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

TL;DR: Both the Alternative DSM-5 Model for Personality Disorders 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.
Abstract: 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.

Summary (2 min read)

Introduction

  • A key assumption in many models is that the correct choice is fixed in time, i.e. decisions are made in a static environment.
  • This assumption may hold in the laboratory, but natural environments are seldom static [15, 16].
  • This model also suggests a biophysical neural implementation 2 for evidence integrators consisting of neural populations whose activity represents the evidence in favor of a particular choice.

II. OPTIMAL DECISIONS IN A STATIC ENVIRONMENT

  • The authors develop their model in a way that parallels the case of a static environment with two possible states.
  • To make a decision, an optimal observer integrates a stream of measurements to infer the present environmental state.
  • In the static case, this can be done using sequential analysis [1, 9]:.

III. TWO ALTERNATIVES IN A CHANGING ENVIRONMENT

  • The authors use the same assumptions to derive a recursive equation for the log likelihood ratio between to alternatives in a changing environment.
  • The authors assume that + and − are known to the observer.
  • The increase in accuracy in time is exceedingly slow for low m.

A. Equal switching rates between two states

  • = + = −, the frequencies of switches between states are equal, also known as When.
  • This distribution is concentrated around ȳ± = ± sinh−1 m2 , the fixed points of the deterministic counterpart of Eq. (9) obtained by setting Wτ ≡ 0.
  • Aggregating new evidence then always tends to increase an optimal observer’s belief in one of the choices.

B. Linear approximation of the SDE

  • An advantage of Eq. (6) is that it is amenable to standard methods of stochastic analysis.
  • The authors can find an accurate piecewise linear approximation to Eq. (6), although, for simplicity, they focus on Eq. (9).
  • Linear drift time nonlin. linear drift FIG.
  • Eq. (11) can be integrated explicitly using standard methods in stochastic calculus [30].

IV. MULTIPLE ALTERNATIVES IN A CHANGING ENVIRONMENT

  • The authors next extend their analysis of evidence accumulation in changing environments to the case of multiple alternatives.
  • The authors again use sequential analysis to obtain the probabilities Ln,i = Pr(H(t) = Hi|ξ1:n) that the environment is in state.
  • The index that maximizes the posterior probability, ı̂ = argmaxi Ln,i, corresponds to the most probable state, given the observations ξ1:n.

V. A CONTINUUM OF STATES IN A CHANGING ENVIRONMENT

  • Lastly, the authors consider the case of a continuum of possible environmental states.
  • (B) In quickly changing environments, the distribution does not have time to equilibriate between switches.
  • The drift gθ(t) is maximal when θ agrees with the present environmental state.

VI. A NEURAL IMPLEMENTATION OF AN OPTIMAL OBSERVER

  • Previous neural models of decision making typically relied on mutually inhibitory neural networks [12, 20, 33], with each population representing one alternative.
  • H± and vanishes otherwise, W± are Wiener processes representing the variability in the input signal with covariance defined as in Eq. (14) .
  • In this case coupling between populations is again excitatory (Fig. 7C).

VII. DISCUSSION

  • The authors have derived a nonlinear stochastic model of optimal evidence accumulation in changing environments.
  • The authors have made several assumptions about the model to simplify these initial derivations.
  • The authors also assumed that changes in the environment follow a memoryless process.
  • This allows for a straightforward approximation of the nonlinear model by a linear SDE, which can be analyzed fully.

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Title
A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for
Personality Disorders.
Permalink
https://escholarship.org/uc/item/17v5n4jd
Journal
Current psychiatry reports, 21(9)
ISSN
1523-3812
Authors
Zimmermann, Johannes
Kerber, André
Rek, Katharina
et al.
Publication Date
2019-08-01
DOI
10.1007/s11920-019-1079-z
Peer reviewed
eScholarship.org Powered by the California Digital Library
University of California

PERSONALITY DISORDERS (K BERTSCH, SECTION EDITOR)
A Brief but Comprehensive Review of Research on the Alternative
DSM-5 Model for Personality Disorders
Johannes Zimmermann
1
& André Kerber
2
& Katharina Rek
3
& Christopher J. Hopwood
4
& Robert F. Krueger
5
#
Springer Science+Business Media, LLC, part of Springer Nature 2019
Abstract
Purpose of Review 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.
Recent Findings 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.
Summary The AMPD has stimulated extensive research with promising findings. We highlight open questions and provide
recommendations for future research.
Keywords Personality disorders
.
DSM-5
.
ICD-11
.
Dimensional models
.
Reliability
.
Validity
Introduction
The current classification systems of personality disorder (PD)
in DSM-5 section II [1] and ICD-10 [2] have various short-
comings. For example, the assumption that PDs are categories
is incompatible with most available evidence, the thresholds
for defining the presence of a PD are largely arbitrary, and the
assignment of individual PD symptoms to specific disorders
does not correspond to their empirical covariation [35]. As a
result of these shortcomings, many patients in clinical practice
misleadingly receive multiple PD diagnoses, a not otherwise
specified PD diagnosis, or no PD diagnosis at all, even if a
PD diagnosis is relevant to the presentation [6, 7].
To overcome this unfortunate situation, the field is current-
ly shifting toward dimensional models of PDs. The m ost
prominent examples of this ongoing process are the
Alternative DSM-5 Model for PD (AMPD) in DSM-5 section
III [1] and the chapter on PD and related traits in the recent
version of ICD-11 [8]. The common denominator of these
models is a twofold conceptualization that involves (a) impair-
ments in self and interpersonal functioning to represent gen-
eral features and severity of PD and (b) maladaptive person-
ality traits to represent stylistic differences in the expression of
PD [911]. In the present paper, we outline the two models,
summarize measures that were recently developed for
assessing PD severity and style according to these models,
and provide a comprehensive review of recent research using
these measures. The focus will be primarily on the AMPD, as
it has accumulated far more research evidence since its publi-
cation in 2013 than the ICD-11 model, which will become
effective in 2022.
This article is part of the Topical Collection on Personality Disorders
* Johannes Zimmermann
jz@uni-kassel.de
1
Department of Psychology, University of Kassel, Holländische Str.
36-38, 34127 Kassel, Germany
2
Freie Universität Berlin, Berlin, Germany
3
Max-Planck-Institut für Psychiatrie, Munich, Germany
4
University of California, Davis, CA, USA
5
University of Minnesota, Minneapolis, MN, USA
Current Psychiatry Reports (2019) 21:92
https://doi.org/10.1007/s11920-019-1079-z

