Longitudinal prediction of psychosocial functioning outcomes: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Section-II personality disorders versus alternative model personality dysfunction and traits.

We aimed to determine and compare the longitudinal predictive power of Diagnostic and Statistical Manual of Mental Disorders, fifth edition's (DSM-5) two models of personality disorder (PD) for multiple clinically relevant outcomes. A sample of 600 community-dwelling adults-half recruited by calling randomly selected phone numbers and screening-in for high-risk for personality pathology and half in treatment for mental health problems-completed an extensive battery of self-report and interview measures of personality pathology, clinical symptoms, and psychosocial functioning. Of these, 503 returned for retesting on the same measures an average of 8 months later. We used Time 1 interview data to assess DSM-5 personality pathology, both the Section-II PDs and the alternative (DSM-5) model of personality disorder's (AMPD) Criterion A (impairment) and Criterion B (adaptive-to-maladaptive-range trait domains and facets). We used these measures to predict 20 Time 2 functioning outcomes. Both PD models significantly predicted functioning-outcome variance, albeit modestly-averaging 12.6% and 17.9% (Section-II diagnoses and criterion counts, respectively) and 15.2% and 23.2% (AMPD domains and facets, respectively). Each model significantly augmented the other in hierarchical regressions, but the AMPD domains (6.30%) and facets (8.62%) predicted more incremental variance than the Section-II diagnoses (3.74%) and criterion counts (3.31%), respectively. Borderline PD accounted for just over half of Section II's predictive power, whereas the AMPD's predictive power was more evenly distributed across components. We note the predictive advantages of dimensional models and articulate the theoretical and clinical advantages of the AMPD's separation of personality functioning impairment from how this is manifested in personality traits. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Competing Models of Personality Disorder: Relations With Psychosocial Functioning.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5; American Psychiatric Association, 2013), includes 10 categorical personality disorders (PD) in Section II (Section II PD) and a dimensional alternative model of PD (AMPD) in Section III. We compared the two models in explaining concurrent psychosocial functioning levels in psychiatric outpatients and community residents screened as at risk for PD pathology (N = 600). The AMPD's fully dimensional form showed stronger associations with psychosocial difficulties and explained more of their variance compared with the categorical Section II PD. AMPD Criterion A (personality functioning impairment) and Criterion B (pathological traits) incrementally predicted psychosocial functioning about equally with some unique predictions. Finally, AMPD's six categorical PD diagnoses did not show stronger associations with psychosocial functioning than the corresponding Section II PD diagnoses. Findings directly comparing the two models remain important and timely for informing future conceptualizations of PD in the diagnostic system.

Personality disorder coverage, prevalence, and convergence: do the DSM-5's two models of personality disorder identify the same patients?

BACKGROUND: Research on the Alternative DSM-5 Model for Personality Disorders (AMPD) in DSM-5's Section-III has demonstrated acceptable interrater reliability, a largely consistent latent structure, substantial correlations with theoretically and clinically relevant measures, and evidence for incremental concurrent and predictive validity after controlling for DSM-5's Section II categorical personality disorders (PDs). However, the AMPD is not yet widely used clinically. One clinician concern may be caseness - that the new model will diagnose a different set of PD patients from that with which they are familiar. The primary aim of this study is to determine whether this concern is valid, by testing how well the two models converge in terms of prevalence and coverage. METHOD: Participants were 305 psychiatric outpatients and 302 community residents not currently in mental-health treatment who scored above threshold on the Iowa Personality Disorder Screen (Langbehn et al., ). Participants were administered a semi-structured interview for DSM-5 PD, which was scored for both Section II and III PDs. RESULTS: Convergence across the two PD models was variable for specific PDs, Good when specific PDs were aggregated, and Very Good for 'any PD.' CONCLUSIONS: Results provide strong evidence that the AMPD yields the same overall prevalence of PD as the current model and, further, identifies largely the same overall population. It also addresses well-known problems of the current model, is more consistent with the ICD-11 PD model, and provides more complete, individualized characterizations of persons with PD, thereby offering multiple reasons for its implementation in clinical settings.

