Mapping the Personality Psychopathology Five Domains Onto DSM–IV Personality Disorders in Dutch Clinical and Forensic Samples: Implications for DSM–5

The Personality Psychopathology Five (PSY–5) model represents 5 broadband dimensional personality domains that align with the originally proposed DSM–5 personality trait system, which was eventually placed in Section III for further study. The main objective of this study was to examine the associations between the PSY–5 model and personality disorder criteria. More specifically, we aimed to determine if the PSY–5 domain scales converged with the alternative DSM–5 Section III model for personality disorders, with a particular emphasis on the personality trait profiles proposed for each of the specific personality disorder types. Two samples from The Netherlands consisting of clinical patients from a personality disorder treatment program (n = 190) and forensic psychiatric hospital (n = 162) were used. All patients had been administered the MMPI–2 (from which MMPI–2–RF PSY–5 scales were scored) and structured clinical interviews to assess personality disorder criteria. Results based on Poisson or negative binomial regression models showed statistically significant and meaningful associations for the hypothesized PSY–5 domains for each of the 6 personality disorders, with a few minor exceptions that are discussed in detail. Implications for these findings are also discussed.     

Deriving an empirical structure of personality pathology for DSM-5

The DSM-IV model of personality disorders is composed of trait sets arranged into 10 theoretically distinct, polythetically assessed categories, with little regard for how the traits comprising these disorders are interrelated and structured. Research since the publication of DSM-III has shown that this model is untenable. The question is not whether this model needs revision; rather, the question is how to move from the existing DSM-IV framework to a model better connected with data. Empirically-based models of personality trait variation provide a starting point for DSM-5, and ongoing research will be used to delineate further the empirical structure of personality traits in the pathological range. The ultimate goal is to frame future DSMs in a way that is maximally useful for clinicians as well as researchers. It is also critical to understand that the DSM-5 is intended to be a living document that will facilitate novel inquiry and clinical applications, as opposed to a document designed to promote and perpetuate a fixed set of constructs. Thus, we view a proposed trait system as a first step on a path to a well-validated, clinically-useful structure.     

Connecting DSM-5 Personality Traits and Pathological Beliefs: Toward a Unifying Model

Dissatisfaction with the DSM-IV model of personality disorders has led to the development of alternative conceptualizations, including pathological trait models and models linked to particular theoretical approaches, such as Beck and Freeman’s (1990) cognitive framework. An important issue involves the potential to interweave such models into a single, parsimonious system that combines their distinct advantages. In this study, pathological trait and dysfunctional belief data from 616 individuals in a non-clinical sample were evaluated for commensurability using structural equation modeling. These models can be integrated via five higher-order factors, and that specific dimensions of dysfunctional beliefs can be differentiated based on features of the DSM-5 trait model. Overall, these results suggest that traits provide scaffolding for individual differences in pathological personality, within which dysfunctional beliefs offer specific vectors for clinical intervention in a cognitive framework. Implications of the empirical commensurability of trait and cognitive models are discussed.     

Beyond Traits in the Study of Personality Coherence

People exhibit coherent patterns of experience and action that cannot be fully described or explained by personality trait models. Rather, personality coherence is expressed in dispositional tendencies that violate the structure of common trait categories. Across contexts, people display predictable patterns of behavioral variation that cannot be captured by trait constructs, which correspond to mean levels of response. In addition to these empirical findings, theoretical work in both psychology and philosophy challenges the conceptual strategies through which trait models explain personality coherence. These empirical and theoretical points can be addressed by alternative theoretical models that specify how underlying psychological systems give rise to both common and idiosyncratic patterns of personality consistency and variability.     

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.     

Accurate diagnosis of personality disorders: Some critical factors

Issues pertaining to the accurate diagnosis of personality disorders are discussed from a scientist-practitioner perspective. An attempt is made to distinguish state (Axis I) from trait (Axis II) disorders, and personality (“normal”) from personality disorders (“abnormal”). The reliability and validity of personality disorder diagnoses are explored, and the four criteria for all personality disorder diagnoses are clarified: These criteria are: 1) presence of psychological symptomology, 2) stability over time, 3) consistency across situations, and 4) under-responsiveness to currently available treatments. Also, a distinction is made between categorical and dimensional diagnostic criteria, similar to the distinction between personality type and trait approaches. Recommendations are provided for improving the clinical and empirical work in this area, and implications for treatment are discussed.     