Dimensional Models of Personality Pathology
in DSM-5 and ICD-11
Alternative DSM-5 Model for PD
The AMPD is considered as an emerging model in section
III of the DSM-5 [1214]. The key innovation of the AMPD is
to define PDs on the basis of impairments in personality func-
tioning (criterion A) and the presence of maladaptive person-
ality traits (criterion B). Further general criteria related to the
cross-situational rigidity and temporal stability of behavioral
patterns (criteria C and D) as well as to the exclusion of var-
ious alternative explanations (criteria EG) largely correspond
to the current classification system of PD in DSM-5 section II.
Criterion A is used to determine the severity of PD and can
be assessed using the Level of Personality Functioning Scale
(LPFS) [15]. The LPFS is based on the assumption that the
shared features of all PDs involve impairments of basic capac-
ities that are crucial for adaptive self and interpersonal func-
tioning. In particular, the LPFS integrates four domains (or
elements) of personality functioning: identity and self-
direction capture capacities related to the self, while empathy
and intimacy capture capacities related to interpersonal rela-
tionships. In addition, each domain is broken down further
into three subdomains. For example, intimacy means that a
person (a) can enter into deep and lasting relationships with
other people; (b) wishes, and is able, to be close to other
people; and (c) treats them with respect. Note that, despite
these fine-grained definitions, all domains and subdomains
are meant to represent one general dimension of PD severity.
The LPFS further grades this continuum along five distinct
levels of impairment, starting with little or no impairment
(level 0), through some (level 1), moderate (level 2), severe
(level 3), and up to extreme impairment (level 4). A moderate
impairment (level 2) defines the threshold value for the pres-
ence of a PD. To facilitate assessment, the LPFS
operationalizes all possible 60 combinations of subdomains
and levels using prototypical descriptions.
Criterion B is used to determine the style of PD. For this
purpose, a hierarchical model of maladaptive personality traits
was developed on the basis of empirical analyses [16]. At a
higher level, the model encompasses five broad trait domains
of negative affectivity, detachment, antagonism, disinhibition,
and psychoticism. At a subordinate level, these domains are
further specified by 25 trait facets. For example, disinhibition
is subdivided into (a) irresponsibility, (b) impulsivity, (c) dis-
tractibility, (d) risk taking, and (e) low rigid perfectionism. For
the diagnosis of PD, at least one maladaptive personality trait
domain or facet must be in the clinically significant range.
The AMPD also allows for the diagnosis of six PD types.
These are antisocial, borderline, narcissistic, schizotypal,
avoidant, and obsessivecompulsive PD. The criteria consist
of specific combinations of impairments in personality
functioning (criterion A) and maladaptive personality traits
(criterion B). For example, to qualify for a diagnosis of nar-
cissistic PD, two of the four domains of functioning must be at
least moderately impaired, and the two trait facets grandiosity
and attention-seeking must be clearly pronounced. If the indi-
vidual pattern does not correspond to any of these prototyp-
ical combinations, the diagnosis of a PD trait specified (PD-
TS) can be assigned.
PD Chapter in ICD-11
The proposal for a revised PD chapter in ICD-11 was first
published in 2011 [17] and subsequently modified based on
scientific, pragmatic, and political debates [7, 9, 18, 19, 20••,
2123]. In October 2018, the joint task force of the WHO has
declared that the recent version of ICD-11 was stable and
ready for the implementation process, and proposed the
ICD-11 to come into effect on 1 January 2022 [24].
The PD chapter in ICD-11 can be implemented using a
three-step procedure [25]: In the first step, the practitioner
examines whether the patients pathology corresponds to the
general definition of PD (code: 6D10), which emphasizes
longstanding problems in self and interpersonal functioning.
In the second step, the practitioner identifies the correspond-
ing degree of severity ranging from subthreshold personality
difficulty (QE50.7) to mild (6D10.0), moderate (6D10.1), and
severe PD (6D10.2). In the third step, the practitioner has the
option to specify the presence of prominent personality traits
(6D11), including negative affectivity (6D11.0), detachment
(6D11.1), dissociality (6D11.2), disinhibition (6D11.3),
anankastia (i.e., obsessivecompulsive features) (6D11.4), as
well as a borderline pattern (6D11.5). The inclusion of the
latter specifier, which essentially corresponds to borderline
PD in DSM-5 section II, was highly controversial and can
be understood as an effort to ensure a minimum amount of
backwards compatibility [9, 18, 19, 20••]. As expertise in PD
is considered necessary for this third step, it would be reserved
for specialist rather than general care settings.
Obviously, the proposal is similar to the AMPD with regard
to the twofold conceptualization of severity and style.
However, there are also noteworthy differences. For example,
the ICD-11 proposal does not include (a) the possibility to
assign specific PD diagnoses (except borderline PD), (b) the
assessment of trait domains as a necessary part of the diagno-
sis, (c) the trait domain of psychoticism, and (d) a subordinate
level of trait facets.
Assessing Severity and Style of Personality
Pathology
Coincident with the publication of these models has been the
development of new measures. T able 1 provides an overview
92 Page 2 of 19 Curr Psychiatry Rep (2019) 21:92

