Personality Disorders
Contents
Chapter 3: Diagnosis and DSM-5: Work in Progress (pp. 35- 57) ..................................................... 4
1. Dimensional Versus Categorical Models ......................................................................................... 4
2. Developing a Hybrid Model of Personality Disorders ..................................................................... 5
3. DSM-5 Personality Disorder Model Proposed for Field Testing ...................................................... 6
4. Clinical Application .......................................................................................................................... 8
5. Critiques of Proposed Model......................................................................................................... 10
Chapter 5: An Integration of Normal and Abnormal Personality Structure: The Five-Factor Model
(pp. 82-107) ............................................................................................................................... 11
1. Five-Factor Model.......................................................................................................................... 11
2. Five-Factor Model and Personality Disorders ............................................................................... 13
3. Five-Factor Model Diagnosis of Personality Disorder ................................................................... 14
4. Advantages of a Five-Factor Model of Personality Disorder ......................................................... 14
5. The Five-Factor Model and the DSM ............................................................................................. 15
Chapter 9: Epidemiology (pp. 186-205) ....................................................................................... 17
Chapter 11: Axis II Comorbidity (pp. 219-236) ............................................................................. 17
1. Personality Disorder Comorbidity in Epidemiological Samples .................................................... 17
2. Personality Disorder Comorbidity in Clinical Samples .................................................................. 19
3. Personality Disorder Comorbidity in Special Populations ............................................................. 21
4. Summary of the Personality Disorder Comorbidity Study Results ............................................... 23
5. The Meaning of Comorbidity Among Personality Disorders ......................................................... 23
Chapter 12: The Relationship of Personality Disorders and Axis I Clinical Disorders (pp. 237- 259) 24
1. Schizotypal Personality Disorder ................................................................................................... 24
2. Avoidant Personality Disorder....................................................................................................... 25
3. Antisocial Personality Disorder ..................................................................................................... 25
4. Obsessive-Compulsive Personality Disorder ................................................................................. 26
5. Borderline Personality Disorder .................................................................................................... 26
Chapter 14: Course of Personality Disorder (pp. 275-295) ............................................................ 27
1. Conceptual and Methodological Issues......................................................................................... 27
2. Contemporary Longitudinal Studies of Course in Personality Disorders ...................................... 28
Chapter 15: Neurobiological Contributions (pp. 299-324)............................................................. 31
1. Quantitative Phenotypes of Personality ....................................................................................... 31
2. Heritability of Personality Disorders ............................................................................................. 31
3. Cluster A ........................................................................................................................................ 31
, 4. Cluster B ........................................................................................................................................ 33
5. Cluster C......................................................................................................................................... 35
Chapter 16: Cognitive Contributions to Personality Disorders (pp. 325-344) ................................. 35
1. Schemas ......................................................................................................................................... 35
2. Schema Modes .............................................................................................................................. 38
3. Cognitive Biases ............................................................................................................................. 38
4. Dichotomous Thinking ................................................................................................................... 39
5. Implicit Assessment of Cognitive Concepts ................................................................................... 39
Chapter 18: A Contemporary Interpersonal Model of Personality Pathology and Personality
Disorder (pp. 372-398) ................................................................................................................ 40
1. Interpersonal Psychology and Personality Psychopathology ........................................................ 40
2. Definition and Description of Personality Psychopathology ......................................................... 40
3. Contemporary Assumptions of Interpersonal Theory................................................................... 40
4. Key Concepts of Interpersonal Theory: I. Describing Interpersonal Themes and Dynamics ........ 42
5. Key Concepts of Interpersonal Theory: II. Development, Motivation, and Regulation ............... 46
6. Clinical Applications....................................................................................................................... 47
Chapter 19: Pathology of Personality Disorder: An Integrative Conceptualization (pp. 399-406) ... 49
1. Temperament, Traits, and Personality Disorders.......................................................................... 49
2. Traits, Disorders, and Prevalence .................................................................................................. 50
3. Biological Factors in Personality Disorders ................................................................................... 50
4. Psychological and Social Factors ................................................................................................... 50
5. Social Factors in Personality Disorders .......................................................................................... 50
6. An Integrative and Interactive Model of Personality Disorder ..................................................... 51
Chapter 20: Borderline Personality Disorder (pp. 409-436) .......................................................... 51
1. Clinical Aspects .............................................................................................................................. 51
2. Comorbidity ................................................................................................................................... 52
3. Epidemiology ................................................................................................................................. 53
4. Etiology and Risk Factors ............................................................................................................... 54
5. Psychological and Neurobiological Aspects of Borderline Personality Disorder........................... 56
6. An Integrated Perspective ............................................................................................................. 59
Chapter 21: Schizotypal Personality Disorder (pp. 437-477) ......................................................... 59
1. Historical and Conceptual Roots of Schizotypal Personality Disorder .......................................... 60
2. Diagnostic Classification of Schizotypal Personality Disorder ....................................................... 61
3. Impairment, Epidemiology, Course, and Comorbidity in STPD ..................................................... 61
4. Multidimensionality of Schizotypal Personality Disorder ............................................................. 62
5. Five-Factor Model and Schizotypal Personality Disorder .............................................................. 63
6. Etiology of Schizotypal Personality Disorder ................................................................................. 63
