Clinical utility of five dimensional systems for personality diagnosis: a "consumer preference" study

Personality Disorders: Current Conceptualizations and Challenges

The personality disorders are said to be at the vanguard in the shift to a dimensional model of classification, as exemplified in the Alternative Model of Personality (AMPD) presented in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for emerging models and in the 11th edition of the International Classification of Diseases (ICD-11). Considered herein are some limitations and challenges. For the DSM-5 AMPD trait model, these include problematic placements, inadequate coverage, perceived complexity, and lack of cutoff points. For the DSM-5 AMPD Level of Personality Functioning (LPF), they include the complexity, the questionable presumption that the LPF defines the core of personality disorder, the presumption that the LPF identifies what is unique to the personality disorders, and the premise that the LPF is distinct from the maladaptive traits. Limitations and challenges of the ICD-11 model are the absence of lower-order facet scales and the fact that only the level of severity is required. This review suggests that the trait of depressivity belongs with negative affectivity and suspicion belongs within antagonism, that maladaptive traits from all 10 poles of the five domains should be provided, and that cutoff points based on social-occupational impairment and/or distress should be provided. The review summarizes research that questions whether the LPF represents the core of personality disorder, identifies what is unique to the personality disorders, and is distinct from maladaptive traits. Finally, the review suggests that the ICD-11 should require the assessment of the traits and include facet scales.

What is a psychopathology dimension?

Coherence in the science and practice of mental health assessment depends upon a tight connection between psychopathology concepts that are used and the way those concepts are operationalized and defined. In contrast, the use of the same word to mean more than one thing contributes to incoherence, inefficiency, and confusion. In this paper, we review three possible meanings of the word "dimension" as it relates to the assessment of psychopathology and describe how the indiscriminate use of this word has caused confusion in the general context of the transition to a more evidence-based approach to mental health diagnosis. We attempt to disambiguate the term "dimension" by demarcating three concepts that can be distinguished based on different empirical standards: continuous variables, unidimensional dimensions, and distinct dimensions.

The relationship between mood disorders, personality disorder and suicidality in adolescence: does general personality disturbance play a significant role in predicting suicidal behavior?

INTRODUCTION

Current research points to the importance personality pathology and Major Depression e as relevant psycopathological risk factors for understanding suicidal risk in adolescence. Literature has mainly focused on the role of BPD, however current orientations in personality pathological functioning suggest that BPD may be the representative of a general personality disturbance, a factor of vulnerability underlying diverse psychopathological variants and aspects of maladaptive functioning. However, recent studies seem to have neglected the contributions that other specific personality disorders and personality pathology as a general factor of vulnerability for suicidality; and only marginally investigated the interaction of personality disorder (PD) as an overall diagnosis and individual PDs and major depression (MDD). In this paper, the independent and cumulative effects of MDD and DSM-IV PDs on suicidal risk are investigated in a sample of adolescents observed in a longitudinal window of observation ranging from three months preceding the assessment to a six-month follow up period of clinical monitoring.

METHODS

A sample of 118 adolescents (mean age = 15.48 ± 1.14) referred for assessment and treatment on account of suicidal ideation or behavior were administered the CSSRS, SCID II, Kiddie-SADS at admission at inpatient and outpatient Units. All subjects included in the study had reported suicidal ideation or suicide attempts at the C-SSRS; The CSSRS was applied again to all patients who reported further suicidal episodes during the six-months follow-up period of clinical monitoring. Dimensional diagnoses of PDs was obtained by summing the number of criteria met by each subject at SCID-%-PD 5, In order, to test the significance of the associations between the variables chosen as predictors (categorical and dimensional PDs and MD diagnosis), and the suicidal outcomes variables suicide attempts, number of suicide attempts and potential lethality of suicide attempt, non-parametric bivariate correlations, logistic regression models and mixed-effects Poisson regression were performed PD.

RESULTS

The categorical and dimensional diagnosis of PD showed to be a significant risk factors for suicide attempt and their recurrence, independently of BPD, that anyway was confirmed to be a specific significant risk factor for suicidal behaviors. Furthermore, PD assessed at a categorical and dimensional level and Major Depression exert an influence on suicidal behaviors and their lethality both as independent and cumulative risk factors.

LIMITATIONS

Besides incorporating dimensional thinking into our approach to assessing psychopathology, our study still relied on traditionally defined assessment of PD. Future studies should include AMPD-defined personality pathology in adolescence to truly represent dimensional thinking.

CONCLUSION

These results point to the importance of early identification of the level of severity of personality pathology at large and its co-occurrence with Major Depression for the management of suicidal risk in adolescence.

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.

Attitudes, Clinical Practices, and Perceived Advocacy Needs of Professionals With Interests in Personality Disorders

Experts in personality disorders (PDs) generally prefer dimensional diagnostic systems to categorical ones, but less is known about experts' attitudes toward personality pathology diagnoses in adolescents, and little is known about public health shortfalls and advocacy needs and how these might differ geographically. To fill these gaps, the International Society for the Study of Personality Disorders surveyed 248 professionals with interests in PDs about their attitudes toward different diagnostic systems for adults and adolescents, their PD-related clinical practices, and perceived advocacy needs in their area. Results suggested that dimensional diagnostic systems are preferable to categorical and that skepticism about personality pathology in adolescents may not be warranted. The most pressing advocacy need was the increased availability of PD-related services, but many other needs were identified. Results provide a blueprint for advocacy and suggest ways that professional societies can collaborate with public health bodies to expand the reach of PD expertise and services.