of all instruments that directly implement the operationalization
of severity and style of PD according to the AMPD and the ICD-
1 1 proposal.
Severity
In the AMPD, the assessment of PD severity was originally
conceived of as applying the LPFS as an expert rating on a
single five-point scale [40]. Other researchers have applied the
LPFS in a more differentiated way by separately rating the
four domains [41, 42], the 12 subdomains [34, 4346], or
the 60 prototypical descriptions [47••] and aggregating the
ratings afterwards. To systematically collect the information
that is relevant to make these ratings, several structured clin-
ical interviews have been developed, including the Semi-
Structured Interview for Personality Functioning DSM-5
(STiP-5.1) [34], the Clinical Assessment of the Level of
Personality Functioning Scale (CALF) [26], and the
Structured Clinical Interview for the Level of Persona lity
Functioning Scale (SCID-AMPD Module I) [35]. For the pur-
pose of gathering self-report data, some researchers have
asked participants to judge themselves according to the proto-
typical descriptions of the 12 subdomains [4850]. Only re-
cently, self-report measures building on the LPFS were newly
developed, including the Level of Personality Functioning
Scale Self Report (LPFS-SR) [29], the Level of
Personality Functioning ScaleBrief Form (LPFS-BF) [30,
31], the DSM-5 Levels of Personality Functioning
Questionnaire (DLOPFQ) [27, 28], the Self and
Interpersonal Functioning Scale (SIFS) [33], and the Levels
of Personality Functioning Questionnaire for adolescents
(LoPF-Q 1218) [32]. For the purpose of informant ratings,
it has been suggested that the 60 prototypical descriptions of
the LPFS can also be rated individually by laypersons [47••,
51]. Research on scale development for assessing severity
according to ICD-11 is still in its beginnings and includes pilot
studies on expert ratings [52] and the development of a brief
self-report measure, the Standardized Assessment of Severity
of Personality Disorder (SASPD) [37].
Maladaptive Traits
The most direct way to assess the maladaptive traits of the
AMPD is via the Personality Inventory for DSM-5 (PID-
5) [16]. The PID-5 is a 220-item self-report questionnaire
that can be conceived of as a by-product of the develop-
ment of the hierarchical trait model. It includes scales for
all 25 trait facets and provides two methods for scoring
the five higher order trait domains from facet scales [53].
In the meantime, a short form with 1 00 items [5459]and
a brief form with 25 items [56, 6066] have been devel-
oped, whereby the brief form only covers the five trait
Table 1 Newly developed measures for the assessment of personality pathology according to DSM-5 section III and ICD-11
Measure Construct Method Items Scales
Clinical Assessment of the Level of Personality
Functioning Scale (CALF) [26]
DSM-5 severity Structured interview 4 1
DSM-5 Levels of Personality Functioning Questionnaire
(DLOPFQ) [27, 28]
DSM-5 severity Self-report 23/132 4/8
Level of Personality Functioning ScaleSelf Report
(LPFS-SR) [29]
DSM-5 severity Self-report 80 4
Level of Personality Functioning Scale (LPFS) [1] DSM-5 severity Expert rating/informant
report/self-report
1/4/12/60 1/4/12
Level of Personality Functioning ScaleBrief Form
(LPFS-BF) [30, 31]
DSM-5 severity Self-report 12 2
Levels of Personality Functioning Questionnaire for
Adolescents from 12 to 18 Years (LoPF-Q 1218) [32]
DSM-5 severity Self-report 97 4/8
Self and Interpersonal Functioning Scale (SIFS) [33] DSM-5 severity Self-report 24 1/4
Semi-Structured Interview for Personality Functioning
DSM-5 (STiP-5.1) [34]
DSM-5 severity Structured interview 12 1/4
Structured Clinical Interview for the Level of Personality
Functioning Scale (SCID-AMPD Module I) [35]
DSM-5 severity Structured interview 12 1/4
Personality Inventory for DSM-5 (PID-5) [16] DSM-5 traits Self-report/informant report 25/75/100/218/220* 5/25
Personality Trait Rating Form (PTRF) [1] DSM-5 traits Expert rating/informant
report/self-report
25 5
Structured Clinical Interview for Personality Traits
(SCID-AMPD Module II) [36]
DSM-5 traits Structured interview 25 5
Standardized Assessment of Severity of Personality
Disorder (SASPD) [37]
ICD-11 severity Self-report 9 1
Personality Inventory for ICD-11 (PiCD) [38] ICD-11 traits Self-report 60 5
*There is also a Norwegian Brief Form (NBF) of the PID-5 that comprises 36 items [39]
Curr Psychiatry Rep (2019) 21:92 Page 3 of 19 92

