Severe personality disorders

Both the Alternative DSM-5 Model for Personality Disorders (AMPD) and the chapter on personality disorders (PD) in the recent version of ICD-11 embody a shift from a categorical to a dimensional paradigm for the classification of PD. We describe these new models, summarize available measures, and provide a comprehensive review of research on the AMPD. A total of 237 publications on severity (criterion A) and maladaptive traits (criterion B) of the AMPD indicate (a) acceptable interrater reliability, (b) largely consistent latent structures, (c) substantial convergence with a range of theoretically and clinically relevant external measures, and (d) some evidence for incremental validity when controlling for categorical PD diagnoses. However, measures of criterion A and B are highly correlated, which poses conceptual challenges. The AMPD has stimulated extensive research with promising findings. We highlight open questions and provide recommendations for future research.

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A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders.

Purpose of review The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders. Recent findings Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust. Summary The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity.

Criteria A of the DSM-5 Alternative Model for Personality Disorders (AMPD) defines personality pathology in terms of impairments in "self" (identity, self-direction) and "interpersonal" (empathy, intimacy) functioning. Articulated as a set of dynamic regulatory and relational processes that are stratified in the Level of Personality Functioning Scale, these impairments involve how individuals think and feel about themselves and others and how they relate to others. Defining personality pathology in terms of regulatory and relational processes involving self and other, and distinguishing severity of personality pathology from individual differences in its expression (Criteria B), offers the AMPD several advantages. First, it distinguishes the nature and severity of personality pathology from other forms of psychopathology. Second, it allows the AMPD to integrate personality structure and personality processes. Third, it is highly suitable for synthesis with the Contemporary Integrative Interpersonal Theory of personality. Finally, beyond the interpersonal perspective, it facilitates even broader theoretical and treatment integration.

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Importance of Self and Other in Defining Personality Pathology.

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Il modello di O.F. Kernberg per lo studio dei disturbi di personalità. Validazione delle versioni italiane dell'inventory of personality organization (IPO) e della structured interview of personality organization (STIPO)

In Section III of DSM-5, the Level of Personality Functioning Scale (LPFS), a component of the DSM-5 Alternative Model for Personality Disorders (AMPD), offers a dimensional approach to the assessment of personality pathology. Similar to the psychoanalytic concept of personality organization developed by Kernberg ( 1984 ), personality disorders are assessed not only by categorical diagnoses, but also by measuring impairment of personality functioning. In this study we empirically investigate the convergence between two instruments examining personality functioning, the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-AMPD) and the Structured Interview of Personality Organization (STIPO). For this goal, correlations between both the overall scores of the two instruments as well as between the corresponding domain scale scores were examined. In addition, the relationship between interview ratings and clinical criteria quantifying the severity of the disorder (suicide attempts, frequency of psychiatric hospitalization, ICD-10 diagnoses) were analyzed. Based on videotaped assessments of 30 psychotherapeutic in- and outpatients with both instruments, significant correlations between overall scores and domain scales of the two interviews were found. Moreover, the ratings from both interviews showed high correlations with criteria of clinical severity.

Comparison of the Structured DSM-5 Clinical Interview for the Level of Personality Functioning Scale With the Structured Interview of Personality Organization.

The concept of personality functioning (Alternative DSM-5 Model of Personality Disorders) has led to increased interest in dimensional personality disorder diagnosis. While differing markedly from the current categorical classification, it is closely related to the psychodynamic concepts of personality structure and personality organization. In this review, the three dimensional approaches, their underlying models, and common instruments are introduced, and empirical studies on similarities and differences between the concepts and the categorical classification are summarized. Additionally, a case example illustrates the clinical application. Numerous studies demonstrate the broad empirical basis, validated assessment instruments and clinical usefulness of the dimensional concepts. Their advantages compared to the categorical approach, but also the respective differences, have been demonstrated empirically, in line with clinical observations. Evidence supports the three dimensional concepts, which share conceptual overlap, but also entail unique aspects of personality pathology, respectively.

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Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization.