,Chapter 22: Psychopathy (pp. 478-504) ....................................................................................... 67
1. Description and Diagnosis ............................................................................................................. 67
2. Psychopathy and Crime ................................................................................................................. 70
3. Representation of FFM Agreeableness and Conscientiousness Traits in Terms of the Four-Factor
Model of Psychopathy ....................................................................................................................... 71
4. APA Diagnostic Manual ................................................................................................................. 71
5. Etiology .......................................................................................................................................... 71
6. Epidemiology ................................................................................................................................. 72
7. Course ............................................................................................................................................ 72
8. Treatment ...................................................................................................................................... 72
9. Cognitive/ Affective Neuroscience ................................................................................................ 73
Chapter 23: Dependent Personality Disorder (pp. 505-526) ......................................................... 73
1. The Evolution of Dependent Personality Disorder ........................................................................ 73
2. Current Diagnostic Frameworks .................................................................................................... 74
3. DPD Assessment Methods ............................................................................................................ 75
4. Epidemiology, Differential Diagnosis, and Comorbidity................................................................ 76
5. Contemporary Theoretical Perspectives ....................................................................................... 76
6. Treatment Strategies ..................................................................................................................... 78
Chapter 25: Avoidant Personality Disorder, Traits, and Type (pp. 549-565)................................... 81
1. Social Sensitivity and the Historical Roots of Avoidant Personality Disorder ............................... 81
2. The Modern Diagnosis of Avoidant Personality Disorder ............................................................. 81
3. Mechanisms and Theories ............................................................................................................. 83
Chapter 34: Cognitive Therapy for Personality Disorders (pp. 727-750) ........................................ 84
1. Dialectical Behaviour Therapy ....................................................................................................... 84
2. Cognitive Model of Personality Disorders ..................................................................................... 84
3. Schema Therapy ............................................................................................................................ 86
4. Similarities and Differences Between Cognitive and Schema Models .......................................... 89
5. Schema Therapy ............................................................................................................................ 89
6. Treatment Outcomes .................................................................................................................... 90
7. Personality Disorders and the Therapeutic Relationships ............................................................ 92
Chapter 36: Mentalization-Based Treatment of Borderline Personality Disorder (pp. 767-784) ..... 93
Chapter 37: Dialectical Behaviour Therapy of BPD and other PDs (pp. 785-793) ........................... 99
1. Biosocial Theory of BPD and Dramatic-Erratic Disorders ............................................................ 100
2. “Doing DBT” ................................................................................................................................. 100
3. Research Support ........................................................................................................................ 101
4. The Underdeveloped Dialectic .................................................................................................... 102
,Chapter 3: Diagnosis and DSM-5: Work in Progress (pp. 35- 57)
− A new hybrid dimensional-categorical model for personality and personality disorder
assessment was proposed for the DSM-5
▪ Multiple reasons
→ Lack of specificity in the DSM-IV-TR definition of personality disorder
→ Inadequate representation of personality disorder severity and arbitrary
thresholds for diagnosis
→ Excessive comorbidity among personality disorders
→ Limited validity for some existing types
→ Heterogeneity within types
→ Instability of current personality disorder criteria sets
− Question whether mental disorders, including personality disorders, should be represented
by sets of dimensions of psychopathology and other features rather than by multiple
categories
− Personality disorders were supposed to be a test case for the return to a dimensional
approach to the diagnosis of mental disorders in DSM-5
1. Dimensional Versus Categorical Models
− Problems with the current categorical model
▪ Excessive co-occurrence among personality disorders diagnosed with the categorical
model
→ Most patients diagnosed with personality disorders meet criteria for more
than one
▪ Extreme heterogeneity among patients receiving the same diagnosis
▪ No empirical rationales for setting the boundaries between pathological and
“normal” personality functioning
▪ Most frequently used personality disorder diagnosis is personality disorder not
otherwise specified (PDNOS)
→ Patient is considered to have a personality disorder but doesn’t meet full
criteria for any one of the types
→ Categorical system may not cover the full domain of personality
psychopathology adequately
− Dimensional models make the co-occurrence of personality disorders and their
heterogeneity more rational
▪ Include multiple dimensions that are continua on all of which people can vary
− Dimensional models are unfamiliar and more difficult to use
▪ 30 dimensions (e.g. five factor model) or more may be necessary to fully describe a
person’s personality
− There’s little empirical information on the treatment or other clinical implications of
dimensional scale elevations and where to set cut points to maximize their utility
− Alternative proposals for dimensional models of personality disorders
▪ Dimensional representations of existing personality disorder constructs
→ Example: convert personality disorder into a 6-point scale ranging from
absent traits to prototypic disorder; significant personality traits and
subthreshold disorders could be noted, in addition to full diagnoses
, → Example: Person-centered dimensional system: protoype matching
approach; patient is compared to a description of prototypic patient with
each disorder
▪ Dimensional reorganizations of diagnostic criteria
→ Assessment model of the Schedule for Nonadaptive and Adaptive Personality
(SNAP); three higher order factors: negative temperament, positive
temperament, and disinhibition; 12 lower order trait scales measuring traits
such as dependency, aggression, and impulsivity
→ Dimensional Assessment of Personality Pathology (DAPP); broad domains of
emotional dysregulation, dissocial behaviour, inhibition, and compulsivity; 28
lower order, primary traits
▪ Integration of Axes II and I via common psychopathological spectra
→ Siever and Davis: fundamental dimensions of cognitive/ perceptual
disturbance, affective instability, impulsivity, and anxiety
→ Another model hypothesizes only two fundamental dimensions:
internalization and externalization
▪ Integration of Axis II with dimensional models of general personality structure
→ Five-Factor Model (FFM)
→ Personality disorders, in general, would be characterized by high neuroticism
→ BPD: low agreeableness, high neuroticism
→ Some research has suggested that it’s easier to distinguish personality
disorders from normality using these models than to distinguish specific
personality disorders from each other
− Attempt to synthesize all models into an overarching dimensional model
▪ E.g. alternative models could be integrated over four levels of specificity
→ Highest level: internalization and externalization
→ Blow: 3-5 broad domains of personality functioning (i.e. extroversion vs.
