Publications by authors named "Donna S Bender"

50 Publications

Borderline personality disorder diagnosis in a new key.

Borderline Personal Disord Emot Dysregul 2019 2;6:18. Epub 2019 Dec 2.

20University of Arizona, 1501 N. Campbell Avenue, PO Box 245017, Tucson, AZ 85724 USA.

Background: Conceptualizations of personality disorders (PD) are increasingly moving towards dimensional approaches. The definition and assessment of borderline personality disorder (BPD) in regard to changes in nosology are of great importance to theory and practice as well as consumers. We studied empirical connections between the traditional DSM-5 diagnostic criteria for BPD and Criteria A and B of the Alternative Model for Personality Disorders (AMPD).

Method: Raters of varied professional backgrounds possessing substantial knowledge of PDs ( = 20) characterized BPD criteria with the four domains of the Level of Personality Functioning Scale (LPFS) and 25 pathological personality trait facets. Mean AMPD values of each BPD criterion were used to support a nosological cross-walk of the individual BPD criteria and study various combinations of BPD criteria in their AMPD translation. The grand mean AMPD profile generated from the experts was compared to published BPD prototypes that used AMPD trait ratings and the DSM-5-III hybrid categorical-dimensional algorithm for BPD. Divergent comparisons with DSM-5-III algorithms for other PDs and other published PD prototypes were also examined.

Results: Inter-rater reliability analyses showed generally robust agreement. The AMPD profile for BPD criteria rated by individual BPD criteria was not isomorphic with whole-person ratings of BPD, although they were highly correlated. Various AMPD profiles for BPD were generated from theoretically relevant but differing configurations of BPD criteria. These AMPD profiles were highly correlated and showed meaningful divergence from non-BPD DSM-5-III algorithms and other PD prototypes.

Conclusions: Results show that traditional DSM BPD diagnosis reflects a common core of PD severity, largely composed of LPFS and the pathological traits of anxiousness, depressively, emotional lability, and impulsivity. Results confirm the traditional DSM criterion-based BPD diagnosis can be reliably cross-walked with the full AMPD scheme, and both approaches share substantial construct overlap. This relative equivalence suggests the vast clinical and research literatures associated with BPD may be brought forward with DSM-5-III diagnosis of BPD.
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http://dx.doi.org/10.1186/s40479-019-0116-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6886204PMC
December 2019

Evaluation of Diagnostic Thresholds for Criterion A in the Alternative Model for Personality Disorders.

J Pers Disord 2019 Nov 4:1-22. Epub 2019 Nov 4.

Department of Mental Health, Sorlandet Hospital, Arendal, Norway.

The Level of Personality Functioning Scale (LPFS) of the Alternative Model for Personality Disorders (AMPD) was formulated to assess the presence and severity of personality disorders (PDs). Moderate impairment (Level 2) in personality functioning, as measured by the LPFS, was incorporated into the AMPD as a diagnostic threshold for PD in Criterion A of the general criteria, as well as for the "any two areas present" rule for assigning a specific PD diagnosis. This study represents the first evaluation of the diagnostic decision rules for Criterion A, in a clinical sample ( = 282). The results indicate that an overall diagnostic threshold for PDs should be used with caution because it may not identify all PDs. The "any two areas present" rule proved to be a reasonable alternative, although this finding should be interpreted with caution because the LPFS does not measure the disorder-specific A criteria.
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http://dx.doi.org/10.1521/pedi_2019_33_455DOI Listing
November 2019

Level of personality functioning as a predictor of psychosocial functioning-Concurrent validity of criterion A.

Personal Disord 2020 03 3;11(2):79-90. Epub 2019 Oct 3.

Department of Psychiatry.

