Clinical utility of dimensional models for personality pathology

Clinical utility is defined as the extent to which the DSM assists clinical decision makers in fulfilling the various clinical functions of a psychiatric classification system. Distinction is made between elements of diagnostic validity that are more or less conditional to utility (i.e., coverage, and consistency with etiology and prognosis) and components of clinical utility in the narrow sense of the term (i.e., user acceptability and accuracy, communication, reliability, subtlety, and clinical decision making). Clinical utility is often considered the driving force behind the respective revisions of the DSM system, yet it has been difficult if not impossible to obtain reasonable levels of clinical utility within categorical classifications of personality disorders. This paper presents evidence that a dimensional diagnostic system will substantially improve clinical utility, especially with respect to coverage, reliability, subtlety, and clinical decision making. In addition, some evidence suggests that the purely dimensional models outperform the so-called hybrid models (i.e., dimensional profiling of categories) with respect to coverage, consistency with etiology, subtlety, and clinical decision making. Several research options that might inform future revisions, including the choice or development of a dimensional classification, are suggested.     

Dimensional and Cross‐Cutting Assessment in the DSM‐5

A significant proposed change to the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) that will significantly affect the way counselors diagnose mental disorders is the addition of dimensional assessments to the categorical diagnoses. The author reviews the current DSM's (4th ed., text rev.; American Psychiatric Association, 2000 ) categorical classification system, describes the proposed dimensional and cross‐cutting assessments, and provides implications about clinical utility and user acceptability of a dimensional diagnostic approach.     

A framework for integrating dimensional and categorical classifications of personality disorder

Although empirical evidence strongly supports a dimensional representation of personality disorder, there is strong resistance to dimensional classification due in part to concerns about clinical utility. Acceptance of an evidence-based dimensional classification would be facilitated by information on how such a system would map onto existing diagnoses. With this objective in mind, an integrated framework is proposed that combines categorical and dimensional diagnoses. A two-component classification is adopted that distinguishes between the diagnosis of general personality disorder and the assessment of individual differences in the form the disorder takes. Then, the DSM definition of personality disorders is extended by defining individual disorders as categories of trait dimensions. This makes it possible to develop an integrated classification organized around a set of empirically derived primary traits. Assessments of these traits may then be combined to generate categorical and dimensional diagnoses. It is argued that this approach would introduce an etiological perspective into the classification of personality disorder and improve categorical classification by providing an explicit definition of each diagnosis. The clinical utility of incorporating a dimensional classification is discussed in terms of convenience and acceptability, value in predicting outcomes and treatment planning, and usefulness in organizing and selecting interventions.     

Dimensional versus categorical classification of mental disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and beyond: comment on the special section

The value of including dimensional elements in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has been recognized for decades. Nevertheless, no proposals have been made for introducing dimensional classification in the diagnostic system in a valid and feasible manner. As an initial step in this endeavor, the authors suggest introducing dimensional severity ratings to the extant diagnostic categories and criteria sets. Although not without difficulties, this would begin to determine the feasibility of dimensional classification and would address some limitations of the purely categorical approach (e.g., failure to capture individual differences in disorder severity, and clinically significant features subsumed by other disorders or falling below conventional DSM thresholds). The utility of incorporating broader dimensions of temperament and personality in diagnostic systems beyond the fifth edition of the DSM is also discussed.     

Assessing personality in the DSM-5: the utility of bipolar constructs

All previous editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) have described and assessed personality solely in terms of pathological categories. Nonetheless, there is compelling evidence that normal-range personality traits also provide clinically useful information, emphasizing the importance of thoroughly assessing both adaptive and maladaptive aspects of personality within a clinical context. The proposed inclusion of a dimensional trait model in the upcoming DSM-5 represents an important shift in the understanding of personality pathology and provides an ideal opportunity to integrate the assessment of normal personality into clinical practice. Building on research conceptualizing personality disorders as maladaptive, extreme variants of general personality traits, it is proposed that both normal and abnormal personality can be assessed within the same dimensional model using bipolar constructs. The inclusion of bipolar traits, such as a continuum ranging from introversion to extraversion, would hold numerous advantages for a dimensional model. These benefits include a strong foundation of existing validity research, comprehensive coverage of personality pathology, and the ability to provide useful information about all individuals. Despite potential complexities, the adoption of bipolar constructs within DSM-5's dimensional model presents the greatest opportunity to maximize efficiency, validity, and clinical utility.     