Association Between Attachment Patterns and Personality Disorders: A Multimethod Multi-Informant Study Using a Clinical Sample

ABSTRACT

We investigated the association between personality disorders (PDs) and attachment patterns, and examined the construct validity of attachment patterns against adaptive functioning. We used a multimeasure multi-informant approach, which allowed us to disentangle the effects of the methods and to examine the utility of the various methods for measuring these constructs. The participants included 80 clinicians and 170 clinical outpatients, recruited via convenience sampling. Results showed that secure attachment was positively associated with adaptive functioning, whereas insecure patterns were negatively associated with adaptive functioning. Both categorical and dimensional PD diagnoses were associated with insecure attachment patterns. However, after controlling for comorbidity among the PD diagnoses, only some findings remained significant, most notably the association between borderline PD and the clinicians' assessment of preoccupied and incoherent/disorganized attachment, and the patients' self-reported attachment anxiety. Our findings underscore the importance of controlling for comorbidity in examining the associations between attachment patterns and PDs.

Livesley's lament on classifying personality pathology: A commentary

This commentary on Livesley's paper in this special issue on International Classification of Diseases (ICD)-11's personality disorder (PD) section addresses each of four issues that Livesley claims are impeding progress towards an evidence-based system for the classification of personality pathology. I focus my commentary on the third issue, but also comment briefly on the others. Regarding, first, the complexity of personality pathology and, second, problematic assumptions about the nature of personality pathology, I contend that Livesley's comments are accurate, but omit that the fundamental impediment is the refusal of the Diagnostic and Statistical Manual of Mental Disorders (DSM) establishment to allow the official classification to reflect the reality of personality pathology that he describes, in contrast to its acceptance in the ICD-11. In response to Livesley's third claim that a viable alternative to categorical diagnosis is not available, I take issue with various aspects of his assertions and develop arguments that the ICD-11 PD model provides a useful, although admittedly imperfect, system. Finally, I agree with Livesley that the revision processes for official classifications are conservative and open to non-scientific influences, but maintain that whereas the Diagnostic and Statistical Manual of Mental Disorders establishment held fast to the status quo, the ICD-11 PD Working Group made considerable progress towards a valid PD diagnostic system. © 2020 John Wiley & Sons, Ltd.

Factor Structure of the Dutch Language Version of the Shedler-Westen Assessment Procedure (SWAP)

Abstract. The Shedler-Westen Assessment Procedure (SWAP) is a Q-sort procedure for personality assessment. Empirical evidence for the psychometric qualities in the United States thus far is solid, but no such data exist for the Dutch language version. In this study we aim to investigate the higher order factor structure of the Personality Syndrome (PS) scales and Trait Dimension (TD) scales of the Dutch language version of the SWAP-200 (SWAP-200-NL) in a psychiatric outpatient sample ( N = 282). For the TD scales Cronbach’s α is also calculated. Results show acceptable to good overall reliability (i.e., Cronbach’s α). Higher order factor analysis of the SWAP-200 (PS) reveals four maladaptive factors that resemble both the higher order personality traits conceptualized in section III of DSM-5 ( APA, 2013 ), as well as the constructs identified by Widiger and Simonsen (2005) after integrating 18 alternative proposals for dimensional classification. Additionally, High-Functioning Depressive PS was most prevalent in our outpatient sample. While this PS is not described in DSM-5, it is discussed here as a possibly overlooked, clinically relevant construct. Finally, this study replicates previously identified higher order factors of the TD, adding to the instrument’s robustness.

The DSM's Reconnection to Psychoanalytic Theory through the Alternative Model for Personality Disorders

Often believed to have Kraepelinian origins, the Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5) defines personality disorders using a categorical, hierarchical taxonomic system. This system possesses many long-standing problems for clinical practice, including a large assortment of symptom combinations that contribute to problematic heterogeneity and likely impair diagnostic validity. The DSM diagnostic system was at one time heavily influenced by psychoanalytic theory (Shorter 2005). A desire for greater theoretical neutrality then encouraged a shift away from psychoanalytic theory, resulting in the problematic atheoretical model of personality pathology introduced in DSM-III (1980) and still used today. The Alternative Model for Personality Disorders (AMPD), introduced in DSM-5 (2013), is an attempt to reconcile many of the categorical model's issues and directly parallels primary themes that characterize psychoanalytic models of personality. After a review of the historical development of DSM, three current systems for diagnosing personality pathology-the DSM-5's categorical model (2013), its AMPD (2013), and the Psychodynamic Diagnostic Manual (2nd ed.; Alliance of Psychoanalytic Organizations 2017) are compared. The comparison illustrates how the AMPD brings psychoanalytic theory back into the DSM system and acknowledges the implications of a more psychoanalytic DSM.

Mental health professionals' perceived clinical utility of the ICD-10 vs. ICD-11 classification of personality disorders

AIM

The ICD-11 classification of personality disorders (PDs) has adopted a dimensional approach which includes three levels of severity (mild, moderate and severe) with the option of specifying five trait qualifiers (negative affectivity, detachment, dissociality, disinhibition and anankastia) and one borderline pattern qualifier. This study examined mental health professionals' perceived clinical utility of the ICD-11 PD framework compared with the ICD-10 categorical PD framework.

METHOD

A sample of 163 mental health professionals (primarily psychologists, nurses and medical doctors) completed a survey in which they were asked to apply the ICD-10 and ICD-11 PD classifications on one of their patients followed by judgement of their clinical utility.

RESULTS

The ICD-11 PD framework was generally rated as being slightly more useful than the ICD-10 framework even when accounting for educational background and years of experience. This advantage particularly involved the utility for treatment planning, communicating with patients, comprehensiveness and ease of use. The two frameworks showed no significant differences with respect to utility for communicating with other professionals and describing global personality.

CONCLUSION

This study provided initial evidence that mental health professionals perceive the ICD-11 PD classification as slightly more useful for clinical practice than the ICD-10 classification. © 2019 John Wiley & Sons, Ltd.