The alternative model for personality disorders (AMPD) in the defines personality functioning by assessment of impairment in Identity and Self-direction (Self component) and in Empathy and Intimacy (Interpersonal). These four domains constitute the Level of Personality Functioning Scale, a trans-diagnostic measure of PD severity. The association between the Level of Personality Functioning Scale and psychosocial impairment based on other previously established psychosocial functioning instruments has not been reported. A total of 317 individuals, including a representative clinical sample of 282 patients (192 with a personality disorder [PD] diagnosis), was evaluated with the Structured Clinical Interview for the AMPD Module I. Self-reported impairment was measured by the Work and Social Adjustment Scale (WSAS), and social and occupational impairment was assessed by the functioning score of the Global Assessment of Functioning scale (GAF-F). WSAS and GAF-F both correlated significantly with mean LPFS scores and the sum of PD criteria. For both measures, the mean LPFS was a stronger predictor for psychosocial impairment than the sum of PD criteria. Within the LPFS, the Self component was a better predictor than the Interpersonal component for both WSAS and GAF-F. For the four domains, the results diverged, with Identity as the strongest predictor by far for WSAS. Empathy was the only significant predictor for impairment evaluated by GAF-F, but its contribution to variance was not substantial. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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http://dx.doi.org/10.1037/per0000352DOI Listing
March 2020

Introduction to the Special Series on the Personality Functioning Component of the Alternative DSM-5 Model for Personality Disorders.

J Pers Assess 2018 Nov-Dec;100(6):565-570

c Department of Psychology, University of Detroit Mercy.

The Alternative DSM-5 Model for Personality Disorders (AMPD; American Psychiatric Association, 2013 ) was created to remedy the previously well-explicated limitations of the categorical DSM-IV personality disorders. The AMPD combines dimensional assessments of personality functioning (Criterion A) and traits (Criterion B), which can be used independently or together, and serve as the basis for defining six categorical disorder options. The Criterion A Level of Personality Functioning Scale (LPFS) defines a continuum characterized by the four elements of identity, self-direction, empathy, and intimacy. Empirical work related to the LPFS has been growing, and this Journal of Personality Assessment special series features reports from a variety of research groups around the world. These studies provide contributions for better understanding the reliability, validity, and utility of the LPFS, as well as describing new measures that have been created to investigate personality functioning.
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http://dx.doi.org/10.1080/00223891.2018.1491856DOI Listing
October 2019

The P-Factor and What It Means to Be Human: Commentary on Criterion A of the AMPD in HiTOP.

Authors:
Donna S Bender

J Pers Assess 2019 Jul-Aug;101(4):356-359. Epub 2018 Aug 30.

a CAPS for Counseling Services , Tulane University.

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http://dx.doi.org/10.1080/00223891.2018.1492928DOI Listing
December 2019

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

J Pers Assess 2018 Nov-Dec;100(6):630-641. Epub 2018 Aug 7.

g Department of Personality Psychiatry, Division of Mental Health and Addiction , Oslo University Hospital , Oslo , Norway.

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.
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http://dx.doi.org/10.1080/00223891.2018.1483377DOI Listing
October 2019

Personality and life events in a personality disorder sample.

Personal Disord 2017 Oct 31;8(4):376-382. Epub 2016 Oct 31.

Department of Psychiatry, Harvard Medical School.

Individuals with a personality disorder (PD) tend to experience more negative life events (NLEs) than positive life events (PLEs). In community samples, the Five Factor Model of personality (FFM) predicts both positive and negative life events. The present research examined whether FFM normal personality traits were associated with positive and negative life events among individuals with 1 of 4 PDs: avoidant, borderline, schizotypal, and obsessive-compulsive, and tested whether associations between the FFM of personality and PLEs and NLEs were similar across the 4 PD groups and a control group. Among aggregated PDs, neuroticism was positively associated with NLEs, whereas extraversion, openness to experience, and conscientiousness were positively associated with PLEs. Comparisons of each PD group to a control group of individuals with a major depressive disorder indicated that the FFM traits operated similarly across clinical samples with and without PD. Our findings indicate that normal personality traits can be used to help understand the lives of individuals with PD. (PsycINFO Database Record
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http://dx.doi.org/10.1037/per0000214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5411350PMC
October 2017

The Alternative DSM-5 Model for Personality Disorders: A Clinical Application.

