Cluster B (borderline and antisocial) and C (avoidant and dependent) PDs.

METHOD

Within a mixed sample of N = 120 clinical PD patients and non-clinical participants, a multivariate path model including interview-assessed childhood maltreatment (emotional abuse, emotional neglect, sexual abuse, and physical abuse), schema modes (child, parent, coping and healthy modes), and borderline, antisocial, avoidant and dependent PDs was explored.

RESULTS

The path model depicted five significant indirect links from emotional abuse on PDs via distinct schema modes. The impact of emotional abuse on borderline PD was mediated by child and coping modes, while parent modes mediated the link to antisocial PD. Healthy modes acted as a mediator on dependent and avoidant PDs.

CONCLUSIONS

The results indicate emotional abuse as a main predictor of schema mode clusters and emphasize the mediating role of schema modes on the maltreatment-related pathways towards PDs. Therapeutic implications are discussed with a special focus on healthy modes.

Dissociating Profiles of Social Cognitive Disturbances Between Mixed Personality and Anxiety Disorder

BACKGROUND

An emerging body of research has begun to elucidate disturbances to social cognition in specific personality disorders (PDs). No research has been conducted on patients with Mixed Personality Disorder (MPD), however, who meet multiple diagnostic criteria. Further, very few studies have compared social cognition between patients with PD and those presenting with symptomatic diagnoses that co-occur with personality pathologies, such as anxiety disorder (AD). The aim of this study was to provide a detailed characterization of deficits to various aspects of social cognition in MPD and dissociate impairments specific to MPD from those exhibited by patients with AD who differ in the severity of personality pathology.

METHOD

Building on our previous research, we administered a large battery of self-report and performance-based measures of social cognition to age-, sex- and education-matched groups of patients with MPD or AD, and healthy control participants (HCs; n = 29, 23, and 54, respectively). This permitted a detailed profiling of these clinical groups according to impairments in emotion recognition and regulation, imitative control, low-level visual perspective taking, and empathic awareness and expression.

RESULTS

The MPD group demonstrated poorer emotion recognition for negative facial expressions relative to both HCs and AD. Compared with HCs, both clinical groups also performed significantly worse in visual perspective taking and interference resolution, and reported higher personal distress when empathizing and more state-oriented emotion regulation.

CONCLUSION

We interpret our results to reflect dysfunctional cognitive control that is common to patients with both MPD and AD. Given the patterns of affective dispositions that characterize these two diagnostic groups, we suggest that prolonged negative affectivity is associated with inflexible styles of emotion regulation and attribution. This might potentiate the interpersonal dysfunction exhibited in MPD, particularly in negatively valenced and challenging social situations.