The DSM-5 personality disorder proposal and future directions in the diagnostic classification of personality disorder.

BACKGROUND: The compilation of DSM-5 presented a substantial opportunity to develop a coherent, evidence-based classification of personality disorder. The irremediable problems with DSM-IV are widely recognized, the field seemed ready for change, and the data and methods for constructing a scientific classification are readily available. Rather than seize this opportunity, DSM-5 advanced an incoherent proposal lacking in evidential support and too poorly organized for clinical use. METHODS: This article examines the problems with the proposal based on a consideration of the basic requirements of a satisfactory classification. It is suggested that an adequate system should have an explicit and coherent conceptual structure, be based on the best available scientific evidence, possess clinical utility, and be as parsimonious as possible. RESULTS: The DSM-5 proposal fails to meet these criteria. Problems with the product and process suggest the need for a radical reconsideration of how personality disorders are classified and how classifications are compiled. CONCLUSIONS: The article proposes that greater emphasis be placed on developing a classification that provides the diagnostic information clinicians need to treat personality disorder and that future classifications should be constructed through an explicit process that is open to public scrutiny.

The General Assessment of Personality Disorder (GAPD) as an instrument for assessing the core features of personality disorders.

UNLABELLED: This study presents a psychometric evaluation of the General Assessment of Personality Disorder (GAPD), a self-report questionnaire for assessing the core components of personality dysfunction on the basis of Livesley's (2003) adaptive failure model. Analysis of samples from a general (n = 196) and a clinical population (n = 280) from Canada and the Netherlands, respectively, found a very similar two-component structure consistent with the two core components of personality dysfunction proposed by the model, namely, self-pathology and interpersonal dysfunction. Moreover, the GAPD discriminated between patients diagnosed with and without Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR) personality disorder(s) and demonstrated discriminative power in detecting the severity of personality pathology. Correlations with a DSM-IV symptom measure and a pathological traits model suggest partial conceptual overlap. Although further testing is indicated, the present findings suggest the GAPD is suitable for assessing the core components of personality dysfunction. It may contribute to a two-step integrated assessment of personality pathology that assesses both personality dysfunction and personality traits. KEY PRACTITIONER MESSAGE: The core features of personality disorder can be defined as disorders in the self and in the capacity for interpersonal functioning. A clinically useful operationalization of disordered functioning of personality is needed to determine the maladaptivity of personality traits. An integrated assessment of personality (dys)functioning and personality traits provides a more comprehensive clinical picture of the patient, which may aid treatment planning.

Toward a genetically-informed model of borderline personality disorder.

This article describes a conceptual framework for describing borderline personality disorder (BPD) based on empirical studies of the phenotypic structure and genetic architecture of personality. The proposed phenotype has 2 components: (1) a description of core self and interpersonal pathology-the defining features of personality disorder-as these features are expressed in the disorder; and (2) a set of traits based on the anxious-dependent or emotional dysregulation factor of the four-factor model of PD. Four kinds of traits are described: emotional (anxiousness, emotional reactivity, emotional intensity, and pessimistic-anhedonia), interpersonal (submissiveness, insecure attachment, social apprehensiveness, and need for approval), cognitive (cognitive dysregulation), and self-harm (behaviors and ideas). Formulation of the phenotype was guided by the conceptualization of personality as a system of interrelated sub-systems. The psychopathology associated with BPD involves most components of the system. The trait structure of the disorder is assumed to reflect the genetic architecture of personality and individual traits are assumed to be based on adaptive mechanisms. It is suggested that borderline traits are organized around the trait of anxiousness and that an important feature of BPD is dysregulation of the threat management system leading to pervasive fearfulness and unstable emotions. The interpersonal traits are assumed to be heritable characteristics that evolved to deal with interpersonal threats that arose as a result of social living. The potential for unstable and conflicted interpersonal relationships that is inherent to the disorder is assumed to result from the interplay between the adaptive structure of personality and psychosocial adversity. The etiology of the disorder is discussed in terms of biological and environmental factors associated with each component of the phenotype.

Introduction to the special feature on the integrated treatment of personality disorder.

The solid evidence that personality disorders can be treated effectively goes side by side with, on the one hand, sparse evidence for disorders other than borderline and for personality disorders co-occurrent with one another, and, on the other hand, with a relative lack of knowledge about the actual effective mechanisms of change that underpin successful psychotherapies. In this introduction we present the rationale for this special feature, advocating for an integrated treatment of personality pathology in which empirically-supported strategies and techniques are selected from different traditions on the basis of the pragmatic principle of what works.

Clinical validity of the "Dimensional Assessment of Personality Pathology (DAPP)" for psychiatric patients with and without a personality disorder diagnosis.

There is a movement towards a dimensional classification of personality disorders (PD). However, data linking dimensional systems and the categorical system for classifying PD are lacking. In the present study, N = 165 normal subjects and N = 222 nonpsychotic in-patients (including N = 81 patients with a PD diagnosis) completed the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ) measuring 18 PD traits. DSM-IV PD symptoms were assessed by SCID-II interviews. Group differences were analyzed by ANCOVA, and the relation between the dimensional and categorical approach was investigated by regression, ROC, and MDS analyses. Patients with PD exhibited elevated scores on all DAPP traits compared with controls. Patients without PD scored in between. Each DSM-IV PD could be described by a distinct profile of DAPP traits. Results support the assumption that the DAPP trait system can represent mean differences between clinically defined subgroups. The categorical system can be mapped onto the dimensional DAPP system with sufficient clinical specificity.

Integrated therapy for complex cases of personality disorder.

In this article, the author presents and illustrates the treatment of a patient with dependent and borderline personality disorders and other maladaptive traits using an integrated and eclectic approach tailored to the patient's psychopathology and personality. Interventions are selected where possible based on evidence of what works. However, because empirical evidence on treatment efficacy for personality disorder is limited, interventions were often selected based on a rational analysis of the most effective way to treat a given problem. The delivery of an eclectic array of interventions was integrated and coordinated through an emphasis on generic methods and on a phases of change model that targets symptoms and problems in a systematic way based on evidence of the stability of symptoms and personality.