From categories to traits: assessing personality dysfunction in ICD-11 and the DSM-5 alternative model for 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.

Social anxiety in the context of the alternative DSM-5 model of personality disorder.

Dimensional Model of Personality Disorder Incorporated Into ICD-11

Both Kernberg's model of personality organization and the alternative model for personality disorders (AMPD) in the Diagnostic and Statistical Manual of Mental Disorders-5th edition provide a multidimensional framework for assessing personality pathology, while having a dual focus on general and specific personality pathology. The present study was the first to investigate the empirical convergence between measures of personality organization and the AMPD (personality functioning and pathological personality traits), considering general and specific personality pathology. A mixed clinical sample completed self-reports for personality organization, personality functioning and pathological personality traits, as well as an interview for personality organization. Two bifactor models with three specific exploratory factors were estimated, comprising a self-report model based on domain scores using exploratory factor analysis (n = 336) and a multi-method model predominantly based on subdomain scores applying exploratory structural equation modelling (n = 277). Both bifactor models yielded strong general factors with high loadings of the personality organization domains identity and primitive defences, as well as the personality functioning domains. The specific factors suggest convergence between other-directed aggression (personality organization), restricted moral functioning (personality organization) and antagonism (pathological personality traits), between diminished reality testing (personality organization) and psychoticism (pathological personality traits) and between maladaptive object relations (personality organization), impaired interpersonal functioning (personality functioning) and detachment (pathological personality traits). It can be concluded that measures of personality organization and the AMPD strongly converge regarding both general and specific personality pathology. Kernberg's model of personality organization may serve as a valuable complement to the AMPD, guiding forthcoming research and the clinical assessment of personality pathology.

The classification of personality disorders (PDs) is in transition. The shortcomings of the categorical PD diagnoses led to the development of the Alternative Model for Personality Disorders (AMPD) in Section III of the DSM–5 regarding a dimensional differentiation of severity of personality pathology. Impairments in personality functioning are defined as a general Criterion A for PD. Inspired by the AMPD, the LoPF–Q 12–18 was developed to assess Levels of Personality Functioning (LoPF) dimensionally in adolescents from 12 to 18 years old in self-report. The questionnaire shows good scale reliabilities, good construct validity by demonstrating a systematic variation with pathology in line with theory, and a valuable clinical utility. The results suggest that the LoPF–Q 12–18 questionnaire is a clinically useful instrument to assess personality pathology in young people and that the concept of personality functioning is useful in detecting and describing central impairments of PD pathology at an early stage of development.

Increasing interest surrounds the relation between Level of Personality Functioning (LPF), as defined by Criterion A of the Alternative Model for Personality Disorders, and the Hierarchical Taxonomy of Psychopathology (HiTOP) model. However, the integration of LPF within HiTOP remains unclear. Using bivariate correlation and linear regression analyses, this study assessed the associations between LPF and HiTOP spectra (externalizing antisocial, externalizing drug use, internalizing, antagonism, detachment, and psychoticism). A sample of 1,183 participants (46.2% female, Mage = 31.3 ± 14.8 years) from the Italian community completed various self-report measures to capture impairments in personality functioning, and several psychopathology symptoms. Bivariate correlations and regression analyses showed that the LPF facets were consistently associated with all HiTOP domains, even though the LPF measures used in this study appeared more reflective of internalizing symptoms than externalizing ones. The identity facet of LPF was uniquely associated with all outcome criteria, whereas no unique associations were evident for self-direction. Empathy facet had the highest association with antagonism while intimacy presented the highest relation with detachment. Overall, the evidence presented in this study partially supports the construct validity of Criterion A, highlighting its relevance across a wide range of psychopathological symptoms and its potential utility in clinical assessment beyond formal personality disorder diagnoses. Thus, this study may contribute to the understanding of LPF's role in the dimensional model of psychopathology and underscores the importance of considering personality functioning in the assessment and treatment of mental disorders. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Level of Personality Functioning (LPF) represents the entry criterion (Criterion A) of the Alternative Model for Personality Disorders (AMPD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It is defined as a dimensional general severity criterion common to all personality disorders and conceptually independent of personality types or traits, and it represents maladaptive self (identity and self-direction) and interpersonal (empathy and intimacy) functioning. We review the history, measurement, and significance of LPF. We show that the inclusion of LPF in the AMPD is well justified if it is defined as a general adaptive failure of a subjective intrapsychic system needed to fulfill adult life tasks. If so defined, LPF distinguishes itself from maladaptive traits (Criterion B of the AMPD) and captures the contribution humans make as agentic authors to the interpretation and management of the self. While Criterion B maladaptive traits provide important descriptive nuance to manifestations of personality pathology, maladaptive LPF is conditional to the diagnosis of personality disorder.