Associations of antidepressant medication consumption with changes in personality pathology and quality of life among community-dwelling adults.

BACKGROUND: Although antidepressant medication (ADM) has produced small advantages over pill placebo in randomized controlled trials, consuming ADM has predicted prospectively increasing depressive symptom severity in samples of community-dwelling adults. OBJECTIVE: We extended the community literature by testing ADM's relations to changes in personality and quality of life that may underpin depression. METHOD: In this longitudinal, observational study, community-dwelling adults (N = 601) were assessed twice, 8 months apart on average. Assessments included depressive symptoms, personality, life satisfaction and quality, and prescription medication consumption. RESULTS: Consuming ADM at time 1 predicted relative increases in depressive symptoms (dysphoria), maladaptive traits (negative affect, negative temperament, disinhibition, low conscientiousness), personality dysfunction (non-coping, self-pathology), and decreases in life satisfaction and quality from time 1 to 2, before and after adjustment for age, gender, race, income, education, physical health problems, and use of other psychotropics. In no analysis did ADM use predict better outcomes. CONCLUSION: Among community-dwelling adults, ADM use is a risk factor for psychosocial deterioration in domains including depressive symptoms, personality pathology, and quality of life. Until mechanisms connecting ADM to poor outcomes in community samples are understood, additional caution in use of ADM and consideration of empirically supported non-pharmacologic treatments is prudent.

Disinhibition domain and facets uniquely predict changes in depressive symptoms and psychosocial functioning.

This study aimed to understand the role of disinhibition (low conscientiousness)-in conjunction with the other major personality traits of negative affectivity, detachment, antagonism, and psychoticism-in predicting changes in depressive symptoms and psychosocial functioning. Both the disinhibition trait domain and its primary facets (i.e., irresponsibility, impulsivity, and distractibility) were examined. In a large sample (Time 1 N = 605, Time 2 N = 497) of psychiatric outpatients and high-risk community residents, personality traits, depressive symptoms (both self-reported and interviewer-rated), and psychosocial functioning levels (i.e., daily functioning, interpersonal functioning, health-related quality of life, and global quality of life) were collected across two time points. Results showed that the disinhibition domain was the strongest predictor of changes in depressive symptoms and general quality of life levels. Disinhibition facets also predicted changes in depressive symptoms but showed a less consistent pattern compared to the broader trait domain. Finally, the irresponsibility and distractibility facets significantly and uniquely explained changes in interpersonal functioning. The study highlights the importance of assessing the disinhibition trait rather than only negative and positive affectivity (which are well-known correlates of depression), for understanding changes in depressive symptoms and psychosocial functioning. The findings identify potential targets in psychotherapy for individuals with disinhibition traits and depressive disorders.

Evaluating a Comprehensive Model of Euthymia.

INTRODUCTION: In research and treatment of mood disorders, "euthymia" traditionally denotes the absence of clinically significant mood disturbance. A newer, expanded definition of euthymia also includes positive affect and psychological well-being. OBJECTIVE: We aimed to test this comprehensive model of euthymia and estimate the coherence and predictive power of each factor in the model. METHODS: Community-dwelling adults (N = 601), including both mental health outpatients and non-patients at high risk for personality pathology, completed a battery of interviews and questionnaires at time 1. Most (n = 497) were reassessed on average 8 months later (time 2). We modeled euthymia using standard mood, personality, and psychosocial functioning assessments rather than measures designed specifically for euthymia. RESULTS: The hypothesized model of euthymia was supported by confirmatory factor analysis: specific measures loaded on three lower order factors (mood disturbance, positive affect, and psychological well-being) that reflected general euthymia at time 1. Each factor (general euthymia plus lower order factors) demonstrated moderately strong concurrent (time 1) and predictive (time 1-2) correlations with outcomes, including employment status, income, mental health treatment consumption, and disability. Compared to positive affect and psychological well-being, mood disturbance had stronger incremental (i.e., nonoverlapping) relations with these outcomes. CONCLUSIONS: Support for a comprehensive model of euthymia reinforces efforts to improve assessment and treatment of mood and other disorders. Beyond dampening of psychological distress, euthymia-informed treatment goals encompass full recovery, including enjoyment and meaning in life.