Validity and clinical utility of DSM and prototype diagnosis for depressive and anxiety spectrum disorders in predicting adaptive functioning

Prototype matching, which involves comparing a patient clinical presentation with a prototype description of the disorder, addresses some of the clinical limitations of categorical approaches. Most research to-date on prototype matching has been conducted with personality disorders. Here, we examined the validity and clinical utility of prototype diagnosis for mood and anxiety disorders. We compared clinicians prototype diagnosis (based on DSM IV and empirically derived) to categorical diagnosis (based on independent SCID interview) in predicting patient global adaptive functioning rated across the clinician, patient and independent interviewer among N = 80 clinicians and N = 170 patients. Our findings show that prototype diagnosis (both one that is based on DSM criteria and empirically derived) demonstrates some incremental validity over and above the categorical DSM IV, in predicting patient's global adaptive functioning. This is particularly pronounced for mood disorders (MDD and dysthymia) as well as several anxiety disorders (OCD, social phobia) across a range of experience level of diagnosticians. Furthermore, clinicians rated the prototype matching approach as more useful in clinical practice compared with the binary categorical system. Using a dimensional approach, which is based on prototype matching that also preserves the advantages of categorical system offers a valid and efficient approach to psychiatric assessment.

Reliability of DSM and empirically derived prototype diagnosis for mood, anxiety and personality disorders

BACKGROUND

Prominent psychiatric diagnostic systems such as the DSM-IV and ICD-10 have shown low reliability in clinical practice. An alternative approach to classification of psychiatric disorders is prototype matching. In the current study, we examined reliability of assessing mood, anxiety and personality disorders using a multi-method multi informant approach. More specifically, we examined diagnosis made by treating clinician and independent expert clinical interviewer, using three different diagnostic systems (DSM symptom count, DSM-IV prototype diagnosis and empirically derived prototype diagnosis).

METHODS

A convenience sample of clinicians (N = 80) and patients (N = 170) from eight community mental health clinics in Israel participated in the study.

RESULTS

Our findings show fair to excellent interrater reliability for prototype dimensional diagnostic systems (ranged from 0.40 to 0.79) for most mood and anxiety disorders examined. Overall, dimensional diagnostic systems, yielded better interrater reliability for mood, anxiety and personality disorders, as compared with categorical diagnosis. There were no significant differences between dimensional systems.

CONCLUSIONS

Our findings provide further support to the advantages of dimensional over categorical models in increasing reliability.

What is the effect on comorbid personality disorder of brief panic-focused psychotherapy in patients with panic disorder?

BACKGROUND

No studies of psychotherapies for panic disorder (PD) have examined effects on comorbid personality disorders (PersD), yet half such patients have a PersD.

METHODS

In a randomized trial for PD with and without agoraphobia comparing Cognitive-Behavioral Therapy (CBT) and Panic-Focused Psychodynamic Psychotherapy (PFPP), PersD was assessed pre-to-post treatment with the Structured Clinical Interview for the Diagnosis of Axis-II Disorders (SCID-II). For patients completing therapy (n = 118, 54 with PersD), covariance between panic and SCID-II criteria improvements was analyzed. SCID-II diagnostic remission and recovery were evaluated. Comparative efficacy of PFPP versus CBT for improving PersD was analyzed both for the average patient, and as a function of PersD severity.

RESULTS

37 and 17% of PersD patients experienced diagnostic PersD remission and recovery, respectively. Larger reductions in PersD were related to more panic improvement, with a modest effect size (r = 0.28). Although there was no difference between treatments in their ability to improve PersD for the average patient (d = 0.01), patients meeting more PersD criteria did better in PFPP compared to CBT (P = .007), with PFPP being significantly superior at 11 criteria and above (d = 0.66; 3 more criteria lost).

CONCLUSIONS

PersD presenting in the context of primary PD rarely resolves during psychotherapies focused on PD, and change in PersD only moderately tracks panic improvements, indicating non-overlap of the constructs. Patients receiving panic-focused psychotherapies may require additional treatment for their PersD. PFPP may be superior at improving severe PersD, but replication of this finding is required.

Personality Organization, Personality Styles, and the Emotional Reactions of Treating Clinicians

This study explores the relationship between clinicians' emotional reactions and patients' level of personality organization and personality style assessed according to the Psychodynamic Diagnostic Manual-2 (Lingiardi & McWilliams, 2017). Level of personality pathology was positively associated with helpless and overwhelmed responses and negatively with positive responses. Parental and disengaged responses were associated with schizoid, anxious and dependent personalities. Parental and criticized responses were associated with narcissistic personalities; their depressed versions were positively associated with parental reactions, but negatively with positive reactions. Parental and overwhelmed responses were associated with counter-dependent and passive-aggressive dependent personalities; the latter also with criticized reactions. Disengaged responses were associated with depressive personalities, particularly with their introjective subtypes, obsessive-compulsive and somatizing personalities. Overwhelmed reactions were associated with relational self-defeating and hysterical/histrionic personalities, the latter also with sexualized reactions. Sexualized and helpless reactions were connected to hypomanic personalities. Findings show that emotional reactions can be useful for understanding personality features.

Clinical utility of the DSM-5 alternative model for borderline personality disorder: Differential diagnostic accuracy of the BFI, SCID-II-PQ, and PID-5

BACKGROUND

With the publication of DSM 5 alternative model for personality disorders it is critical to assess the components of the model against evidence-based models such as the five factor model and the DSM-IV-TR categorical model. This study explored the relative clinical utility of these models in screening for borderline personality disorder (BPD).

METHODS

Receiver operator characteristics and diagnostic efficiency statistics were calculated for three personality measures to ascertain the relative diagnostic efficiency of each measure. A total of 1653 adult inpatients at a specialist psychiatric hospital completed SCID-II interviews. Sample 1 (n=653) completed the SCID-II interviews, SCID-II Questionnaire (SCID-II-PQ) and the Big Five Inventory (BFI), while Sample 2 (n=1,000) completed the SCID-II interviews, Personality Inventory for DSM5 (PID-5) and the BFI.

