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The Level of Personality Functioning Scale‐Brief Form 2.0: Update of a brief
instrument for assessing level of personality functioning
Weekers, L.C.; Hutsebaut, J.; Kamphuis, J.H.
DOI
10.1002/pmh.1434
Publication date
2018
Document Version
Final published version
Published in
Personality and Mental Health
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Article 25fa Dutch Copyright Act
Link to publication
Citation for published version (APA):
Weekers, L. C., Hutsebaut, J., & Kamphuis, J. H. (2018). The Level of Personality Functioning
Scale‐Brief Form 2.0: Update of a brief instrument for assessing level of personality
functioning.
Personality and Mental Health
,
13
(1), 3-14. https://doi.org/10.1002/pmh.1434
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Download date:09 Aug 2022
The Level of Personality Functioning Scale-
Brief Form 2.0: Update of a brief instrument for
assessing level of personality functioning
LAURA C. WEEKERS
1
, JOOST HUTSEBAUT
1
AND JAN H. KAMPHUIS
1,2
,
1
Viersprong Institute
for Studies on Personality Disorders, Halsteren, The Netherlands;
2
Department of Clinical Psychol-
ogy, University of Amsterdam, Amsterdam, The Netherlands
ABSTRACT
Section III of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.) introduced the alternative
model of personality disorders that includes assessing levels of personality functioning. Here, we describe the de-
velopment, preliminary psychometric evaluation and sensitivity to change of a revised brief self-report question-
naire, the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0). Patients (N = 201) referred
to a specialized centre for the assessment and treatment of personality disorders completed the LPFS-BF 2.0, the
Brief Symptom Inventory and the Severity Indices of Personality Problems Short Form and were administered
the Structured Clinical Interview for DSM-IV Axis I and Axis II Disorders. Internal structure and aspects of
construct validity were examined. A subsample of 39 patients also completed the questionnaires after 3 months
of inpatient treatment. Confirmatory factor analyses demonstrated better fit for a two-factor solution (interpret-
able as self-functioning and interpersonal functioning) than for a unidimensional model, though acceptable model
fit was evident only after two post hoc modifications. The LPFS-BF 2.0 demonstrated satisfactory internal con-
sistency and promising construct validity. Sensitivity to change after 3 months of treatment was high. The LPFS-
BF 2.0 constitutes a short, user-friendly instrument that provides a quick impression of the severity of personality
pathology. © 2018 John Wiley & Sons, Ltd.
Introduction
The Level of Personality Functioning Scale
(LPFS) was introduced in the alternative model
for personality disorders (PDs) in DSM-5
1
to pro-
vide a measure for the assessment of impairments
in personality functioning. The model builds upon
the assumption that all types of PDs are character-
ized by ‘essential commonalities’ with regard to
moderate or more severe limitations in self and in-
terpersonal functioning.
2,3
These ‘commonalities’
are thought to be reflected by 12 facets, including
impairments in identity (experience of oneself as
unique, stability of self-esteem and capacity for
and ability to regulate a range of emotional experi-
ence), self-direction (pursuit of coherent and
meaningful goals, constructive and prosocial inter-
nal standards of behaviour and self-re flection), em-
pathy (comprehension and appreciation of others’
experiences and motivations, tolerance of differing
perspectives and understanding the effects of one’s
own behaviour on others) and intimacy (depth
© 2018 John Wiley & Sons, Ltd. 13:3–14 (2019)
DOI: 10.1002/pmh
Personality and Mental Health
13:3–14 (2019-02)
Published online 19 September 2018 in Wiley Online Library
(wileyonlinelibrary.com) DOI 10.1002/pmh.1434
and duration of connection with others, desire and
capacity for closeness and mutuality of regard).
The LPFS identifies five levels of functioning for
each of these 12 facets, offering a severity index
for personality pathology. The addition of a sever-
ity dimension is seen as a major addition to the tra-
ditional assessment of maladaptive personality
traits. Severity of personality pathology is a strong
predictor of current and future functioning
4
and
likely has greater impact on treatment planning
and course of treatment than the particular type
of personality problems.
