An evaluation and proposed modifications of personality disorder trait diagnostic sets in the alternative model of personality disorders.

A Young Attorney Presents for Outpatient Treatment of Depression Ms.Bisa32-year-oldsingleCaucasianwomanwhowasreferred byafriend’spsychiatristformentalhealthtreatmentforthe first time after a 4-month period of depression. She reported persistent feelings of “emptiness” and “worthlessness,” increased sleeping with difficulty getting out of bed, impaired concentration, decreased energy nearly every day, slight weight gain, and ruminations about her childhood and family life. The depressionstartedaftershewastoldather firmthatshewasnotgoingto be considered for partnership. Her initial reaction was one of anger, bitter disappointment, and shame, but this gave way to feelingsofdepressionandworryaboutherfuture.Sheadmittedto thoughts of death and dying but denied having any suicidal ideation. Ms. B does notdrink alcoholor use any other substances and she denies ever having felt “manic.” Her physical health is good. Ms. B also reported that she did not consider her life, in general, to be satisfactory or fulfilling. Although she had been highly successful in school, earning excellent grades at a firstrate college and law school, she has had difficulty making friends and now sees the few friends who she believes “like her” only occasionally, for “attention” and “support.” She has only“dated”oneman,brieflyincollege,butshefeltinhibitedin the relationship, afraid and ashamed to let the man know that she cared about him. Even though they drifted apart after only afewmonths,sheoftenthinksofhimandwonderswhetherher life would be better if they had gotten together. She is pessimisticaboutherprospectsforanotherrelationshipinthefuture because she believes that it would be very hard for her to find someone who would live up to her expectations. Ms. B has few interests outside of work. With respect to music, art, or sports, she said that whatever she tried, she was “not very good at it,” quickly lost interest, and gave up.

Borderline personality disorder (BPD) is defined by the presence of at least five of nine symptoms in Section II of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. In the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Section III Alternative Model of Personality Disorders (AMPD), BPD is defined by deficits in self and/or interpersonal functioning (Criterion A), elevated negative affectivity, and elevated antagonism and/or disinhibition (Criterion B). However, it is unclear if these definitions describe the same people and if the AMPD criteria explain unique variability in treatment outcomes in this population. In a treatment-seeking sample of adult participants diagnosed with BPD according to Section II criteria (n = 65, Mage = 27.60, 70.8% female, 76.9% White), we found a majority (66.2%) would have also received the diagnosis based on AMPD criteria. Those meeting AMPD criteria reported more severe Section II BPD symptoms than those who did not, ps < .02, ds > 0.60, and the presence or severity of Section II fears of abandonment and inappropriate anger uniquely predicted AMPD BPD diagnoses, ps < .03, ORs ≥ 2.31. Changes in AMPD dimensions explained 34% of the variability in change in work/social adjustment (p = .13) and quality of life (p = .22), respectively, over and above changes in Section II symptoms during a novel cognitive-behavioral treatment for BPD. These results suggest that AMPD criteria capture a more severe subset of BPD than Section II criteria and may be important predictors of treatment outcomes. We discuss the potential trade-offs of this shift in diagnosis. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The alternative model for personality disorders (AMPD) is outlined in Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. This model includes 25 dimensional trait facets that are used as criteria for six personality disorders in addition to impairment in functioning. Numerous previous studies have examined the degree to which the proposed trait facets converge with the Section II personality disorders (PDs) they are meant to capture, but the results from these various studies have been inconsistent. The current investigation sought to provide a meta-analysis of published and unpublished data, and in particular, to develop empirically derived trait criterion profiles for each of the six AMPD PDs. A total of 25 independent data sets utilizing diverse samples and methods that included measurement of AMPD traits and at least one Section II PD derived from both published and unpublished work were considered for this review. The findings indicated general support for the traits proposed for each of the six PDs within the AMPD, with obsessive-compulsive PD the notable exception. The discriminant validity, however, was questionable for several of the PDs; several nonproposed traits also correlated with the Section II PD counterparts at moderate to large degrees. Intraclass correlations used to model the agreement across the empirically derived trait profiles for each of the six PDs, however, revealed that most of the disorders were relatively distinct from one another. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The alternative model of personality disorder (AMPD) included in Section III of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) reconceptualized personality pathology in terms of pathological traits and impairments in functioning. For example, the construct of obsessive-compulsive personality disorder (OCPD) was reconceptualized via the traits of rigid perfectionism as well as at least 2 of perseveration, intimacy avoidance, and restricted affectivity. We review the literature to summarize how effectively the legacy construct of OCPD is captured by the AMPD. We conclude that although the trait of rigid perfectionism is highly related to scores on OCPD measures, the AMPD as a whole fails to adequately account for the broader features of the legacy OCPD construct. Specifically, the AMPD trait model lacks a number of traits, such as workaholism, excessive deliberation, and moral scrupulousness, which are necessary for a fulsome dimensional trait system. These limitations in the inclusion of important traits stem from the AMPD's development process that left out crucial content. We outline how the AMPD could be improved in its ability to account for problems of overcontrolled behavior. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published in 2013, includes an alternative model of personality disorders (AMPD) focusing on a maladaptive trait model utilized to diagnose several personality disorders. Borderline personality disorder (BPD) and antisocial personality disorder (ASPD) are two conditions categorized by AMPD that exhibit high rates of violence and aggression. Several of the traits outlined in the AMPD, including hostility, impulsivity, risk-taking, and callousness, have been previously linked to aggression in BPD and ASPD. However, to the best of our knowledge, there has never been a synthesis of neuroimaging studies that have investigated links between these traits and aggression in BPD and ASPD. To overcome this gap, we conducted a systematic review under the PRISMA framework to locate neuroimaging articles published since the release of AMPD linking trait anger/hostility, impulsivity, risk-taking, and callousness to aggression in BPD and ASPD. Key findings included the following: i) anger/hostility, associated with alterations in the interplay between prefrontal and subcortical regions (primarily the amygdala), may be a common factor explaining aggressive reactions to response to interpersonal threat or provocation; ii) alterations of fronto-temporal-limbic regions and serotonergic and endocannabinoid signaling systems may link impulsivity to aggression in BPD and ASPD; iii) weaker cortico-striatal connectivity could relate to greater risk taking and greater proclivity for violence. Insufficient evidence from neuroimaging articles was discerned to describe a relationship between callousness and aggression. Overall, results of this review reveal a relative paucity of neuroimaging studies examining AMPD traits relevant to aggression in BPD and ASPD. In addition to encouraging further investigation of neuroimaging markers of AMPD traits linked to aggression, we recommend multi-methodological designs, including the incorporation of other biomarkers, such as hormones and indices of physiological arousal, to fully expand our understanding of aggression in BPD and ASPD.

