The problem of severity in the classification of personality disorder

Personality Disorders in Criminal Offenders - A Systematic Literature Review

PURPOSE OF REVIEW

We summarized studies investigating measures related to the Alternative Model for Personality Disorders (AMPD) of the DSM-5 and the personality model in ICD-11 in offenders in forensic-psychiatric treatment or prison to evaluate its forensic utility.

RECENT FINDINGS

The reformation of the DSM and ICD with regards to the introduction of dimensional assessments of personality disorders holds many advantages over categorical models concerning clinical utility. With regards to DSM-5 AMPD Criterion A, a limited number of studies (k = 4) report impairments in interpersonal functioning in offenders. Studies assessing Criterion B (k = 13) predominantly report higher personality impairment measures for offenders, especially for antagonism and disinhibition. Due to the heterogeneity of the selected studies, this review cannot draw conclusions with regard to the predictive value of dimensional models for offenders in forensic-psychiatric treatment or prison, but provides initial evidence for the validity and utility of DSM-5 AMPD and ICD-11 in these settings.

The Dimensional Conceptualization of Personality Disorders: Personality Organization, Personality Functioning, and Personality Disorders

Over the past several decades, significant criticism of the categorical classification system for personality disorders has highlighted the need to transition to a dimensional classification system. This study reviewed key issues involved in the potential conversion of the diagnostic system of personality disorders from a categorical to a dimensional model. The result suggests that Kernberg's concept of personality organization can be used to indicate the overall severity of personality pathology.

A new performance-based measure of personality functioning impairment: development and preliminary evaluation of reliability and validity

Personality functioning impairment is at the center of many dimensional models of personality. Available measures of personality functioning impairment are limited to self-report, clinician-/informant-rated, and interview methods. Although researchers have begun investigating established performance-based instruments' potential for assessing personality functioning impairment, administration and scoring of these instruments is complex and the latent variables they measure diverge from personality functioning impairment as described in the ICD-11 and the Alternative Model for Personality Disorders (AMPD) of the DSM. We address this absence by developing and psychometrically evaluating the Level of Personality Functioning Scale-Questionnaire-based Implicit Association Test (LPFS-qIAT). The LPFS-qIAT's psychometric properties were evaluated across four studies, producing initial evidence supporting the new instrument's reliability as well as its convergent, discriminant, and criterion-related validity. As the first performance-based measure of personality functioning impairment that aligns with the AMPD and, to a degree the ICD-11, that is easily administered, scored, and interpreted, the LPFS-qIAT shows potential to become a valuable tool in both research and clinical practice.

The underlying structure of the Personality Inventory for DSM-5 (PID-5): a general factor of personality psychopathology

BACKGROUND

The psychopathology of personality is currently undergoing a paradigm shift from a categorical to a dimensional approach. This work aimed to study the underlying structure of pathological personality traits of the DSM-5 Alternative Model for Personality Disorders (AMPD). For this purpose, the internal structure of a version of the Personality Inventory for the DSM-5 (PID-5) was examined by a confirmatory factor analysis. This version assesses the five higher-order pathological personality domains (negative affectivity, detachment, antagonism, disinhibition, and psychoticism) and the 25 lower-order pathological personality facets through a reduced number of items. Four alternative models were compared: five-factor oblique; second-order (five first-order factors and one second-order factor); bifactor (five specific factors and a general factor), and one-factor.

PARTICIPANTS AND PROCEDURE

We worked with an Argentinean sample of N = 525 subjects from the general population who answered the Argentine version of the PID-5.

RESULTS

The five-factor model was slightly superior to the second order model, and the bifactor model presented the best fit.

CONCLUSIONS

These findings, while preliminary, suggest that the PID-5 facets could reflect five specific pathological personality traits (which correspond to AMPD domains) but also a general factor (which would reflect a general propensity for psychopathology).

Intergenerational transmission of personality disorder severity and the role of psychosocial risk factors

BACKGROUND

Familial influences on the development of many psychopathologies are well recognised, yet the psychosocial risk factors that could help explain apparently intergenerational continuities of personality disorder (PD) are less well understood.

AIMS

To establish whether there is an association between the severity of PD in men and their offspring in a community cohort, and whether factors recognised as having the potential to increase risk of psychopathology mediate this.

METHODS

Participants in the Cambridge Study in Delinquent Development (n = 452 dyads) were assessed using the Tyrer and Johnson model of PD severity. Severe PD was defined as antisocial PD plus at least one other PD from a different cluster. Original participants were assessed by interview and their offspring by screening questionnaire. Chi-square tests and mediation models were used to investigate the intergenerational continuity of PD severity and its relationship with psychosocial risk factors.

RESULTS

An association between severe PD in fathers and severe PD in their offspring was confirmed, regardless of whether the offspring were male or female. Whilst preliminary tests suggested that employment problems, poor parental supervision and family disruption we associated with severe PD in daughters, mediation analysis suggested that these variables had very little effect once severity of father's disorder was in the model.

CONCLUSIONS

Psychosocial risk factors appear to play a limited role in the intergenerational transmission of PD severity, although future studies should take account of interaction data, for example, quality and quantity of paternal interaction given a child's temperamental traits.

Severity in the ICD-11 personality disorder model: Evaluation in a Spanish mixed sample

Severity is the main component of the ICD-11 personality disorder (PD) classification, but pertinent instruments have only recently been developed. We analyzed the psychometric properties of the ICD-11 Personality Disorder Severity scale (PDS-ICD-11) in a mixed sample of 726 community and clinical subjects. We also examined how the different components of the ICD-11 PD system -five trait domains, the borderline pattern specifier, and severity, all of them measured through self-reports- are interconnected and operate together. PDS-ICD-11 properties were adequate and similar to those of the original instrument. However, regressions and factor analyses showed a considerable overlap of severity with the five personality domains and the borderline specifier (72.6%). Bifactor modeling resulted in a general factor of PD (g-PD) that was not equivalent to severity nor improved criterion validity. The whole ICD-11 PD system, i.e., five personality domains, borderline, and severity, explained an average of 43.6% of variance of external measures of well-being, disability, and clinical problems, with severity contributing 4.8%. Suggestions to further improve the ICD-11 PD taxonomy include remodeling the present definition of severity to give more weight to the real-life consequences of traits.