4–7
Although the LPFS is
described in the DSM-5 as a unidimensional con-
struct, studies to date yielded inconsistent factor
structures. Morey
8
found a single factor solution
and thus argued that Criterion A is a unidimen-
sional construct. Zimmerman et al.
9
, however, con-
cluded that the LPFS was best conceptualized as a
two-dimensional construct. They found two dis-
tinct factors: self-functioning and interpersonal
functioning. This is in line with a study by
Berghuis et al.
10
, which corroborated the two
factors of the General Assessment of PDs:
self-pathology and interpersonal pathology.
Bastiaansen et al.
11
used the Severity Indices of
Personality Problems 118 to assess the LPFS and
concluded that the LPFS consists of four-factors,
that is, self-control, identity integration, relational
functioning and responsibility. Previous research
on the structure of the Severity Indices of Personality
Problems 118 by Verheul et al.
12
yielded a five-factor
solution. In sum, the results to date are inconclusive
with regard to the structure of Criterion A of the
Alternative Model of Personality Disorder (AMPD)
(i.e. levels of personality functioning). In addition
to the LPFS, the alternative model for PDs included
25 pathological personality traits, organized by five
higher order domains (negative affectivity, detach-
ment, antagonism, disinhibition and psychoticism)
for which the Personality Inventory for DSM-5 was
proposed as assessment instrument.
13
The alternative model of PD was primarily de-
signed to meet the shortcomings regarding validity
and clinical utility of the prevailing model. How-
ever, soon after publication, concerns were raised
concerning the presumed complexity of the
model. Indeed, findings with regard to the applica-
tion of the LPFS revealed some mixed results
when using clinical interview data or Structured
Clinical Interview for DSM data.
14,15
On the
other hand, other studies demonstrated the model
lends itself well for instruction, such that graduate
students and inexperienced raters were able to ap-
ply the model with adequate interrater reliabil-
ity.
16–18
An important way to improve clinical
utility and ease of use is to develop assessment in-
struments for assessing the LPFS and pathological
personality traits. Since its publication, several in-
struments for assessing the LPFS have been devel-
oped independently by different research groups,
including two interview schedules
3,14
and (at
least) three self-report questionnaires. Huprich
et al.
19
developed the DSM-5 Levels of Personality
Functioning Questionnaire (DLOPFQ), a 132-
item questionnaire assessing the LPFS in both so-
cial and work/school domains. Initial results were
promising, with high internal consistency rates
and conceptually relevant correlations with mal-
adaptive personality traits and overall well-being.
Morey
8
developed the Level of Personality Func-
tioning Scale-self report (LPFS-SR), an 80-item
self-report scale. The LPFS-SR includes items for
each marker of severity as proposed by the LPFS,
leading up to 80 items to represent 60 descriptions
of severity. The LPFS-SR demonstrated high inter-
nal consistency, high test–retest reliability, high
intercorrelations between each of its dimensions
and high correlations with related instruments.
8,20
Our group developed the Level of Personality
Functioning Scale-Brief Form (LPFS-BF).
21
This
instrument was initially developed as a quick
screening tool related to the LPFS. Our primary
aim was to formulate one item for each facet of
the LPFS, yielding a global estimate of impairment
related to personality functioning. The LPFS-BF
thus became a very brief instrument, including only
12 items to be rated ‘yes’ or ‘no’. Therefore, both
the LPFS-BF and LPFS-sr may have different areas
of application, with the LPFS-BF offering a ‘quick
and dirty’ assessment of general impairment in
4 Laura C. Weekers, Joost Hutsebaut and Jan H. Kamphuis
© 2018 John Wiley & Sons, Ltd. 13:3–14 (2019)
DOI: 10.1002/pmh
personality functioning, while the LPFS-SR might
enable a more precise and detailed assessment of
different domains of personality functioning.