Am J Psychiatry 2015 Jul;172(7):606-13

From the Department of Psychiatry, University of Arizona College of Medicine, Tucson; the Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York; the Department of Psychology, Texas A&M University, College Station; the Department of Psychiatry and Behavioral Sciences and Counseling and Psychological Services, Tulane University, New Orleans; the Menninger Clinic, Houston; and the Department of Psychiatry, Baylor College of Medicine, Houston.

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http://dx.doi.org/10.1176/appi.ajp.2015.14101220DOI Listing
July 2015

When is it time to move on? Rejoinder for "the ironic fate of the personality disorders in DSM-5".

Personal Disord 2013 Oct;4(4):354

Menninger Clinic.

Presents a rejoinder to comments by Silk (see record 2013-45025-005) and Zimmerman (see record 2013-45025-006) on the original article by Skodol et al. (see record 2013-45025-004) regarding personality disorders in the DSM-5. Here, Skodol et al. comment that many of the early decisions made by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) PPDWG and within the Personality and Personality Disorders Work Group (PPDWG) noted in Silk's commentary should be viewed in light of the original goals of the DSM-5, which included a break from past practices of "tinkering" with categorical criteria. In the end, a compromise hybrid dimensional-categorical model-the favored option of most personality disorder (PD) experts-was developed and was published in DSM-5 Section III. The "alternative model" preserves continuity with current clinical practice while also addressing numerous shortcomings of the exclusively categorical approach to PDs. The personality functioning and pathological trait components of the revised general criteria and the criteria for the six specific disorders and PD-TS are based on extensive data on the core features of PDs and the trait representation of personality pathology. The final model's thresholds for diagnosis, its criteria composition, and its decision rules are based for the first time on empirical data, unlike the diagnostic thresholds and decision rules for DSM-IV (now also in DSM-5 Section II), which for the most part are unsubstantiated. Thus, Zimmerman's comments to the contrary, the Section III alternative model has a greater empirical basis than much of what is in Section II and holds more promise for the future.
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http://dx.doi.org/10.1037/per0000054DOI Listing
October 2013

The ironic fate of the personality disorders in DSM-5.

Personal Disord 2013 Oct;4(4):342-9

Menninger Clinic.

An alternative model for the diagnosis of personality disorders (PDs), based on assessments of impairments in personality functioning and of pathological personality traits, was intended for the official classification in the Diagnostic and Statistical Manual for Mental Disorders-Fifth Edition (DSM-5), but was instead placed in Section III, "Emerging Measures and Models." This article attempts to describe forces in play during the development of DSM-5 that may have contributed to this outcome, from the perspectives of the Chair of the Personality and Personality Disorders Work Group (PPDWG) and three of its members. These include a failed imperative to shift away from the Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition (DSM-IV) categories toward a dimensional perspective on psychopathology, dynamics within the American Psychiatric Association DSM-5 Task Force and PPDWG and the roles and impact of individuals and groups in the PD community. From these considerations, we present some suggestions for how the field might move forward in the future. A new opportunity exists to use the proposed alternative model as a foundation for research. In the immediate future, with the existence of two different models of PDs in DSM-5, studies can be done comparing the models to each other and to other models with respect to reliability and antecedent, concurrent, and predictive validity. If the Section III model continues to perform as early studies suggest, it may migrate into Section II of a planned DSM-5.1. This valuable research, already underway, will shape future editions of the DSM, by providing data to articulate a clearer vision, with broader representation of reliable and valid models. Going forward, personal investments must be put aside for the benefit of the greater good.
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http://dx.doi.org/10.1037/per0000029DOI Listing
October 2013

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

J Pers Assess 2014 13;96(4):397-409. Epub 2013 Nov 13.

a Department of Psychology , University of Kassel , Germany.

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.
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http://dx.doi.org/10.1080/00223891.2013.852563DOI Listing
February 2015

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

J Nerv Ment Dis 2013 Sep;201(9):729-35

Department of Psychology, Texas A&M University, College Station, TX 77843-4235, USA.