Change in the Definition of Personality Disorder in Transition to ICD-11: A Look from Clinical and Developmental Perspectives

The recent body of research reveals fundamental limitations to the categorical concept of a personality disorder that has led researchers to adopt a new personality disorder concept. During the last decade DSM-5 and ICD-11 diagnostic classifications have accepted the dimensional view towards personality pathology. Despite the differences between the two classifications, the joint aspect of both models is the construct of Levels of personality functioning. The construct of personality functioning involves personality (dys)function in the self and interpersonal domains. This two-step conceptualization includes (a) impairments of self and interpersonal functioning, indicating general signs and severity of personality disorder, and (b) pathological personality traits, reflecting ‘stylistic’ differences in the expression of personality disorder. The new conceptualization of personality disorder reflects the innovative multi-theoretical integration of known, empirically-based personality assessment paradigms. The relationship between personality functioning and interpersonal, psychodynamic, and personological paradigms provides the theoretical integrity and empirically-based structure necessary to understand the overall severity of personality pathology. Many methods (interviews, self-assessment scales, and questionnaires) have already been developed for the assessment of personality functioning, and their development will be encouraged by the ICD-11 classification established in 2022. At present, only one instrument has been developed in Lithuania for assessing the level of personality functioning in young people aged 12–18 (Barkauskienė & Skabeikytė, 2020). The empirical data about the validity of this construct and its capability to differentiate between the normal and impaired personality in adults and adolescents provide promising results, but are still accumulating. Research suggests that adolescence is a stage in development when personality pathology can fully unfold and be validly confirmed, which opens up opportunities for early intervention. Although the dimensional personality disorder model needs to further prove its importance, there is already evidence that it is less stigmatizing and returns psychology and personality into the concept of a personality disorder. This review presents changes in the conceptualization of personality disorders by discussing them from both clinical and developmental perspectives and highlighting the results of key research in recent years.

ICD-11 Personality Disorders: A Psychodynamic Perspective on Personality Functioning

The new ICD-11 introduces a fully dimensional classification of personality disorders representing a fundamental change in personality disorder diagnosis with major implications for clinical practice and research. The new system centers on the evaluation of the severity of impairment in the areas of self and interpersonal functioning. This focus on personality functioning converges with long-standing psychoanalytic/psychodynamic conceptualizations of personality pathology. In a detailed conceptual analysis and review of existing empirical data, points of convergence and notable differences between major exponents of the psychodynamic tradition-object relations theory as developed by Kernberg et al. and the Operationalized Psychodynamic Diagnosis-and the ICD-11 system are critically discussed. Personality functioning can be considered to be the current "common ground" for the assessment of personality disorders and constitutes a considerable step forward in making personality disorder diagnosis both clinically meaningful and suitable for research purposes.

Temperaments and characters: incompatible or complementary components for criterion B of the alternative model in predicting DSM-5 section II personality disorders?

BACKGROUND

Many studies have found clear correspondence among the domains of the five-factor model of personality (FFM) and the alternative model of personality disorders (AMPD) in DSM-5-III, which is assessed with the Personality Inventory for DSM-5 (PID-5). However, very few studies have compared the PID-5 with the other well-known established dimensional models of personality such as Cloninger's model. The present study examined whether the Temperament and Character Inventory (TCI-125) dimensions, PID-5 dimensions, or a combination would represent PD-scale scores more accurately.

PARTICIPANTS AND PROCEDURE

In this regard, 437 college students completed the Persian version of the PID-5, TCI-125 and SCID-II Screening Questionnaire.RESULTS The results indicated that cooperativeness (low), self-directedness (low), and self-transcendence (high) characters of the TCI-125 and the psychoticism (high) domain of the PID-5 are the most consistent predictors of all PD-scale scores.

CONCLUSIONS

Overall, the findings showed that an integrative model, combining dimensions of the TCI-125 and PID-5, represented the features of PD-scale scores most effectively.

Global personality dysfunction and the relationship of pathological and normal trait domains in the DSM-5 alternative model for personality disorders

OBJECTIVE

The DSM-5 Alternative Model of Personality Disorders distinguishes core personality dysfunction common to all personality pathology from maladaptive traits that delineate specific variants of disorder. Previous research shows the convergence between maladaptive and normal range trait domains as well as substantial correlations between maladaptive traits and core dysfunctions, leading some to conclude that personality traits and dysfunction are redundant. This study sought to examine the potential utility of the concept of core dysfunctions as a means of clarifying the nature of the relationship between maladaptive and normal-range traits.

METHOD

Three nonclinical samples (n = 178, 307, and 1,008) were evaluated for personality dysfunction, maladaptive traits, and normal-range traits using different measures.

RESULTS

Results indicated that: (1) normal trait domains and core dysfunction contribute independently to understanding maladaptive traits; (2) the correlation of a normal trait domain with its putative maladaptive equivalent is consistently accounted for in part by core dysfunction; and (3) the multitrait multimethod matrices of normal and maladaptive personality trait domains demonstrate appreciable discriminant validity problems that are clarified by a consideration of core dysfunction.

CONCLUSION

These results suggest that maladaptive traits reflect the distinguishable contributions of core personality dysfunction (problems) and normal-range personality traits (person).

Comparative Content Analysis of Self-Report Scales for Level of Personality Functioning

Content validity analyses of eight self-report instruments for assessing severity of personality disorder (PD), also known as Level of Personality Functioning (LPF), were conducted using the conceptual scheme of the Alternative Model for Personality Disorders (AMPD; APA, 2013). The item contents of these eight inventories were characterized for the LPF constructs of Identity (ID), Self-Direction (SD), Empathy (EM), and Intimacy (IN) along with the pathological personality trait domains of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Severity of pathology (SV) reflected in item content was also rated. Raters demonstrated robust agreement for AMPD and SV constructs across instruments. Similarity between instrument AMPD construct profiles was quantified by intraclass correlations (ICC). Results showed the instruments were generally similar in AMPD-construct coverage, but some important differences emerged. The subscales of the instruments also were characterized for the degree to which they reflect the four LPF (ID, SD, EM, IN) domain constructs. Collectively, these content validity comparisons clarify the equivalence of instruments for AMPD constructs and the relative proportions of construct coverage within instrument subscales. These results can inform future research with LPF self-report instruments and guide clinicians in selecting an LPF-related instrument for use in practice.