8
Although the LPFS-BF was initially developed
to only serve as a website screening tool for pa-
tients to self-assess whether their problems might
be related to personality dysfunction, the instru-
ment showed acceptable psychometric properties.
It yielded a clear two-factor solution, resembling
self and interpersonal domains, and the internal
consistencies in a sample of patients with person-
ality pathology were borderline acceptable, with
coefficient αs of 0.69 for the total score and 0.57
and 0.65 for the subscales, respectively.
21
With re-
gard to construct validity, the LPFS-BF scores
were associated as expected with related measures
of personality pathology. On the other hand, anal-
yses also demonstrated that some items of the orig-
inal scale did not perform well, specifically item 6
(I am often very strict with myself, referring to im-
pairments in constructive and prosocial internal
standards of behaviour as an aspect of self-
direction) and item 11 (There is almost no one
who is really close to me, referring to impairments
in desire and capacity for closeness as an aspect of
intimacy). The item-total correlation of these
questions was low, and deletion of these items re-
sulted in better internal consistency. With the
newly formulated item 11, we tried to capture
the subjective sense of a lack of safety in close re-
lationships, which is characteristic of more severe
disturbance in the closeness facet. The
reformulated item now reads as ‘I often feel very
vulnerable when relations become more personal’.
We reformulated item 6 to capture a more severe
level of self-direction: ‘I often make unrealistic de-
mands on myself ’. Furthermore, (only) one of the
initial items (item 4) was reversed (I have clear
aims in my life and succeed in achieving these, refer-
ring to ‘goals’ as an aspect of self-direction). How-
ever, as the absence of health might not
necessarily equal the presence of pathology and
vice versa, we changed the reversed item. The up-
dated LPFS-BF 2.0 therefore consists of nine of
the original items and three reformulated items.
In addition, to improve psychometric function-
ing, we opted for a response scale instead of a binary
yes/no response format. This modification related
to our aim of expanding the use of the LPFS-BF
2.0 as a screening tool to a tool for assessing
changes in personality functioning during treat-
ment. Assessing (lack of) progress during treatment
is increasingly included in treatments of mental
disorders in order to inform treatment decisions,
for example, reformulating treatment goals or ter-
minating treatment.
22,23
In the Netherlands, rou-
tine outcome monitoring (ROM) was introduced
nationwide in 2011 and typically consists of sys-
tematic periodic data collection on the mental
health and level of functioning of patients as an in-
dicator of treatment outcome.
24,25
Although using
ROM during treatment to inform treatment deci-
sions is considered clinically useful by its advocates,
several prominent clinical researchers have raised
concern about indiscriminate use of ROM for
benchmarking (using ROM data to compare treat-
ment results),
26,27
potential bias, confounds and
the need for disorder-specific instruments to more
accurately assess the complexity of what consti-
tutes treatment outcome. Moreover, implementa-
tion of disorder-specific instruments in treatment
for PDs is hindered by lack of data on sensitivity
to change for most personality questionnaires,
and many conceptually relevant questionnaires
are too lengthy for multiple assessments over treat-
ment. By including a response scale—similar to the
Personality Inventory for DSM-5 response scale—
we intended to increase variation in responses
and therefore facilitate sensitivity of the instru-
ment to identify relevant changes in personality
functioning during treatment.
In sum, this study investigated aspects of reli-
ability and construct validity of the updated ver-
sion of the LPFS-BF
21
, the LPFS-BF 2.0. We
expected the internal structure of the LPFS-BF
2.0 to reflect two intercorrelated, internally consis-
tent factors corresponding to self-functioning and
interpersonal functioning domains. Futhermore,
we expected conceptually meaningful associations
with related measures of personality functioning,
5The Level of Personality Functioning Scale - Brief Form 2.0
© 2018 John Wiley & Sons, Ltd. 13:3–14 (2019)
DOI: 10.1002/pmh
the Severity Indices of Personality Functioning
Short Form (SIPP-SF) and the DSM-IV-TR PDs.