Comparing Five Sets of Five‐Factor Model Personality Disorder Counts in a Heterogeneous Sample of Psychiatric Patients

The research agenda for DSM‐5 emphasizes the implementation of dimensional trait models into the classification of personality disorders (PDs). However, because assessment psychologists may still want to recover the traditional DSM‐IV categories, researchers developed a count technique that uses sums of selected Five‐Factor Model facets to assess the DSM‐IV PDs. The presented study examined the convergent and divergent validity of different linear combinations of trait facets to describe specific DSM‐IV PDs in a heterogeneous clinical sample (N = 155) with sufficient prevalence of all PDs, using semi‐structured interviews to obtain all diagnostic information, and comparing alternative counts from five different sources for each PD. The results show that none of the schizotypal, antisocial, and dependent counts succeeded in combining good convergent with adequate divergent validity. However, the original counts could be optimized for five of the seven remaining PDs by using alternative Five‐Factor Model prototypes. The diagnostic and taxonomic implications of these findings are discussed. Copyright © 2012 John Wiley & Sons, Ltd.     

Clinicians' judgments of clinical utility: a comparison of the DSM-IV and five-factor models

Clinical utility, or the usefulness of a diagnostic system in clinical practice, has been identified as an important construct in proposed revisions to the diagnostic nomenclature and a significant limitation of dimensional models of personality disorder, such as the 5-factor model (FFM). Only 1 study to date has addressed explicitly the clinical utility of the FFM, and the findings suggested significant limitations. In the current study, 245 practicing psychologists described 3 historic cases using both the FFM and the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2000) and then rated each model on 6 aspects of clinical utility. In contrast to prior research, the psychologists in this study considered the FFM to have greater clinical utility than the existing diagnostic categories.     

Development and Validation of Personality Disorder Spectra Scales for the MMPI–2–RF

The purpose of this study was to develop and validate a set of MMPI–2–RF (Ben-Porath &; Tellegen, 2008/2011) personality disorder (PD) spectra scales. These scales could serve the purpose of assisting with DSM–5 PD diagnosis and help link categorical and dimensional conceptions of personality pathology within the MMPI–2–RF. We developed and provided initial validity results for scales corresponding to the 10 PD constructs listed in the DSM–5 using data from student, community, clinical, and correctional samples. Initial validation efforts indicated good support for criterion validity with an external PD measure as well as with dimensional personality traits included in the DSM–5 alternative model for PDs. Construct validity results using psychosocial history and therapists' ratings in a large clinical sample were generally supportive as well. Overall, these brief scales provide clinicians using MMPI–2–RF data with estimates of DSM–5 PD constructs that can support cross-model connections between categorical and dimensional assessment approaches.     

A Psychometric Review of the Personality Inventory for DSM–5 (PID–5): Current Status and Future Directions

The paradigm of personality psychopathology is shifting from one that is purely categorical in nature to one grounded in dimensional individual differences. Section III (Emerging Measures and Models) of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM–5]; American Psychiatric Association, 2013), for example, includes a hybrid categorical/dimensional model of personality disorder classification. To inform the hybrid model, the DSM–5 Personality and Personality Disorders Work Group developed a self-report instrument to assess pathological personality traits—the Personality Inventory for the DSM–5 (PID–5). Since its recent introduction, 30 papers (39 samples) have been published examining various aspects of its psychometric properties. In this article, we review the psychometric characteristics of the PID–5 using the Standards for Educational and Psychological Testing as our framework. The PID–5 demonstrates adequate psychometric properties, including a replicable factor structure, convergence with existing personality instruments, and expected associations with broadly conceptualized clinical constructs. More research is needed with specific consideration to clinical utility, additional forms of reliability and validity, relations with psychopathological personality traits using clinical samples, alternative methods of criterion validation, effective employment of cut scores, and the inclusion of validity scales to propel this movement forward.     

Public acceptance of driver state monitoring for automated vehicles: Applying the UTAUT framework

Driver state monitoring (DSM) systems aim to measure driver/occupant state, considering factors such as fatigue, workload, attentiveness, and wellbeing. They are influential for some vehicles on the road today, but as we move towards higher levels of automation their use is expected to become even more important. Uncertainty around public perception of these systems is a potentially limiting factor, with potential concerns for privacy, data storage, perceived utility, and reliability amongst other things posing potential threats. A survey was conducted based on the Universal Theory of Acceptance and Use of Technology (UTAUT) framework, which collected 311 individual responses to explore the acceptability of this technology in specific relation to conditionally and partially automated vehicles. This paper identified that the factors of effort expectancy, performance expectancy, social influence, and attitudes towards using new technology are all positively related to overall behavioural intention, whereas anxiety is negatively related. Other demographic influences are discussed, and recommendations made for future research and marketing/implementation of DSM systems to ensure acceptance by future users.     