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.

Introduction to the Special Series on the Personality Functioning Component of the Alternative DSM-5 Model for Personality Disorders

The Alternative DSM-5 Model for Personality Disorders (AMPD; American Psychiatric Association, 2013 ) was created to remedy the previously well-explicated limitations of the categorical DSM-IV personality disorders. The AMPD combines dimensional assessments of personality functioning (Criterion A) and traits (Criterion B), which can be used independently or together, and serve as the basis for defining six categorical disorder options. The Criterion A Level of Personality Functioning Scale (LPFS) defines a continuum characterized by the four elements of identity, self-direction, empathy, and intimacy. Empirical work related to the LPFS has been growing, and this Journal of Personality Assessment special series features reports from a variety of research groups around the world. These studies provide contributions for better understanding the reliability, validity, and utility of the LPFS, as well as describing new measures that have been created to investigate personality functioning.

The Differential Profile of Social Anxiety Disorder (SAD) and Avoidant Personality Disorder (APD) on the Basis of Criterion B of the DSM-5-AMPD in a College Sample

BACKGROUND

The present study was conducted to determine the differential profile of social anxiety disorder (SAD) and avoidant personality disorder (APD) based on dimensional diagnosis in criterion B of the DSM-5 Alternative Model for Personality Disorders (DSM-5-AMPD) in a college sample.

METHODS

Samples of this cross-sectional study included 320 (23.08 ± 2.66 years; 57% female) college students in western Iran during February 2015 to December 2017. Liebowitz-social anxiety scale, PID-5, SCID-II, SCID-II-SQ and diagnostic interview for SAD were the tools. The data were analysed using Pearson correlation and multiple linear regression analysis.

RESULTS

Forty-three and 38 participants met criteria for SAD alone and APD, respectively. Five main domains of PID-5 could explain 29% and 54% of the variance of SAD and APD, respectively. Facets of negative affect, detachment, antagonism, disinhibition, and psychoticism could explain 25% versus 43%, 26% versus 54%, 7% versus 27%, 21% versus 41%, 13% versus 30% of the variance of SAD and APD, respectively.

CONCLUSION

SAD and APD probably refer to two distinct mental states having prominent anxiety, emotional instability, and interpersonal pattern of avoidance and detachment of challenge. SAD is a simple form of mental disturbances with anxiety in its core features; although, APD is possibly referring to more complicated psychopathology.

Comparing Hierarchical Models of Personality Pathology

Two dimensional, hierarchical classification models of personality pathology have emerged as alternatives to traditional categorical systems: multi-tiered models with increasing numbers of factors and models that distinguish between a general factor of severity and specific factors reflecting style. Using a large sample (N=840) with a range of psychopathology, we conducted exploratory factor analyses of individual personality disorder criteria to evaluate the validity of these conceptual structures. We estimated an oblique, "unfolding" hierarchy and a bifactor model, then examined correlations between these and multi-method functioning measures to enrich interpretation. Four-factor solutions for each model, reflecting rotations of each other, fit well and equivalently. The resulting structures are consistent with previous empirical work and provide support for each theoretical model.

The Level of Personality Functioning Scale-Brief Form 2.0: Update of a brief instrument for assessing level of personality functioning

Section III of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) introduced the alternative model of personality disorders that includes assessing levels of personality functioning. Here, we describe the development, preliminary psychometric evaluation and sensitivity to change of a revised brief self-report questionnaire, the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0). Patients (N = 201) referred to a specialized centre for the assessment and treatment of personality disorders completed the LPFS-BF 2.0, the Brief Symptom Inventory and the Severity Indices of Personality Problems Short Form and were administered the Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders. Internal structure and aspects of construct validity were examined. A subsample of 39 patients also completed the questionnaires after 3 months of inpatient treatment. Confirmatory factor analyses demonstrated better fit for a two-factor solution (interpretable as self-functioning and interpersonal functioning) than for a unidimensional model, though acceptable model fit was evident only after two post hoc modifications. The LPFS-BF 2.0 demonstrated satisfactory internal consistency and promising construct validity. Sensitivity to change after 3 months of treatment was high. The LPFS-BF 2.0 constitutes a short, user-friendly instrument that provides a quick impression of the severity of personality pathology. © 2018 John Wiley & Sons, Ltd.

Application of the DSM-5 Level of Personality Functioning Scale by Lay Raters

One concern that has been expressed with the Alternative Model for Personality Disorders (AMPD) presented in DSM-5 is that the description of characteristic impairments in personality function uses concepts requiring considerable experience and clinical inference to apply. To examine this question, the individual indicators included in the AMPD's Level of Personality Functioning Scale (LPFS) that describes these core impairments were abstracted as individual items, and then rated on a target acquaintance by 194 undergraduate college students with minimal training in personality disorder and no training in the AMPD. Results indicated that the LPFS indicators were highly internally consistent as rated in this sample, and that the degree of discrimination between groups corresponded very well with the putative level of severity represented for each indicator in the LPFS. These findings support the contention that using the LPFS might not require any particular clinical experience or training.

Personality traits in recent-onset-of-psychosis patients compared to a control sample by gender

Personality traits in recent onset of psychosis (ROP) patients are an under-researched area. Our aim was to examine clinical and clinically significant personality traits in ROP patients compared with a healthy control sample by gender. Data were obtained from 94 ROP patients and a control sample matched in gender and age. The Millon Clinical Multiaxial Inventory and a sociodemographic scale were used. T for independent samples, U-Mann-Whitney and Fisher tests were applied to make comparisons. All personality traits were significantly higher in ROP than control participants in the general sample, except histrionic, narcissistic, and compulsive traits which were higher in controls. Clinically significant schizoid, avoidant, dependent and antisocial personality traits were more common in the ROP than the control participants. However, histrionic clinically significant trait was more common in the control sample. In relation to the males and female samples, more significant differences were found in the male sample in comparison to their control counterparts than in the female sample. These results highlight the importance of the study of clinical personality traits in patients with ROP and the importance of viewing these differences in relation to gender because of the possible therapeutic implications.