How can the DSM-5 alternative model of personality disorders advance understanding of depression?

BACKGROUND: The DSM-5 introduced an alternative model of personality disorder (AMPD) that includes personality dysfunction plus maladaptive-range traits. This study clarifies relations of depression diagnoses and symptoms with AMPD personality pathology. METHOD: Two samples (Ns 402 and 601) of outpatients and community-dwelling adults completed four depression (criteria met for major depressive disorder and dysthymia; dysphoria and low well-being scales), ten trait (two scales for each of five domains-negative affectivity, detachment, disinhibition, antagonism, psychoticism), and eight dysfunction (four scales for each of two domains-self- and interpersonal pathology) measures. Diagnoses were made using a semi-structured interview; other measures were self-reports. We quantified cross-sectional relations between depression and personality pathology with correlation and multiple regression analyses. RESULTS: Collectively (median R2; ps < 0.0001), the trait (0.46) and dysfunction (0.50) scales predicted the depression measures strongly, with most predictive power shared (0.41) between traits and dysfunction. However, trait and dysfunction scales altogether predicted depression (median R2 = 0.54) more strongly than either domain alone, ps < 0.0001. Participants with depression diagnoses showed elevations on all nonadaptive trait and personality dysfunction measures, particularly negative temperament/affectivity and self-pathology measures. LIMITATIONS: Generalization of findings to other populations (e.g., adolescents), settings (e.g., primary care), and measures (e.g., traditional personality disorder diagnoses) is uncertain. Cross-sectional analyses did not test changes over time or establish causality. CONCLUSIONS: The AMPD is highly relevant to depression. Assessment of personality pathology, including both personality dysfunction and maladaptive-range traits, stands to advance understanding of depression in adults.

Personality profiles as potential targets for intervention: Identification and replication.

The alternative dimensional model of personality disorder (PD) diagnosis, based on personality-functioning impairment and pathological traits, opens the door for tailoring treatments to individuals with more homogeneous personality profiles than diagnostic categories. Such a transdiagnostic PD treatment approach requires robust, replicable, personality-relevant dimensions, which we found using a large battery of self-report measures: Self-pathology and negative affectivity (NA) traits, interpersonal pathology and detachment traits, and interpersonal pathology and antagonism traits. Using these dimensions, we identified three groups that had, respectively, elevations on (1) all three dimensions, (2) self-pathology/NA (with/without interpersonal-pathology elevation(s)) and (3) either or both interpersonal-pathology dimensions, without elevated self-pathology/NA. Using the same personality-functioning measures and a half-overlapping trait set, we replicated these profiles in an additional sample. Interview-based measures of functioning and personality pathology provided external validity evidence for the method, suggesting it represents a critical first step towards treatment research targeting transdiagnostic processes rather than diagnoses. For example, two groups might benefit from treatments focused, respectively, on emotional dysregulation and interpersonal relations, whereas the multiple-problem group may need a sequenced treatment approach. Research is needed to test these hypotheses and to expand the method to include a wider range of pathological personality traits. © 2019 John Wiley & Sons, Ltd.

The "me too" decision: An analog study of therapist self-disclosure of psychological problems.

OBJECTIVES: To test the exploratory hypothesis that client perceptions of therapists are most favorable when therapists self-disclose their own personal experience with the same psychological problem to a moderate (vs. none, mild, or extreme) extent. METHOD: Undergraduate participants (N = 104; 63.5% female) were randomly assigned to read one of the four vignettes, which differed only in the extent to which the therapist disclosed their own personal experience with the same presenting problem (none, mild, moderate, or extreme). Participants then responded to questions assessing their perceptions of the therapist. RESULTS: The data generally supported the hypothesis. The moderate disclosure condition yielded the most favorable client perceptions, which differed significantly from those yielded by the no disclosure condition. CONCLUSIONS: Despite limitations and need for replication, this study provides perhaps the first empirical data regarding the effect of the extent, rather than the mere presence or absence, of therapist self-disclosure regarding personal psychological experiences.

