Borderline personality disorder symptom networks across adolescent and adult clinical samples: examining symptom centrality and replicability.

BACKGROUND: Numerous theories posit different core features to borderline personality disorder (BPD). Recent advances in network analysis provide a method of examining the relative centrality of BPD symptoms, as well as examine the replicability of findings across samples. Additionally, despite the increase in research supporting the validity of BPD in adolescents, clinicians are reluctant to diagnose BPD in adolescents. Establishing the replicability of the syndrome across adolescents and adults informs clinical practice and research. This study examined the stability of BPD symptom networks and centrality of symptoms across samples varying in age and clinical characteristics. METHODS: Cross-sectional analyses of BPD symptoms from semi-structured diagnostic interviews from the Collaborative Longitudinal Study of Personality Disorders (CLPS), the Methods to Improve Diagnostic Assessment and Service (MIDAS) study, and an adolescent clinical sample. Network attributes, including edge (partial association) strength and node (symptom) expected influence, were compared. RESULTS: The three networks were largely similar and strongly correlated. Affective instability and identity disturbance emerged as relatively central symptoms across the three samples, and relationship difficulties across adult networks. Differences in network attributes were more evident between networks varying both in age and in BPD symptom severity level. CONCLUSIONS: Findings highlight the relative importance of affective, identity, and relationship symptoms, consistent with several leading theories of BPD. The network structure of BPD symptoms appears generally replicable across multiple large samples including adolescents and adults, providing further support for the validity of the diagnosis across these developmental phases.

The Incremental Utility of Criteria A and B of the DSM-5 Alternative Model for Personality Disorders for Predicting DSM-IV/DSM-5 Section II Personality Disorders.

The DSM-5 Alternative Model for Personality Disorders (AMPD) includes two main criteria: moderate or greater impairment in personality functioning (Criterion A) and the presence of one or more pathological personality traits (Criterion B). The aim of the study was to investigate the incremental utility of Criteria A and B for predicting DSM-5 Section II personality disorders (PD). The sample (N = 317) consisted of three well-defined groups: non-clinical participants (n = 35), psychiatric patients with PD (n = 193), and without PD (n = 83). All were assessed using the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-5-AMPD-I): Level of Personality Functioning Scale (LPFS), and the Personality Inventory for DSM-5 (PID-5). Logistic regression analyses showed that the SCID-5-AMPD-I could predict the presence of PDs in general, and the three specific PDs that were investigated (i.e., Antisocial, Borderline, and Avoidant PDs). The PID-5 domains enhanced prediction of the specific PDs, but not the presence of PDs in general, when entered in the second step. Our results support the AMPD model: Criterion A predicted the presence of DSM-5 Section II PDs in general, whereas measures of Criterion B incremented prediction of Antisocial, Borderline, and Avoidant PDs.

The Hierarchical Taxonomy of Psychopathology (HiTOP) in psychiatric practice and research.

The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.

Les progrès dans la réalisation de la classification quantitative de la psychopathologie.

Shortcomings of approaches to classifying psychopathology based on expert consensus have given rise to contemporary efforts to classify psychopathology quantitatively. In this paper, we review progress in achieving a quantitative and empirical classification of psychopathology. A substantial empirical literature indicates that psychopathology is generally more dimensional than categorical. When the discreteness versus continuity of psychopathology is treated as a research question, as opposed to being decided as a matter of tradition, the evidence clearly supports the hypothesis of continuity. In addition, a related body of literature shows how psychopathology dimensions can be arranged in a hierarchy, ranging from very broad "spectrum level" dimensions, to specific and narrow clusters of symptoms. In this way, a quantitative approach solves the "problem of comorbidity" by explicitly modeling patterns of co-occurrence among signs and symptoms within a detailed and variegated hierarchy of dimensional concepts with direct clinical utility. Indeed, extensive evidence pertaining to the dimensional and hierarchical structure of psychopathology has led to the formation of the Hierarchical Taxonomy of Psychopathology (HiTOP) Consortium. This is a group of 70 investigators working together to study empirical classification of psychopathology. In this paper, we describe the aims and current foci of the HiTOP Consortium. These aims pertain to continued research on the empirical organization of psychopathology; the connection between personality and psychopathology; the utility of empirically based psychopathology constructs in both research and the clinic; and the development of novel and comprehensive models and corresponding assessment instruments for psychopathology constructs derived from an empirical approach.

