Reconceptualizing personality pathology in DSM-5: limitations in evidence for eliminating dependent personality disorder and other DSM-IV syndromes

The DSM-5 Personality and Personality Disorders Workgroup proposed that five DSM-IV personality disorders be eliminated as formal diagnostic categories (paranoid, schizoid, histrionic, narcissistic, and dependent), because these syndromes purportedly have low clinical utility and minimal evidence for validity. Scrutiny of studies cited in support of this proposal reveals difficulties in three areas: (1) Inadequate information regarding parameters of the literature search; (2) Mixed empirical support for proposed changes; and (3) Selective attention to certain disorders and not others. Review of validity and clinical utility data related to dependent personality disorder indicates that evidence regarding this syndrome does not differ from that of syndromes proposed for retention in DSM-5. Limitations in the research base cited by the workgroup illuminates gaps in the personality disorder literature, and may serve as a starting point for systematic research on personality pathology so that adequate empirical data are available to decide which syndromes to retain, revise, or remove in future versions of the diagnostic manual.     

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.     

Prototype Personality Diagnosis in Clinical Practice: A Viable Alternative for DSM-V and ICD-11

Several studies suggest that a prototype matching approach yields diagnoses of comparable validity to the more complex diagnostic algorithms outlined in DSM-IV. Furthermore, clinicians prefer prototype diagnosis of personality disorders (PDs) to the current categorical diagnostic system or alternative dimensional methods. An important extension of this work is to investigate the degree to which clinicians are able to make prototype diagnoses reliably. The aim of this study is to assess the inter-rater reliability of a prototype matching approach to personality diagnosis in clinical practice. Using prototypes derived empirically in prior research, outpatient clinicians diagnosed patients' personality after an initial evaluation period. External evaluators independently diagnosed the same patients after watching videotapes of the same clinical hours. Inter-rater reliability for prototype diagnosis was high, with a median r = .72. Cross-correlations between disorders were low, with a median r = .01. Clinicians and clinically trained independent observers can assess complex personality constellations with high reliability using a simple prototype matching procedure, even with prototypes that are relatively unfamiliar to them. In light of its demonstrated reliability, efficiency, and versatility, prototype diagnosis appears to be a viable system for DSM-V and ICD-11 with exceptional utility for research and clinical practice.     

Development and validation of a new procedure for the diagnostic assessment of personality disorder: the Multidimensional Personality Disorder Rating Scale (MPDRS)

Data from a community-based prospective longitudinal study were used to investigate the utility of a structured assessment of the DSM-IV General Diagnostic Criteria for a Personality Disorder (PD). The Structured Clinical Interview for DSM-IV PDs (SCID-II) was administered to 154 adults. After completing the interview, an experienced clinician assessed the General Diagnostic Criteria for a PD using a structured rating scale. PD diagnoses, based solely on the rating scale data, demonstrated strong agreement with diagnoses obtained using the diagnostic thresholds for specific PDs (Kappa = 0.89). The sensitivity, specificity, predictive power, and internal reliability of the rating scale were satisfactory. PD diagnoses, based on both of the assessment procedures, were associated with substantial impairment and distress. These findings suggest that a structured assessment of the DSM-IV General Diagnostic Criteria for a Personality Disorder may constitute a useful alternative or supplement to standard assessments of the diagnostic thresholds for specific DSM-IV PDs.     

The convergent and concurrent validity of trait-based prototype assessment of personality disorder categories in homeless persons

The DSM-5 proposal indicates that personality disorders (PDs) be defined as collections of maladaptive traits but does not provide a specific diagnostic method. However, researchers have previously suggested that PD constructs can be assessed by comparing individuals' trait profiles with those prototypic of PDs and evidence from the five-factor model (FFM) suggests that these prototype matching scores converge moderately with traditional PD instruments. The current study investigates the convergence of FFM PD prototypes with interview-assigned PD diagnoses in a sample of 99 homeless individuals. This sample had very high rates of PDs, which extends previous research on samples with more modest prevalence rates. Results indicated that diagnostic agreement between these methods was generally low but consistent with the agreement previously observed between explicit PD measures. Furthermore, trait-based and diagnostic interview scores evinced similar relationships with clinically important indicators such as abuse history and past suicide attempts. These findings demonstrate the validity of prototype methods and suggest their consideration for assessing trait-defined PD types within DSM-5.     