introversion; antagonism vs. compliance; impulsivity vs. constraint;
emotional dysregulation vs. emotional stability; unconventionality vs. closed
to experience
→ Below: a number of lower order traits, each with behaviourally specific
diagnostic criteria
2. Developing a Hybrid Model of Personality Disorders
− Personality disorders show consistency as syndromes over time but rates of improvement
that are inconsistent with their DSM definitions
▪ Functional impairment is more stable than personality psychopathology itself
▪ Personality traits are more stable than personality disorders
− Personality disorders may be best conceptualized as hybrids of more stable personality traits
and less stable symptomatic behaviors
▪ Defining the core features of personality disorders (distinct from personality traits) is
a high priority
→ E.g. disturbance of self-other representations
→ To meet the criteria for a certain personality disorder, a patient would need
to meet the generic criteria for a personality disorder and to have extreme
levels on a number of prototypic traits
− Recent studies support a hybrid model of personality psychopathology consisting of ratings
of bother disorder and trait constructs
,3. DSM-5 Personality Disorder Model Proposed for Field Testing
− Original hybrid model consisted of four parts
▪ A severity rating of levels of impairment in personality functioning
▪ Narrative prototypes for five personality disorder types
▪ A six-domain/ thirty-seven-facet trait rating system
▪ A revised definition and general criteria for personality disorder
− Has been revised twice
▪ First revision: ratings from the first three assessments were combined to comprise
the essential criteria for a personality disorder
→ A rating of mild impairment or greater on the Levels of Personality
functioning (criterion A), associated with a “good match” or a “very good
match” to a Personality Disorder Type or with a rating of “quite a bit” or
“extremely” descriptive on one or more Personality Trait Domains (criterion
B)
▪ Second revision: diagnostic criteria for six specific personality disorder types to
replace the narrative prototypes
→ Category of personality disorder trait specified, consisting of core
impairments in personality functioning and pathological personality traits
− Levels of personality functioning are based on the severity of disturbances in self and
interpersonal functioning
▪ Disturbances in thinking about the self: identity and self-directedness
▪ Interpersonal disturbances: empathy and intimacy
3.1. Rationales for Proposed Changes
− Lack of specificity in the DSM definition of personality disorder
− Inadequate representation of personality disorder severity
− Arbitrary thresholds for diagnosis
− Excessive comorbidity among personality disorders
▪ Reduction in the number of personality disorder types is expected to reduce
comorbidity
− Limited validity for some existing types
− Heterogeneity within types
▪ Addition of traits facilitates the heterogeneity within types
− Instability of current personality disorder criteria sets
▪ Addition of traits is expected to increase diagnostic stability
− The current general criteria for personality disorder aren’t empirically based and aren’t
sufficiently specific to personality pathology
▪ The requirement of core impairments in self and interpersonal functioning helps to
distinguish personality pathology from other disorders
▪ The use of traits in conjunction with core impairments in personality functioning to
diagnose “personality disorder trait-specified” reduces the need for PDNOS
3.2. Severity of Impairment in Personality Functioning
− Generalized severity may be the most important single predictor of concurrent and
prospective dysfunction in assessing personality psychopathology
, ▪ Personality disorders are optimally characterized by a generalized personality
severity continuum
→ Additional specification of stylistic elements, derived from personality
disorder symptom constellations and personality traits
▪ Severity level is essential to any dimensional system for assessing personality
psychopathology
− Personality disorders are associated with distorted thinking about self and others
▪ Maladaptive patterns of mentally representing the self and others serve as
substrates for personality psychopathology
▪ A self-other dimensional perspective has an empirical basis and significant clinical
utility
− Continuum of impairment in self and interpersonal functioning
▪ Greater impairment in personality functioning predict the presence of a personality
disorder, of more severe personality disorder diagnoses and of personality disorder
comorbidity
3.3. Personality Disorder Types
− Six specific personality disorders
▪ Antisocial, borderline, schizotypal, avoidant, obsessive-compulsive, and narcissistic
personality disorder
− PDNOS becomes personality disorder trait-specific (PDTS)
▪ Represented by significant impairment on the Levels of Personality Functioning
continuum, combined with descriptive specification of patients’ unique pathological
personality trait profiles
− Hybrid model of personality psychopathology consisting of both disorder and trait constructs
▪ Personality traits alone, esp. in the absence of clinical context, are too ambiguous for
clinicians to interpret
3.4. Personality Traits
− Five higher order domains
▪ Negative affectivity, detachment, antagonism, disinhibition, and psychoticism
▪ Each is comprised of three to seven (total =25) lower order trait facets
− Trait-based diagnostic system helps to resolve excessive comorbidity
▪ The personality traits that comprise personality disorders overlap across diagnoses
▪ Traits can combine in virtually an infinite number of ways
→ A personality disorder diagnostic system that’s trait based provides a means
to describe the personality (normal or abnormal) of every patient
− DSM criteria are a mix of more stable trait-like criteria and less stable state-like criteria
▪ Personality disorder diagnoses are less stable than their trait components
▪ Basing diagnostic criteria on more stable traits and considering the more state-like
features that occur in individuals with PDs to be associated symptoms would
eliminate the conceptual-empirical gap with regards to temporal stability
3.5. General Criteria for Personality Disorder
− Failure to develop coherent sense of self or identity and chronic interpersonal dysfunction
▪ Integrity of self-concept
→ Differentiation of self-understanding or self-knowledge
, ▪ Identity integration
→ Integration of this information into a coherent identity
▪ Self-directedness
→ The ability to set and attain satisfying and rewarding personal goals that give
direction, meaning, and purpose to life
▪ Empathy/ Intimacy
▪ Cooperativeness
▪ Complex and integrated representations of others
− Criteria were simplified!
4. Clinical Application
− Decide whether a personality-related problem exists and how severe it is
▪ Characterize personality type according to proposed criteria
▪ Identify other important personality characteristics