Interrater Reliability of the Structured Clinical Interview for the DSM-5 Alternative Model of Personality Disorders Module i: Level of Personality Functioning Scale.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) presents an alternative model for personality disorders in which severity of personality pathology is evaluated by the Level of Personality Functioning Scale (LPFS). The Structured Interview for the DSM-5 Alternative Model for Personality Disorders, Module I (SCID-5-AMPD I) is a new tool for LPFS assessment, but its interrater reliability (IRR) has not yet been tested. Here we examined the reliability of the Norwegian translation of the SCID-5-AMPD I, applying two different designs: IRR assessment based on ratings of 17 video-recorded SCID-5-AMPD I interviews by five raters; and test-retest IRR based on interviews of 33 patients administered by two different raters within a short interval. For the video-based investigation, intraclass correlation coefficient (ICC) values ranged from .77 to .94 for subdomains, .89 to .95 for domains, and .96 for total LPFS. For the test-retest investigation, ICC ranged from .24 to .72 for subdomains, .59 to .90 for domains, and .75 for total LPFS. The test-retest study revealed questionable reliability estimates for some subdomains. However, overall the level of personality functioning was measured with a sufficient degree of IRR when assessed by the SCID-5-AMPD I.

Impact of Adolescent Personality Disorders on Obesity 17 Years Later.

OBJECTIVES: To investigate associations between adolescent personality disorder (PD) and obesity 17 years later. METHODS: The Children in the Community is a longitudinal study based on a randomly sampled cohort of families, in effect since 1975. PDs were assessed in youths by self-report and mother report in 1985 to 1986, when participants were at an average age of 16 years. Obesity was assessed in 2001 to 2004 when participants were an average age of 33 years (n = 621). RESULTS: Prevalence of obesity was 16.59% (103/621) at an average age of 33 years. Prevalence of any adolescent PD was 17.55% (109/621) at an average age of 16 years. Adolescents who had any PD were 1.84 (95% confidence interval [CI] = 1.05-3.22) times as likely to be obese 17 years later after adjusting for demographic variables and known risk factors. Paranoid, histrionic, and obsessive-compulsive PDs in adolescence were significantly associated with obesity in adulthood, with odds ratios of 3.45 (95% CI = 1.46-8.17), 4.49 (95% CI = 1.91-10.53), and 6.80 (95% CI = 2.50-18.55), respectively. CONCLUSIONS: This is the first study to report a significant independent long-term association based on prospective data between adolescent PDs and adult obesity in a community-based sample. Findings will contribute to the design of preventive measures against the development of obesity.

Personality disorders in DSM-5: emerging research on the alternative model.

The current categorical classification of personality disorders, originally introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), has been found to suffer from numerous shortcomings that hamper its usefulness for research and for clinical application. The Personality and Personality Disorders Work Group for DSM-5 was charged with developing an alternative model that would address many of these concerns. The developed model involved a hybrid dimensional/categorical model that represented personality disorders as combinations of core impairments in personality functioning with specific configurations of problematic personality traits. The Board of Trustees of the American Psychiatric Association did not accept the Task Force recommendation to implement this novel approach, and thus this alternative model was included in Sect. III of the DSM-5 among concepts requiring additional study. This review provides an overview of the emerging research on this alternative model, addressing each of the primary components of the model.

Personality disorders and the persistence of anxiety disorders in a nationally representative sample.

BACKGROUND: Among individuals with anxiety disorders, comorbid personality disorders (PDs) increase cross-sectional symptom severity and decrease functioning. Little is known, however, about how PDs influence the course of anxiety disorders over time. The purpose of this study was to examine the effect of PDs on the persistence of four anxiety disorders in a nationally representative sample in the United States. METHODS: Two waves of data were collected on 34,653 participants, 3 years apart. At both waves, participants were evaluated for generalized anxiety disorder (GAD), social and specific phobias, and panic disorder. Predictors of persistence included all DSM-IV PDs. Control variables included demographics, comorbid PDs, age at onset of the anxiety disorder, number of prior episodes, duration of the current episode, treatment history, and cardinal symptoms of exclusionary diagnoses for each anxiety disorder. RESULTS: Any PD, two or more PDs, borderline PD, schizotypal PD, mean number of PD criteria met, and mean number of PDs diagnosed predicted the persistence of all four anxiety disorders. Narcissistic PD predicted persistence of GAD and panic disorder. Schizoid and avoidant PDs also predicted persistence of GAD. Finally, avoidant PD predicted persistence of social phobia. Particular patterns of cross-cluster PD comorbidity were strong predictors of the persistence of individual anxiety disorders as well. CONCLUSIONS: In this national sample, a variety of PDs robustly predicted the persistence of anxiety disorders over 3 years, consistent with the results of recent prospective clinical studies. Personality psychopathology should be assessed and addressed in treatment for all patients with anxiety disorders.