With respect to ROM purposes, we tested associa-
tions with a widely used routine outcome measur-
ing questionnaire, the Brief Symptom Inventory
(BSI)
28
and compared their respective sensitivities
to change in the context of a residential treatment
programme for PD.
Method
Participants
Two subsamples of patients were used in the analy-
sis. All participants were treatment-seeking adults
who were referred to de Viersprong, a specialized
mental health care centre for the assessment and
treatment of adolescents and adults with PDs.
The first sample of 201 participants completed
the LPFS-BF 2.0 as part of the standard admission
procedure. All intakes took place between April
2016 and February 2017. About two-thirds of the
total sample (n = 131; 65.2%) were female. Pa-
tients’ age ranged from 18 to 62 years old, with a
mean age of 36.2 (standard deviation (SD) = 11.0).
Clinical characteristics of the participants are pre-
sented in Table 1; for 18 participants, data on clin-
ical characteristics were missing. Most patients met
criteria for at least one PD (90.7%), with border-
line and PD not otherwise specified (PD-NOS) be-
ing the most prevalent PDs. The second sample of
47 participants was administered the LPFS-BF 2.0
at the start of their 3-month residential treatment
programme, based on a transactional analysis treat-
ment model.
29
The comprehensive treatment pro-
gramme specifically targeted patients with a cluster
C PD and includes psychotherapy, psychomotor
and art therapy, sociotherapy and milieu therapy.
Questionnaires were collected between September
2016 and November 2017. Clinical characteristics
of the second sample are presented in Table 1; data
were missing for one participant. Thirty-nine of the
47 participants also completed the LPFS-BF 2.0 at
the end of treatment. These data were used in the
subsequent (treatment responsivity) analyses.
Measures
Level of Personality Functioning Scale-Brief Form
2.0. The LPFS-BF 2.0 is a brief self-report ques-
tionnaire, which assesses the LPFS as described in
Section III of the DSM-5.
1
The LPFS consists of
12 items, clustered into two higher order domains:
self-functioning and interpersonal functioning.
Participants are asked to rate the 12 items on a
4-point Likert scale from 1 (completely untrue)
to 4 (completely true). Table 2 shows the distribu-
tion of responses of all items in the current sample.
Structured Clinical Interview for DSM-IV Axis I
Disorders. The Structured Clinical Interview
for DSM-IV Axis I Disorders
30,31
is a semi-
structured interview designed to assess the
Table 1: Diagnostic characteristics of Samples 1 and 2
DSM-IV-TR diagnosis
Sample 1
(N = 183)
N (%)
Sample 2
(N = 46)
N (%)
Personality disorders
Avoidant PD 40 (21.9) 29 (63)
Dependent PD 5 (2.7) 1 (2.2)
Obsessive–compulsive
PD
24 (13.1) 9 (19.6)
Paranoid PD 3 (1.6) 0 (0)
Histrionic PD 1 (0.5) 0 (0)
Narcissistic PD 9 (4.9) 3 (6.5)
Borderline PD 63 (34.4) 7 (15.2)
Antisocial PD 5 (2.7) 0 (0)
PD-NOS 81 (44.3) 21 (45.7)
Any PD 166 (90.7) 44 (95.7)
Clinical disorders
Mood disorder 97 (64.2) 24 (52.2)
Anxiety disorder 65 (36.3) 14 (30.4)
Substance use disorder 19 (11.8) 2 (4.3)
Psychotic disorder 1 (0.5) 0 (0)
Somatoform disorder 19 (10.4) 4 (8.7)
Eating disorder 16 (9) 3 (6.5)
Any Axis-I disorder 142 (86.1) 34 (79.1)
Note: The sum of the number of patients across the different
diagnostic groups is higher than the total number of patients
because of comorbidity.
NOS, not otherwise specified; PD, personality disorder.
6 Laura C. Weekers, Joost Hutsebaut and Jan H. Kamphuis
© 2018 John Wiley & Sons, Ltd. 13:3–14 (2019)
DOI: 10.1002/pmh