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.
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http://dx.doi.org/10.1097/NMD.0b013e3182a20ea8DOI Listing
September 2013

Narcissistic personality disorder in DSM-5.

Personal Disord 2014 Oct 8;5(4):422-7. Epub 2013 Jul 8.

Department of Psychology, Texas A&M University.

The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. Therefore, the diagnosis of Section II narcissistic personality disorder (NPD) will perpetuate all of the well-enumerated shortcomings associated with the diagnosis since DSM-III. In this article, we will briefly review problems associated with Section II NPD and then discuss the evolution of a new model of personality disorder and the place in the model of pathological narcissism and NPD. The new model was intended to be the official approach to the diagnosis of personality pathology in DSM-5, but was ultimately placed as an alternative in Section III for further study. The new model is a categorical-dimensional hybrid based on the assessment of core elements of personality functioning and of pathological personality traits. The specific criteria for NPD were intended to rectify some of the shortcomings of the DSM-IV representation by acknowledging both grandiose and vulnerable aspects, overt and covert presentations, and the dimensionality of narcissism. In addition, criteria were assigned and diagnostic thresholds set based on empirical data. The Section III representation of narcissistic phenomena using dimensions of self and interpersonal functioning and relevant traits offers a significant improvement over Section II NPD.
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http://dx.doi.org/10.1037/per0000023DOI Listing
October 2014

An ecumenical approach to conceptualizing and studying the core of personality psychopathology: a commentary on Hopwood et al.

Authors:
Donna S Bender

J Pers Disord 2013 Jun;27(3):311-9

Department of Psychiatry, University of Arizona College of Medicine, USA.

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http://dx.doi.org/10.1521/pedi.2013.27.3.311DOI Listing
June 2013

Socioeconomic-status and mental health in a personality disorder sample: the importance of neighborhood factors.

J Pers Disord 2013 Dec 17;27(6):820-31. Epub 2012 Sep 17.

This cross-sectional study examined the associations between neighborhood-level socioeconomic-status (NSES), and psychosocial functioning and personality pathology among 335 adults drawn from the Collaborative Longitudinal Personality Disorders Study. Participants belonged to four personality disorder (PD) diagnostic groups: Avoidant, Borderline, Schizotypal, and Obsessive Compulsive. Global functioning, social adjustment, and PD symptoms were assessed following a minimum two-year period of residential stability. Residence in higherrisk neighborhoods was associated with more PD symptoms and lower levels of functioning and social adjustment. These relationships were consistent after controlling for individual-level socioeconomic-status and ethnicity; however, the positive association between neighborhood-level socio-economic risk and PD symptoms was evident only at higher levels of individual-level socio-economic risk. Our findings identify NSES as a candidate for explaining some of the variability in symptoms and functioning among PD individuals.
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http://dx.doi.org/10.1521/pedi_2012_26_061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4628287PMC
December 2013

Toward a model for assessing level of personality functioning in DSM-5, part II: empirical articulation of a core dimension of personality pathology.

J Pers Assess 2011 Jul;93(4):347-53

Department of Psychology, Texas A&M University, College Station, TX 77843–4235, USA.

The extensive comorbidity among Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]; American Psychiatric Association, 1994 ) personality disorders might be compelling evidence of essential commonalities among these disorders reflective of a general level of personality functioning that in itself is highly relevant to clinical decision making. This study sought to identify key markers of such a level, thought to reflect a core dimension of personality pathology involving impairments in the capacities of self and interpersonal functioning, and to empirically articulate a continuum of severity of these problems for DSM-5. Using measures of hypothesized core dimensions of personality pathology, a description of a continuum of severity of personality pathology was developed. Potential markers at various levels of severity of personality pathology were identified using item response theory (IRT) in 2 samples of psychiatric patients. IRT-based estimates of participants' standings on a latent dimension of personality pathology were significantly related to the diagnosis of DSM-IV personality disorder, as well as to personality disorder comorbidity. Further analyses indicated that this continuum could be used to capture the distribution of pathology severity across the range of DSM-IV personality disorders. The identification of a continuum of personality pathology consisting of impairments in self and interpersonal functioning provides an empirical foundation for a "levels of personality functioning" rating proposed as part of a DSM-5 personality disorder diagnostic formulation.
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http://dx.doi.org/10.1080/00223891.2011.577853DOI Listing
July 2011

Toward a model for assessing level of personality functioning in DSM-5, part I: a review of theory and methods.