Alternative DSM-5 Model for Personality Disorders

The constructs of atypical depression, bipolar II disorder and borderline personality disorder (BPD) overlap. We explored the relationships between these constructs and their temperamental underpinnings. We examined 107 consecutive patients who met DSM-IV criteria for major depressive episode with atypical features. Those who also met the DSM-IV criteria for BPD (BPD+), compared with those who did not (BPD-), had a significantly higher lifetime comorbidity for body dysmorphic disorder, bulimia nervosa, narcissistic, dependent and avoidant personality disorders, and cyclothymia. BPD+ also scored higher on the Atypical Depression Diagnostic Scale items of mood reactivity, interpersonal sensitivity, functional impairment, avoidance of relationships, other rejection avoidance, and on the Hopkins Symptoms Check List obsessive-compulsive, interpersonal sensitivity, anxiety, anger-hostility, paranoid ideation and psychoticism factors. Logistic regression revealed that cyclothymic temperament accounted for much of the relationship between atypical depression and BPD, predicting 6 of 9 of the defining DSM-IV attributes of the latter. Trait mood lability (among BPD patients) and interpersonal sensitivity (among atypical depressive patients) appear to be related as part of an underlying cyclothymic temperamental matrix.

In the 10 years following the publishing of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), studies have accumulated testing the validity and utility of the alternative model for personality disorders (AMPD) in the context of borderline personality disorder (BPD). In this article, we review the studies that have tested how well the AMPD conceptualization of BPD captures the traditional (DSM-5, Section II) conceptualization of BPD. Although we note that studies that measure the full conceptualization of the AMPD-BPD are limited compared with studies focusing on a single aspect of the AMPD, studies reviewed suggest that the AMPD conceptualization of BPD largely overlaps with Section II, is associated with a similar range of external constructs, and can be measured with similar levels of interrater reliability. This evidence is promising in terms of the goal of the AMPD developers to not lose relevant and clinically meaningful information associated with traditional conceptualizations of BPD. However, further applied research is needed to understand how the AMPD may improve upon our existing categorical conceptualization of BPD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Personality disorders describe enduring, pervasive, pathologic patterns of behavior and inner experiences that deviate from a patient's culture. Personality disorders are divided into three clusters depending on core features. Diagnosis of a personality disorder is generally made based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, although other diagnostic modalities exist. The most common disorders in primary care settings include obsessive-compulsive personality, narcissistic personality, and borderline personality disorders. Obsessive-compulsive personality disorder is associated with pathologic perfectionism and intense rigidity. Treatment is primarily psychotherapy, although there is some evidence for using selective serotonin reuptake inhibitors. Narcissistic personality disorder is marked by grandiosity, need for admiration, and a lack of empathy. Psychotherapy is the primary treatment. Borderline personality disorder is associated with instability and intense reactivity, and the primary treatment is typically psychotherapy. Dialectical behavior therapy was developed specifically for borderline personality disorder, although evidence suggests other behavior therapies may be as beneficial.

There is a paucity of research examining the relationship between personality disorders (PDs) and chronic physical comorbidities. Consequently, we investigated associations between individual PDs and PD Clusters, and various common disease groups [cardiovascular disease (CVD), diabetes, arthritis and gastrointestinal disease (GI)] in a nationally representative survey of adults from the United States. This study utilized pooled data (n = 34,653; ≥20 years) from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. PDs were assessed using the Alcohol Use Disorder and Associated Disabilities Interview Schedule- Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Physical conditions were based on self-reports of being diagnosed by a health professional. Unadjusted and adjusted logistic regressions examined the relationship between PDs and physical conditions. After adjustment (sociodemographic factors, past-year mood, anxiety and substance use disorders), Clusters A, B and C PDs were each associated with physical conditions (all p ≤ 0.01). Of the individual PDs, schizoid, schizotypal, narcissistic, borderline and obsessive-compulsive PDs were associated with CVD (all p ≤ 0.01) among younger adults. Paranoid, antisocial, borderline and avoidant PDs and younger adults with schizoid, schizotypal and obsessive-compulsive PDs were each associated with arthritis (all p ≤ 0.01). Significant associations were seen between paranoid, schizoid and schizotypal PDs and diabetes (all p ≤ 0.01). Finally, schizotypal, antisocial, borderline and narcissistic PDs were associated with GI conditions (all p ≤ 0.01). PDs were consistently associated with physical conditions. Investigation of PDs and their relationship with physical health outcomes warrant further research attention as these findings have important clinical implications.

Dimensional Model of Personality Disorder Incorporated Into ICD-11

Since the 2001 publication of APA’s Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (1), more studies have been published on borderline personality disorder (BPD) than on any other personality disorder (2, 3). New analyses of the validity of the DSMIV-TR criteria–defined construct of BPD have been published, new data on the prevalence of BPD are available, risk factors for and biological characteristics of BPD are being elucidated, and new studies on the treatment of BPD have been carried out. This guideline watch highlights the most important of these developments.