Validity of the DSM-5 Levels of Personality Functioning Scale-Self Report

In this study we examined the structure, reliability, and validity of the Levels of Personality Functioning Scale-Self Report (LPFS-SR) in 3 large community samples. The LPFS-SR is a questionnaire with content that corresponds directly to the DSM-5 alternative model of personality disorders, Criterion A. We found that the LPFS-SR was highly reliable across a brief retest interval. LPFS-SR scores correlated substantially with a wide range of maladaptive personality traits, personality disorder constructs, and interpersonal problems. The LPFS-SR did not correlate as strongly with aspects of personality with less clear relations to distress and dysfunction. Data further support that identity, self-direction, intimacy, and empathy components of the LPFS-SR can be characterized by a single factor and have similar correlations with criterion variables, consistent with the hypothesis that DSM-5 Criterion A is a relatively homogeneous construct. Overall, these results support the validity of the LPFS-SR, highlight important issues in assessing personality pathology, and point toward novel avenues for research on personality disorder classification.

Developing a decision tool to identify patients with personality disorders in need of highly specialized care

BACKGROUND

Current guidelines recommend referral to highly specialized care for patients with severe personality disorders. However, criteria for allocation to highly specialized care are not clearly defined. The aim of the present study was to develop a decision tool that can support clinicians to identify patients with a personality disorder in need of highly specialized care.

METHODS

Steps taken to develop a decision tool were a literature search, concept mapping, a meeting with experts and a validation study.

RESULTS

The concept mapping method resulted in six criteria for the decision tool. The model used in concept mapping provided a good fit (stress value = 0.30) and reasonable reliability (ρ = 0.49). The bridging values were low, indicating homogeneity. The decision tool was subsequently validated by enrolling 368 patients from seven centers. A multilevel model with a Receiver Operating Characteristic Curve (ROC) was applied. In this way, an easily implementable decision tool with relatively high sensitivity (0.74) and specificity (0.69) was developed.

CONCLUSIONS

A decision tool to identify patients with personality disorders for highly specialized care was developed using advanced methods to combine the input of experts with currently available scientific knowledge. The tool appeared to be able to accurately identify this group of patients. Clinicians can use this decision tool to identify patients who are in need of highly specialized treatment.

Personality traits and psychotic symptoms in recent onset of psychosis patients

OBJECTIVE

Personality in patients with psychosis, and particularly its relation to psychotic symptoms in recent onset of psychosis (ROP) patients, is understudied. The aims of this research were to study the relation between dimensional and categorical clinical personality traits and symptoms, as well as the effects that symptoms, sex and age have on clinically significant personality traits.

METHODS

Data for these analyses were obtained from 94 ROP patients. The Millon Clinical Multiaxial Inventory and the Positive and Negative Syndrome Scale were used to assess personality and symptoms. Correlational Analysis, Mann-Whitney test, and, finally, logistic regression were carried out.

RESULTS

The negative dimension was higher in patients with schizoid traits. The excited dimension was lower for those with avoidant and depressive traits. The anxiety and depression dimension was higher for patients with dependent traits. The positive dimension was lower for patients with histrionic and higher for patients with compulsive traits. Logistic regression demonstrated that gender and the positive and negative dimensions explained 35.9% of the variance of the schizoid trait. The excited dimension explained 9.1% of the variance of avoidant trait. The anxiety and depression dimension and age explained 31.3% of the dependent trait. Gender explained 11.6% of the histrionic trait, 14.5% of the narcissistic trait and 11.6% of the paranoid trait. Finally gender and positive dimension explained 16.1% of the compulsive trait.

CONCLUSIONS

The study highlights the importance of studying personality in patients with psychosis as it broadens understating of the patients themselves and the symptoms suffered.

Psychopathological Functioning Levels (PFLs) and their possible relevance in psychiatric treatments: a qualitative research project

BACKGROUND

Symptoms description is often not enough to provide clinicians with guidelines for treatments and patients' clinical history does not represent an exhaustive source of data. Psychopathological dysfunctions are known to relate to the core disturbances that underlie different forms of psychopathology so the identification of such dysfunctions could be helpful for treatments. Some tools are available although highly complex and lengthy. This study aimed to provide clinicians with an easy-to-administer instrument able to capture different levels of impairment in psychopathological functioning, namely the Psychopathological Functioning Levels - Rating Scale (PFL-RS).

METHODS

The Psychopathological Functioning Level - Research and Training Committee (PFL-RTC) has been established in Turin since 2002 including psychiatrists and clinical psychologists with extensive clinical and research experience. Our research was grounded on the Qualitative Research Criteria (QRC) 1-7 and conducted with subsequent steps in order to identify those core psychopathological dysfunctions to be rated by this tool.

RESULTS

From 2002 until 2014, 316 outpatients were administered the clinical interview on at least two different occasions. Diagnoses were mixed and included: Schizophrenic and Psychotic Disorders, Depressive Disorders, Anxiety Disorders, Obsessive-Compulsive Disorder, Post- Traumatic Stress Disorder, Somatic Symptoms Disorders, Eating Disorders and Personality Disorders. Focus groups were conducted to identify those psychopathological dysfunctions which needed to be rated, according to two Phenomenological Selection Criteria (PhSC) and four Etiopathogenetic Selection Criteria (EtSC). As a result, five dysfunctional areas emerged: Identity (ID); Comprehension (CO); Negative Emotions (NE); Action-Regulation (AR); Social Skills (SS). After checking such dimensions for consistency with the existing instruments, 7 levels of severity were identified for each area. Finally, a provisional Italian schedule of Psychopathological Functioning Levels - Rating Scale (PFL-RS) was obtained and checked for semantic comprehension and then administered gathering preliminary data.

CONCLUSIONS

Psychopathological dysfunctions underlying mental disorders have been recognized in the present study with the PFL-RS. This instrument seems promising to inform in a specific way treatments strategies and goals, specifically concerning psychotherapy. Notwithstanding, further research is needed in order to confirm validity, sensitivity and reliability of this instrument.

Disturbed self concept mediates the relationship between childhood maltreatment and adult personality pathology

BACKGROUND

Despite a robust literature documenting the relationship between childhood maltreatment and personality pathology in adulthood, there is far less clarity about the mechanism underlying this relationship. One promising candidate for such a linking mechanism is disturbance in the sense of self. This paper tests the hypothesis that disturbances in the sense of self mediate the relationship between childhood maltreatment and adult personality pathology. Specifically, we assess the self-related traits of stable self-image, self-reflective functioning, self-respect and feeling recognized.