Introduction to the special issue on personality assessment in the DSM-5

The DSM-5 is poised to dramatically reshape the way clinicians and researchers assess personality by reconfiguring the conceptualization of DSM-IV personality disorders. This special issue brings together leading scholars in personality pathology, including members of the DSM-5 Personality and Personality Pathology Work Group, as well as personality assessors operating from a variety of theoretical perspectives, to describe various facets of these changes and their potential impacts and in some cases to propose alternative solutions. As we describe in this brief introductory article, the articles in this special issue highlight several important and controversial issues in the transition to DSM-5 personality assessment.     

Validation of the Wisconsin Personality Disorders Inventory-IV with the SCID-II

The Wisconsin Personality Disorders Inventory (WISPI-IV; Klein & Benjamin, 1996) is the latest version of a self-report measure of DSM-IV personality disorders (PDs) derived from an interpersonal perspective. When categorical diagnoses derived from the WISPI-IV were compared with independent SCID-II diagnoses, the majority of the kappas were poor (>.40). However, all but one of the effect sizes for the differences in WISPI-IV means between groups with and without SCID-II diagnoses were large (>.80). When SCID-II and WISPI-IV dimensional scores were considered, the average r between profiles was .61 (median = .58) and correlations between corresponding PD scales (mean diagonal r = .48; mean off-diagonal r = .18) indicated good convergent and discriminant validity for five of the WISPI-IV scales. These results add to the cumulating evidence suggesting greater reliability and validity of dimensional over categorical scores for PDs. Researchers and clinicians interested in having an efficient method of assessing PDs may consider using a dimensional approach such as the WISPI-IV as an alternative to diagnostic interview.     

Evaluation of the SCID-II personality disorder traits for DSM-IV: coherence, discrimination, relations with general personality traits, and functional impairment

The utility of the DSM personality disorder (PD) system remains a concern. The strategy employed represents one approach designed to evaluate and improve the diagnostic efficiency of the SCID-II PDs. Using a sample of 203 patients, SCID-II PD items-based on the criterion sets of the 10 DSM-IV PDs-were evaluated with respect to (a) convergent validity; (b) divergent validity; (c) relation to general personality traits; and (d) association with functional impairment. Only Borderline PD items were satisfactory on all four evaluation criteria. Histrionic and Obsessive-Compulsive PD items met criteria for convergent and divergent validity and relation to personality dimensions of the Five-Factor Model of Personality (FFM) but were not related to functional impairment, suggesting they might be reconsidered as disorders. Schizotypal PD items met three of the four criteria but showed no relation to FFM dimensions, suggesting that it may be a candidate for reassignment to Axis I.     

DSM-5 personality traits and DSM-IV personality disorders

Two issues pertinent to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) proposal for personality pathology, the recovery of DSM-IV personality disorders (PDs) by proposed DSM-5 traits and the validity of the proposed DSM-5 hybrid model, which incorporates both personality pathology symptoms and maladaptive traits, were evaluated in a large undergraduate sample (N = 808). Proposed DSM-5 traits as assessed with the Personality Inventory for DSM-5 explained a substantial proportion of variance in DSM-IV PDs as assessed with the Personality Diagnostic Questionnaire-4+, and trait indicators of the 6 proposed DSM-5 PDs were mostly specific to those disorders with some exceptions. Regression analyses support the DSM-5 hybrid model in that pathological traits, and an indicator of general personality pathology severity provided incremental information about PDs. Findings are discussed in the context of broader issues around the proposed DSM-5 model of personality disorders.     

Building an evidence base for DSM-5 conceptualizations of oppositional defiant disorder and conduct disorder: introduction to the special section

The DSM-5 ADHD and Disruptive Behavior Disorders Work Group recently outlined a research agenda designed to support possible revisions to the diagnostic criteria for oppositional defiant disorder (ODD) and conduct disorder (CD). Some of the areas in need of further investigation include (a) examining the clinical utility of the current diagnostic system in girls, (b) further clarifying the developmental progression from ODD to CD, (c) determining whether facets of ODD symptoms can help explain heterotypic continuity and enhance predictive validity, (d) evaluating the clinical utility of a new subtyping scheme for CD on the basis of the presence of callous-unemotional traits, and (e) comparing the clinical utility of dimensional versus categorical conceptualizations of ODD and CD. This special section was organized in an attempt to provide data on these issues using a diverse array of longitudinal data sets consisting of both epidemiological and clinic-based samples that collectively cover a large developmental span ranging from childhood through early adulthood.     