domains. Informant-report forms with 218 items [67]and
75 items [47••] for assessing the 25 trait facets are also
available. For the purpose of expert ratings, researchers
have applied a Personality Trait Rating Form (PTRF)
[41] that i ncludes short descriptions of the 25 trait facets
from the DSM-5 manual to be rated o n 4-point scales.
Recently, the PTRF has a lso been applied as a self-
report measure for laypersons [68]. To systematically col-
lect the information that is relevant for expert ratings, the
Structured Clinical Interview for Personality Traits
(SCID-AMPD Module II) [36] has been developed. For
the assessment of trait domains according to ICD-11, one
can use a specific scoring algorithm for the PID-5 [69, 70]
or the r ecently developed Personality Inventory for ICD-
11 (PiCD) [38].
Further Issues
Instruments related to the AMPD have been translated into a
number of different languages and cultural contexts. For ex-
ample, the PID-5 is available and has been successfully ap-
plied in Arabic [71], Brazilian [72, 73], Czech [74], Danish
[56], Dutch [75], French [76], German [77], Italian [60, 78],
Norwegian [54, 79], Persian [8082], Polish [83], Portuguese
[84], Russian [85], Spanish [57, 63, 86], and Swedish [64].
Further developmentsare underway onassessing severity
and style according to the AM PD. For e xample, di sorder-
specific impairment scales of criterion A have been devel-
oped that allow for investigating whether the individual im-
pairment criteria for the six specific PDs listed under the
rubric of criterion A are valid and useful [87, 88•• , 89].
Moreover, it has been shown that the Personality
Assessment Inventory (PAI) [90], a well-established broad-
band clinical self-report measure, can b e scored to recover
the DSM-5 trait domains and facets [91, 92]. For the purpose
of assessing dynamic changes in personality pathology, am-
bulatory assessment measures have been applied with the
potential to uncover nuanced temporal dynamics of impair-
ments and maladaptive t rait expressi ons [45, 49, 93].
To ascertain the validity of individual PID-5 results in
higher stakes clinical situations, it is important that pro-
cedure s are in pl ace to safe gu ard scale in ter p ret at io n from
negligent or malingered response patterns. To this end, the
PID-5 Inconsistency Scale has been developed [94]and
subsequently replicated in two independent reports [95,
96] to identify random respon se patterns in the PID-5.
Moreover, the PID-5 Over-reporting Scale [97] can detect
the tendency to exaggerate or fabricate personality prob-
lems, and further scales are available for detecting differ-
ent types of faking good [98]. A promising way to deal
with such response patterns is using alternative measures
that employ forced choice technique such as the
Goldsmiths-60-item questionnaire [99].
A Comprehensive Review of Research
on the AMPD
Several reviews have already summarized theoretical under-
pinnings and recent research on the AMPD in general [9, 100,
101, 102••, 103105], or on criterion A [106, 107, 108, 109]
and criterion B [110, 111, 112] in particular. Moreover, sev-
eral reviews, case reports, and consumer surveys have been
published illustrating the clinical utility of the AMPD [113,
114, 115123]. In the following, we provide an updated,
comprehensive summary of research on the AMPD. We in-
clude only studies that (fully) applied one of the measures
listed in Table 1, thereby ensuring a high specificity to the
DSM-5 definitions of severity and maladaptive traits. In total,
relevant measures were applied in 237 publications, with 18
(7.6%) publications focusing only on criterion A, 201 publi-
cations (84.8%) focusing only on criterion B, and 18 publica-
tions (7.6%) focusing on both criteria (see Fig. 1). The find-
ings are organized along the questions of interrater reliability
(i.e., Do judges agree when assessing the same persons?),
internal consistency and latent structure (i.e., Can item re-
sponses be aggregated to reliable test scores?), convergent
validity (i.e., Are the test scores meaningfully related to other
measures?), and incremental validity (i.e., Do test scores pro-
vide unique information when predicting outcomes?). Note
that we will not cover research on the ICD-11 proposal in this
regard, because relevant studies were often based on archival
data using earlier measures [124126], and studies using mea-
sures that were explicitly designed for the ICD-11 PD chapter
are still scarce [25, 37, 38, 52, 127130].
Severity
Interrater Reliability
Several studies have examined the interrater reliability of the
LPFS. Results indicated that when using the LPFS based on
written life history data, case vignettes, systematic interviews,
or unstructured clinical impressions, interrater reliability was
largelyacceptable(withICCsrangingfrom0.42to0.67),even
for untrained and clinically inexperienced raters [4144, 46, 50,
131]. However , training sessions may increase the inte rrater reli-
ability [132], and the interrater reliability tends to be better when
based on structured interviews that were explicitly tailored to
gathering the required information [26, 34, 133, 134].
Internal Consistency and Latent Structure
Internal consistency of the LPFS total score has been shown to
be acceptable when computed based on ratings of the four
domains [40, 42] and very high when computed based on
ratings of subdomains [34, 46, 48, 135]orindividualitems
[29, 51, 136••]. Moreover, the four domains [27, 29, 43, 46,
92 Page 4 of 19 Curr Psychiatry Rep (2019) 21:92