Personality disorder classification: stuck in neutral, how to move forward?

An "Alternative DSM-5 Model for Personality Disorders" was published in Sect. III of DSM-5, while the identical categories and criteria from DSM-IV for the personality disorders (PDs) are in Sect. II. Given strong shifts from categorical diagnoses toward dimensional representations in psychiatry, how did the PDs end up "stuck in neutral," with the flawed DSM-IV model perpetuated? This article reviews factors that influenced the development of the new model and data to encourage and facilitate its use by clinicians. These include recognizing 1) a dimensional structure for psychopathology for which personality may be foundational; 2) a consensus on the structure of normal and abnormal personality; 3) the clinical significance of personality; 4) PD-specific severity required to establish disorder; 5) disruption, discontinuity, and perceived clinical utility of the Alternative Model may not be problems; and 6) a way forward involving collaborative research on neurobiological and psychosocial processes, treatment planning, and outcomes.

Assessing DSM-5 level of personality functioning from videotaped clinical interviews: a pilot study with untrained and clinically inexperienced students.

Several authors have raised the concern that the DSM-5 Level of Personality Functioning Scale (LPFS) is relatively complex and theory laden, and thus might put high requirements on raters. We addressed this concern by having 22 untrained and clinically inexperienced students assess the personality functioning of 10 female psychotherapy inpatients from videotaped clinical interviews, using a multi-item version of the LPFS. Individual raters' LPFS total scores showed acceptable interrater reliability, and were significantly associated with 2 distinct expert-rated measures of the severity of personality pathology. These findings suggest that, contrary to the previously mentioned concerns, successfully applying the LPFS to clinical cases might require neither extensive clinical experience nor training.

Individuals with single versus multiple suicide attempts over 10years of prospective follow-up.

BACKGROUND: The study attempted to identify characteristics that differentiate multiple suicide attempters from single attempters in individuals with personality disorders (PDs) and/or major depression. METHOD: Participants were 431 participants enrolled in the Collaborative Longitudinal Study of Personality Disorders from July 1996 to June 2008. Suicide attempts were assessed with the Longitudinal Interval Follow-up Evaluation at 6 and 12months, then yearly through 10years. Logistic regression was used to compare single attempters to multiple attempters on Axis I and II psychiatric disorders and personality trait variables. RESULTS: Twenty-one percent of participants attempted suicide during the 10years of observation, with 39 (9.0%) reporting a single suicide attempt and 54 (12.5%) reporting multiple suicide attempts. Although no significant differences in were found in baseline Axis I disorders, multiple attempters were significantly more likely to meet criteria for borderline personality disorder and to have higher impulsivity scores than single attempters. CONCLUSION: These results underscore the importance of considering both personality disorders and traits in the assessment of suicidality.

Validating the proposed diagnostic and statistical manual of mental disorders, 5th edition, severity indicator for personality disorder.

The authors sought to determine whether a 5-point global rating of personality dysfunction on the Level of Personality Functioning Scale proposed as a severity index for Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), would be related to DSM-IV personality disorder diagnosis as well as to other key clinical judgments. Data were collected from a national sample of 337 mental health clinicians who provided complete diagnostic information relevant to DSM-IV and proposed DSM-5 personality disorder diagnoses, as well as demographic information and other clinical judgments, on one of their patients. Of the 337 patients described, 248 met criteria for 1 of the 10 specific DSM-IV personality disorders. A "moderate" or greater rating of impairment in personality functioning on the Level Scale demonstrated 84.6% sensitivity and 72.7% specificity for identifying patients meeting criteria for a specific DSM-IV personality disorder. The Level of Personality Functioning Scale had significant and substantial validity correlations with other measures of personality pathology and with clinical judgments regarding functioning, risk, prognosis, and optimal treatment intensity. Furthermore, the single-item Level of Personality Functioning rating was viewed as being as clinically useful as the 10 DSM-IV categories for treatment planning and patient description and was a better predictor of clinician ratings of broad psychosocial functioning than were the 10 DSM-IV categories combined. These results confirm hypotheses that the single-item Level of Personality Functioning Scale rating provides an indication of severity of personality pathology that predicts both assignment of personality disorder diagnosis and clinician appraisals of functioning, risk, prognosis, and needed treatment intensity.

Ethnicity and psychiatric comorbidity in a national sample: evidence for latent comorbidity factor invariance and connections with disorder prevalence.