Domains of psychosocial disability and mental disorders.

OBJECTIVES: This study examined relations between comprehensive domains of psychosocial disability and mental disorders to determine (1) whether differential patterns of associations exist between psychosocial disability dimensions and commonly diagnosed mental disorders and (2) whether these relations differ between self-reported and interviewer-rated psychosocial disability domains. METHOD: Self-reported and interviewer-rated psychosocial functioning measures and an interviewer-rated diagnostic assessment tool were administered to 181 psychiatric outpatients. RESULTS: Internalizing disorders showed the strongest and most pervasive associations with psychosocial impairment across both self-reported and interviewer-rated measures, followed by thought disorder; externalizing showed the weakest associations. More specifically, logistic regression analyses indicated that lower well-being factor score significantly increased the odds of distress-disorder diagnoses, and poor basic functioning increased the odds of PTSD. CONCLUSIONS: Results clearly showed differences in the magnitude of associations between three dimensions of psychosocial-disability and commonly diagnosed disorders, and that these differences were similar regardless of rater type.

Manifestations of personality impairment severity: comorbidity, course/prognosis, psychosocial dysfunction, and 'borderline' personality features.

Impairment in personality functioning (briefly, personality impairment) is the core pathology in personality disorder (PD) and an essential indicator of PD-severity. It also is a difficult construct to define and assess. We argue that personality-impairment severity is a latent construct that can be modeled with four indicators: within-PD comorbidity, problematic course/prognosis of both PD and comorbid clinical syndromes, PD-associated psychosocial dysfunction, and features of DSM-5-II borderline PD (BPD). Our literature review documents interrelations among the first three indicators, and studies of PD structure reveal a higher order factor of general PD severity marked most strongly by BPD features. Together, these findings indicate that BPD features may be helpful in the important tasks of defining and assessing personality-impairment severity.

Antagonism trait facets and comprehensive psychosocial disability: Comparing information across self, informant, and interviewer reports.

It is widely known that personality traits collectively discussed as the Dark Triad are antagonistic and associated with poor interpersonal relationships, but few studies have examined how specific facets of antagonism are associated with psychosocial adjustment or how antagonism relates to psychosocial adjustment other than interpersonal functioning. The purpose of this study was to examine how 6 antagonism facets-manipulativeness, grandiosity, attention-seeking, hostility, callousness, and deceitfulness-relate to comprehensive psychosocial functional domains (i.e., well-being, interpersonal relationships, basic daily functioning) using information about both antagonism and functioning from 3 sources-self, informant, and interviewer. Data were from 318 primary participants and informants. We present 3 main findings: (1) When psychosocial functioning and antagonism traits were both rated by informants, all psychosocial disability domains were consistently positively associated with antagonism traits. (2) We next created a single psychosocial-disability factor score via principal factors analysis of all raters' psychosocial-functioning scores. When all 3 raters' reports of domain-level antagonism were used as independent variables in a simultaneous regression analysis to predict this overall functioning score, informant-reported antagonism most strongly predicted psychosocial functioning, followed by interviewer-rated antagonism. (3) We then created 6 facet scores by summing the 3 raters' scores on each. When we used these scores to predict psychosocial functioning, hostility was the main trait significantly predicting psychosocial functioning. The study provides further insight into associations of psychosocial disability with antagonism facets from different raters' perspectives. The findings thus further our understanding of psychosocial outcomes associated with antagonism, the core of the dark traits. (PsycINFO Database Record

The Brave New World of Personality Disorder-Trait Specified: Effects of Additional Definitions on Coverage, Prevalence, and Comorbidity.