METHODS

The sample included 113 non-psychotic psychiatric inpatients. Participants completed the Child Trauma Questionnaire (CTQ), the Personality Diagnostic Questionnaire-4 (PDQ-4+), and the self-reflexive functioning, stable self image, self-respect, and feeling recognized scales from the Severity Indices of Personality Problems (SIPP-118). A series of linear regressions was then performed to assess the direct and indirect effects of childhood trauma on personality disorder traits (PDQ-4+ total score), as mediated by self concept (SIPP-118 scales). Aroian tests assessed the statistical significance of each mediating effect.

RESULTS

There was a significant mediating effect for all SIPP self concept variables, with a full mediating effect for the SIPP composite score and for SIPP feeling recognized and self-reflexive functioning, such that the direct effect of childhood trauma on personality did not retain significance after accounting for the effect of these variables. There was a partial mediating effect for SIPP stable self image and self-respect, such that the direct effect of the CTQ retained significance after accounting for these variables. SIPP feeling recognized had the strongest mediating effect.

CONCLUSIONS

Multiple facets of self concept, particularly the degree to which an individual feels understood by other people, may mediate the relationship between childhood maltreatment and adult personality pathology. This underscores the importance of attending to disturbances in the sense of self in patients with personality pathology and a history of childhood maltreatment. These findings also support the centrality of disturbed self concept to the general construct of personality pathology.

The DSM-5 Levels of Personality Functioning and Severity of Iranian Patients With Antisocial and Borderline Personality Disorders

BACKGROUND

Fundamental problems with Personality Disorders (PD) diagnostic system in the previous version of DSM, led to the revision of DSM. Therefore, a multidimensional system has been proposed for diagnosis of personality disorder features in DSM-5. In the dimensional approach of DSM-5, personality disorders diagnosis is based on levels of personality functioning (Criteria A) and personality trait domains (Criteria B).

OBJECTIVES

The purpose of this study was firstly, to examine the DSM-5 levels of personality functioning in antisocial and borderline personality disorders, and second, to explore which levels of personality functioning in patients with antisocial and borderline personality disorders can better predicted severity than others.

PATIENTS AND METHODS

This study had a cross sectional design. The participants consisted of 252 individuals with antisocial (n = 122) and borderline personality disorders (n = 130). They were recruited from Tehran prisoners, and clinical psychology and psychiatry centers of Razi and Taleghani Hospitals, Tehran, Iran. The sample was selected based on judgmental sampling. The SCID-II-PQ, SCID-II and DSM-5 levels of personality functioning were used to diagnose and assess personality disorders. The data were analyzed by correlation and multiple regression analysis. All statistical analyses were performed using the SPSS 16 software.

RESULTS

Firstly, it was found that DSM-5 levels of personality functioning have a strong correlation with antisocial and borderline personality symptoms, specially intimacy and self-directedness (P < 0.001). Secondly, the findings showed that identity, intimacy and self-directedness significantly predicted antisocial personality disorder severity (P < 0.0001). The results showed that intimacy and empathy were good predictors of borderline personality disorder severity, as well (P < 0.0001).

CONCLUSIONS

Overall, our findings showed that levels of personality functioning are a significant predictor of personality disorders severity. The results partially confirm existing studies.

Severity of personality disorders and domains of general personality dysfunction related to attachment

This is the first study to link attachment to both severity of total DSM-IV personality disorder (PD) traits and domains of general personality dysfunction, using a sample of 72 inpatients from New York City. We assessed a measure of global PD severity and the core domains of personality functioning using the severity indices of personality problems (SIPP-118). Attachment was measured with the experience in close relationships-revised (ECR-R) and the relationship style questionnaire (RSQ). Global PD severity correlated most strongly with attachment anxiety (r = 0.65). Regression of the SIPP-118 domains on attachment produced models that accounted for a substantial proportion of variance in those scales (R(2) ranging from 28.2 to 54.2%). SIPP-118 relational capacities were the strongest predictor of ECR-R avoidance (β = -0.88) and anxiety (β = -0.58), as well as RSQ secure (β = 0.53) and fearful (β = -0.65). In conclusion, insecure attachment strongly related to the severity of global PD traits and specifically to relational capacities, which are a higher-order domain of general personality dysfunction. These findings provide further evidence that interpersonal problems are at the core of PDs and that attachment could constitute an important mediator of the social dysfunction in persons with personality pathology.

Personality disorders in DSM-5: emerging research on the alternative model

The current categorical classification of personality disorders, originally introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), has been found to suffer from numerous shortcomings that hamper its usefulness for research and for clinical application. The Personality and Personality Disorders Work Group for DSM-5 was charged with developing an alternative model that would address many of these concerns. The developed model involved a hybrid dimensional/categorical model that represented personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. The Board of Trustees of the American Psychiatric Association did not accept the Task Force recommendation to implement this novel approach, and thus this alternative model was included in Sect. III of the DSM-5 among concepts requiring additional study. This review provides an overview of the emerging research on this alternative model, addressing each of the primary components of the model.

An integrative examination of general personality dysfunction in a large community sample

Recently, the severity of general personality dysfunction has gained broad interest in personality disorder (PD) research. We analysed data of 511 participants aged 20-41 years from a comprehensive psychiatric survey in the general population of Zurich, Switzerland. We added the trait-scores from all DSM-IV PDs, as assessed by a self-report questionnaire, to provide a measure of general personality dysfunction. Adjusting for the Big Five personality domains as a proxy for stylistic PD elements, this composite PD score exhibited strong associations with neuroticism and schizotypy. General personality dysfunction additionally revealed a moderate detrimental association with psychosocial functioning and a strong effect on coping resources, on heavy drinking and drug use and on most psychopathological syndromes. Of particular interest is the strong association with total psychopathological distress and co-occurrence of multiple disorders, suggesting that increasing PD severity relates to the degree of global impairment independent of specific PD traits. Discussed herein are implications for public mental health policies, classification, conceptualization and treatment of PDs.

Personality disorder classification: stuck in neutral, how to move forward?