RESULTS

BFI measure evidenced moderate accuracy for two composites: High Neuroticism+ low agreeableness composite (AUC=0.72, SE=0.01, p<0.001) and High Neuroticism+ Low+Low Conscientiousness (AUC=0.73, SE=0.01, p<0.0001). The SCID-II-PQ evidenced moderate-to-excellent accuracy (AUC=0.86, SE=0.02, p<0.0001) with a good balance of specificity (SP=0.80) and sensitivity (SN=0.78). The PID-5 BPD algorithm (consisting of elevated emotional lability, anxiousness, separation insecurity, hostility, depressivity, impulsivity, and risk taking) evidenced moderate-to-excellent accuracy (AUC=0.87, SE=0.01, p<0.0001) with a good balance of specificity (SP=0.76) and sensitivity (SN=0.81).

CONCLUSIONS

Findings generally support the use of SCID-II-PQ and PID-5 BPD algorithm for screening purposes. Furthermore, findings support the accuracy of the DSM 5 alternative model Criteria B trait constellation for diagnosing BPD. Limitations of the study include the single inpatient setting and use of two discrete samples to assess PID-5 and SCID-II-PQ.

The Challenge of Transforming the Diagnostic System of Personality Disorders

While the DSM-5 alternative model of personality disorder (PD) diagnosis allows the field to systematically compare categorical and dimensional classifications, the ICD-11 proposal suggests a radical change by restricting the classification of PDs to one category, deleting all specific types, basing clinical service provision exclusively upon a severity dimension, and restricting trait domains to secondary qualifiers without defining cutoff points. This article reflects broad international agreement about the state of PD diagnosis. It is argued that diagnosis according to the ICD-11 proposal is based on broad, potentially stigmatizing descriptions of impaired functioning and ignores much of the impressive body of research and treatment guidelines that have advanced the care of adults and adolescents with borderline and other PDs. Before radically changing classification, which highly impacts the provision of health care, head-to-head field trials coupled with the views of patients as well as thorough debate among scientists are urgently needed.

Incremental validity of the PID-5 in relation to the five factor model and traditional polythetic personality criteria of the DSM-5

BACKGROUND

This study assessed the incremental validity of the Personality Inventory for DSM-5 (PID-5) beyond the impact of demographic, burden of illness, five-factor model of personality, and DSM-5 personality disorder criteria with respect to associations with admission psychiatric symptoms and functional disability.

METHODS

Psychiatric inpatients (N = 927) were administered the Big Five Inventory, PID-5, and personality disorder criteria counts. Prior treatment utilization, as well as baseline depression, anxiety, emotion regulation, and functional disability were administered within two days of the personality measures. Hierarchical regression models were used to explore the association of personality functioning with symptom functioning, emotion regulation and disability.

RESULTS

Neuroticism was associated with all symptom measures, providing further support for its relevance in clinical populations. Personality trait domains (negative affect, detachment, and psychoticism) from the PID-5 demonstrated incremental validity in predicting baseline symptom and disability functioning over and above demographic, burden of illness, and psychiatric comorbidity and five-factor model (FFM) personality traits.

CONCLUSIONS

Dimensional measures of personality functioning were consistently associated with baseline symptom functioning, supporting the relevance of personality functioning as it relates to psychiatric symptoms. The PID-5 uniquely contributed to the prediction of baseline symptom functioning, thus providing incremental validity over gold-standard personality trait measures.

Clinical importance of personality difficulties: diagnostically sub-threshold personality disorders

BACKGROUND

Current categorical classification of personality disorders has been criticized for overlooking the dimensional nature of personality and that it may miss some sub-threshold personality disturbances of clinical significance. We aimed to evaluate the clinical importance of these conditions. For this, we used a simple four-level dimensional categorization based on the severity of personality disturbance.

METHODS

The sample consisted of 352 patients admitted to mental health services. All underwent diagnostic assessments (SCID-I and SCID-II) and filled in questionnaires concerning their social situation and childhood adversities, and other validated tools, including the Beck Depression Inventory (BDI), Alcohol Use Disorders Identification Test (AUDIT), health-related quality of life (15D), and the five-item Mental Health Index (MHI-5). The patients were categorized into four groups according to the level of personality disturbance: 0 = No personality disturbance, 1 = Personality difficulty (one criterion less than threshold for one or more personality disorders), 2 = Simple personality disorder (one personality disorder), and 3 = Complex/Severe personality disorder (two or more personality disorders or any borderline and antisocial personality disorder).

RESULTS

The proportions of the groups were as follows: no personality disturbance 38.4% (n = 135), personality difficulty 14.5% (n = 51), simple personality disorder 19.9% (n = 70), and complex/severe personality disorder 24.4% (n = 86). Patients with no personality disturbance were significantly differentiated (p < 0.05) from the other groups regarding the BDI, 15D, and MHI-5 scores as well as the number of Axis I diagnoses. Patients with complex/severe personality disorders stood out as being worst off. Social dysfunction was related to the severity of the personality disturbance. Patients with a personality difficulty or a simple personality disorder had prominent symptoms and difficulties, but the differences between these groups were mostly non-significant.

CONCLUSIONS

An elevated severity level of personality disturbance is associated with an increase in psychiatric morbidity and social dysfunction. Diagnostically sub-threshold personality difficulties are of clinical significance and the degree of impairment corresponds to actual personality disorders. Since these two groups did not significantly differ from each other, our findings also highlight the complexity related to the use of diagnostic thresholds for separate personality disorders.

Relating DSM-5 section II and section III personality disorder diagnostic classification systems to treatment planning

BACKGROUND

Beginning with DSM-III, the inclusion of a "personality" axis was designed to encourage awareness of personality disorders and the treatment-related implications of individual differences, but since that time there is little accumulated evidence that the personality disorder categories provide substantial treatment-related guidance. The DSM-5 Personality and Personality Disorders Work Group sought to develop an Alternative Model for personality disorder, and this study examined whether this model is more closely related to clinicians' decision-making processes than the traditional categorical personality disorder diagnoses.