Citations
More filters
Journal ArticleDOI
TL;DR: The modified PID5BF+ may be employed internationally by clinicians and researchers for brief and reliable assessment of the 6 combined DSM-5 and ICD-11 domains, including 18 primary subfacets, as well as meaningful associations with familiar interview-rated PD types.
Abstract: Introduction The DSM-5 Alternative Model of Personality Disorders (AMPD) and the ICD-11 classification of personality disorders (PD) are largely commensurate and, when combined, they delineate 6 trait domains: negative affectivity, detachment, antagonism/dissociality, disinhibition, anankastia, and psychoticism. Objective The present study evaluated the international validity of a brief 36-item patient-report measure that portrays all 6 domains simultaneously including 18 primary subfacets. Methods We developed and employed a modified version of the Personality Inventory for DSM-5 - Brief Form Plus (PID5BF+). A total of 16,327 individuals were included, 2,347 of whom were patients. The expected 6-factor structure of facets was initially investigated in samples from Denmark (n = 584), Germany (n = 1,271), and the USA (n = 605) and subsequently replicated in both patient- and community samples from Italy, France, Switzerland, Belgium, Norway, Portugal, Spain, Poland, Czech Republic, the USA, and Brazil. Associations with interview-rated DSM-5 PD categories were also investigated. Results Findings generally supported the empirical soundness and international robustness of the 6 domains including meaningful associations with familiar interview-rated PD types. Conclusions The modified PID5BF+ may be employed internationally by clinicians and researchers for brief and reliable assessment of the 6 combined DSM-5 and ICD-11 domains, including 18 primary subfacets. This 6-domain framework may inform a future nosology for DSM-5.1 that is more reasonably aligned with the authoritative ICD-11 codes than the current DSM-5 AMPD model. The 36-item modified PID5BF+ scoring key is provided in online supplementary Appendix A see www.karger.com/doi/10.1159/000507589 (for all online suppl. material).

71 citations

Journal ArticleDOI
TL;DR: A meta-analysis of the internal structure of the PID-5 was conducted to offset potential variability associated with sampling error and gain a clearer picture of the lower-order structure of pid-5 facet scales.
Abstract: The Alternative Model for Personality Disorders (AMPD) in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, Section III, presents a new approach to conceptualizing personality psychopathology and diagnosing personality disorders. The Personality Inventory for DSM-5 (PID-5) was designed to measure Criterion B of the AMPD and is composed of 25 lower-order facet trait scales that form 5 higher-order domain trait scales. Although the PID-5 has mostly adequate to strong psychometric qualities, the lower-order factor structure of PID-5 facet scales has shown considerable variability across studies, and several PID-5 facets scales show evidence of interstitiality-the cross-loading of facets onto more than 1 domain. This interstitiality is neither unexpected nor especially problematic because complex models of personality have traits that are by nature interstitial. What is problematic, however, is that the factor loadings of these interstitial facets vary across samples, suggesting that some PID-5 facet scales are likely susceptible to sampling error and sampling variability. Moreover, the magnitude of some cross-loadings in some studies is substantive (i.e., ≥ .30). The objective of the current study was to conduct a meta-analysis of the internal structure of the PID-5 to offset potential variability associated with sampling error and gain a clearer picture of the lower-order structure of PID-5 facet scales. This was accomplished using weighted mean factor loadings of the PID-5 facet scales across 14 independent samples (N = 14,743). Results supported that the level of interstitiality decreased when multiple samples were combined, and a clearer picture of the internal structure of the PID-5 facet scales emerged. (PsycINFO Database Record

60 citations

Journal ArticleDOI
TL;DR: While latent structure, reliability, and criterion validity were ascertained in the original and in two separate validation samples, results suggest further modifications for capturing ICD-11 Anankastia.
Abstract: While Diagnostic and Statistical Manual of Mental Disorders-Fifth edition (DSM-5) Section III and ICD-11 (International Classification of Diseases 11th-Revision) both allow for dimensional assessment of personality pathology, the models differ in the definition of maladaptive traits. In this study, we pursued the goal of developing a short and reliable assessment for maladaptive traits, which is compatible with both models, using the item pool of the Personality Inventory for DSM-5 (PID-5). To this aim, we applied ant colony optimization algorithms in English- and German-speaking samples comprising a total N of 2,927. This procedure yielded a 34-item measure with a hierarchical latent structure including six maladaptive trait domains and 17 trait facets, the "Personality Inventory for DSM-5, Brief Form Plus" (PID5BF+). While latent structure, reliability, and criterion validity were ascertained in the original and in two separate validation samples (n = 849, n = 493) and the measure was able to discriminate personality disorders from other diagnoses in a clinical subsample, results suggest further modifications for capturing ICD-11 Anankastia.

46 citations


Cites background or methods from "A Brief but Comprehensive Review of..."

  • ...…as interpersonal problems, childhood maltreatment, maladaptive schemas, pathological beliefs, attachment anxiety and avoidance, emotion dysregulation and neuronal connectivity, suggesting their significant role in general psychopathology (for a comprehensive overview, see Zimmermann et al., 2019)....

    [...]

  • ...Since the publication of the PID-5 in 2012, a huge amount of research supporting its validity has accumulated (Zimmermann et al., 2019)....

    [...]

  • ...The instrument has been extensively tested in clinical and nonclinical samples and has demonstrated adequate psychometric properties (Al-Dajani et al., 2016; Zimmermann et al., 2019)....

    [...]

  • ...The emerging dimensional models aim to address these issues by incorporating individual differences in PD severity and style (Zimmermann et al., 2019)....

    [...]