An "Alternative DSM-5 Model for Personality Disorders" was published in Sect. III of DSM-5, while the identical categories and criteria from DSM-IV for the personality disorders (PDs) are in Sect. II. Given strong shifts from categorical diagnoses toward dimensional representations in psychiatry, how did the PDs end up "stuck in neutral," with the flawed DSM-IV model perpetuated? This article reviews factors that influenced the development of the new model and data to encourage and facilitate its use by clinicians. These include recognizing 1) a dimensional structure for psychopathology for which personality may be foundational; 2) a consensus on the structure of normal and abnormal personality; 3) the clinical significance of personality; 4) PD-specific severity required to establish disorder; 5) disruption, discontinuity, and perceived clinical utility of the Alternative Model may not be problems; and 6) a way forward involving collaborative research on neurobiological and psychosocial processes, treatment planning, and outcomes.

Systems Training for Emotional Predictability and Problem Solving (STEPPS): program efficacy and personality features as predictors of drop-out -- an Italian study

In this study we present a clinical application of the STEPPS model in an Italian sample of severely affected patients with borderline personality disorder (BPD) or personality disorder (PD) with prominent borderline features in comorbidity with a mood disorder. The aims of this work are: 1) to confirm our preliminary results in a larger sample and at a 12-month follow-up, and 2) to identify predictors of drop-out vs completion of STEPPS in order to understand which characteristics of patients make them suitable or not for this treatment. The sample is composed of 32 subjects recruited from a population of inpatients of the Mood Disorders Center, Department of Clinical Neurosciences, Hospital San Raffaele-Turro, Milan. To confirm STEPPS efficacy at 12-month follow-up, we selected the following outcome criteria: reduction in the number of hospitalizations related to self-harm acts; reduction in the number of suicidal attempts; reduction of perceived emotional intensity levels; changes in cognitive filter scores; changes in the scores on self-report questionnaires. To identify predictors of drop-out vs completion, we analysed the following variables: demographic features (sex, marital status, school level achieved, and job status); Axis-I diagnosis; Axis-II categorical and dimensional diagnosis; and personality features. Seventeen (53%) subjects completed the treatment successfully. The drop-out rate was 47%. Patients who completed the program show a significant decrease in the number of hospitalizations, both at the end of the treatment and at 12-month follow-up. Friedman ANOVA test shows a significant decrease in suicidal attempts during and after STEPPS, and at 12-month follow-up. Analysis of drop-outs showed no significant differences with regard to sex, marital status, school level and job status between the two groups. Axis-I and Axis-II categorical diagnoses did not discriminate between the two groups. Those patients who dropped differ significantly from completers in histrionic personality traits and magical thinking index, given by the interaction between low scores in Self-Directedness and high scores in Self-Transcendence.

Is the residential combined (psychotherapy plus medication) treatment of patients with severe personality disorder effective in terms of suicidality and impulsivity?

The aim of this study was to compare the effectiveness of combined treatment-medication plus psychodynamic psychotherapy-and psychodynamic psychotherapy alone on the outcome variables of suicidality and impulsivity in a population of adult inpatients with severe personality disorder (SPD). This is a naturalistic-empirical (observational) study under the conditions of clinical practice (an intensive specialized inpatient psychotherapeutic program [SIPP]). The sample consisted of 33 inpatients with SPD who were allocated to two subgroups (groups A and B). The patients in group A received psychodynamic psychotherapy and adjunctive pharmacotherapy, whereas the patients in group B received multimodal psychodynamic psychotherapy only. A statistically significant reduction in suicidality score was observed in the patients in group A, whereas a tendency for significant reduction in impulsivity score was observed in group B after the SIPP termination. Pharmacotherapy combined with multimodal psychodynamic psychotherapy, always within the SIPP, seems more effective in the case of suicidality rather than impulsivity.

Three-pronged assessment and diagnosis of personality disorder and its consequences: personality functioning, pathological traits, and psychosocial disability

The alternative dimensional model of personality disorder (PD) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013), Section III, has two main criteria: impairment in personality functioning and one or more pathological personality traits. The former is defined as disturbances in self-functioning (viz., identity, self-direction), and/or interpersonal functioning (viz., empathy, intimacy). Distinguishing personality functioning and traits is important conceptually, because simply having extreme traits is not necessarily pathological. However, adding personality functioning to PD diagnosis represents an empirical challenge, because the constructs overlap conceptually. Further, there is debate regarding whether diagnosis of mental disorder requires either distress or disability, concepts that also overlap with maladaptive-range personality traits and personality dysfunction. We investigated interrelations among these constructs using multiple self-report measures of each domain in a mixed community-patient sample (N = 402). We examined the structures of functioning (psychosocial disability and personality) and personality traits, first independently, then jointly. The disability/functioning measures yielded the 3 dimensions we have found previously (Ro & Clark, 2013). Trait measures had a hierarchical structure which, at the 5-factor level, reflected neuroticism/negative affectivity (N/NA), (low) sociability, disinhibition, (dis)agreeableness, and rigid goal engagement. When all measures were cofactored, a hierarchical structure again emerged which, at the 5-factor level, included (a) internalizing (N/NA and self-pathology vs. quality-of-life/satisfaction); (b) externalizing (social/interpersonal dysfunction, low sociability, and disagreeableness); (c) disinhibition; (d) poor basic functioning; and (e) rigid goal engagement. Results are discussed in terms of developing an integrated PD diagnostic model.

Validating the proposed diagnostic and statistical manual of mental disorders, 5th edition, severity indicator for personality disorder

The authors sought to determine whether a 5-point global rating of personality dysfunction on the Level of Personality Functioning Scale proposed as a severity index for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), would be related to DSM-IV personality disorder diagnosis as well as to other key clinical judgments. Data were collected from a national sample of 337 mental health clinicians who provided complete diagnostic information relevant to DSM-IV and proposed DSM-5 personality disorder diagnoses, as well as demographic information and other clinical judgments, on one of their patients. Of the 337 patients described, 248 met criteria for 1 of the 10 specific DSM-IV personality disorders. A "moderate" or greater rating of impairment in personality functioning on the Level Scale demonstrated 84.6% sensitivity and 72.7% specificity for identifying patients meeting criteria for a specific DSM-IV personality disorder. The Level of Personality Functioning Scale had significant and substantial validity correlations with other measures of personality pathology and with clinical judgments regarding functioning, risk, prognosis, and optimal treatment intensity. Furthermore, the single-item Level of Personality Functioning rating was viewed as being as clinically useful as the 10 DSM-IV categories for treatment planning and patient description and was a better predictor of clinician ratings of broad psychosocial functioning than were the 10 DSM-IV categories combined. These results confirm hypotheses that the single-item Level of Personality Functioning Scale rating provides an indication of severity of personality pathology that predicts both assignment of personality disorder diagnosis and clinician appraisals of functioning, risk, prognosis, and needed treatment intensity.