Classifying personality disorder according to severity

Current systems for classifying personality disorder according to specific categories are unsatisfactory because they do not take account of wide variations in levels of personality disturbance and associated impairment. We review previous attempts to classify personality disorder according to severity and place these findings in the context of work exploring the severity of other mental disorders. On the basis of these findings, we propose a new system for classifying personality-related problems based on severity defined by the extent of personality disturbance, the level of social dysfunctioning, and the impact of the disorder for individuals and society. We recognize that studies using these definitions will need piloting and testing in field trials, but believe that this simplified approach to classifying personality disorder would encourage greater use by clinicians and assist those involved in planning services for people with personality disorder.     

Charakterpathologie – Persönlichkeitsorganisationen – Strukturniveaus

Following the recent development of special treatment for people with defective ego structures, the diagnosis of ego structures has become highly relevant. Four models, developed during the last 40 years for the differentiation of particular levels of the ego structure are presented: the classification of character pathology (Kernberg 1966), the personality organisations (Kernberg 1977 and 1996), the structure axis of the OPD (Operationalized Psychodynamic Diagnosis 1996) and the personality organisations of the STIPO (2006). Because the levels of character pathology, the personality organisations as well as the structural levels of the OPD are widely used and the last two often even in parallel, it is worthwhile comparing them concerning their strengths, weaknesses and compatibility. It turns out that especially the categories between the neurotic and the borderline personality organisation (Kernberg 1977) show significant differences. The fact that the OPD as well as the STIPO pay much more attention to these levels as the models of personality organisations also do, is to be considered because of its great clinical significance as an advantageous innovation. In addition, both instruments offer the possibility to assign different structural levels to particular dimensions and, due to their operationalization, assure comparability and allow change measurement.     

The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications

The Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000) was developed to fill gaps in our understanding of the nature, course, and impact of personality disorders (PDs). Here, we review published findings to date, discuss their implications for current conceptualizations of PDs, and raise questions that warrant future consideration. We have found that PDs are more stable than major depressive disorder, but that meaningful improvements are possible and not uncommon. We have confirmed also that PDs constitute a significant public health problem, with respect to associated functional impairment, extensive treatment utilization, negative prognostic impact on major depressive disorder, and suicide risk. At the same time, we have demonstrated that dimensional models of PDs have clinical validity that categories do not, especially greater temporal stability. Furthermore, dimensional personality traits appear to be the foundation of behaviors described by many PD criteria. Taken together, our results lead us to hypothesize that PDs may be reconceptualized as hybrids of stable personality traits and intermittently expressed symptomatic behaviors.     

Narcissism and Empathy in Young Offenders and Non‐offenders

Understanding the individual factors that predispose persons to criminal behaviour is vital to reducing offending and rehabilitating those who have been sentenced to prison. This study examined the roles of narcissism (at both clinical and subclinical trait levels) and empathy, by comparing levels in young adult males currently serving a prison sentence to those with no history of criminal convictions. Prison participants had significantly higher levels of narcissism—in particular entitlement—than control participants, and this link was sequentially mediated by lower perspective‐taking and subsequently lack of empathic concern. Trait narcissism showed stronger effects than narcissistic personality disorder symptoms. Narcissistic young men's feelings of entitlement and ensuing lack of empathy for others may account for their greater likelihood of criminal behaviour. Copyright © 2013 John Wiley & Sons, Ltd.     

Cross-cultural clinical judgment bias in personality disorder diagnosis by forensic psychiatrists in the UK: a case-vignette study

Previous research in the UK has suggested that cross-cultural bias in personality disorder diagnosis might partly account for the smaller proportion of Black, relative to White, patients with personality disorder in secure psychiatric hospitals. Using the case-vignette method, we investigated cross-cultural clinical judgment bias in the diagnosis of personality disorder in African Caribbean men by 220 forensic psychiatrists in the UK. In the vignette describing possible DSM-IV antisocial personality disorder, Caucasians were 2.8 times more likely to be given a diagnosis of personality disorder than African Caribbeans. Diagnosis also varied according to the ethnicity of the clinicians. No cross-cultural bias was found in the vignette describing possible DSM-IV borderline personality disorder. These findings are important in relation to recent policies for offenders and others with personality disorder, and to the current focus on delivering race equality in mental health services in the UK. Ongoing debates about the strengths and limitations of the case-vignette method are also discussed.     