PURPOSE: Prevalence rates, and bivariate comorbidity patterns, of many common mental disorders differ significantly across ethnic groups. While studies have examined multivariate comorbidity patterns by gender and age, no studies to our knowledge have examined such patterns by ethnicity. Such an investigation could aid in understanding the nature of ethnicity-related health disparities in mental health and is timely given the likely implementation of multivariate comorbidity structures (i.e., internalizing and externalizing) to frame key parts of DSM-5. METHODS: We investigated whether multivariate comorbidity of 11 common mental disorders, and their associated latent comorbidity factors, differed across five ethnic groups in a large, nationally representative sample (n = 43,093). We conducted confirmatory factor analyses and factorial invariance analyses in White (n = 24,507), Hispanic/Latino (n = 8,308), Black (n = 8,245), Asian/Pacific Islander (n = 1,332), and American Indian/Alaska Native (n = 701) individuals. RESULTS: Results supported a two-factor internalizing-externalizing comorbidity factor model in both lifetime and 12-month diagnoses. This structure was invariant across ethnicity, but factor means differed significantly across ethnic groups. CONCLUSIONS: These findings, taken together, indicated that observed prevalence rate differences between ethnic groups reflect ethnic differences in latent internalizing and externalizing factor means. We discuss implications for classification (DSM-5 and ICD-11 meta-structure), health disparities research, and treatment.

Ten-year rank-order stability of personality traits and disorders in a clinical sample.

OBJECTIVE: This study compares the 10-year retest stability of normal traits, pathological traits, and personality disorder dimensions in a clinical sample. METHOD: Ten-year rank-order stability estimates for the Revised NEO Personality Inventory, Schedule for Nonadaptive and Adaptive Personality, and Diagnostic Interview for DSM-IV Personality Disorders were evaluated before and after correcting for test-retest dependability and internal consistency in a clinical sample (N = 266). RESULTS: Dependability-corrected stability estimates were generally in the range of.60-.90 for traits and.25-.65 for personality disorders. CONCLUSIONS: The relatively lower stability of personality disorder symptoms may indicate important differences between pathological behaviors and relatively more stable self-attributed traits and imply that a full understanding of personality and personality pathology needs to take both traits and symptoms into account. The five-factor theory distinction between basic tendencies and characteristic adaptations provides a theoretical framework for the separation of traits and disorders in terms of stability in which traits reflect basic tendencies that are stable and pervasive across situations, whereas personality disorder symptoms reflect characteristic maladaptations that are a function of both basic tendencies and environmental dynamics.

The validity of the Personality Diagnostic Questionnaire-4 Narcissistic Personality Disorder scale for assessing pathological grandiosity.

Although controversy surrounds the definition and measurement of narcissism, the claim that pathological grandiosity is central to the construct generates little disagreement. Yet representations of pathological grandiosity vary across measures of narcissism, leading to conceptual confusion in the literature. The validity of a DSM-based measure of pathological narcissism, the Personality Diagnostic Questionnaire-4 Narcissistic Personality Disorder scale (PDQ-4 NPD), was evaluated in 1 clinical and 3 nonclinical samples (total N=2,391) for its ability to measure pathological grandiosity. Findings were generally supportive: average scores were higher in the clinical than nonclinical samples and the PDQ-4 NPD scale correlated most strongly with (a) other measures of NPD; (b) other DSM Cluster B personality disorders; (c) traits involving antagonism, hostility, and assertiveness; and (d) interpersonal distress and disaffiliative dominance. However, the low internal consistency of the PDQ-4 NPD scale and unexpected associations with Cluster A and obsessive-compulsive features point to potential psychometric weaknesses with this instrument. These findings are useful for evaluating the PDQ-4 NPD scale and for informing ongoing debates regarding how to define and assess pathological narcissism.

Exploring the predictive validity of personality disorder criteria.

We tested the predictive validity of personality disorder (PD) indicators at different levels of aggregation, ranging from general PD severity to PD syndrome scales to individual PD criteria. We compared the predictive validity of models on these levels based on interview data on all 78 DSM-IV PD criteria, by using 19 outcome scales in three different samples (N = 651, N = 552, and N = 1,277). We hypothesized that criteria of personality pathology yield a significant increase in predictive validity compared with scales that are aggregated at the syndrome- or general severity-level. We assessed out of sample performance of predictive models in a repeated cross-validation design using regularized linear regression and regression forest algorithms. We observed no significant difference in predictive performance between models trained at the item-level and models trained on scale-level data. We further tested the predictive performance of the trained linear models across samples on outcome measures shared between samples and inspected models for criteria-level information they relied on to make predictions. Our results suggest that little predictive variance is lost when interview items assessing DSM-IV PD criteria are aggregated to dimensional PD scales. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Stressful life events predict eating disorder relapse following remission: six-year prospective outcomes.