Convergence between DSM-IV-TR and DSM-5 diagnostic models for personality disorder: evaluation of strategies for establishing diagnostic thresholds

The Personality and Personality Disorders Work Group for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) recommended substantial revisions to the personality disorders (PDs) section of DSM-IV-TR, proposing a hybrid categorical-dimensional model that represented PDs as combinations of core personality dysfunctions and various configurations of maladaptive personality traits. Although the DSM-5 Task Force endorsed the proposal, the Board of Trustees of the American Psychiatric Association (APA) did not, placing the Work Group's model in DSM-5 Section III ("Emerging Measures and Models") with other concepts thought to be in need of additional research. This paper documents the impact of using this alternative model in a national sample of 337 patients as described by clinicians familiar with their cases. In particular, the analyses focus on alternative strategies considered by the Work Group for deriving decision rules, or diagnostic thresholds, with which to assign categorical diagnoses. Results demonstrate that diagnostic rules could be derived that yielded appreciable correspondence between DSM-IV-TR and proposed DSM-5 PD diagnoses-correspondence greater than that observed in the transition between DSM-III and DSM-III-R PDs. The approach also represents the most comprehensive attempt to date to provide conceptual and empirical justification for diagnostic thresholds utilized within the DSM PDs.

Personality disorders and treatment drop out in the homeless

The homeless drop out of treatment relatively frequently. Also, prevalence rates of personality disorders are much higher in the homeless group than in the general population. We hypothesize that when both variables coexist - homelessness and personality disorders - the possibility of treatment drop out grows. The aim of this study was to analyze the hypotheses, that is, to study how the existence of personality disorders affects the evolution of and permanence in treatment. One sample of homeless people in a therapeutic community (N = 89) was studied. The structured clinical interview for the diagnostic and statistical manual of mental disorders (DSM-IV-TR) was administered and participants were asked to complete the Millon Clinical Multiaxial Inventory-II (MCMI-II). Cluster B personality disorders (antisocial, borderline, and narcissistic) avoided permanence in the treatment process while cluster C disorders, as dependent, favored adhesion to the treatment and improved the prognosis. Knowledge of these personality characteristics should be used to advocate for better services to support homeless people and prevent their dropping out before completing treatment.

Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods

Personality disorders are associated with fundamental disturbances of self and interpersonal relations, problems that vary in severity within and across disorders. This review surveyed clinician-rated measures of personality psychopathology that focus on self-other dimensions to explore the feasibility and utility of constructing a scale of severity of impairment in personality functioning for DSM-5. Robust elements of the instruments were considered in creating a continuum of personality functioning based on aspects of identity, self-direction, empathy, and intimacy. Building on preliminary findings (Morey et al., 2011 /this issue), the proposed Levels of Personality Functioning will be subjected to extensive empirical testing in the DSM-5 field trials and elsewhere. The resulting version of this severity measure is expected to have clinical utility in identifying personality psychopathology, planning treatment, building the therapeutic alliance, and studying treatment course and outcome.

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.

Tailoring common treatment principles to fit individual personalities

The American Psychological Association Task Force headed by Castonguay and Beutler (2006) distilled general treatment principles common to all therapies from the empirical literature. As part of this work, Critchifield and Benjamin (2006a, 2006b) summarized principles for treatment of personality disorder. The principles are pragmatic in the sense that they are based on evidence of what works, and clinicians are encouraged to apply them in ways that fit the unique presentation and needs of a given patient. An important element of the recommended approach is that it be coherent, well-coordinated, and agreed upon by the patient. Additional principles emphasize the importance of an individual's attachment and trauma history. A complex case example is presented to illustrate one way in which emphasis on an individual's relational learning history can be used to further refine and extend wisdom inherent in the cross-cutting principles and move in the direction of an integrative treatment that is closely tailored to specific case features. A research approach is also outlined for how to test the validity of principles that prescribe differential use of technique to address diverse patient presentations.

Effectiveness of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality problems in a 'real-world' sample: moderation by diagnosis or severity?

BACKGROUND

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment for borderline personality disorder (BPD). Two prior randomized controlled trials (RCTs) have shown the efficacy of this training. In both RCTs, patients with borderline features who did not meet the DSM-IV criteria for BPD were excluded, which were many. We investigated the effectiveness of STEPPS in a sample representative of routine clinical practice and examined whether DSM-IV diagnosis and/or baseline severity were related to differential effectiveness.

METHODS

Patients whom their practicing clinician diagnosed with BPD were randomized to STEPPS plus adjunctive individual therapy (STEPPS, n = 84) or to treatment as usual (TAU, n = 84).

RESULTS

STEPPS recipients showed more improvement on measures of general and BPD-specific psychopathology as well as quality of life than TAU recipients, both at the end of treatment and at a 6-month follow-up. Presence of DSM-IV-diagnosed BPD was not related to differential treatment effectiveness, but dimensional measures of symptom severity were; STEPPS was superior to TAU particularly in patients with higher baseline severity scores.

CONCLUSIONS

The findings show the effectiveness of STEPPS in a 'real-world' sample, and underscore the importance of dimensional versus categorical measures of personality disturbance.

