Beyond dysfunction and threshold-based classification: a multidimensional model of personality disorder diagnosis

An alternative dimensional model of personality disorder (PD) diagnosis that addresses several difficulties inherent in the current DSM conceptualization of PDs (excessive PD overlap and comorbidity, use of arbitrary thresholds to distinguish normal from pathological personality functioning, failure to capture variations in the adaptative value of PD symptoms, and inattention to the impact of situational influences on PD-related behaviors) is outlined. The model uses a set of diagnostician-friendly strategies to render PD diagnosis in three steps: (1) the diagnostician assigns every patient a single dimensional rating of overall level of personality dysfunction on a 50-point continuum; (2) the diagnostician assigns separate intensity and impairment ratings for each PD dimension (e.g., narcissism, avoidance, dependency); and (3) the diagnostician lists any personality traits-including PD-related traits-that enhance adaptation and functioning (e.g., histrionic theatricality, obsessive attention to detail). Advantages of the proposed model for clinicians and clinical researchers are discussed.     

Beliefs in personality disorders: a test with the personality disorder belief questionnaire

The hypothesis that each personality disorder (PD) is characterized by a specific set of beliefs was tested in a sample of 643 subjects, including non-patient controls, axis-I and axis-II patients, diagnosed with SCID-I and -II interviews. Beliefs of six PDs (avoidant, dependent, obsessive-compulsive, paranoid, histrionic, borderline) were assessed with the Personality Disorder Belief Questionnaire (PDBQ). Factor analyses supported the existence of six hypothesized sets of beliefs. Structural equation modeling (SEM) supported the hypothesis that each PD is characterized by a specific set of beliefs. Path coefficients were however in the medium range, suggesting that PDs are not solely determined by beliefs. Nevertheless, empirically derived cutoff scores of the six belief subscales were reasonably successful in classifying subjects, percentages ranging form 51% to 83%. It appeared that there was a monotonical increase in scores on each belief subscale from non-patient controls, to patients without any PD, to patients with PDs (other than the pertinent PD), to patients with the pertinent PD. This suggests that PD-related beliefs are at least partly associated with (personality) psychopathology in general. Another explanation is that many patients' position on the underlying dimensions is not high enough to lead to a DSM PD diagnosis, but high enough to lead to an elevated belief score.     

Age Neutrality of Categorically and Dimensionally Measured DSM–5 Section II Personality Disorder Symptoms

Studies on the face validity of DSM–5 Section II categorical personality disorder (PD) symptoms indicate a bias against older adults. To extend these results, this article explores whether categorically and dimensionally scored PD symptoms of DSM–5 Section II, as measured in the Assessment of DSM–IV Personality Disorders (ADP–IV; Schotte & de Doncker, 1994), corroborate potential age bias across younger (aged 18–34), middle-aged (35–59 years), and older adults (aged 60–75). Differential item functioning (DIF) analyses, following a classical test theory approach, showed that 2 of the 79 symptoms were measured differently across 3 age groups when categorically assessed, and 4 when dimensionally measured. Nevertheless, subsequent differential test functioning analyses supported a low aggregated impact of DIF on the dimensional scales, justifying mean-level comparisons across age groups. Generalizability of the results is discussed in light of methodological issues concerning the research of age neutrality of PD symptoms, including the employed measurement instrument, PD symptom measurement approach, and sample and age range used to describe older adults.     

Continuity of axes I and II: toward a unified model of personality, personality disorders, and clinical disorders

In the current standard psychiatric nomenclature, the DSM-IV-TR (APA, 2000), mental disorders are divided into two groups: Clinical Disorders (CDs) and Personality Disorders (PDs), and CD and PD diagnoses are recorded on two separate axes (Axes I and II, respectively). This article considers evidence regarding putative bases for distinguishing between CDs and PDs, and finds that these constructs are more similar than distinct. Links between the domains may be better understood by focusing on how personality connects CDs and PDs. This perspective underlines the need to work toward a more unified model of personality, PDs, and CDs in research and in future editions of the DSM.     

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.     