Journal ArticleDOI
TL;DR: In this paper, a common metric across 6 widely used self-report measures of personality disorder severity using item response theory models is established, which may facilitate instrument-independent assessment of severity of personality disorders and increase comparability across studies.
Abstract: Introduction: Dimensional models of personality disorders (PD) in the DSM-5 and ICD-11 share a focus on impairments in self and interpersonal functioning to represent the general features and severity of PD. This new perspective has led to the development of numerous measures for assessing individual differences in PD severity. While this improves choices for researchers and practitioners, it also poses the challenge of an increasing lack of standardization. Objective: The aim of this study is to establish a common metric across 6 widely used self-report measures of PD severity using item response theory models. Methods: 849 participants completed a survey including the Inventory of Personality Organization – 16-item version (IPO-16), the Level of Personality Functioning Scale – Brief Form 2.0, the Level of Personality Functioning Scale – Self-Report, the Operationalized Psychodynamic Diagnosis – Structure Questionnaire Short Form, the Personality Inventory for DSM-5 – Brief Form Plus and the Standardized Assessment of Severity of Personality Disorder (SASPD). We fitted exploratory multidimensional graded response models and used bifactor rotation to extract a general factor across measures. Factor scores were linked to representative T scores using data from a representative survey of 2,502 participants who completed the IPO-16. Results: When using bifactor rotation in a 7-factor model, all items loaded positively on the general factor, and the general factor explained 65.5% of the common variance. With the exception of the SASPD, all measures provided highly discriminating items (factor loadings >0.70) for measuring the general factor and reached an acceptable reliability (>0.80) across a wide range of the latent continuum. We constructed a crosswalk table linking total scores of the 6 measures to each other and to representative T scores. Conclusions: Our results suggest that 6 different self-report measures of the severity of PD capture a strong common factor and can therefore be scaled along a single latent continuum. Our results may facilitate instrument-independent assessment of severity of PD and increase comparability across studies.

45 citations

Journal ArticleDOI
TL;DR: Key future directions pertain to linking the AMPD literature with applied efforts to improve the lives of persons who suffer from PDs, and surmounting challenges germane to the evolution of the DSM itself.
Abstract: Authoritative classification systems for psychopathology such as the DSM and ICD are shifting toward more dimensional approaches in the field of personality disorders (PDs). In this paper, we provide a brief overview of the dimensionally oriented DSM-5 alternative model of PDs (AMPD). Since its publication in 2013, the AMPD has inspired a substantial number of studies, underlining its generative influence on the field. Generally speaking, this literature illustrates both the reliability and validity of the constructs delineated in the AMPD. The literature also illustrates empirical challenges to the conceptual clarity of the AMPD, such as evidence of substantial correlations between indices of personality functioning (criterion A in the AMPD) and maladaptive personality traits (criterion B in the AMPD). Key future directions pertain to linking the AMPD literature with applied efforts to improve the lives of persons who suffer from PDs, and surmounting challenges germane to the evolution of the DSM itself.