J Pers Assess 2011 Jul;93(4):332-46

Department of Psychiatry, University of Arizona College of Medicine, USA.

Personality disorders are associated with fundamental disturbances of self and interpersonal relations, problems that vary in severity within and across disorders. This review surveyed clinician-rated measures of personality psychopathology that focus on self-other dimensions to explore the feasibility and utility of constructing a scale of severity of impairment in personality functioning for DSM-5. Robust elements of the instruments were considered in creating a continuum of personality functioning based on aspects of identity, self-direction, empathy, and intimacy. Building on preliminary findings (Morey et al., 2011 /this issue), the proposed Levels of Personality Functioning will be subjected to extensive empirical testing in the DSM-5 field trials and elsewhere. The resulting version of this severity measure is expected to have clinical utility in identifying personality psychopathology, planning treatment, building the therapeutic alliance, and studying treatment course and outcome.
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http://dx.doi.org/10.1080/00223891.2011.583808DOI Listing
July 2011

Mirror, mirror on the wall: reflecting on narcissism.

Authors:
Donna S Bender

J Clin Psychol 2012 Aug 21;68(8):877-85. Epub 2012 Jun 21.

University of Arizona, USA.

This article introduces a special issue of the Journal of Clinical Psychology: In Session focused on the conceptualization and treatment of narcissism. Obscured by an ongoing debate about how best to define pathological narcissism, clinicians have often lost sight of the fact that narcissistic investment in the self is a normal developmental trend that can be disturbed to varying degrees by environmental stresses and failures of nurturing. Using case presentations, contributing authors demonstrate the following: the importance of understanding the closely interrelated grandiosity and vulnerability associated with narcissistic difficulties; variation in the expression of narcissistic "types"; the role of perfectionism and sadomasochism; and the possibility that narcissistic issues are present across all types of personality psychopathology. Specific alliance-building recommendations are offered, and the greater utility of defining narcissism dimensionally rather than categorically is explored. A clinical case in the current article illustrates each of these central ideas. Together, the discussions presented in this issue invite greater insight into, and appreciation of, narcissistic phenomena, along with examples of effective and empathic treatment approaches.
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http://dx.doi.org/10.1002/jclp.21892DOI Listing
August 2012

Personality disorder types proposed for DSM-5.

J Pers Disord 2011 Apr;25(2):136-69

University of Arizona College of Medicine and Sunbelt Collaborative, 6340 N. Campbell Ave., Tucson, AZ 85718, USA.

The Personality and Personality Disorders Work Group has proposed five specific personality disorder (PD) types for DSM-5, to be rated on a dimension of fit: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal. Each type is identified by core impairments in personality functioning, pathological personality traits, and common symptomatic behaviors. The other DSM-IV-TR PDs and the large residual category of personality disorder not otherwise specified (PDNOS) will be represented solely by the core impairments combined with specification by individuals' unique sets of personality traits. This proposal has three main features: (1) a reduction in the number of specified types from 10 to 5; (2) description of the types in a narrative format that combines typical deficits in self and interpersonal functioning and particular configurations of traits and behaviors; and (3) a dimensional rating of the degree to which a patient matches each type. An explanation of these modifications in approach to diagnosing PD types and their justifications--including excessive co-morbidity among DSM-IV-TR PDs, limited validity for some existing types, lack of specificity in the definition of PD, instability of current PD criteria sets, and arbitrary diagnostic thresholds--are the subjects of this review.
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http://dx.doi.org/10.1521/pedi.2011.25.2.136DOI Listing
April 2011

Proposed changes in personality and personality disorder assessment and diagnosis for DSM-5 Part II: Clinical application.