Depressive personality disorder: rates of comorbidity with personality disorders and relations to the five-factor model of personality

Depressive personality disorder (DPD) is listed in the DSM-IV as one of the "Disorders for Further Study." In this investigation we examined (1) the rates of comorbidity of DPD with the 10 personality disorders (PDs) in the main text of DSM-IV, and (2) the convergent and discriminant validity of DPD in its relation to the 30 facet traits of the Five-Factor Model of personality (FFM). One hundred and sixty-nine participants with psychiatric diagnoses were interviewed with the Structured Clinical Interview for DSM-IV Personality Disorders Questionnaire (SCID-II) and completed the Revised NEO Personality Inventory (NEO PI-R). A total of 26 (15%) of the participants met diagnostic criteria for at least one of the 10 main text PDs, and 15 (9%) met criteria for DPD. Of those who met criteria for DPD, 10 (59%) of the participants also met criteria for one or more of the 10 main text PDs. Regression analyses indicated a four-facet trait set derived from the NEO PI-R thought to be uniquely associated with DPD accounted for a significant amount of variance in DPD SCID-II PD scores and was significantly larger for DPD than it was for the 9 of the 10 main text PDs; the sole exception was for avoidant PD. Diagnostically, DPD overlaps significantly with other PDs but is distinguishable in its unique relation with traits from the FFM.     

Prevalence and construct validity of Personality Disorder Not Otherwise Specified (PDNOS)

Personality Disorder Not Otherwise Specified (PDNOS) is one of the most frequently used Axis II diagnoses, yet explicit guidelines for its assessment are lacking. To investigate the prevalence and construct validity of various definitions of PDNOS, 1760 psychotherapy referrals were diagnosed using the Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Construct validity parameters included severity of psychiatric complaints, personality symptoms, and functional impairment. Results show that PDNOS is highly prevalent in this sample (21.6% or 70.8%, depending on whether co-occurrence with formal PD is allowed). Patients with both formal PD and PDNOS have more severe problems than those with formal PD only. In terms of severity, PDNOS takes an intermediate position between formal and no PD. For mixed PD, a cut-off of 5 criteria would yield a large (12.0%) additional PD group with a similar level of functional impairment as compared to mixed PD with a cut-off of either 10 or 15 criteria. In conclusion, the high prevalence of PDNOS warrants proportional attention in science and practice. If PDNOS is retained in DSM-V, it is recommendable to develop explicit guidelines for its assessment.     

Proposals for DSM-5: introduction to special section of Journal of Personality Disorders

On February 10, 2010, the official proposals for the personality disorders section of the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) were posted (see www.dsm5.org ). The posting by the DSM-5 Personality and Personality Disorders Work Group has been helpful in informing the field of the possible changes that may occur with DSM-5. Their presence allows for and encourages persons to provide their suggestions and concerns. The extent of the proposals is considerable. As expressed on the website, "the work group recommends a major reconceptualization of personality psychopathology" (Skodol, 2010, "Reformulation of personality disorders in DSM-5," para. 1). The proposals have generated some controversy. The Journal of Personality Disorders has always sought to be a participant in the crucial debates in our field. The purpose of this special issue is to provide members of the Work Group the opportunity to further articulate the rationale for the proposals, and to provide others an opportunity to articulate their concerns. Copies of this special issue were distributed to interested persons when the complete set of final papers were received (October of 2010).     

The ADP-IV questionnaire: differential validity and concordance with the semi-structured interview

The Assessment of DSM-IV Personality Disorders questionnaire (ADP-IV) is a self-report measure of the DSM-IV Axis II personality disorders (PDs). The ADP-IV assesses for each DSM-IV criterion its typicality as well as the accompanying distress and impairment. This study investigates two important aspects of the construct validity of the ADP-IV: (a) the differential validity (i.e., the ability to differentiate between a sample of the general Flemish population ( n = 659) and a sample of psychiatric inpatients ( n = 487) with a high prevalence of clinical PD diagnoses, and patients with and without a PD in the psychiatric sample; (b) the convergent validity with the SCID-II semi-structured interview in a population of psychiatric inpatients ( n = 59). The results indicate a good differential validity: the dimensional scales and the categorical measures discriminated well between both groups and between patients with and without a PD diagnosis in the psychiatric sample. Concerning the concordance with the SCID-II, a decent level of agreement is exemplified by a correlation of.67 between the dimensional total scores of both instruments and by kappa coefficients for an "any" Axis II diagnosis at the.50 level. In conclusion, the results indicate that the ADP-IV is an efficient method for assessing PD in dimensional and categorical ways.     

Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD): a continuous measure of DSM-IV borderline psychopathology

The purpose of this study was to assess the psychometric properties of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), the first clinician-administered scale for the assessment of change in DSM-IV borderline psychopathology. The questions for the measure were adapted from the BPD module of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) to reflect a 1-week time frame and each of the nine criteria for BPD is rated on a five-point anchored rating scale of 0 to 4, yielding a total score of 0 to 36. Two diagnostic interviews that assess the presence of BPD were administered to 200 nonpsychotic patients: the BPD module of the DIPD-IV and the Revised Diagnostic Interview for Borderlines (DIB-R). The ZAN-BPD was also administered, blind to diagnostic information. In addition, each patient filled out a self-report measure of general psychopathology that is often used in borderline treatment studies, the Symptom Checklist 90 (SCL-90). The convergent validity of the ZAN-BPD and relevant scales of the SCL-90 and the DIB-R was assessed and found to be highly significant. The discriminant validity of the various scores of the ZAN-BPD was also found to be highly significant, easily discriminating the 139 patients who met the DSM-IV criteria for BPD from the 61 patients who did not. In addition, internal consistency of the ZAN-BPD was found to be high (Cronbach's alpha=0.85). The interrater reliability of the ZAN-BPD was assessed using 32 conjoint interviews, while same day test-retest reliability was assessed in a separate sample of 40 patients. All reliability raters were blind to all previously collected information concerning each subject. All intraclass correlations were in the good to excellent range. Finally, the sensitivity of the ZAN-BPD to change was assessed using a third sample of 41 patients who were reinterviewed by a blind rater 7 to 10 days after the ZAN-BPD was first administered. The SCL-90 was also readministered at this time. The correlations between difference scores of the ZAN-BPD and difference scores of the SCL-90 were found to be significant, indicating that the ZAN-BPD measures change in a clinically meaningful manner. Taken together, the results of this study suggest that the ZAN-BPD is a promising clinician-administered scale for the assessment of change in borderline psychopathology over time.     

Do DSM-5 personality disorder proposals meet criteria for clinical utility?

The Work Group for the DSM-5 personality disorders has submitted their proposal to the professional community. In this paper, we consider the proposal in light of its ability to meet criteria for clinical utility as proposed by First and colleagues (2004). While the Work Group's proposal has addressed some of these concerns, we conclude that there remain several unanswered problems with how the proposal will improve the clinical utility of personality disorders section of the DSM-5. Though these concerns can be addressed to some extent in the field trials, it is incumbent upon the Work Group and clinical researchers to attend carefully to these issues so that shortcomings of previous diagnostic manuals are not repeated in the future.     

Levels of Personality Functioning Questionnaire (LoPF-Q) 12–18 Turkish Version: Reliability,Validity, Factor Structure and Relationship with Comorbid Psychopathology in a Turkish Adolescent Sample

Levels of Personality Functioning Questionnaire (LoPF-Q 12–18) is a scale developed for adolescents to assess impairments in personality functioning inspired by criterion A in the Alternative Models for Personality Disorder (AMPD) in DSM-5 and the upcoming ICD-11. In this study, we aim to evaluate the validity and reliability of a Turkish culture-adaption of LoPF-Q 12–18. The study was conducted with a student (n?=?282) and a clinical sample (n?=?52), 41% of the participants were male, and 59% were female. The questionnaire showed good scale reliability alpha and a sound unidimensional factor structure build of four scales of functioning: Identity, Self-direction, Empathy, and Intimacy. Aspects of convergent and discriminant validity were evaluated using the Strengths and Difficulties Questionnaire (SDQ). There were medium to strong positive relationships between the LoPF-Q 12–18 and the SDQ scores reflecting pathology in line with theory. Clinical validity could be demonstrated, the LoPF-Q 12–18 total score differed significantly and with a large effect size of 1.2 standard deviations between the school sample and a sample of N?=?25 patients with diagnosed PD. In general, our results support the validity of the Turkish version of the LoPF-Q 12–18 and emphasize the benefits of using the dimensional severity concept for the classification of personality disorders already in adolescence.