− The levels of functioning and trait profile steps are informative regardless of whether
patients is believed to have a personality disorder
− Trait assessment is also needed to describe the trait profile of patients who have sufficient
personality psychopathology to receive a personality disorder diagnosis but don’t match one
of the six types
4.1. Assessment of Levels of Personality
Functioning
− Levels of Personality Functioning Scale
▪ 5-point rating scale of functional
impairment in the self and
interpersonal domains
▪ Any rating above zero is significant
and consistent with a personality
disorder
▪ The more severe the level of
impairment, the more likely the
person is to have a personality
disorder, and to receive multiple
diagnoses
4.2. Assessment of Personality Trait Domains and Facets
− Two kinds of trait ratings
▪ Domain ratings
→ Five domains
▪ Facet ratings
− 4-point rating scale
▪ 0 = very little or not at all descriptive
▪ 1= mildly descriptive
▪ 2 = moderately descriptive
, ▪ 3 = extremely descriptive
− A rating of 2 or greater on one or more of the personality trait domains in the presence of
impairment in personality functioning qualifies for a personality disorder diagnosis
▪ Exclusion criteria for the general criteria for personality disorder have to be met
− The most detailed trait profile is derived from the rating of the trait facets
▪ May be found in myriad combinations
▪ Convert a nonspecific PDNOS diagnosis into a specific personality disorder trait-
specified diagnosis
4.3. Assessment of the Criteria for Personality Disorder
− Three reasons for first assessing personality functioning and traits
▪ Even if a patient doesn’t have a personality disorder the descriptive information from
the other parts of the assessment can be clinically useful
▪ The assessment of levels of personality functioning and personality traits are needed
to rate the criteria and must precede them
, ▪ The various exclusion criteria are the most time-consuming and labour-intensive
parts of the assessment and require the most knowledge about patients and their
clinical histories
5. Critiques of Proposed Model
− Confusion about how the model works in practice
▪ Clinical application emphasizes the flexible nature of the assessment, whereby
clinicians can describe a patient’s personality problems with increasing degrees of a
specificity, depending on the need to do so, as well as on available time and
information
− Critiques have almost universally been against the deletion of any of the DSM personality
disorder types
▪ Existing types have clinical utility and treatment relevance
▪ Empirical basis for retaining vs. deleting types has been questioned
→ Limited research doesn’t mean lack of utility
▪ Deletion of types is expected to result in loss of coverage of personality
psychopathology
− Most critiques believe that the originally proposed linking of traits to types is ambiguous and
without an empirical basis
▪ Traits should be rated separately from the types
− Proposed trait system has been criticized as unfamiliar to clinicians and unlikely to be used
because the traits lack an experiential or empirical basis for clinical salience
− Insufficient research base regarding cut points for diagnosis
− Traits are nonspecific
▪ The same trait may apply to many types
▪ Inherently ambiguous, static representations of personality
Contents
Chapter 3: Diagnosis and DSM-5: Work in Progress (pp. 35- 57) ..................................................... 4
1. Dimensional Versus Categorical Models ......................................................................................... 4
2. Developing a Hybrid Model of Personality Disorders ..................................................................... 5
3. DSM-5 Personality Disorder Model Proposed for Field Testing ...................................................... 6
4. Clinical Application .......................................................................................................................... 8
5. Critiques of Proposed Model......................................................................................................... 10
Chapter 5: An Integration of Normal and Abnormal Personality Structure: The Five-Factor Model
(pp. 82-107) ............................................................................................................................... 11
1. Five-Factor Model.......................................................................................................................... 11
2. Five-Factor Model and Personality Disorders ............................................................................... 13
3. Five-Factor Model Diagnosis of Personality Disorder ................................................................... 14
4. Advantages of a Five-Factor Model of Personality Disorder ......................................................... 14
5. The Five-Factor Model and the DSM ............................................................................................. 15
Chapter 9: Epidemiology (pp. 186-205) ....................................................................................... 17
Chapter 11: Axis II Comorbidity (pp. 219-236) ............................................................................. 17
1. Personality Disorder Comorbidity in Epidemiological Samples .................................................... 17
2. Personality Disorder Comorbidity in Clinical Samples .................................................................. 19
3. Personality Disorder Comorbidity in Special Populations ............................................................. 21
4. Summary of the Personality Disorder Comorbidity Study Results ............................................... 23
5. The Meaning of Comorbidity Among Personality Disorders ......................................................... 23
Chapter 12: The Relationship of Personality Disorders and Axis I Clinical Disorders (pp. 237- 259) 24
1. Schizotypal Personality Disorder ................................................................................................... 24
2. Avoidant Personality Disorder....................................................................................................... 25
3. Antisocial Personality Disorder ..................................................................................................... 25
4. Obsessive-Compulsive Personality Disorder ................................................................................. 26
5. Borderline Personality Disorder .................................................................................................... 26
Chapter 14: Course of Personality Disorder (pp. 275-295) ............................................................ 27
1. Conceptual and Methodological Issues......................................................................................... 27
2. Contemporary Longitudinal Studies of Course in Personality Disorders ...................................... 28
Chapter 15: Neurobiological Contributions (pp. 299-324)............................................................. 31