Personal Disord 2011 Jan;2(1):23-40

Department of Psychiatry, University of Arizona, College of Medicine, Tucson, USA.

The four-part assessment of personality psychopathology proposed for DSM-5 focuses attention on identifying personality psychopathology with increasing degrees of specificity, based on a clinician's available time, information, and expertise. In Part I of this two-part article, we described the components of the new model and presented brief rationales for them. In Part II, we illustrate the clinical application of the model with vignettes of patients with varying degrees of personality psychopathology, selected from the DSM-IV-TR Casebook, to show how assessments might be conducted and diagnoses reached.
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http://dx.doi.org/10.1037/a0021892DOI Listing
January 2011

Proposed changes in personality and personality disorder assessment and diagnosis for DSM-5 Part I: Description and rationale.

Personal Disord 2011 Jan;2(1):4-22

Department of Psychiatry, University of Arizona, College of Medicine, Tucson, USA.

A major reconceptualization of personality psychopathology has been proposed for DSM-5 that identifies core impairments in personality functioning, pathological personality traits, and prominent pathological personality types. A comprehensive personality assessment consists of four components: levels of personality functioning, personality disorder types, pathological personality trait domains and facets, and general criteria for personality disorder. This four-part assessment focuses attention on identifying personality psychopathology with increasing degrees of specificity, based on a clinician's available time, information, and expertise. In Part I of this two-part article, we describe the components of the new model and present brief theoretical and empirical rationales for each. In Part II, we will illustrate the clinical application of the model with vignettes of patients with varying degrees of personality psychopathology, to show how assessments might be conducted and diagnoses reached.
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http://dx.doi.org/10.1037/a0021891DOI Listing
January 2011

Personality disorders predict relapse after remission from an episode of major depressive disorder: a 6-year prospective study.

J Clin Psychiatry 2010 Dec 15;71(12):1629-35. Epub 2010 Jun 15.

Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519, USA.

Objective: To examine prospectively the course of major depressive disorder (MDD) and to test for the moderating effects of personality disorder (PD) comorbidity on relapse after remission from an episode of MDD.

Method: Participants were 303 patients (196 women and 107 men) with current DSM-IV-diagnosed MDD at baseline enrollment in the Collaborative Longitudinal Personality Disorders Study. Major depressive disorder and Axis I psychiatric disorders were assessed with the Structured Clinical Interview for DSM-IV, and Axis II PDs were assessed with the Diagnostic Interview for DSM-IV Personality Disorders. The course of MDD was assessed with the Longitudinal Interval Follow-up Evaluation at 6 and 12 months and then yearly through 6 years. Survival analyses were used to analyze time to remission and time to relapse. The study was conducted from July 1996 to June 2005.

Results: Of 303 patients, 260 (86%) remitted from MDD; life table survival analyses revealed that patients with MDD who had PDs at baseline had significantly longer time to remission from MDD than patients without PDs. Among the 260 patients whose MDD remitted, 183 (70%) relapsed. Patients with MDD with PDs-specifically those with borderline and obsessive-compulsive PDs-at baseline had significantly shorter time to relapse than patients with MDD without PDs. Cox proportional hazards regression analyses revealed that the presence of PDs at baseline (hazard ratio = 1.5) and recurrent-type MDD (hazard ratio = 2.2), but not sex (hazard ratio = 1.03) or dysthymic disorder (hazard ratio = 0.97), significantly predicted time to relapse.

Conclusions: Personality disorders at baseline were robust predictors prospectively of accelerated relapse after remission from an episode of MDD. Personality disorders at baseline significantly moderated eventual time to relapse in MDD among patients who remitted from an episode of MDD, even when controlling for other potential negative prognostic predictors.
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http://dx.doi.org/10.4088/JCP.08m04200greDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4615714PMC
December 2010

The future of personality disorders in DSM-V?