Computerized adaptive assessment of personality disorder: introducing the CAT-PD project

Assessment of personality disorders (PD) has been hindered by reliance on the problematic categorical model embodied in the most recent Diagnostic and Statistical Model of Mental Disorders (DSM), lack of consensus among alternative dimensional models, and inefficient measurement methods. This article describes the rationale for and early results from a multiyear study funded by the National Institute of Mental Health that was designed to develop an integrative and comprehensive model and efficient measure of PD trait dimensions. To accomplish these goals, we are in the midst of a 5-phase project to develop and validate the model and measure. The results of Phase 1 of the project--which was focused on developing the PD traits to be assessed and the initial item pool--resulted in a candidate list of 59 PD traits and an initial item pool of 2,589 items. Data collection and structural analyses in community and patient samples will inform the ultimate structure of the measure, and computerized adaptive testing will permit efficient measurement of the resultant traits. The resultant Computerized Adaptive Test of Personality Disorder (CAT-PD) will be well positioned as a measure of the proposed DSM-5 PD traits. Implications for both applied and basic personality research are discussed.     

Opinions of personality disorder experts regarding the DSM-IV personality disorders classification system

OBJECTIVE: To survey the opinions of personality disorder (PD) experts on possible revisions in the classification system for PDs in the DSM-V. METHOD: Four hundred members of two international associations, the Association for Research on Personality Disorders, and the International Society for the Study of Personality Disorders, were asked to take a 78-item web survey. RESULTS: Of the experts who completed the survey (N = 96), 74% felt that the DSM-IV's categorical system of PD diagnosis should be replaced. Eighty percent felt that PDs are better conceived of as personality dimensions or illness spectra, than as categories. The most frequently endorsed alternative system for PDs was a mixed system of categories and dimensions. Most experts preferred the PDs to remain on Axis II. Only 31.3% wanted the term, "Borderline Personality Disorder," retained in the DSM-V. CONCLUSIONS: A clear majority of the PD experts were dissatisfied with the current diagnostic system for PDs.     

Theodore Millon's Contributions to Conceptualizing Personality Disorders

We review Theodore Millon's contributions to conceptualizing personality disorders in contemporary clinical science and practice. Millon worked tirelessly across professional domains and theoretical orientations, developing a rich integrative theory of personality and its pathology, directly and indirectly impacting the evolving iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM–III through DSM–5), and advocating for the personality disorders through his contributions to cofounding the International Society for the Study of Personality Disorders and the Journal of Personality Disorders. We conclude with a closer look at Millon's final major contributions to conceptualizing personality disorders as well as the strengths and limitations of his approach.     

From symptom to process: how the PDM alters goals and strategies in psychological assessment

In many respects the Psychodynamic Diagnostic Manual (PDM) P and M Axes represent psychoanalytic versions of Diagnostic and Statistical Manual of Mental Disorders (DSM) Axes II and V: Whereas the DSM axes focus on surface behaviors and their associated mental states (e.g., thought patterns, affective responses), the PDM axes emphasize underlying psychodynamic processes (e.g., implicit motives, conflicts, defenses), with more modest attention to expressed behavior. The paradigmatic shift envisioned by the PDM creates tremendous opportunities for clinicians and researchers, and significant assessment challenges as well. This article discusses those opportunities and challenges. After briefly contrasting the DSM and PDM conceptualizations of personality pathology and global psychological functioning, I discuss the implications of these contrasting perspectives for diagnosis and psychological assessment, outline strategies for documenting the construct validity of DSM and PDM symptom criteria using symptom-focused and process-focused methods, and offer suggestions for how DSM symptom-focused data can be integrated with PDM process-focused data to facilitate case conceptualization and treatment planning.     

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.     