According to the alternative model for personality disorders (AMPD) of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a moderate or greater impairment in personality functioning is the essential criterion for a personality disorder diagnosis. Personality functioning is operationalized in the Level of Personality Functioning Scale via 4 domains (identity, self-direction, empathy, and intimacy) and 2 higher order dimensions (self and interpersonal functioning). The current study examined the reliability (interrater, test-retest), structure, and validity (convergent, discriminant, and incremental) of the Structured Clinical Interview for the AMPD-Module I (SCID-5-AMPD-I). A clinical sample (n = 121) completed the SCID-5-AMPD-I, along with an interview for DSM-5 Section II personality disorders and self-reports for personality pathology (personality functioning, personality organization, personality structure, and pathological personality traits) and other forms of psychopathology (depression, anxiety, somatization, and general disability). Interrater and test-retest reliability was excellent for overall personality functioning, the higher order dimensions, and the domains, except for the empathy domain in the test-retest condition. Factor analyses suggest that personality functioning is an essentially unidimensional construct. Personality functioning demonstrated high convergence with other forms of personality pathology and showed good discriminant validity in relation to depression, anxiety, and somatization but not in relation to the broader construct of general disability. Personality functioning (Criterion A) showed incremental validity over pathological personality traits (Criterion B) in predicting interview-assessed DSM-5 Section II personality disorders but not in predicting self-reported personality and general psychopathology. The present study suggests that the SCID-5-AMPD-I is a viable measure for personality functioning. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Reliability, structure, and validity of module I (personality functioning) of the Structured Clinical Interview for the alternative DSM-5 model for personality disorders (SCID-5-AMPD-I).

Objectives: The concept of narcissism contains a yet unresolved paradox: Its grandiose facet depicts the psychopathological core but is often associated with life-satisfaction and overall functioning, whereas its vulnerable facet is associated with psychological distress, but still not included in the international classification systems. Our goal was to investigate the relationship between the two facets of narcissism expecting underlying defense mechanisms to be core elements. First, we aimed to identify defense mechanisms specific to grandiose and vulnerable narcissism. Second, we explored how both facets are differentially associated with psychological distress, assuming that grandiose narcissism would be associated with less psychological distress than vulnerable narcissism. Third, we investigated the mediating role of defense mechanisms between narcissism and psychological distress. Methods: In a non-clinical sample of N = 254 individuals, the Pathological Narcissism Inventory was used for the assessment of grandiose and vulnerable facets of narcissism, the Defense Style Questionnaire for defense mechanisms, and the Brief Symptom Inventory for psychological distress. Structural equation modeling was employed to identify distinct factors of grandiose and vulnerable narcissism. Associations between specific defense mechanisms and both facets were calculated. Furthermore, the direct association between both facets and psychological distress was examined. We finally explored whether defense mechanisms mediate the association between distress and both grandiose and vulnerable narcissism. Results: A distinct pattern of defense mechanisms for each facet of narcissism could be extracted: Both facets showed significant positive correlations with specific intermediate and all maladaptive defense mechanisms. Only grandiose narcissism showed significant positive correlations with adaptive defenses. Vulnerable narcissism showed negative correlations with all adaptive defenses. Specifically, grandiose narcissism was significantly related to anticipation, pseudo-altruism, rationalization, and dissociation, whereas vulnerable narcissism was negatively related to all these defense mechanisms. While grandiose narcissism was not related to psychological distress, vulnerable narcissism showed high correlations with psychological distress. Intriguingly, mediator analysis found that grandiose narcissism was related to psychological distress when mediated by maladaptive defense mechanisms. Discussion: The role of defense mechanisms is central for a differentiated understanding of the two different faces of narcissism. The relevance of assessing defense mechanisms in clinical settings, and related empirical findings are discussed.

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Leonie Kampe

Papers

Comparison of the Structured DSM-5 Clinical Interview for the Level of Personality Functioning Scale With the Structured Interview of Personality Organization.

Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization.

Reliability, structure, and validity of module I (personality functioning) of the Structured Clinical Interview for the alternative DSM-5 model for personality disorders (SCID-5-AMPD-I).

It's Not That Great Anymore: The Central Role of Defense Mechanisms in Grandiose and Vulnerable Narcissism.

How Personality Functioning Relates to Psychological Distress and Behavioral Attitudes During the Covid-19 Pandemic