PROCEDURES

A national sample of 337 clinicians provided complete personality disorder diagnostic information and several treatment-related clinical judgments about one of their patients.

FINDINGS

The dimensional concepts of the DSM-5 Alternative Model for personality disorders demonstrated stronger relationships than categorical DSM-IV/DSM-5 Section II diagnoses to 10 of 11 clinical judgments regarding differential treatment planning, optimal treatment intensity, and long-term prognosis.

CONCLUSIONS

The constructs of the DSM-5 Alternative Model for personality disorders may provide more clinically useful information for treatment planning than the official categorical personality disorder diagnostic system retained in DSM-5 Section II.

The Importance of Considering Clinical Utility in the Construction of a Diagnostic Manual

The development of major diagnostic manuals primarily has been guided by construct validity rather than clinical utility. The purpose of this article is to summarize recent research and theory examining the importance of clinical utility when constructing and evaluating a diagnostic manual. We suggest that construct validity is a necessary but not sufficient criterion for diagnostic constructs. This article discusses components of clinical utility and how these have applied to the current and forthcoming diagnostic manuals. Implications and suggestions for future research are provided.

Personality disorders and the DSM-5: Scientific and extra-scientific factors in the maintenance of the status quo

OBJECTIVE

The aim of this study was to review and discuss the evidence for dimensional classification of personality disorders and the historical and sociological bases of psychiatric nosology and research.

METHOD

Categorical and dimensional conceptualisations of personality disorder are reviewed, with a focus on the Diagnostic and Statistical Manual of Mental Disorders-system's categorisation and the Five-Factor Model of personality. This frames the events leading up to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, personality disorder debacle, where the implementation of a hybrid model was blocked in a last-minute intervention by the American Psychiatric Association Board of Trustees. Explanations for these events are discussed, including the existence of invisible colleges of researchers and the fear of risking a 'scientific revolution' in psychiatry.

RESULTS

A failure to recognise extra-scientific factors at work in classification of mental illness can have a profound and long-lasting influence on psychiatric nosology. In the end it was not scientific factors that led to the failure of the hybrid model of personality disorders, but opposing forces within the mental health community in general and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Task Force in particular.

CONCLUSION

Substantial evidence has accrued over the past decades in support of a dimensional model of personality disorders. The events surrounding the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, Personality and Personality Disorders Work Group show the difficulties in reconciling two different worldviews with a hybrid model. They also indicate the future of a psychiatric nosology that will be increasingly concerned with dimensional classification of mental illness. As such, the road is paved for more substantial changes to personality disorder classification in the International Classification of Diseases, 11th Revision, in 2017.

Association between Clinician's Subjective Experience during Patient Evaluation and Psychiatric Diagnosis

BACKGROUND

Classical psychopathology greatly valued the interaction between clinician and patient, and assigned to the clinician's subjective experience a significant role in the diagnostic process. Psychoanalysis, too, ascribed a privileged position to the clinician's feelings and empathic participation in the assessment and deep understanding of the patient. This study aimed at testing the traditional, though still relatively unexplored empirically, tenet that particular diagnostic groups elicit distinct and diagnostically useful reactions from clinicians.

SAMPLING AND METHODS

The study was performed in several psychiatric inpatient and outpatient units in Rome, Italy. The clinicians completed the Assessment of Clinician's Subjective Experience (ACSE) questionnaire and other standardized assessment instruments when they evaluated a previously unknown patient. All adult patients diagnosed with schizophrenia (n = 119), cluster B personality disorder (n = 114), manic or mixed bipolar I episode (n = 59), and unipolar depression or anxiety disorder (n = 130) were included in the study, for a total of 422 patients evaluated by 35 clinicians.

RESULTS

We found a significant and theoretically consistent relationship between the clinicians' pattern of subjective experience during the first visit and patients' clinical diagnoses. Patients with unipolar depression/anxiety showed significantly lower scores than the other groups on all ACSE scales except engagement; patients with schizophrenia displayed significantly higher scores than the other groups on difficulty in attunement, and significantly higher scores than patients with cluster B personality disorder on impotence. Compared with the other groups, the patients with cluster B personality disorder displayed significantly lower scores on engagement, and significantly higher scores on disconfirmation. In multivariate models controlling for patient's age and education, symptom severity, clinician's sex, duration of visit and setting, diagnosis remained a significant predictor of scores on all ACSE scales except for impotence.

CONCLUSIONS

The main limitations of the study are its reliance on clinical diagnoses and the non-independence of assessments. Further studies based on diagnoses made by a third observer through standardized instruments are needed to provide a most stringent test of the hypothesis that different diagnoses are associated with distinct profiles of clinicians' subjective experience. This study provided intriguing, though preliminary, evidence that the clinician's subjective experience may play a useful role in the diagnostic process. Time may have come to reintroduce the concept of intersubjectivity at the core of the diagnostic process.

Generalized social anxiety disorder: A still-neglected anxiety disorder 3 decades since Liebowitz's review

In the 3 decades since Liebowitz's review of 'a neglected anxiety disorder,' controversy and challenges have remained in the study of social anxiety disorder (SAD). This review examines evidence around the classification and subtyping of SAD, focusing on generalized SAD. Substantial discrepancies and variation in definition, epidemiology, assessment, and treatment of generalized SAD exist as the international literature on it has grown. In East Asian cultures in particular, study of taijin kyofusho has been important to a broadened conceptualization of SAD into generalized SAD. Despite important progress with biological and other studies, many challenges in the understanding of generalized SAD will remain in the years to come.

A dimensional approach to assessing personality functioning: examining personality trait domains utilizing DSM-IV personality disorder criteria

BACKGROUND

This study compared a dimensional, trait domain approach to characterizing personality pathology with the traditional polythetic approach with respect to their associations with interpersonal functioning and personality traits from the five factor model.