Toward a multidimensional model of personality disorder diagnosis: implications for DSM-5

This article outlines a model of personality disorder (PD) diagnosis that combines clinically useful constructs from the Diagnostic and Statistical Manual of Mental Disorders (DSM) with assessment procedures that maximize reliability and clinical utility while minimizing problems associated with threshold-based PD classification. I begin by addressing limitations in the current DSM conceptualization of PDs: excessive comorbidity, use of arbitrary cutoffs to distinguish normal from pathological functioning, failure to capture variations in the adaptive value of PD symptoms, and inattention to situational influences that shape PD-related behaviors. The revisions proposed by the DSM-5 Personality and Personality Disorders Work Group help resolve some of these issues, but create new problems in other areas. A better solution would be to employ a multidimensional model of PD diagnosis in which clinicians (a) assign a single dimensional rating of overall level of personality dysfunction, (b) provide separate intensity and impairment ratings for each PD dimension, and (c) list those personality traits-including PD-related traits-that enhance adaptation and functioning. Preliminary evidence bearing on the multidimensional model is reviewed, and broader clinical and empirical implications of the model are discussed.     

Innovations in the Identification and Referral of Mothers at Risk for Depression: Development of a Peer-to-Peer Model

This paper describes a feasibility study of a peer-delivered prevention intervention to identify mothers at high risk for depression and facilitate engagement in mental health services for their emotional health. Sixteen family peer advocates and their supervisors partnered with academic researchers over a period of 6 months to develop a four-session intervention that focused on identifying symptoms of depression, providing education about depression and treatment, actively linking caregivers to treatment for their own emotional health, and assisting caregivers in becoming active participants in their mental health care. Collaborating with peers to develop the model enhanced its perceived relevance and utility, and resulted in an intervention that was complimentary to their roles and the mission of peer-delivered support services. Peer/professional partnerships may be beneficial for enhancing the feasibility and acceptability of research efforts; the impact of peers’ participation in the current project and the need for future research to develop and study peer-delivered models is discussed.     

The Shedler-Westen Assessment Procedure-200 as a basis for modifying DSM personality disorder categories

The Shedler-Westen Assessment Procedure-200 (SWAP) is a Q-sort instrument designed to assess personality pathology on the basis of clinician ratings. On the basis of research with the SWAP, its creators have proposed a group of 12 personality disorder (PD) diagnoses that can be used to replace or modify current Axis II categories of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The authors discuss conceptual and empirical issues that require clarification before this proposal can be properly evaluated. They identify problematic psychometric features of the SWAP, including its unrepresentative normative sample, its reliance on a fixed skewed distribution, and anomalies in its T-score approach to diagnoses. In addition, a review of research on SWAP-based PD categories indicates that important information regarding diagnostic coverage, validity, and temporal stability is presently lacking. The authors conclude that research evidence is currently insufficient to justify the use of SWAP-based PD categories to guide revision of the DSM.     

Dimensional Assessment of Emotional Disorder Outcomes in Transdiagnostic Treatment: A Clinical Case Study

Current classification systems for mental disorders emphasize categorical assessment. In the domain of emotional disorders, this is inconsistent with a growing consensus that anxiety, depressive, and related disorders are best conceptualized as variations on shared underlying processes, chiefly heightened negative affect, and aversion to unwanted emotional experiences. Dimensional assessment of transdiagnostic emotional disorder constructs offers advantages for clinical and research applications, including increased parsimony and improved validity, yet there are drawbacks to many dimensional assessment systems for emotional disorders. The case presented in this paper illustrates the potential clinical utility of a new self-report instrument—the Multidimensional Emotional Disorders Inventory (MEDI)—which assesses nine dimensions characteristic of emotional disorders. MEDI scores for a highly comorbid patient are examined over the course of transdiagnostic emotion-focused cognitive-behavioral treatment. At baseline, midtreatment, and posttreatment, the MEDI offered information above and beyond DSM categorical assessment, including detection of subclinical symptoms and symptom change, while remaining parsimonious. Implications for possible use as a treatment planning instrument, integration with categorical assessment, and future research directions are discussed.     