1. Quantitative Phenotypes of Personality ....................................................................................... 31
2. Heritability of Personality Disorders ............................................................................................. 31
3. Cluster A ........................................................................................................................................ 31
, 4. Cluster B ........................................................................................................................................ 33
5. Cluster C......................................................................................................................................... 35
Chapter 16: Cognitive Contributions to Personality Disorders (pp. 325-344) ................................. 35
1. Schemas ......................................................................................................................................... 35
2. Schema Modes .............................................................................................................................. 38
3. Cognitive Biases ............................................................................................................................. 38
4. Dichotomous Thinking ................................................................................................................... 39
5. Implicit Assessment of Cognitive Concepts ................................................................................... 39
Chapter 18: A Contemporary Interpersonal Model of Personality Pathology and Personality
Disorder (pp. 372-398) ................................................................................................................ 40
1. Interpersonal Psychology and Personality Psychopathology ........................................................ 40
2. Definition and Description of Personality Psychopathology ......................................................... 40
3. Contemporary Assumptions of Interpersonal Theory................................................................... 40
4. Key Concepts of Interpersonal Theory: I. Describing Interpersonal Themes and Dynamics ........ 42
5. Key Concepts of Interpersonal Theory: II. Development, Motivation, and Regulation ............... 46
6. Clinical Applications....................................................................................................................... 47
Chapter 19: Pathology of Personality Disorder: An Integrative Conceptualization (pp. 399-406) ... 49
1. Temperament, Traits, and Personality Disorders.......................................................................... 49
2. Traits, Disorders, and Prevalence .................................................................................................. 50
3. Biological Factors in Personality Disorders ................................................................................... 50
4. Psychological and Social Factors ................................................................................................... 50
5. Social Factors in Personality Disorders .......................................................................................... 50
6. An Integrative and Interactive Model of Personality Disorder ..................................................... 51
Chapter 20: Borderline Personality Disorder (pp. 409-436) .......................................................... 51
1. Clinical Aspects .............................................................................................................................. 51
2. Comorbidity ................................................................................................................................... 52
3. Epidemiology ................................................................................................................................. 53
4. Etiology and Risk Factors ............................................................................................................... 54
5. Psychological and Neurobiological Aspects of Borderline Personality Disorder........................... 56
6. An Integrated Perspective ............................................................................................................. 59
Chapter 21: Schizotypal Personality Disorder (pp. 437-477) ......................................................... 59
1. Historical and Conceptual Roots of Schizotypal Personality Disorder .......................................... 60
2. Diagnostic Classification of Schizotypal Personality Disorder ....................................................... 61
3. Impairment, Epidemiology, Course, and Comorbidity in STPD ..................................................... 61
4. Multidimensionality of Schizotypal Personality Disorder ............................................................. 62
5. Five-Factor Model and Schizotypal Personality Disorder .............................................................. 63
6. Etiology of Schizotypal Personality Disorder ................................................................................. 63
,Chapter 22: Psychopathy (pp. 478-504) ....................................................................................... 67
1. Description and Diagnosis ............................................................................................................. 67
2. Psychopathy and Crime ................................................................................................................. 70
3. Representation of FFM Agreeableness and Conscientiousness Traits in Terms of the Four-Factor
Model of Psychopathy ....................................................................................................................... 71
4. APA Diagnostic Manual ................................................................................................................. 71
5. Etiology .......................................................................................................................................... 71
6. Epidemiology ................................................................................................................................. 72
7. Course ............................................................................................................................................ 72
8. Treatment ...................................................................................................................................... 72
9. Cognitive/ Affective Neuroscience ................................................................................................ 73
Chapter 23: Dependent Personality Disorder (pp. 505-526) ......................................................... 73
1. The Evolution of Dependent Personality Disorder ........................................................................ 73