OBJECTIVE: To examine prospectively the natural course of bulimia nervosa (BN) and eating disorder not-otherwise-specified (EDNOS) and test for the effects of stressful life events (SLE) on relapse after remission from these eating disorders. METHOD: 117 female patients with BN (N = 35) or EDNOS (N = 82) were prospectively followed for 72 months using structured interviews performed at baseline, 6- and 12-months, and then yearly thereafter. ED were assessed with the structured clinical interview for DSM-IV, and monitored over time with the longitudinal interval follow-up evaluation. Personality disorders were assessed with the diagnostic interview for DSM-IV-personality-disorders, and monitored over time with the follow-along-version. The occurrence and specific timing of SLE were assessed with the life events assessment interview. Cox proportional-hazard-regression-analyses tested associations between time-varying levels of SLE and ED relapse, controlling for comorbid psychiatric disorders, ED duration, and time-varying personality-disorder status. RESULTS: ED relapse probability was 43%; BN and EDNOS did not differ in time to relapse. Negative SLE significantly predicted ED relapse; elevated work and social stressors were significant predictors. Psychiatric comorbidity, ED duration, and time-varying personality-disorder status were not significant predictors. DISCUSSION: Higher work and social stress represent significant warning signs for triggering relapse for women with remitted BN and EDNOS.

Prospective investigation of a PTSD personality typology among individuals with personality disorders.

This study investigated the replicability of a previously proposed personality typology of posttraumatic stress disorder (PTSD, and explored stability of cluster membership over a 6-month period. Participants with current PTSD (n = 156) were drawn from the Collaborative Longitudinal Personality Disorders Study (CLPS). The CLPS project tracked a large sample of individuals who met criteria for 1 of 4 target diagnoses (borderline, schizotypal, avoidant, and obsessive-compulsive) and a contrast group of individuals who met criteria for depression but no personality disorder. A cluster analysis using scales from the Schedule of Nonadaptive and Adaptive Personality yielded 3 clusters: "internalizing," "externalizing," and "low pathology." Using K-means cluster analysis, the results did not replicate previous work. Using Ward's method, the hypothesized 3-cluster structure was confirmed at baseline but did not demonstrate temporal stability at 6 months.

Personality disorders in DSM-5.

A substantive revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM) last occurred in 1994; therefore, the mental health field should anticipate significant changes to the classification of mental disorders in the fifth edition. Since DSM-5 Work Groups have recently proposed revisions for the major diagnostic classes of mental disorders, an article on the current status of the personality disorders (PDs) is timely. This article reviews scientific principles that have influenced the development of proposed changes for the assessment and diagnosis of personality psychopathology in DSM-5, presents the proposed model as of the summer of 2011, summarizes rationales for the changes, and discusses critiques of the model. Scientific principles were articulated for DSM-5 more than a decade ago; their application to the process has not been straightforward, however. Work Group members have labored to improve the DSM-5 approach to personality and PDs to make the classification more valid and more clinically useful. The current model continues to be a work in progress.

Criterion A: Level of personality functioning in the alternative DSM-5 model for personality disorders.

Criterion A, as represented by Level of Personality Functioning (LPF), offers a means by which to conceptualize the core impairment in self and interpersonal functioning that distinguishes personality disorder (PD) from other forms of psychopathology. One of the most widely cited criticisms of the current Section II in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition categorical diagnostic system is the high level of comorbidity among the categorical PD diagnoses. The Section III alternative Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition model for PDs (AMPD) addresses this problem by assessing the commonalities of the PDs using a single severity continuum, represented in the AMPD by the Level of Personality Functioning Scale (LPFS), which comprises both self and interpersonal pathology. Since its initial introduction, the LPFS has generated an expansive literature base and has also seen significant advancements in its measurement, including both semistructured and self-report methods. Such studies have generally demonstrated that the LPFS can be rated reliably, across both experienced and inexperienced raters, and demonstrates strong validity as evidenced by associations with relevant criterion variables and demonstrations of predictive and clinical utility. This review offers a brief history of the conceptualization and development of Criterion A and the LPFS, describes the major advancements in its measurement, and provides a summary of the status of the empirical literature regarding Criterion A's structure, reliability, and validity. (PsycInfo Database Record (c) 2022 APA, all rights reserved).