The psychometric properties of the Portuguese version of the Personality Inventory for DSM‐5

The DSM‐5 Section III proposes a hybrid dimensional‐categorical model of conceptualizing personality and its disorders that includes assessment of impairments in personality functioning (criterion A) and maladaptive personality traits (criterion B). The Personality Inventory for the DSM‐5 is a new dimensional tool, composed of 220 items organized into 25 facets that delineate five higher order domains of clinically relevant personality differences, and was developed to operationalize the DSM‐5 model of pathological personality traits. The current studies address the internal consistency (study 1), the test‐retest reliability (study 2) and the criterion validity (studies 3 and 4) of the Portuguese version of the PID‐5 in samples of native speaking psychology students. Results indicated good internal consistency reliabilities and good temporal stability reliabilities for the majority of the PID‐5 traits. The correlational pattern of the PID‐5 traits with two measures of personality was in accordance with theoretical expectations and showed its concurrent validity.     

The hierarchical structure of the Dimensional Assessment of Personality Pathology (DAPP-BQ)

Hierarchical personality models have the potential to identify common and specific components of DSM-IV personality disorders (PDs), and may offer a solution for the re-tooling of personality pathology in future versions of the DSM. In this paper, we examined the hierarchical structure of the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ; Livesley & Jackson, 2009) and the capacity of various trait components at different levels to predict DSM-IV PD symptoms. Participants were 275 psychiatric outpatients and 365 undergraduate students. Goldberg's (2006) bass-ackwards method was used to investigate the hierarchical structure of the DAPP-BQ. The predictive capacity of hierarchy components was assessed. We found that Level 5 of the hierarchy enhanced the capacity of the DAPP-BQ for predicting DSM PD symptoms beyond a four-factor structure, particularly for borderline PD.     

Personality profiles and the prediction of categorical personality disorders

Personality disorders (PDs) are usually construed as psychiatric categories characterized by a unique configuration of traits and behaviors. To generate clinical hypotheses from normal personality trait scores, profile agreement statistics can be calculated using a prototypical personality profile for each PD. Multimethod data from 1,909 psychiatric patients in the People's Republic of China were used to examine the accuracy of such hypotheses in the Interpretive Report of the Revised NEO Personality Inventory. Profile agreement indices from both self-reports and spouse ratings were significantly related to PD symptom scores derived from questionnaires and clinical interviews. However, accuracy of diagnostic classification was only modest to moderate, probably because PDs are not discrete categorical entities. Together with other literature, these data suggest that the current categorical system should be replaced by a more comprehensive system of personality traits and personality-related problems.     

Assessing DSM–5 Level of Personality Functioning From Videotaped Clinical Interviews: A Pilot Study With Untrained and Clinically Inexperienced Students

Several authors have raised the concern that the DSM–5 Level of Personality Functioning Scale (LPFS) is relatively complex and theory laden, and thus might put high requirements on raters. We addressed this concern by having 22 untrained and clinically inexperienced students assess the personality functioning of 10 female psychotherapy inpatients from videotaped clinical interviews, using a multi-item version of the LPFS. Individual raters’ LPFS total scores showed acceptable interrater reliability, and were significantly associated with 2 distinct expert-rated measures of the severity of personality pathology. These findings suggest that, contrary to the previously mentioned concerns, successfully applying the LPFS to clinical cases might require neither extensive clinical experience nor training.     

The structure of personality disorders: comparing the DSM-IV-TR Axis II classification with the five-factor model framework using structural equation modeling

Earlier factor analytical studies on the empirical validity of the DSM-IV-TR (American Psychological Association, 2000) Axis II classification have offered little support for the current three-cluster structure. In his large-scale meta-analysis of previously published personality disorder correlation matrices, O'Connor (2005) found four factors, corresponding to the neuroticism, extraversion, agreeableness, and conscientiousness domains of the five-factor model of personality. In the present study, this dimensional four-factor model and the categorical DSM three-cluster structure were fitted to the Assessment of DSM-IV Personality Disorders questionnaire (ADP-IV; Schotte & De Doncker, 1994) scale scores using structural equation modelling. The results strongly favored the dimensional model, which also resembled other well-founded four-factor proposals (Livesley, Jang, & Vernon, 1998; Widiger & Simonsen, 2005). Moreover, a multigroup confirmatory factor analysis showed that this model was highly invariant and thus generalizable across two large clinical (n = 1,029) and general population (n = 659) samples.