Toward resolution of a longstanding controversy in personality disorder diagnosis: Contrasting correlates of schizoid and avoidant traits

Although the construct validity and clinical utility of separate schizoid and avoidant personality disorder (PD) categories has been controversial since avoidant PD was first introduced in DSM-III, few studies have compared individuals with schizoid versus avoidant features on variables relevant to their contrasting personality dynamics. Those few investigations that exist have yielded inconclusive results. In this study a mixed-sex sample of nonclinical participants (N = 123) completed the International Personality Disorder Examination Screening Questionnaire (IPDE-SQ) and self-report measures of attachment style, defense style, empathy, internalized shame, need to belong, rejection sensitivity, and social anhedonia. High levels of social anhedonia were uniquely predictive of schizoid features; high levels of need to belong and internalized shame were uniquely predictive of avoidance. These findings support retaining the two PD categories in future versions of the DSM. Supplementary analyses revealed that among women—but not men—schizoid and avoidant traits were positively and significantly intercorrelated; it may be that women show more of a blended schizoid–avoidant profile, whereas men display the more prototypical categorical profile where either schizoid or avoidant features predominate.     

Methodological Strategies in Child Clinical Trials: Advancing the Efficacy and Effectiveness of Psychosocial Treatments

The present paper reviews issues of treatment efficacy (i.e., potency) and effectiveness (i.e., clinical utility) in applied clinical child research. Threats to treatment evaluation are reviewed in the context of these two dimensions. It is proposed that treatment outcome research faces new challenges stemming from the ever increasing emphasis on generalization of gains and dissemination of interventions outside of clinical research settings. Issues and approaches proposed as warranting further development and attention include development, flexibility, acceptability, and disseminability of psychosocial assessment and treatment methods. A research emphasis is promoted that balances experimental control with the need for treatment generalization and delivery outside of the research setting, in order to maximize the utility of clinical research.     

Reliability and Validity of a DSM-IV Based ADHD Screener

The Diagnostic Rating Scale (DRS) was completed by the parents and teachers of 82 children referred for clinical evaluations, 73 referred children seen twice, and 218 non-referred children from the community. The DRS, which uses a categorical rather than a dimensional rating approach, was 70% to 90% sensitive to diagnoses of Attention Deficit/Hyperactivity Disorder (ADHD) made by blind clinical teams. In research and clinical applications, the DRS could improve screening efficiency, especially in situations where it would be desirable to exclude all children who might have ADHD or identify all children with Hyperactive-Impulsive symptoms. Because of its objectivity and consistency with the Diagnostic and Statistical Manual (DSM)-IV criteria, the DRS could facilitate comparison of participant samples across studies.     

The myth of DSM's invention of new categories of disorder: Houts's diagnostic discontinuity thesis disconfirmed

Houts (2001) argues that increases in DSM diagnostic categories are due to the invention of new disorders that are discontinuous with old conceptions of disorder and would not have been previously diagnosed. He maintains that DSM category increases are not comparable in nature to ICD category increases, which are mainly refinements of recognized disorders. I survey categories of disorder introduced after DSM-II and assess whether they are discontinuous with old concepts and categories of disorder. Candidate categories are identified from: Houts and Follette (1998), Mentalism, mechanisms, and medical analogues: Reply to Wakefield. Journal of Consulting and Clinical Psychology; Kutchins and Kirk (1997) Making us crazy: DSM: The psychiatric bible and the creation of mental disorders. New York: Free Press; and my own list. The result is that virtually none of the candidate categories are invented, discontinuous categories. In almost every case, the newly labeled conditions were considered disorders at the time of DSM-II and would have been diagnosed under DSM-II categories. I also reexamine DSM-IV sleep disorder categories, which Houts claims are discontinuous with past diagnostic conceptions. The result is that all DSM-IV sleep disorders were recognized as disorders at the time of DSM-II, and most were recognized as mental disorders. I conclude that DSM category increases are comparable in nature to ICD category increases, and that the invention-of-disorder account cannot explain the vast majority of such increases.     

Reliability and validity of a DSM-IV based ADHD screener.

The Diagnostic Rating Scale (DRS) was completed by the parents and teachers of 82 children referred for clinical evaluations, 73 referred children seen twice, and 218 non-referred children from the community. The DRS, which uses a categorical rather than a dimensional rating approach, was 70% to 90% sensitive to diagnoses of Attention Deficit/Hyperactivity Disorder (ADHD) made by blind clinical teams. In research and clinical applications, the DRS could improve screening efficiency, especially in situations where it would be desirable to exclude all children who might have ADHD or identify all children with Hyperactive-Impulsive symptoms. Because of its objectivity and consistency with the Diagnostic and Statistical Manual (DSM)-IV criteria, the DRS could facilitate comparison of participant samples across studies.