Am J Psychiatry 2009 Apr;166(4):388-91

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http://dx.doi.org/10.1176/appi.ajp.2009.09010090DOI Listing
April 2009

Ethnicity and mental health treatment utilization by patients with personality disorders.

J Consult Clin Psychol 2007 Dec;75(6):992-9

Institute for Mental Health Research, USA.

The authors examined the relationship between ethnicity and treatment utilization by individuals with personality disorders (PDs). Lifetime and prospectively determined rates and amounts of mental health treatments received were compared in over 500 White, African American, and Hispanic participants with PDs in a naturalistic longitudinal study. Minority, especially Hispanic, participants were significantly less likely than White participants to receive a range of outpatient and inpatient psychosocial treatments and psychotropic medications. This pattern was especially pronounced for minority participants with more severe PDs. A positive support alliance factor significantly predicted the amount of individual psychotherapy used by African American and Hispanic but not White participants, underscoring the importance of special attention to the treatment relationship with minority patients. These treatment use differences raise complex questions about treatment assessment and delivery, cultural biases of the current diagnostic system, and possible variation in PD manifestation across racial/ethnic groups. Future studies need to assess specific barriers to adequate and appropriate treatments for minority individuals with PDs.
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http://dx.doi.org/10.1037/0022-006X.75.6.992DOI Listing
December 2007

Borderline personality as a self-other representational disturbance.

J Pers Disord 2007 Oct;21(5):500-17

Columbia University College of Physicians and Surgeons, New York State Psychiatric Institute, USA.

A great deal has been written about the nature of borderline personality. We maintain that borderline psychopathology emanates from particular disturbances in mental representations-impairment in the ability to maintain and use benign and integrated internal images of self and others-and that these troubled ways of thinking drive the troubled interpersonal relations, affective instability, and impulsivity associated with borderline. Aspects of borderline self-other representational disturbances are present across a wide theoretical spectrum, and a number of research methodologies already exist to assess the phenomena. We conclude that borderline attributes exist on continua, and summarize important features as: (1) unstable mental images of self and others, often marked by self-loathing and attributions of malevolence to others; (2) interactions with others organized around a fundamental need for care that is felt to be necessary for basic functioning; (3) fear of others based on expectations of being mistreated and disappointed and/or terror of having one's identity subsumed by another person; (4) difficulty considering multiple and/or conflicting perspectives, with a tendency toward concrete, all-or-none, or black-and-white, thinking and distortion of reality; and (5) sadomasochistic interpersonal interactions in which a person alternatively inflicts suffering on others and suffers at the hands of others.
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http://dx.doi.org/10.1521/pedi.2007.21.5.500DOI Listing
October 2007

Longitudinal diagnostic efficiency of DSM-IV criteria for borderline personality disorder: a 2-year prospective study.

Can J Psychiatry 2007 Jun;52(6):357-62

Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut 06520, USA.

Objective: To examine the longitudinal diagnostic efficiency of the DSM-IV criteria for borderline personality disorder (BPD).

Methods: At baseline, we used semistructured diagnostic interviews to determine criteria and diagnoses; blinded assessments were performed 24 months later with 550 participants. Diagnostic efficiency indices (specifically, conditional probabilities, total predictive power, and kappa) were calculated for each criterion determined at baseline, with the independent BPD diagnosis at follow-up used as the standard.

Results: Longitudinal diagnostic efficiencies for the BPD criteria varied, with the criteria of suicidality or self-injury and unstable relationships demonstrating the most predictive utility.

Conclusions: BPD criteria differ in their predictive utility for the diagnosis of BPD when considered longitudinally. These findings have implications both for clinicians who are considering diagnoses and for researchers concerned with forthcoming revisions of our nosological system.
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http://dx.doi.org/10.1177/070674370705200604DOI Listing
June 2007

Positive childhood experiences: resilience and recovery from personality disorder in early adulthood.