Distinguishing general and specific personality disorder features and implications for substance dependence comorbidity

Clinical and population-based samples show high comorbidity between Substance Use Disorders (SUDs) and Axis II Personality Disorders (PDs). However, Axis II disorders are frequently comorbid with each other, and existing research has generally failed to distinguish the extent to which SUD/PD comorbidity is general or specific with respect to both specific types of PDs and specific types of SUDs. We sought to determine whether ostensibly specific comorbid substance dependence-Axis II diagnoses (e.g., alcohol use dependence and borderline personality disorder) are reflective of more pervasive or general personality pathology or whether the comorbidity is specific to individual PDs. Face-to-face interview data from Wave 1 and Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. Participants included 34,653 adults living in households in the United States. We used hierarchical factor models to statistically partition general and specific personality disorder dimensions while simultaneously testing for specific PD-substance dependence relations. Results indicated that substance dependence-Axis II comorbidity is characterized by general (pervasive) pathology and by Cluster B PD pathology over and above the relationship to the general PD factor. Further, these relations between PD factors and substance dependence diagnoses appeared to largely account for the comorbidity among substance dependence diagnoses in the younger but not older participants. Our findings suggest that a failure to consider the general PD factor, which we interpret as reflecting interpersonal dysfunction, can lead to potential mischaracterizations of the nature of certain PD and SUD comorbidities.

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

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

Personality disorder types proposed for DSM-5

The Personality and Personality Disorders Work Group has proposed five specific personality disorder (PD) types for DSM-5, to be rated on a dimension of fit: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal. Each type is identified by core impairments in personality functioning, pathological personality traits, and common symptomatic behaviors. The other DSM-IV-TR PDs and the large residual category of personality disorder not otherwise specified (PDNOS) will be represented solely by the core impairments combined with specification by individuals' unique sets of personality traits. This proposal has three main features: (1) a reduction in the number of specified types from 10 to 5; (2) description of the types in a narrative format that combines typical deficits in self and interpersonal functioning and particular configurations of traits and behaviors; and (3) a dimensional rating of the degree to which a patient matches each type. An explanation of these modifications in approach to diagnosing PD types and their justifications--including excessive co-morbidity among DSM-IV-TR PDs, limited validity for some existing types, lack of specificity in the definition of PD, instability of current PD criteria sets, and arbitrary diagnostic thresholds--are the subjects of this review.

Organization of co-occurring Axis II features in borderline personality disorder

OBJECTIVES

Considerable heterogeneity exists in the comorbid Axis II features that frequently accompany borderline personality disorder (BPD). These features have potential to be meaningfully organized, relate to specific BPD presentation, and have implications for treatment process and outcome. The present study explored patterns of Axis II comorbidity in order to identify subtypes of BPD.

DESIGN

A well-defined sample of 90 patients diagnosed with BPD was recruited as part of an RCT study. Participants were administered the International Personality Disorder Examination (Loranger, 1999) to diagnose BPD and assess comorbid Axis II features. Other measures were also administered to assess aspects of current work and relationship functioning, symptomatology, and self-concept.

METHODS AND RESULTS

Q-factoring was used to develop subtypes based on commonly occurring Axis II profiles, identifying three: Cluster A (elevated paranoid and schizotypal features), Cluster B (elevated narcissistic and histrionic features), and Cluster C (elevated avoidant and obsessive-compulsive features). An additional factor analysis revealed two dimensions underlying the comorbid features identifiable as: extraversion versus introversion and antagonism versus constraint. Validity of these two maps of comorbidity was explored in terms of the BPD criteria themselves, as well as on work and relationship functioning, identity diffusion, views of self and others, positive and negative affect, behavioural dyscontrol, and symptomatic distress.

CONCLUSIONS

Clinically meaningful subtypes can be identified for BPD based on co-occurring Axis II features. Further research is needed to replicate and further establish base-rates of these subtypes as well as their differential implications for treatment.

Complex personality disorder in bulimia nervosa

OBJECTIVE

Recent research has suggested a move toward a dimensional system for the classification of personality disorders (PDs). Tyrer's dimensional model using severity as a form of categorizing PDs was used to compare eating disorder outcome in women with bulimia nervosa (BN) over 3 years.

METHOD

One hundred thirty-four women with BN were divided into 4 groups based on PD severity: no PD (n = 32), personality difficulty (n = 27), simple PD (n = 29), and complex PD (n = 46). Eating disorder symptoms and attitudes, general psychosocial functioning, and depressive symptoms were examined at pretreatment and at 1-year and 3-year follow-up (posttreatment).

RESULTS

The complex PD group had greater Axis I comorbidity and psychopathology than the remaining 3 groups at pretreatment. At 1-year and 3-year follow-up, there were no differences in eating disorder outcome, general psychosocial functioning, and depressive symptoms across the 4 groups.

CONCLUSION

These results suggest that having an increased number of PDs comorbid with BN does not influence eating disorder outcome up to 3 years after treatment.

Dangerous and severe personality disorder: An investigation of the construct

Introduction of the construct "Dangerous and Severe Personality Disorder" (DSPD) by the UK Home Office and Department of Health has provoked strong debate and opposition. Its aims and that of proposed subsequent legislation was to enhance public protection by identifying and detaining a minority of persons with severe personality disorder who pose a high risk of serious sexual/violent offending. The most serious criticism was the ethical implication of allowing indefinite detention of people without criminal convictions. More recently, policy emphasis has shifted towards treatment. 1396 male prisoners serving sentences of 2+years for sexual/violent offenses were prospectively interviewed (personality disorders, psychopathy, and risk) at a mean follow-up of 2 years. The prevalence of DSPD was 15%. Significantly more re-offended. Five DSPD offenders would need treatment to prevent one violent act. Based on an estimate of attributable risk, successful treatment of DSPD could reduce violent re-convictions among DSPD offenders by 71% and violent/sexual re-offenses in the prison population by 27%. DSPD criteria correctly identify high risk prisoners but primarily through risk-related demographic features. DSPD does not accurately identify serious sexual/violent re-offenders. The DSPD programme may reduce major violent re-offending if treatment interventions prove effective.

Clinical problems in community mental health care for patients with severe borderline personality disorder

The objective of this research was to assess the problems that professionals perceive in the community mental health care for patients with severe borderline personality disorder that do not fit into specialized therapy. A group of national experts (n = 8) participated in a four-phase Delphi-procedure to identify and prioritize the problems. A total of 36 problems reflecting five categories was found: patient-related, professional-related, interaction-related, social system-related, and mental health care-related. Problems with attachment and dependency and social issues were important patient problems while a lack of skills was an important professional problem. Support from the patient's social system and the mental health system were identified as limited, which resulted in both the patient and the professional feeling isolated. Patient, professional, and organisational characteristics of community care differ substantially from those of specialized care. The field is thus in need of a more tailored approach that takes these differences into account.