The alternative dimensional model for personality disorder (PD) in DSM-5, Section III (DSM-5-III) includes two main criteria: (A) personality-functioning impairment, and (B) personality-trait pathology; provides specific functioning-and-trait criteria for six PD-type diagnoses; and introduces PD-trait specified (PD-TS), which requires meeting the general PD criteria and not meeting criteria for any specific PD type. We termed this Simple PD-TS and developed two additional definitions: Mixed PD-TS, meeting criteria for one or two PD types and having five or more additional pathological traits; and Complex PD-TS, meeting criteria for three or more PD types. In a mixed sample of 165 outpatients and 215 community adults screened to be at high-risk for PD, we investigated the effect of these additional definitions on prevalence, coverage, comorbidity, and within-diagnosis heterogeneity, and conclude that eliminating the PD-type diagnoses and thus having PD-TS as the only PD diagnosis would be both more parsimonious and more useful clinically.

Three-pronged assessment and diagnosis of personality disorder and its consequences: personality functioning, pathological traits, and psychosocial disability.

The alternative dimensional model of personality disorder (PD) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013), Section III, has two main criteria: impairment in personality functioning and one or more pathological personality traits. The former is defined as disturbances in self-functioning (viz., identity, self-direction), and/or interpersonal functioning (viz., empathy, intimacy). Distinguishing personality functioning and traits is important conceptually, because simply having extreme traits is not necessarily pathological. However, adding personality functioning to PD diagnosis represents an empirical challenge, because the constructs overlap conceptually. Further, there is debate regarding whether diagnosis of mental disorder requires either distress or disability, concepts that also overlap with maladaptive-range personality traits and personality dysfunction. We investigated interrelations among these constructs using multiple self-report measures of each domain in a mixed community-patient sample (N = 402). We examined the structures of functioning (psychosocial disability and personality) and personality traits, first independently, then jointly. The disability/functioning measures yielded the 3 dimensions we have found previously (Ro & Clark, 2013). Trait measures had a hierarchical structure which, at the 5-factor level, reflected neuroticism/negative affectivity (N/NA), (low) sociability, disinhibition, (dis)agreeableness, and rigid goal engagement. When all measures were cofactored, a hierarchical structure again emerged which, at the 5-factor level, included (a) internalizing (N/NA and self-pathology vs. quality-of-life/satisfaction); (b) externalizing (social/interpersonal dysfunction, low sociability, and disagreeableness); (c) disinhibition; (d) poor basic functioning; and (e) rigid goal engagement. Results are discussed in terms of developing an integrated PD diagnostic model.

Interrelations between psychosocial functioning and adaptive- and maladaptive-range personality traits.

Decrements in one or more domains of psychosocial functioning (e.g., poor job performance, poor interpersonal relations) are commonly observed in psychiatric patients. The purpose of this study is to increase understanding of psychosocial functioning as a broad, multifaceted construct as well as its associations with both adaptive- and maladaptive-range personality traits in both nonclinical and psychiatric outpatient samples. The study was conducted in two phases. In Study 1, a nonclinical sample (N = 429) was administered seven psychosocial functioning and adaptive-range personality trait measures. In Study 2, psychiatric outpatients (N = 181) were administered the same psychosocial functioning measures, and maladaptive- as well as adaptive-range personality trait measures. Exploratory (both studies) and confirmatory (Study 2) factor analyses indicated a common three-factor, hierarchical structure of psychosocial functioning-Well Being, Social/Interpersonal Functioning, and Basic Functioning. These psychosocial functioning domains were closely--and differentially--linked with personality traits, especially strongly so in patients. Across samples, Well Being was associated with both Neuroticism/Negative Affectivity and Extraversion/Positive Affectivity, Social/Interpersonal Functioning was associated with both Agreeableness and Conscientiousness/Disinhibition, and Basic Functioning was associated with Conscientiousness/Disinhibition, although only modestly in the nonclinical sample. These relations generally were maintained even after partialing out current general dysphoric symptoms. These findings have implications for considering psychosocial functioning as an important third domain in a tripartite model together with personality and psychopathology.

Integrating normal and pathological personality: relating the DSM-5 trait-dimensional model to general traits of personality.