37 citations

References
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Journal ArticleDOI
TL;DR: An issue concerning the criteria for tic disorders is highlighted, and how this might affect classification of dyskinesias in psychotic spectrum disorders.
Abstract: Given the recent attention to movement abnormalities in psychosis spectrum disorders (e.g., prodromal/high-risk syndromes, schizophrenia) (Mittal et al., 2008; Pappa and Dazzan, 2009), and an ongoing discussion pertaining to revisions of the Diagnostic and Statistical Manuel of Mental Disorders (DSM) for the upcoming 5th edition, we would like to take this opportunity to highlight an issue concerning the criteria for tic disorders, and how this might affect classification of dyskinesias in psychotic spectrum disorders. Rapid, non-rhythmic, abnormal movements can appear in psychosis spectrum disorders, as well as in a host of commonly co-occurring conditions, including Tourette’s Syndrome and Transient Tic Disorder (Kerbeshian et al., 2009). Confusion can arise when it becomes necessary to determine whether an observed movement (e.g., a sudden head jerk) represents a spontaneous dyskinesia (i.e., spontaneous transient chorea, athetosis, dystonia, ballismus involving muscle groups of the arms, legs, trunk, face, and/or neck) or a tic (i.e., stereotypic or patterned movements defined by the relationship to voluntary movement, acute and chronic time course, and sensory urges). Indeed, dyskinetic movements such as dystonia (i.e., sustained muscle contractions, usually producing twisting and repetitive movements or abnormal postures or positions) closely resemble tics in a patterned appearance, and may only be visually discernable by attending to timing differences (Gilbert, 2006). When turning to the current DSM-IV TR for clarification, the description reads: “Tic Disorders must be distinguished from other types of abnormal movements that may accompany general medical conditions (e.g., Huntington’s disease, stroke, Lesch-Nyhan syndrome, Wilson’s disease, Sydenham’s chorea, multiple sclerosis, postviral encephalitis, head injury) and from abnormal movements that are due to the direct effects of a substance (e.g., a neuroleptic medication)”. However, as it is written, it is unclear if psychosis falls under one such exclusionary medical disorder. The “direct effects of a substance” criteria, referencing neuroleptic medications, further contributes to the uncertainty around this issue. As a result, ruling-out or differentiating tics in psychosis spectrum disorders is at best, a murky endeavor. Historically, the advent of antipsychotic medication in the 1950s has contributed to the confusion about movement signs in psychiatric populations. Because neuroleptic medications produce characteristic movement disorder in some patients (i.e. extrapyramidal side effects), drug-induced movement disturbances have been the focus of research attention in psychotic disorders. However, accumulating data have documented that spontaneous dyskinesias, including choreoathetodic movements, can occur in medication naive adults with schizophrenia spectrum disorders (Pappa and Dazzan, 2009), as well as healthy first-degree relatives of chronically ill schizophrenia patients (McCreadie et al., 2003). Taken together, this suggests that movement abnormalities may reflect pathogenic processes underlying some psychotic disorders (Mittal et al., 2008; Pappa and Dazzan, 2009). More specifically, because spontaneous hyperkinetic movements are believed to reflect abnormal striatal dopamine activity (DeLong and Wichmann, 2007), and dysfunction in this same circuit is also proposed to contribute to psychosis, it is possible that spontaneous dyskinesias serve as an outward manifestation of circuit dysfunction underlying some schizophrenia-spectrum symptoms (Walker, 1994). Further, because these movements precede the clinical onset of psychotic symptoms, sometimes occurring in early childhood (Walker, 1994), and may steadily increase during adolescence among populations at high-risk for schizophrenia (Mittal et al., 2008), observable dyskinesias could reflect a susceptibility that later interacts with environmental and neurodevelopmental factors, in the genesis of psychosis. In adolescents who meet criteria for a prodromal syndrome (i.e., the period preceding formal onset of psychotic disorders characterized by subtle attenuated positive symptoms coupled with a decline in functioning), there is sometimes a history of childhood conditions which are also characterized by suppressible tics or tic like movements (Niendam et al., 2009). On the other hand, differentiating between tics and dyskinesias has also complicated research on childhood disorders such as Tourette syndrome (Kompoliti and Goetz, 1998; Gilbert, 2006). We propose consideration of more explicit and operationalized criteria for differentiating tics and dyskinesias, based on empirically derived understanding of neural mechanisms. Further, revisions of the DSM should allow for the possibility that movement abnormalities might reflect neuropathologic processes underlying the etiology of psychosis for a subgroup of patients. Psychotic disorders might also be included among the medical disorders that are considered a rule-out for tics. Related to this, the reliability of movement assessment needs to be improved, and this may require more training for mental health professionals in movement symptoms. Although standardized assessment of movement and neurological abnormalities is common in research settings, it has been proposed that an examination of neuromotor signs should figure in the assessment of any patient, and be as much a part of the patient assessment as the mental state examination (Picchioni and Dazzan, 2009). To this end it is important for researchers and clinicians to be aware of differentiating characteristics for these two classes of abnormal movement. For example, tics tend to be more complex than myoclonic twitches, and less flowing than choreoathetodic movements (Kompoliti and Goetz, 1998). Patients with tics often describe a sensory premonition or urge to perform a tic, and the ability to postpone tics at the cost of rising inner tension (Gilbert, 2006). For example, one study showed that patients with tic disorders could accurately distinguish tics from other movement abnormalities based on the subjective experience of some voluntary control of tics (Lang, 1991). Another differentiating factor derives from the relationship of the movement in question to other voluntary movements. Tics in one body area rarely occur during purposeful and voluntary movements in that same body area whereas dyskinesia are often exacerbated by voluntary movement (Gilbert, 2006). Finally, it is noteworthy that tics wax and wane in frequency and intensity and migrate in location over time, often becoming more complex and peaking between the ages of 9 and 14 years (Gilbert, 2006). In the case of dyskinesias among youth at-risk for psychosis, there is evidence that the movements tend to increase in severity and frequency as the individual approaches the mean age of conversion to schizophrenia spectrum disorders (Mittal et al., 2008). As revisions to the DSM are currently underway in preparation for the new edition (DSM V), we encourage greater attention to the important, though often subtle, distinctions among subtypes of movement abnormalities and their association with psychiatric syndromes.

67,017 citations

Journal ArticleDOI
TL;DR: The meaning of the terms "method" and "method bias" are explored and whether method biases influence all measures equally are examined, and the evidence of the effects that method biases have on individual measures and on the covariation between different constructs is reviewed.
Abstract: Despite the concern that has been expressed about potential method biases, and the pervasiveness of research settings with the potential to produce them, there is disagreement about whether they really are a problem for researchers in the behavioral sciences. Therefore, the purpose of this review is to explore the current state of knowledge about method biases. First, we explore the meaning of the terms “method” and “method bias” and then we examine whether method biases influence all measures equally. Next, we review the evidence of the effects that method biases have on individual measures and on the covariation between different constructs. Following this, we evaluate the procedural and statistical remedies that have been used to control method biases and provide recommendations for minimizing method bias.

8,719 citations

Journal ArticleDOI
TL;DR: The HiTOP promises to improve research and clinical practice by addressing the aforementioned shortcomings of traditional nosologies and provides an effective way to summarize and convey information on risk factors, etiology, pathophysiology, phenomenology, illness course, and treatment response.
Abstract: The reliability and validity of traditional taxonomies are limited by arbitrary boundaries between psychopathology and normality, often unclear boundaries between disorders, frequent disorder co-occurrence, heterogeneity within disorders, and diagnostic instability. These taxonomies went beyond evidence available on the structure of psychopathology and were shaped by a variety of other considerations, which may explain the aforementioned shortcomings. The Hierarchical Taxonomy Of Psychopathology (HiTOP) model has emerged as a research effort to address these problems. It constructs psychopathological syndromes and their components/subtypes based on the observed covariation of symptoms, grouping related symptoms together and thus reducing heterogeneity. It also combines co-occurring syndromes into spectra, thereby mapping out comorbidity. Moreover, it characterizes these phenomena dimensionally, which addresses boundary problems and diagnostic instability. Here, we review the development of the HiTOP and the relevant evidence. The new classification already covers most forms of psychopathology. Dimensional measures have been developed to assess many of the identified components, syndromes, and spectra. Several domains of this model are ready for clinical and research applications. The HiTOP promises to improve research and clinical practice by addressing the aforementioned shortcomings of traditional nosologies. It also provides an effective way to summarize and convey information on risk factors, etiology, pathophysiology, phenomenology, illness course, and treatment response. This can greatly improve the utility of the diagnosis of mental disorders. The new classification remains a work in progress. However, it is developing rapidly and is poised to advance mental health research and care significantly as the relevant science matures. (PsycINFO Database Record