2. Current Diagnostic Frameworks .................................................................................................... 74
3. DPD Assessment Methods ............................................................................................................ 75
4. Epidemiology, Differential Diagnosis, and Comorbidity................................................................ 76
5. Contemporary Theoretical Perspectives ....................................................................................... 76
6. Treatment Strategies ..................................................................................................................... 78
Chapter 25: Avoidant Personality Disorder, Traits, and Type (pp. 549-565)................................... 81
1. Social Sensitivity and the Historical Roots of Avoidant Personality Disorder ............................... 81
2. The Modern Diagnosis of Avoidant Personality Disorder ............................................................. 81
3. Mechanisms and Theories ............................................................................................................. 83
Chapter 34: Cognitive Therapy for Personality Disorders (pp. 727-750) ........................................ 84
1. Dialectical Behaviour Therapy ....................................................................................................... 84
2. Cognitive Model of Personality Disorders ..................................................................................... 84
3. Schema Therapy ............................................................................................................................ 86
4. Similarities and Differences Between Cognitive and Schema Models .......................................... 89
5. Schema Therapy ............................................................................................................................ 89
6. Treatment Outcomes .................................................................................................................... 90
7. Personality Disorders and the Therapeutic Relationships ............................................................ 92
Chapter 36: Mentalization-Based Treatment of Borderline Personality Disorder (pp. 767-784) ..... 93
Chapter 37: Dialectical Behaviour Therapy of BPD and other PDs (pp. 785-793) ........................... 99
1. Biosocial Theory of BPD and Dramatic-Erratic Disorders ............................................................ 100
2. “Doing DBT” ................................................................................................................................. 100
3. Research Support ........................................................................................................................ 101
4. The Underdeveloped Dialectic .................................................................................................... 102
,Chapter 3: Diagnosis and DSM-5: Work in Progress (pp. 35- 57)
− A new hybrid dimensional-categorical model for personality and personality disorder
assessment was proposed for the DSM-5
▪ Multiple reasons
→ Lack of specificity in the DSM-IV-TR definition of personality disorder
→ Inadequate representation of personality disorder severity and arbitrary
thresholds for diagnosis
→ Excessive comorbidity among personality disorders
→ Limited validity for some existing types
→ Heterogeneity within types
→ Instability of current personality disorder criteria sets
− Question whether mental disorders, including personality disorders, should be represented
by sets of dimensions of psychopathology and other features rather than by multiple
categories
− Personality disorders were supposed to be a test case for the return to a dimensional
approach to the diagnosis of mental disorders in DSM-5
1. Dimensional Versus Categorical Models
− Problems with the current categorical model
▪ Excessive co-occurrence among personality disorders diagnosed with the categorical
model
→ Most patients diagnosed with personality disorders meet criteria for more
than one
▪ Extreme heterogeneity among patients receiving the same diagnosis
▪ No empirical rationales for setting the boundaries between pathological and
“normal” personality functioning
▪ Most frequently used personality disorder diagnosis is personality disorder not
otherwise specified (PDNOS)
→ Patient is considered to have a personality disorder but doesn’t meet full
criteria for any one of the types
→ Categorical system may not cover the full domain of personality
psychopathology adequately
− Dimensional models make the co-occurrence of personality disorders and their
heterogeneity more rational
▪ Include multiple dimensions that are continua on all of which people can vary
− Dimensional models are unfamiliar and more difficult to use
▪ 30 dimensions (e.g. five factor model) or more may be necessary to fully describe a
person’s personality
− There’s little empirical information on the treatment or other clinical implications of
dimensional scale elevations and where to set cut points to maximize their utility
− Alternative proposals for dimensional models of personality disorders
▪ Dimensional representations of existing personality disorder constructs
→ Example: convert personality disorder into a 6-point scale ranging from
absent traits to prototypic disorder; significant personality traits and
subthreshold disorders could be noted, in addition to full diagnoses
, → Example: Person-centered dimensional system: protoype matching
approach; patient is compared to a description of prototypic patient with
each disorder
▪ Dimensional reorganizations of diagnostic criteria
→ Assessment model of the Schedule for Nonadaptive and Adaptive Personality
(SNAP); three higher order factors: negative temperament, positive
temperament, and disinhibition; 12 lower order trait scales measuring traits
such as dependency, aggression, and impulsivity
→ Dimensional Assessment of Personality Pathology (DAPP); broad domains of
emotional dysregulation, dissocial behaviour, inhibition, and compulsivity; 28
lower order, primary traits
▪ Integration of Axes II and I via common psychopathological spectra
→ Siever and Davis: fundamental dimensions of cognitive/ perceptual
disturbance, affective instability, impulsivity, and anxiety
→ Another model hypothesizes only two fundamental dimensions:
internalization and externalization
▪ Integration of Axis II with dimensional models of general personality structure
→ Five-Factor Model (FFM)
→ Personality disorders, in general, would be characterized by high neuroticism
→ BPD: low agreeableness, high neuroticism
→ Some research has suggested that it’s easier to distinguish personality
disorders from normality using these models than to distinguish specific
personality disorders from each other
− Attempt to synthesize all models into an overarching dimensional model
▪ E.g. alternative models could be integrated over four levels of specificity
→ Highest level: internalization and externalization
→ Blow: 3-5 broad domains of personality functioning (i.e. extroversion vs.