J Clin Psychiatry 2007 Jul;68(7):1102-8

New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, New York, USA.

Objective: Recent follow-along studies of personality disorders have shown significant improvement in psychopathology over time. The purpose of this study was to prospectively investigate the association between positive childhood experiences related to resiliency and remission from personality disorder.

Method: Five hundred twenty patients with DSM-IV-based semistructured interview diagnoses of schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders were evaluated 6 times over 4 years between September 1996 and June 2002. Positive childhood experiences, including achievements, positive interpersonal relationships with others, and caretaker competencies, were measured using the Childhood Experiences Questionnaire-Revised. The effects of positive childhood experiences on clinically significant remission from personality disorder were determined using survival and proportional hazard regression analyses.

Results: Positive achievement experiences and positive interpersonal relationships during childhood or adolescence were significantly associated with remission from avoidant and schizo-typal personality disorders. The greater the number of positive experiences and the broader the developmental period they spanned, the better the prognosis of these personality disorders.

Conclusions: The prognosis of certain personality disorders is better in patients whose developmental histories include positive experiences. Early treatment designed to foster personal strengths and competencies and to develop interpersonal skills might benefit young patients diagnosed with personality disorders.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705622PMC
http://dx.doi.org/10.4088/jcp.v68n0719DOI Listing
July 2007

Predictors of 2-year outcome for patients with borderline personality disorder.

Am J Psychiatry 2006 May;163(5):822-6

McLean Hospital, 155 Mill St., Belmont, MA 02478, USA.

Objective: The primary purpose of this report was to investigate whether characteristics of subjects with borderline personality disorder observed at baseline can predict variations in outcome at the 2-year follow-up.

Method: Hypothesized predictor variables were selected from prior studies. The patients (N=160) were recruited from the four clinical sites of the Collaborative Longitudinal Personality Disorders Study. Patients were assessed at baseline and at 6, 12, and 24 months with the Structured Clinical Interview for DSM-IV Axis I Disorders; the Diagnostic Interview for DSM-IV Personality Disorders, a modified version of that instrument; the Longitudinal Interval Follow-Up Evaluation; and the Childhood Experiences Questionnaire-Revised. Univariate Pearson's correlation coefficients were calculated on the primary predictor variables, and with two forward stepwise regression models, outcome was assessed with global functioning and number of borderline personality disorder criteria.

Results: The authors' most significant results confirm prior findings that more severe baseline psychopathology (i.e., higher levels of borderline personality disorder criteria and functional disability) and a history of childhood trauma predict a poor outcome. A new finding suggests that the quality of current relationships of patients with borderline personality disorder have prognostic significance.

Conclusions: Clinicians can estimate 2-year prognosis for patients with borderline personality disorder by evaluating level of severity of psychopathology, childhood trauma, and current relationships.
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http://dx.doi.org/10.1176/ajp.2006.163.5.822DOI Listing
May 2006

Prospective assessment of treatment use by patients with personality disorders.

Psychiatr Serv 2006 Feb;57(2):254-7

Department of Psychiatry, New York State Psychiatric Institute, Columbia University College of Physicians and Surgeons, 1051 Riverside Drive, New York, New York 10032, USA.

Objective: This study examined the utilization of mental health treatments over a three-year period among patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorders compared with patients with major depressive disorder and no personality disorder.

Methods: A prospective, longitudinal study design was used to measure treatment use for 633 individuals aged 18 to 45 years during a three-year period.

Results: Patients with borderline personality disorder were significantly more likely than those with major depressive disorder to use most types of treatment. Furthermore, all patients continued using high-intensity, low-duration treatments throughout the study period, whereas individual psychotherapy attendance declined significantly after one year.

Conclusions: Although our data showed that patients with borderline personality disorder used more mental health services than those with major depressive disorder, many questions remain about the adequacy of the treatment received by all patients with personality disorders.
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http://dx.doi.org/10.1176/appi.ps.57.2.254DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2705621PMC
February 2006
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