1,635 citations

Journal ArticleDOI
TL;DR: A maladaptive personality trait model and corresponding instrument are developed as a step on the path toward helping users of DSM-5 assess traits that may or may not constitute a formal personality disorder.
Abstract: Background DSM-IV-TR suggests that clinicians should assess clinically relevant personality traits that do not necessarily constitute a formal personality disorder (PD), and should note these traits on Axis II, but DSM-IV-TR does not provide a trait model to guide the clinician. Our goal was to provide a provisional trait model and a preliminary corresponding assessment instrument, in our roles as members of the DSM-5 Personality and Personality Disorders Workgroup and workgroup advisors. Method An initial list of specific traits and domains (broader groups of traits) was derived from DSM-5 literature reviews and workgroup deliberations, with a focus on capturing maladaptive personality characteristics deemed clinically salient, including those related to the criteria for DSM-IV-TR PDs. The model and instrument were then developed iteratively using data from community samples of treatment-seeking participants. The analytic approach relied on tools of modern psychometrics (e.g. item response theory models). Results A total of 25 reliably measured core elements of personality description emerged that, together, delineate five broad domains of maladaptive personality variation: negative affect, detachment, antagonism, disinhibition, and psychoticism. Conclusions We developed a maladaptive personality trait model and corresponding instrument as a step on the path toward helping users of DSM-5 assess traits that may or may not constitute a formal PD. The inventory we developed is reprinted in its entirety in the Supplementary online material, with the goal of encouraging additional refinement and development by other investigators prior to the finalization of DSM-5. Continuing discussion should focus on various options for integrating personality traits into DSM-5.

1,322 citations

Related Papers (5)
Frequently Asked Questions (13)
Q1. What are the contributions in "A brief but comprehensive review of research on the alternative dsm-5 model for personality disorders" ?

The authors describe these new models, summarize available measures, and provide a comprehensive review of research on the AMPD. The authors highlight open questions and provide recommendations for future research. The AMPD has stimulated extensive research with promising findings. 

However, several questions remain unanswered and should be addressed in future research. Finally, future research should continue pursuing a comprehensive conceptualization of mental disorders that integrates major dimensions of personality and psychopathology [ 313–318 ]. Such limitations may be overcome by multitrait–multimethod designs, as demonstrated by a recent study on the construct validity of trait facets related to antagonism [ 306 ]. Currently, there is only a single study showing that the LPFS-BF can be used as an outcome measure in a 3- month residential treatment program [ 31 ]. 

factor analyses of individual items failed to recover the theoretical structure [137], which may in part be due to method factors of items with positive and negative valence. 

To ascertain the validity of individual PID-5 results in higher stakes clinical situations, it is important that procedures are in place to safeguard scale interpretation from negligent or malingered response patterns. 

Further issues that have been addressed include measurement invariance or item bias due to age [287, 288], gender [217, 289], and clinical status [290]; response styles in PID-5 self-reports [154, 155, 291, 292]; heritability and familial aggregation of maladaptive traits [39, 289, 293–295]; and perceived likability, impairment, functionality, as well as desire and ability for change of maladaptive traits [68, 158, 296–298]. 

negative affectivity was consistently associated with low emotional stability, detachment with low extraversion, antagonismwith low agreeableness, and disinhibition with low conscientiousness. 

In the AMPD, the assessment of PD severity was originally conceived of as applying the LPFS as an expert rating on a single five-point scale [40]. 

considerable evidence has accumulated in favor of the hypothesis that the PID-5 trait domains can be conceived of as maladaptive variants of general personality traits [77, 84, 144, 149, 152, 165, 168, 173–182]. 

Two recent meta-analyses [141, 142] covering a large body of research including clinical and nonclinical samples from different countries have confirmed that the latent structure of trait facets is mainly in line with the five-factor model featured in the AMPD [55, 56, 59, 62, 67, 74–79, 86, 140, 143–151]. 

In addition, representative samples from the general population should be collected to establish normative values, which will greatly enhance the interpretation of test scores in single-case scenarios. 

In the first step, the practitioner examines whether the patient’s pathology corresponds to the general definition of PD (code: 6D10), which emphasizes longstanding problems in self and interpersonal functioning. 

Research on scale development for assessing severity according to ICD-11 is still in its beginnings and includes pilot studies on expert ratings [52] and the development of a brief self-report measure, the Standardized Assessment of Severity of Personality Disorder (SASPD) [37]. 

More research is needed into the validity of the specific PDs listed in the AMPD, incorporating the specific impairment criteria [88••] and using mixture modeling to test whether they indeed represent latent categories [312].