The goal of this study was to compare the predictive validity of the alternative model for personality disorders (AMPD) versus the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Section II categorical model regarding clinician judgments about mental health outcomes. To do so, we instructed a national sample of 136 mental health professionals to provide clinical judgments on a random subset of four (out of a possible 12) case vignettes. For each case, they made a variety of diagnostic judgments corresponding to each model, as well as clinical outcome judgments (e.g., prognosis). Our analyses included hierarchical and individual regressions to compare the predictive value of each diagnostic system toward these clinical outcome judgments. We found that the AMPD predictors consistently added unique variance beyond the Section II predictors, whereas the Section II predictors were rarely incremental above the AMPD. Further, the AMPD judgments predicted outcome judgments very consistently (98.3% of regressions) compared to the Section II predictors (70% of regressions), and the single Criterion A judgment (level of personality functioning) was the strongest overall predictor. Finally, the categorical borderline personality disorder diagnoses from the two systems performed similarly in predicting clinical outcomes and agreed in 79% of cases. We interpreted our results to suggest that the AMPD is at least as effective, and by some measures more effective, than the DSM-5 categorical model at predicting clinician's judgment of outcomes in clinical cases. We conclude by discussing the value of this evidence in relation to the broader AMPD literature, as well as possible paths forward for the diagnosis of personality disorders. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The clinical relevance of nonsuicidal self-injury (NSSI) has received growing recognition, and NSSI represents a relevant risk factor for suicide. The present study aimed at running a head-to-head comparison between interview scores of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) Section II personality disorders (PDs) criteria, and DSM-5 Alternative Model of Personality Disorder (AMPD) Criterion A and Criterion B measures in providing significant and relevant information for understanding NSSI and suicidal ideation and behavior among psychotherapy participants. To this aim, a clinical sample of 103 adult participants was administered the Clinician-Administered Nonsuicidal Self-Injury Disorder Index (CANDI), the Columbia Suicide Severity Rating Scale (C-SSRS), as well as the Structured Clinical Interview for DSM-5 Personality Disorders, the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I, and a self-report measure of dysfunctional personality traits (i.e., the Personality Inventory for DSM-5 [PID-5]). Logistic ordinal regression dominance analysis results showed that, when compared to the 10 DSM-5 Section II PD symptom counts, the DSM-5 Section III PD measure scores provided the same amount of information in the CANDI Global Severity Index scores (Nagelkerke pseudo-R² value = .41), and a markedly larger information quantity in the case of the C-SSRS Suicidal Ideation (+35.1%), and Suicidal Behavior Index (+35.9%) levels. As a whole, our data suggested the clinical usefulness of the DSM-5 AMPD in understanding NSSI and suicidal ideation and behavior. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Objectifs La cinquième édition du Manuel diagnostique et statistique des troubles mentaux (DSM-5) inclut un Modèle alternatif pour les troubles de la personnalité (MATP), qui définit la pathologie de la personnalité en s’appuyant sur 2 principaux critères dimensionnels. Le critère A correspond à la sévérité du dysfonctionnement de la personnalité dans la sphère du soi et dans la sphère interpersonnelle, alors que le critère B propose 5 domaines pathologiques de la personnalité se déclinant en 25 facettes. Six troubles spécifiques, incluant le trouble de personnalité limite (TPL), sont définis dans le MATP sur la base des critères A et B. Il existe toutefois très peu de données à l’heure actuelle sur ces diagnostics tels qu’opérationnalisés dans le MATP. La présente étude vise à présenter des données québécoises sur cette récente opérationnalisation du TPL. Plus spécifiquement, nous présenterons d’abord une procédure, basée sur des questionnaires autorévélés couvrant les 2 critères principaux du MATP, permettant de générer le diagnostic. Puis, nous évaluerons sa validité : a) en documentant la prévalence du diagnostic dans un échantillon clinique ; b) en déterminant son degré de correspondance avec le diagnostic catégoriel « traditionnel » du TPL et avec une mesure dimensionnelle de symptomatologie associée au trouble ; c) en présentant des données de validité convergente avec des construits pertinents pour l’étude du TPL (impulsivité, agression) ; et d) en déterminant la validité incrémentielle de la procédure proposée par rapport à une approche simplifiée où seul le critère B serait considéré. Méthode Les données de 287 patients recrutés dans le cadre de la démarche d’admission au Centre de traitement le Faubourg Saint-Jean du CIUSSS-Capitale-Nationale ont été analysées. Le diagnostic de TPL selon le MATP a été généré à partir de 2 questionnaires validés, dans leur version francophone, soit le Self and Interpersonal Functioning Scale (critère A) et le Personality Inventory for DSM-5-Faceted Brief Form (critère B). Résultats Le diagnostic de TPL, tel qu’opérationnalisé par le MATP, présentait une prévalence de 39,7 % dans l’échantillon. Une correspondance modérée avec le diagnostic de TPL posé par les cliniciens selon le modèle catégoriel traditionnel du DSM-5 a été observée, de même qu’une forte corrélation avec une mesure dimensionnelle de symptomatologie limite. L’analyse du réseau nomologique a révélé des corrélations élevées et théoriquement attendues entre le trouble et des mesures d’agression et d’impulsivité. La procédure d’extraction du diagnostic, qui utilise les critères A et B, montre une validité incrémentielle dans la prédiction statistique des variables externes (symptomatologie limite, agression, impulsivité) par rapport à une procédure simplifiée n’utilisant que le critère B. Conclusions La procédure proposée pour générer le diagnostic de TPL selon la définition du MATP génère des résultats valides et pourrait permettre un dépistage du trouble selon cette conceptualisation contemporaine des pathologies de la personnalité.