METHODS

Psychiatric inpatients (N=1476) were administered the Structured Clinical Interview for DSM-IV Axis II personality disorders. Dimensional representations of trait domains were derived from reorganizing DSM-IV criteria into personality trait domains from DSM-5 Alternative Model. Dimensional scores and personality disorder (PD) total criterion scores served as independent variables in predicting interpersonal profile clusters, as well as extraversion, agreeableness conscientiousness, neuroticism and openness from the five factor model traits.

RESULTS

Trait domain scores and PD criteria totals were significantly correlated with submissive interpersonal style yet none proved significant in regression analyses. Avoidant and borderline PD total criteria were negatively associated with a normative interpersonal style. Combined trait domain of detachment and avoidant PD total criteria predicted a hostile/withdrawn interpersonal style. The trait domain of detachment was negatively associated with five factor traits of extroversion, whereas borderline PD total criteria were negatively associated with conscientiousness. Avoidant and borderline PD total criteria were positively associated with neuroticism.

CONCLUSIONS

The cross-cutting dimensional approach provided useful information in predicting a hostile/withdrawn interpersonal style as well as extroversion. Importantly, PD criterion scores and dimensional trait scores combined to predict this interpersonal style providing support to the alternative model of personality diagnosis in DSM-5. Clinicians are encouraged to assess dimensions of personality traits as these are related to interpersonal problems frequently encountered in psychiatric settings. While potentially useful, the dimensional approach articulated here did not yield substantial prediction of behavior.

Clinical validity of prototype personality disorder ratings in adolescents

A growing body of research shows that personality pathology in adolescents is clinically distinctive and frequently stable into adulthood. A reliable and useful method for rating personality pathology in adolescent patients has the potential to enhance conceptualization, dissemination, and treatment effectiveness. The aim of this study is to examine the clinical validity of a prototype matching approach (derived from the Shedler Westen Assessment Procedure-Adolescent Version) for quantifying personality pathology in an adolescent inpatient sample. Sixty-six adolescent inpatients and their parents or legal guardians completed forms of the Child Behavior Checklist (CBCL) assessing emotional and behavioral problems. Clinical criterion variables including suicide history, substance use, and fights with peers were also assessed. Patients' individual and group therapists on the inpatient unit completed personality prototype ratings. Prototype diagnoses demonstrated substantial reliability (median intraclass correlation coefficient =.75) across independent ratings from individual and group therapists. Personality prototype ratings correlated with the CBCL scales and clinical criterion variables in anticipated and meaningful ways. As seen in prior research with adult samples, prototype personality ratings show clinical validity across independent clinician raters previously unfamiliar with the approach, and they are meaningfully related to clinical symptoms, behavioral problems, and adaptive functioning.

Dimensions of personality and personality pathology: factor structure of the Shedler-Westen assessment procedure-II (SWAP-II)

Researchers have proposed replacing the current system for diagnosing personality disorders with a dimensional trait model. Proposed trait models have been derived primarily from data provided by untrained lay informants (often via self-report questionnaires) using item sets derived from lay conceptions of personality. An alternative is to derive personality trait dimensions from data provided by clinically expert informants using an instrument that includes personality features salient to clinicians who treat personality dysfunction. The authors report the factor structure of the latest edition of the Shedler-Westen Assessment Procedure (SWAP-II) using a normative clinical sample of 1,201 North American patients assessed by experienced psychologists and psychiatrists. Factor analysis identified 14 clinically and empirically coherent factors. The findings highlight dimensions of personality and personality pathology that have not emerged in personality item sets designed for lay personality description.

The Schedule for Nonadaptive and Adaptive Personality for Youth (SNAP-Y): a new measure for assessing adolescent personality and personality pathology

The Schedule for Nonadaptive and Adaptive Personality-Youth Version (SNAP-Y) is a new, reliable self-report questionnaire that assesses 15 personality traits relevant to both normal-range personality and the alternative DSM-5 model for personality disorder. Community adolescents, 12 to 18 years old (N = 364), completed the SNAP-Y; 347 also completed the Big Five Inventory-Adolescent, 144 provided 2-week retest data, and 128 others completed the Minnesota Multiphasic Personality Inventory-Adolescent. Outpatient adolescents (N = 103) completed the SNAP-Y, and 97 also completed the Minnesota Multiphasic Personality Inventory-Adolescent. The SNAP-Y demonstrated strong psychometric properties, and structural, convergent, discriminant, and external validities. Consistent with the continuity of personality, results paralleled those in adult and college samples using the adult Schedule for Nonadaptive and Adaptive Personality-Second Edition (SNAP-2), from which the SNAP-Y derives and which has established validity in personality-trait assessment across the normal-abnormal continuum. The SNAP-Y thus provides a new, clinically useful instrument to assess personality traits and personality pathology in adolescents.

Five-Factor Model personality disorder prototypes: a review of their development, validity, and comparison to alternative approaches

In this article, the development of Five-Factor Model (FFM) personality disorder (PD) prototypes for the assessment of DSM-IV PDs are reviewed, as well as subsequent procedures for scoring individuals' FFM data with regard to these PD prototypes, including similarity scores and simple additive counts that are based on a quantitative prototype matching methodology. Both techniques, which result in very strongly correlated scores, demonstrate convergent and discriminant validity, and provide clinically useful information with regard to various forms of functioning. The techniques described here for use with FFM data are quite different from the prototype matching methods used elsewhere.

Contributions from personality- and psychodynamically oriented assessment to the development of the DSM-5 personality disorders

Advances in personality assessment over the past 20 years have notably influenced the proposed assessment and classification of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM-5]). However, a considerable body of personality assessment and psychodynamically oriented assessment research has significant relevance to the way in which personality disorders are evaluated that appears to have gone unrecognized in the current proposals for DSM-5. In this article, I discuss the ways in which some of these 2 bodies of literature can and should inform the DSM-5 so that the diagnostic nomenclature can be more scientifically and comprehensively informed and consequently improve the clinical utility of a diagnostic system in need of considerable revision.