introversion; antagonism vs. compliance; impulsivity vs. constraint;
emotional dysregulation vs. emotional stability; unconventionality vs. closed
to experience
→ Below: a number of lower order traits, each with behaviourally specific
diagnostic criteria
2. Developing a Hybrid Model of Personality Disorders
− Personality disorders show consistency as syndromes over time but rates of improvement
that are inconsistent with their DSM definitions
▪ Functional impairment is more stable than personality psychopathology itself
▪ Personality traits are more stable than personality disorders
− Personality disorders may be best conceptualized as hybrids of more stable personality traits
and less stable symptomatic behaviors
▪ Defining the core features of personality disorders (distinct from personality traits) is
a high priority
→ E.g. disturbance of self-other representations
→ To meet the criteria for a certain personality disorder, a patient would need
to meet the generic criteria for a personality disorder and to have extreme
levels on a number of prototypic traits
− Recent studies support a hybrid model of personality psychopathology consisting of ratings
of bother disorder and trait constructs
,3. DSM-5 Personality Disorder Model Proposed for Field Testing
− Original hybrid model consisted of four parts
▪ A severity rating of levels of impairment in personality functioning
▪ Narrative prototypes for five personality disorder types
▪ A six-domain/ thirty-seven-facet trait rating system
▪ A revised definition and general criteria for personality disorder
− Has been revised twice
▪ First revision: ratings from the first three assessments were combined to comprise
the essential criteria for a personality disorder
→ A rating of mild impairment or greater on the Levels of Personality
functioning (criterion A), associated with a “good match” or a “very good
match” to a Personality Disorder Type or with a rating of “quite a bit” or
“extremely” descriptive on one or more Personality Trait Domains (criterion
B)
▪ Second revision: diagnostic criteria for six specific personality disorder types to
replace the narrative prototypes
→ Category of personality disorder trait specified, consisting of core
impairments in personality functioning and pathological personality traits
− Levels of personality functioning are based on the severity of disturbances in self and
interpersonal functioning
▪ Disturbances in thinking about the self: identity and self-directedness
▪ Interpersonal disturbances: empathy and intimacy
3.1. Rationales for Proposed Changes
− Lack of specificity in the DSM definition of personality disorder
− Inadequate representation of personality disorder severity
− Arbitrary thresholds for diagnosis
− Excessive comorbidity among personality disorders
▪ Reduction in the number of personality disorder types is expected to reduce
comorbidity
− Limited validity for some existing types
− Heterogeneity within types
▪ Addition of traits facilitates the heterogeneity within types
− Instability of current personality disorder criteria sets
▪ Addition of traits is expected to increase diagnostic stability
− The current general criteria for personality disorder aren’t empirically based and aren’t
sufficiently specific to personality pathology
▪ The requirement of core impairments in self and interpersonal functioning helps to
distinguish personality pathology from other disorders
▪ The use of traits in conjunction with core impairments in personality functioning to
diagnose “personality disorder trait-specified” reduces the need for PDNOS
3.2. Severity of Impairment in Personality Functioning
− Generalized severity may be the most important single predictor of concurrent and
prospective dysfunction in assessing personality psychopathology
, ▪ Personality disorders are optimally characterized by a generalized personality
severity continuum
→ Additional specification of stylistic elements, derived from personality
disorder symptom constellations and personality traits
▪ Severity level is essential to any dimensional system for assessing personality
psychopathology
− Personality disorders are associated with distorted thinking about self and others
▪ Maladaptive patterns of mentally representing the self and others serve as
substrates for personality psychopathology
▪ A self-other dimensional perspective has an empirical basis and significant clinical
utility
− Continuum of impairment in self and interpersonal functioning
▪ Greater impairment in personality functioning predict the presence of a personality
disorder, of more severe personality disorder diagnoses and of personality disorder
comorbidity
3.3. Personality Disorder Types
− Six specific personality disorders
▪ Antisocial, borderline, schizotypal, avoidant, obsessive-compulsive, and narcissistic
personality disorder
− PDNOS becomes personality disorder trait-specific (PDTS)
▪ Represented by significant impairment on the Levels of Personality Functioning
continuum, combined with descriptive specification of patients’ unique pathological
personality trait profiles
− Hybrid model of personality psychopathology consisting of both disorder and trait constructs