There is an ongoing debate on which model for diagnosing personality disorders is optimal, with the DSM-5 Alternative Model for Personality Disorders being one of the most prominent. The Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders (SCID-5-AMPD) is a semistructured diagnostic interview to guide the assessment of the three parts of the Alternative DSM-5 Model for Personality Disorders (hereafter referred to as the Alternative Model), as published in DSM-5 Section III. The structured interview has been tested and translated to several languages, however, not to Swedish. To examine the psychometric properties of the Swedish translation of the Structured Clinical Interview for DSM-5 Alternative Model for Personality Disorders, Module I and Module II for treatment seeking persons with suspected personality pathology including reliability in a Swedish clinical context. This study of 38 outpatients with suspected personality disorder studied the test-retest interrater reliability (Intraclass correlation coefficient (ICC)), estimates of Cronbach's alpha values in a clinical setting. The main results were that ICC ranged between 0.1 and 0.56 for the domain scales of Modules I and II, whereas the estimates of scale reliability (α) ranged from 0.25 to 0.85. Despite the challenges posed by the limited number of raters and the small sample size, this study provides valuable insights into the application of the SCID-5-AMPD model within a Swedish context. While the results suggest that further exploration is needed to fully establish the model's effectiveness and benefits in clinical practice, they also highlight the importance of proper training, clinical experience and calibration for achieving optimal reliability. Continued research is essential to refine the tool and assess its broader applicability. With appropriate enhancements in training and methodological rigor, the SCID-5-AMPD has the potential to significantly contribute to the assessment of personality disorders.

The Minnesota Multiphasic Personality Inventory (MMPI) instruments are frequently used to assess personality and psychopathology. Recent publications of personality disorder (PD) spectra scales for dimensionalized PD syndromes with MMPI instruments may advance PD assessment. To this end, we examined MMPI-Second Edition (2) and MMPI-2-Restructured Form (-RF) PD Spectra scales within the lens of a contemporary dimensional model of PDs, the alternative model for personality disorders (AMPD). The core dimension of PD, Criterion A of the AMPD or level of personality functioning (LPF), was characterized quantitatively within the PD Spectra scales. By sequentially factor analyzing the scales of the Severity Indices of Personality Problems (SIPP-118) to a common general factor of PD, an index of LPF external to the MMPI item pool was established. This LPF dimension was strongly represented across most PD Spectra scales. LPF variances within the PD Spectra scales were deconstructed using measures of general demoralization (RCdemoralization) and maladaptive personality traits indexed by the Personality Psychopathology-5 (PSY-5). Nuanced LPF and PD Spectra scale relationships were discerned. Dimensionalized Antisocial PD, Borderline PD, Dependent PD, and Paranoid PD showed meaningful association with LPF after demoralization, and maladaptive trait variances were removed. The examination of the MMPI-3 item pool reveals that the existing PD Spectra scale item sets are largely carried forward in the new edition of the MMPI. This suggests PD Spectra scale correlates, including LPF relationships, may be discernable in the newest edition of the MMPI, pending future study.

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).