An empirically-based classification of personality disorder

An empirically-based classification is proposed based on studies of the phenotypic structure and genetic architecture of personality disorder. The proposed system has two parts: (1) a definition of general personality disorder, and (2) a system for diagnosing different forms of disorder. General personality disorder is conceptualized as a pervasive disturbance in the overall structure and organization of the personality system that is manifested as the failure to establish a coherent self-system and the capacity for adaptive interpersonal and social behavior. Different forms of disorder are represented by a dimensional system consisting of 30 primary traits organized into four higher-order domains. The system is intended to offer a systematic and comprehensive diagnosis of personality disorder for clinical and research purposes. It is also intended to be used in a flexible but prescribed way to provide a diagnostic assessment tailored to different assessment needs.     

特质、动机和叙事:人格研究的三种范式及其整合

人格心理学以整体的个人为研究对象,以人性问题为核心关切。在对人性的研究过程中,先后出现了三种研究范式:特质、动机和叙事。特质研究考察的是人格的静态结构,即人格由哪些因素构成,回答的是人格的"所有"问题;动机研究考察人格的动力机制,回答的是人格的"所为"问题;叙事研究考察人格的发展过程,回答的是人格的"所成"问题。近年来,研究者们提出,人格叙事研究范式能够将人格特质范式和人格动机范式整合起来一同去理解人格。但叙事研究刚刚兴起,还面临着许多困难和局限,有待进一步完善。     

Empirical evaluation of the MCMI-III personality disorder scales

The MCMI-III personality disorder scales were empirically validated with a sample of 870 clinical patients and inmates. Prevalence rates of personality disorders were in general lower on the MCMI-III than clinical ratings, but trait prevalence was generally higher; thus a base rate of 75 on the MCMI-III could be a guideline in the screening of trait prevalence. However, the sensitivity of some MCMI-III scales was very low. Moreover, the correlations of most personality disorder scales of the MCMI-III were significant and positive with corresponding measures on clinical ratings and MMPI-2 personality disorder scales, but these were, in general, not significantly higher than some other correlations. As a consequence the discriminant validity seems to be questionable. The MCMI-III alone cannot be used as a diagnostic inventory, but the test could be useful as a screening device as a part of a multimethod approach that allows aggregation over measures in making diagnostic decisions.     

An interpersonal analysis of pathological personality traits in DSM-5

The proposed changes to the personality disorder section of the Diagnostic and statistical manual of mental disorders (5th ed.) places an increased focus on interpersonal impairment as one of the defining features of personality psychopathology. In addition, a proposed trait model has been offered to provide a means of capturing phenotypic variation on the expression of personality disorder. In this study, the authors subject the proposed DSM-5 traits to interpersonal analysis using the inventory of interpersonal problems-circumplex scales via the structural summary method for circumplex data. DSM-5 traits were consistently associated with generalized interpersonal dysfunction suggesting that they are maladaptive in nature, the majority of traits demonstrated discriminant validity with prototypical and differentiated interpersonal problem profiles, and conformed well to a priori hypothesized associations. These results are discussed in the context of the DSM-5 proposal and contemporary interpersonal theory, with a particular focus on potential areas for expansion of the DSM-5 trait model.     

Predicting dimensions of personality disorder from domains and facets of the Five-Factor Model

We compared the utility of several trait models for describing personality disorder in a heterogeneous clinical sample (N = 94). Participants completed the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993b), a self-report measure that assesses traits relevant to personality disorder, and two measures of the Five-Factor Model: the Revised NEO Personality Inventory (NEO-PI-R; Costa and McCrae, 1992) and the Big Five Inventory (BFI; John, Donahue, & Kentle, 1991). Regression analyses indicated substantial overlap between the SNAP scales and the NEO-PI-R facets. In addition, use of the NEO-PI-R facets afforded substantial improvement over the Five-Factor Model domains in predicting interview-based ratings of DSM-IV personality disorder (American Psychiatric Association, 1994), such that the NEO facets and the SNAP scales demonstrated roughly equivalent levels of predictive power. Results support assessment of the full range of NEO-PI-R facets over the Five-Factor Model domains for both research and clinical use.     

The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder

The working alliance between therapist and patient is an important component of effective interventions for borderline personality disorder (BPD). The current study examines whether client personality affects the development of the working alliance during the treatment of BPD, and whether this influences treatment effectiveness. Data was based on 87 patients with BPD who were participants in a randomized controlled trial comparing Dialectical Behavior Therapy (DBT) and general psychiatric management. Higher levels of trait Agreeableness were associated with steeper increases in working alliance throughout treatment, but only in the DBT condition. Increases in working alliance were in turn associated with better clinical outcomes. Mediation models revealed a significant indirect path from Agreeableness to better clinical outcomes, mediated through larger improvements in working alliance over time. These results highlight the role that patient personality can play during the therapeutic process, with a specific focus on the importance of Agreeableness for alliance development.