▪ Personality traits alone, esp. in the absence of clinical context, are too ambiguous for
clinicians to interpret
3.4. Personality Traits
− Five higher order domains
▪ Negative affectivity, detachment, antagonism, disinhibition, and psychoticism
▪ Each is comprised of three to seven (total =25) lower order trait facets
− Trait-based diagnostic system helps to resolve excessive comorbidity
▪ The personality traits that comprise personality disorders overlap across diagnoses
▪ Traits can combine in virtually an infinite number of ways
→ A personality disorder diagnostic system that’s trait based provides a means
to describe the personality (normal or abnormal) of every patient
− DSM criteria are a mix of more stable trait-like criteria and less stable state-like criteria
▪ Personality disorder diagnoses are less stable than their trait components
▪ Basing diagnostic criteria on more stable traits and considering the more state-like
features that occur in individuals with PDs to be associated symptoms would
eliminate the conceptual-empirical gap with regards to temporal stability
3.5. General Criteria for Personality Disorder
− Failure to develop coherent sense of self or identity and chronic interpersonal dysfunction
▪ Integrity of self-concept
→ Differentiation of self-understanding or self-knowledge
, ▪ Identity integration
→ Integration of this information into a coherent identity
▪ Self-directedness
→ The ability to set and attain satisfying and rewarding personal goals that give
direction, meaning, and purpose to life
▪ Empathy/ Intimacy
▪ Cooperativeness
▪ Complex and integrated representations of others
− Criteria were simplified!
4. Clinical Application
− Decide whether a personality-related problem exists and how severe it is
▪ Characterize personality type according to proposed criteria
▪ Identify other important personality characteristics
− The levels of functioning and trait profile steps are informative regardless of whether
patients is believed to have a personality disorder
− Trait assessment is also needed to describe the trait profile of patients who have sufficient
personality psychopathology to receive a personality disorder diagnosis but don’t match one
of the six types
4.1. Assessment of Levels of Personality
Functioning
− Levels of Personality Functioning Scale
▪ 5-point rating scale of functional
impairment in the self and
interpersonal domains
▪ Any rating above zero is significant
and consistent with a personality
disorder
▪ The more severe the level of
impairment, the more likely the
person is to have a personality
disorder, and to receive multiple
diagnoses
4.2. Assessment of Personality Trait Domains and Facets
− Two kinds of trait ratings
▪ Domain ratings
→ Five domains
▪ Facet ratings
− 4-point rating scale
▪ 0 = very little or not at all descriptive
▪ 1= mildly descriptive
▪ 2 = moderately descriptive
, ▪ 3 = extremely descriptive
− A rating of 2 or greater on one or more of the personality trait domains in the presence of
impairment in personality functioning qualifies for a personality disorder diagnosis
▪ Exclusion criteria for the general criteria for personality disorder have to be met
− The most detailed trait profile is derived from the rating of the trait facets
▪ May be found in myriad combinations
▪ Convert a nonspecific PDNOS diagnosis into a specific personality disorder trait-
specified diagnosis
4.3. Assessment of the Criteria for Personality Disorder
− Three reasons for first assessing personality functioning and traits
▪ Even if a patient doesn’t have a personality disorder the descriptive information from
the other parts of the assessment can be clinically useful
▪ The assessment of levels of personality functioning and personality traits are needed
to rate the criteria and must precede them
, ▪ The various exclusion criteria are the most time-consuming and labour-intensive
parts of the assessment and require the most knowledge about patients and their
clinical histories
5. Critiques of Proposed Model
− Confusion about how the model works in practice
▪ Clinical application emphasizes the flexible nature of the assessment, whereby
clinicians can describe a patient’s personality problems with increasing degrees of a
specificity, depending on the need to do so, as well as on available time and
information
− Critiques have almost universally been against the deletion of any of the DSM personality
disorder types
▪ Existing types have clinical utility and treatment relevance
▪ Empirical basis for retaining vs. deleting types has been questioned
→ Limited research doesn’t mean lack of utility
▪ Deletion of types is expected to result in loss of coverage of personality
psychopathology
− Most critiques believe that the originally proposed linking of traits to types is ambiguous and
without an empirical basis
▪ Traits should be rated separately from the types
− Proposed trait system has been criticized as unfamiliar to clinicians and unlikely to be used
because the traits lack an experiential or empirical basis for clinical salience
− Insufficient research base regarding cut points for diagnosis
− Traits are nonspecific
▪ The same trait may apply to many types
▪ Inherently ambiguous, static representations of personality