Personality disorders in DSM-5

A substantive revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) last occurred in 1994; therefore, the mental health field should anticipate significant changes to the classification of mental disorders in the fifth edition. Since DSM-5 Work Groups have recently proposed revisions for the major diagnostic classes of mental disorders, an article on the current status of the personality disorders (PDs) is timely. This article reviews scientific principles that have influenced the development of proposed changes for the assessment and diagnosis of personality psychopathology in DSM-5, presents the proposed model as of the summer of 2011, summarizes rationales for the changes, and discusses critiques of the model. Scientific principles were articulated for DSM-5 more than a decade ago; their application to the process has not been straightforward, however. Work Group members have labored to improve the DSM-5 approach to personality and PDs to make the classification more valid and more clinically useful. The current model continues to be a work in progress.

An empirically derived taxonomy for personality diagnosis: bridging science and practice in conceptualizing personality

OBJECTIVE

The authors describe a system for diagnosing personality pathology that is empirically derived, clinically relevant, and practical for day-to-day use.

METHOD

A random national sample of psychiatrists and clinical psychologists (N=1,201) described a randomly selected current patient with any degree of personality dysfunction (from minimal to severe) using the descriptors in the Shedler-Westen Assessment Procedure–II and completed additional research forms.

RESULTS

The authors applied factor analysis to identify naturally occurring diagnostic groupings within the patient sample. The analysis yielded 10 clinically coherent personality diagnoses organized into three higher-order clusters: internalizing, externalizing, and borderline-dysregulated. The authors selected the most highly rated descriptors to construct a diagnostic prototype for each personality syndrome. In a second, independent sample, research interviewers and patients' treating clinicians were able to diagnose the personality syndromes with high agreement and minimal comorbidity among diagnoses.

CONCLUSIONS

The empirically derived personality prototypes described here provide a framework for personality diagnosis that is both empirically based and clinically relevant.

The Shedler-Westen assessment procedure (SWAP): evaluating psychometric questions about its reliability, validity, and impact of its fixed score distribution

The Shedler-Westen assessment procedure (SWAP) is a personality assessment instrument designed for use by expert clinical assessors. Critics have raised questions about its psychometrics, most notably its validity across observers and situations, the impact of its fixed score distribution on research findings, and its test-retest reliability. We review empirical data addressing its validity, emphasizing the multitrait-multimethod approach to evaluating test validity. To evaluate the hypothesis that the fixed, asymmetric score distribution artifactually inflates correlations between SWAP profiles, we conducted Monte Carlo simulations and also presented empirical data from a large patient sample. We observed a mean correlation of zero between simulated SWAP profiles, indicating that the score distribution does not impact the correlation coefficients. Empirical correlations between SWAP profiles of actual patients were small and similar to those obtained using Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) personality disorder scales that had no fixed score distributions, suggesting that the correlations were not a methodological artifact of the SWAP. We report new test-retest reliability data (median coefficient > .85) for the SWAP's trait and personality disorder dimensions. The SWAP appears to be reliable and valid. The data do not support its primary psychometric critiques.

Prototype diagnosis of psychiatric syndromes

The method of diagnosing patients used since the early 1980s in psychiatry, which involves evaluating each of several hundred symptoms for their presence or absence and then applying idiosyncratic rules for combining them for each of several hundred disorders, has led to great advances in research over the last 30 years. However, its problems have become increasingly apparent, particularly for clinical practice. An alternative approach, designed to maximize clinical utility, is prototype matching. Instead of counting symptoms of a disorder and determining whether they cross an arbitrary cutoff, the task of the diagnostician is to gauge the extent to which a patient's clinical presentation matches a paragraph-length description of the disorder using a simple 5-point scale, from 1 ("little or no match") to 5 ("very good match"). The result is both a dimensional diagnosis that captures the extent to which the patient "has" the disorder and a categorical diagnosis, with ratings of 4 and 5 corresponding to presence of the disorder and a rating of 3 indicating "subthreshold" or "clinically significant features". The disorders and criteria woven into the prototypes can be identified empirically, so that the prototypes are both scientifically grounded and clinically useful. Prototype diagnosis has a number of advantages: it better captures the way humans naturally classify novel and complex stimuli; is clinically helpful, reliable, and easy to use in everyday practice; facilitates both dimensional and categorical diagnosis and dramatically reduces the number of categories required for classification; allows for clinically richer, empirically derived, and culturally relevant classification; reduces the gap between research criteria and clinical knowledge, by allowing clinicians in training to learn a small set of standardized prototypes and to develop richer mental representations of the disorders over time through clinical experience; and can help resolve the thorny issue of the relation between psychiatric diagnosis and functional impairment.

An Integrative Conceptual Framework for Assessing Personality and Personality Pathology

As a contribution to the ongoing debate over the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, we present a framework for jointly conceptualizing personality and personality pathology. The key element is an explicit distinction between personality description (which is the realm of basic personality psychology) and personality evaluation (which is the realm of clinical personality psychology). Previous diagnostic systems did not acknowledge this crucial distinction. We created a sample diagnostic system, to illustrate how a practical application of our conceptual framework may look like. The system comprises two ingredients: First, a list of personality dispositions that may become problematic. These are described at a “basic level” of abstraction (i.e., the level at which patients and clinicians intuitively communicate about personality problems). Second, a list of negative consequences that are used to evaluate the extent to which a patient's personality pattern is “problematic.” A sample of therapists used the system for describing actual patients and found it to be better than the International Classification of Diseases (ICD)-10 and DSM–IV. Based on our conceptual deliberations, we analyze the DSM-5 proposal for personality and personality disorders. The proposal contains three different sets of “higher-order concepts” (personality traits, personality types, and levels of personality functioning). Only the first of these is sufficiently supported by empirical evidence, including analyses of our own set of personality dispositions.