The Personality Inventory for DSM-5 (PID-5) assesses traits relevant for diagnosing personality disorder in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). We examined the PID-5 in relation to the Big-Three and Big-Five personality traits in outpatient and community adult samples. Domain-level analyses revealed that PID-5 Negative Affectivity correlated strongly with Neuroticism, and PID-5 Antagonism and Disinhibition correlated strongly negatively with Agreeableness and Conscientiousness, respectively; Antagonism and Disinhibition also were both linked strongly to Big-Three trait Disinhibition. PID-5 Detachment related strongly to personality, including Extraversion/Positive Temperament, but did not show its expected specificity to this factor. Finally, PID-5 Psychoticism correlated only modestly with Openness. Facet-level analyses indicated that some PID-5 scales demonstrated replicable deviations from their DSM-5 model placements. We discuss implications of these data for the DSM-5 model of personality disorder, and for integrating it with well-established structures of normal personality.

The Relationship Quality Interview: evidence of reliability, convergent and divergent validity, and incremental utility.

Relationship satisfaction and adjustment have been the target outcome variables for almost all couple research and therapies. In contrast, far less attention has been paid to the assessment of relationship quality. The present study introduces the Relationship Quality Interview (RQI), a semistructured, behaviorally anchored individual interview. The RQI was designed to provide a more objective assessment of relationship quality as a dynamic, dyadic construct across 5 dimensions: (a) quality of emotional intimacy in the relationship, (b) quality of the couple's sexual relationship, (c) quality of support transactions in the relationship, (d) quality of the couple's ability to share power in the relationship, and (e) quality of conflict/problem-solving interactions in the relationship. Psychometric properties of RQI ratings were examined through scores obtained from self-report questionnaires and behavioral observation data collected cross-sectionally from a sample of 91 dating participants and longitudinally from a sample of 101 married couples. RQI ratings demonstrated strong reliability (internal consistency, interrater agreement, interpartner agreement, and correlations among scales), convergent validity (correlations between RQI scale ratings and questionnaire scores assessing similar domains of relationship quality), and divergent validity (correlations between RQI scale ratings and (a) behavioral observation codes assessing related constructs, (b) global relationship satisfaction scores, and (c) scores on individual difference measures of related constructs). Clinical implications of the RQI for improving couple assessment and interventions are discussed.

Psychosocial functioning in the context of diagnosis: assessment and theoretical issues.

Psychosocial functioning is an important focus of attention in the revision of the Diagnostic and Statistical Manual of Mental Disorders. Researchers and clinicians are converging upon the opinion that psychometrically strong, comprehensive assessment of individuals' functioning is needed to characterize disorder fully. Also shared is the realization that existing theory and research in this domain have critical shortcomings. The authors urge that the field reexamine the empirical evidence and address theoretical issues to guide future development of the construct and its measurement. The authors first discuss several theoretical issues relevant to the conceptualization and assessment of functioning: (a) definitions of functioning, (b) the role of functioning in defining disorder, and (c) understanding functioning within environmental contexts. The authors then present data regarding empirical domains of psychosocial functioning and their interrelations. Self-reported data on multiple domains of psychosocial functioning were collected from 429 participants. Factor-analytic results (promax rotation) suggest a 4-factor structure of psychosocial functioning: Well-Being, Basic Functioning, Self-Mastery, and Interpersonal and Social Relationships. Finally, the authors propose an integration of theory and empirical findings, which they believe will better incorporate psychosocial functioning into future diagnostic systems.

Is psychological aggression as detrimental as physical aggression? The independent effects of psychological aggression on depression and anxiety symptoms.

The differential effects of psychological and physical victimization on depression and anxiety symptoms were examined via APIM and growth curve modeling techniques in a sample of newlyweds (N = 103 couples) assessed four times over the first 3 years of marriage. On average, husbands and wives reported moderate levels of psychological aggression, and there were no sex differences in prevalence rates or mean levels. Changes in psychological victimization were associated with changes in depression and anxiety symptoms, even after controlling for the effects of physical victimization. This study demonstrates the severe impact of psychological aggression on its victims and expands on previous studies of battering samples to demonstrate that psychological victimization may be more damaging than physical victimization in nonbattering, community couples.