Currently, 3 competing conceptualizations of personality dysfunction can be distinguished: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) categorical model delineating 10 distinct types of personality disorders (PDs); the alternative model for PDs (DSM-5 Section III), which assesses personality functioning and traits separately; and the International Classification of Diseases, 11th Version conceptualization, which provides 1 single code for the presence of a PD (which is based on problems in functioning) as well as codes that specify the level of the disorder (mild/moderate/severe), and prominent trait domains or patterns (5 domains and 1 pattern). The current study aims to assess the incremental value of the DSM-5 PDs over and above a global personality dysfunction factor, using expert ratings obtained with the Structured Clinical Interview for DSM-IV PDs and the Structured Clinical Interview for DSM-5 PDs interview in a large sample of clinical patients (N = 3,851). All estimated bifactor models provided adequate fit to the data. We found a surprisingly low explained common variance for the g-factor (<40%), indicating that ignoring the specific PD factors would lead to a substantial loss of information. The strongest specific PDs in terms of explained common variance were the avoidant, schizotypal, and schizoid PD factors and the conduct disorder criteria set if included. Correlations between our factors and external variables were relatively low, except for the Severity Indices of Personality Problems, which aims to measure personality functioning. Our findings suggest that specific PDs still have an important role to play in the assessment of personality pathology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

More work is needed to establish the validity of the Alternative Model of Personality Disorders (AMPD) in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Acceptance of the AMPD as the primary model of personality disorder requires identifying neurocognitive validators of AMPD-defined personality functioning and demonstrating superiority of the AMPD over the traditional categorical model of personality disorder. It is also important to establish the utility of the AMPD in a developmental context given evidence that personality disorder emerges in adolescence. We assessed the incremental validity of AMPD-defined level of personality functioning (LPF) versus borderline personality features (BPF) in explaining alterations in neural processing of social acceptance feedback in early adolescent girls. One hundred nine girls (Mage= 12.21, SD=1.21; N= 79 with a psychiatric history) completed a computerized peer interaction task to elicit neural response to social acceptance feedback via electroencephalogram (EEG). Subjects or caregivers reported adolescent psychopathology. In hierarchical regressions controlling for neural response to social rejection and internalizing and externalizing symptoms, LPF incremented BPF and all other covariates in predicting response to social acceptance, but BPF did not. Higher LPF impairment was associated with enhanced reactivity to social acceptance (St.b =0.274, p=0.018). LPF appears to provide additional information about neural response to social reward in early adolescence beyond that provided by borderline personality features. These findings add to an emerging literature demonstrating the validity and superiority of the AMPD and help build the rationale for moving toward the AMPD as the primary model of personality disorder classification.

Le modèle alternatif des troubles de la personnalité en population française : évaluation avec des outils brefs

The Alternative Model of Personality Disorders (AMPD), introduced in Section III of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013), was proposed as a new operationalization of personality disorders (PDs) aiming to overcome the several limitations of the traditional symptom-based model (Waugh et al., 2017; Zimmerman et al., 2019). In the AMPD, PDs are defined by two-dimensional criteria (the level of personality functioning and maladaptive personality traits), but as a hybrid model, it also allows for categorical assessment of PDs (i.e., "hybrid types") to facilitate continuity with clinical practice. The present study aimed to provide normative data for two widely used instruments assessing Criterion A (Level of Personality Functioning Scale-Self-Report; Morey, 2017) and B (Personality Inventory for DSM-5; Krueger et al., 2012) in a large populational French-Canadian sample. Regarding the categorical assessment, Gamache et al. (2022) recently tested scoring approaches for extracting the PD hybrid types from dimensional measures of the AMPD. In the present study, these approaches were used to estimate prevalence rates for these PD hybrid types in two samples. In the populational sample, results showed that prevalence rates varied from 0.2% (antisocial PDs) to 3.0% (trait-specified PDs), with an overall prevalence of 5.9% to 6.1% for any PD hybrid type. Prevalence was higher in men than in women in the populational sample, but the contrary was observed in the at-risk sample. Prevalence was higher in younger adults than in middle-aged and older adults. (PsycInfo Database Record (c) 2023 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).