Was bringt das DSM-V Neues zur Klassifikation der Persönlichkeitsstörungen?

Zusammenfassung. Es stehen grundsätzliche Veränderungen in der Klassifikation von Persönlichkeitsstörungen an mit der Zielsetzung der Reduktion von Komorbidität, der Besserung von Konstrukt- und diskriminativer Validität sowie einer höheren Stabilität. Die allgemeine Definition einer Persönlichkeitsstörung stellt Kerndefizite in ihr Zentrum, die auf einer Selbst/Anderen Dimension angesiedelt sind. Vorgeschlagen wird eine Reduktion der Persönlichkeitsstörungstypen auf solche 5 Kategorien, die am besten empirisch validiert sind. Ihr Ausprägungsgrad wird hinsichtlich der Übereinstimmung mit einem Prototyp bewertet. Jeder Typ wird identifiziert anhand von Kernbeeinträchtigungen im Funktionsniveau, symptomatischem Verhalten und in pathologischen Persönlichkeitsmerkmalen. Bei allen Patienten sollen stabile Persönlichkeitsdimensionen beschrieben werden und zwar zum einen auf der Ebene von sechs übergeordneten Domänen (personality trait domains) und zum anderen anhand von feingliedrigen Fazetten. Die Domänen werden in ihrem Ausprägungsgrad beurteilt.

Clinician's judgments of the utility of the DSM-IV and five-factor models for personality disordered patients

The purpose of the current study was to examine the clinical utility of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 2000) and the Five Factor Model of personality disorder (FFM; Widiger, Costa, & McCrae, 2002) in describing personality pathology. In the current study, practicing psychologists described one or two of their personality disordered patients in terms of the FFM and DSM models. In some instances, the patient was someone who met the criteria for one of the 10 DSM-IV personality disorders; in others, the patient was someone who received a diagnosis of personality disorder, not otherwise specified. Participants then rated each model on six aspects of clinical utility. The current study found that the FFM was consistently rated higher than the DSM model in terms of four of the six aspects of clinical utility. Across both cases, the clinicians rated the FFM as significantly more useful with respect to its ability to provide a global description of the individual's personality, to communicate information to clients, and to encompass all of the individual's important personality difficulties.

Integrating normal and abnormal personality structure: a proposal for DSM-V

The personality disorders section of the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is currently being developed. The purpose of the current paper is to encourage the authors of DSM-V to integrate normal and abnormal personality structure within a common, integrative model, and to suggest that the optimal choice for such an integration would be the five-factor model (FFM) of general personality structure. A proposal for the classification of personality disorder from the perspective of the FFM is provided. Discussed as well are implications and issues associated with an FFM of personality disorder, including validity, coverage, feasibility, clinical utility, and treatment implications.

Can personality disorder experts recognize DSM-IV personality disorders from five-factor model descriptions of patient cases?

BACKGROUND

Dimensional models of personality are under consideration for integration into the next Diagnostic and Statistical Manual of Mental Disorders (DSM-5), but the clinical utility of such models is unclear.

OBJECTIVE

To test the ability of clinical researchers who specialize in personality disorders to diagnose personality disorders using dimensional assessments and to compare those researchers' ratings of clinical utility for a dimensional system versus for the DSM-IV.

METHOD

A sample of 73 researchers who had each published at least 3 (median = 15) articles on personality disorders participated between December 2008 and January 2009. The Five-Factor Model (FFM), one of the most-studied dimensional models to date, was compared to the DSM-IV. Participants provided diagnoses for case profiles in DSM-IV and FFM formats and then rated the DSM-IV and FFM on 6 aspects of clinical utility.

RESULTS

Overall, participants had difficulty identifying correct diagnoses from FFM profiles (t₇₂ = 12.36, P < .01), and the same held true for a subset reporting equal familiarity with the DSM-IV and FFM (t₂₃ = 6.96, P < .01). Participants rated the FFM as less clinically useful than the DSM for making prognoses, devising treatment plans, and communicating with professionals (all t₆₉ > 2.19, all P < .05), but more useful for communicating with patients (t₆₉ = 3.03, P < .01).

CONCLUSIONS

The results suggest that personality disorder expertise and familiarity with the FFM are insufficient to correctly diagnose personality disorders using FFM profiles. Because of ambiguity inherent in FFM profile descriptors, this insufficiency may prove unlikely to be attenuated with increased clinical familiarity with the FFM.

A critique of the proposed prototype rating system for personality disorders in DSM-5

The DSM-5 Personality and Personality Disorders (PDs) Work Group has recommended a reformulation of the PD section, one component of which is a replacement of specified operational criteria with a prototype matching dimensional rating system. The Work Group indicated that prototype ratings have been demonstrated to have good interrater reliability. No study was cited to support this statement, and a review of the reliability literature does not support this claim. The one study that directly compared the reliability of prototype and DSM-IV criteria counting approaches found the DSM-IV approach was much more reliably applied. The Work Group cited 2 studies supporting the validity of the prototype matching approach, one of which had significant methodological limitations and the other changed the a priori threshold on the PD prototype dimensional rating scale to categorize patients into PD positive and negative groups. The Work Group also cited 2 studies suggesting that prototype matching approaches are preferred by clinicians. Several studies have raised concerns about the adequacy of psychiatric diagnostic evaluations conducted in routine clinical practice thereby raising questions about the value of studies of clinicians' preferences in comparing different diagnostic practices. In conclusion, if the prototype matching dimensional approach described in the DSM-5 draft proposal is adopted, then it will have been adopted with essentially no empirical support demonstrating improved reliability or validity. In fact, there is evidence that reliability will be worse than the DSM-IV approach.