Journal of Personality Assessment

ISSN: 0022-3891 (Print) 1532-7752 (Online) Journal homepage: http://www.tandfonline.com/loi/hjpa20

Assessment of DSM–5 Personality Disorder Thomas A. Widiger To cite this article: Thomas A. Widiger (2015) Assessment of DSM–5 Personality Disorder, Journal of Personality Assessment, 97:5, 456-466, DOI: 10.1080/00223891.2015.1041142 To link to this article: http://dx.doi.org/10.1080/00223891.2015.1041142

Published online: 26 May 2015.

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Date: 30 September 2015, At: 04:04

Journal of Personality Assessment, 97(5), 456–466, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 0022-3891 print / 1532-7752 online DOI: 10.1080/00223891.2015.1041142

SPECIAL SECTION: Personality Assessment and the DSM: A Match Made in Heaven?

Assessment of DSM–5 Personality Disorder THOMAS A. WIDIGER

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Department of Psychology, University of Kentucky The purpose of this article is to present an approach to defining, identifying, and assessing personality disorders, including the links between these definitions and personality assessment, with a particular reference to the proposed revisions to the personality disorders section of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM–5]; American Psychiatric Association, 2013). The article discusses measures of maladaptive variants of the Five-factor model (FFM) that are coordinated with both the traditional personality disorder syndromes as well as the DSM–5 dimensional trait model. Discussed as well is the assessment of the more psychodynamically oriented deficits in sense of self and interpersonal relatedness that are also included within the hybrid model proposed for DSM–5.

The Personality and Personality Disorders Work Group for the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders proposed a new approach for diagnosis, referred to as a “hybrid model” (Skodol, 2012, p. 35). The hybrid model combines maladaptive personality traits (Krueger, Derringer, Markon, Watson, & Skodol, 2012) with self and interpersonal deficits, the latter written in large part from a psychodynamic perspective concerning hypothesized core features of a personality disorder (Bender, Morey, & Skodol, 2011; Kernberg, 2012; Pincus, 2011). The hybrid model has the appearance, if not the reality, of being a compromise among committee members who had originally proposed two alternative, independent methods for obtaining a personality disorder diagnosis. The hybrid model was not the initial proposal. The initial proposal (American Psychiatric Association, 2010b) included three independent components: an assessment of level of personality functioning that focused in particular on deficits in the sense of self and interpersonal relatedness (Bender et al., 2011); narrative descriptions of each personality disorder (Westen, Shedler, & Bradley, 2006); and a dimensional trait model (Clark & Krueger, 2010). The maladaptive trait model was presented as one means for diagnosing a personality disorder (Clark & Krueger, 2010); the prototype narrative was presented as another means to diagnose the same personality disorders (Skodol, 2010). It was not clear what the clinician would do if the trait and narrative models were in disagreement as to which personality disorder(s) were present, but the prototype narratives appeared likely to serve as the primary basis for diagnosis (American Psychiatric Association, 2010b). The dimensional trait model was to be used primarily to cover what was referred to in the Diagnostic and Statistical Manual

Received September 2, 2014; Revised January 14, 2015. Address correspondence to Thomas A. Widiger, Department of Psychology, University of Kentucky, 115 Kastle Hall, Lexington, KY 40506-0044; Email: [email protected]

of Mental Disorders (4th ed., text rev. [DSM–IV–TR; American Psychiatric Association, 2000) as personality disorder not otherwise specified (PDNOS) or what would have been called in DSM–5, “personality trait, specified” (Skodol, 2010). The prototype narrative proposal was eventually withdrawn, due in large part to concerns regarding the validity and reliability of narrative prototype matching (Pilkonis, Hallquist, Morse, & Stepp, 2011; Widiger, 2011; Zimmerman, 2011). The DSM–5 work group, though, did not return to the specific and explicit criterion sets of DSM–IV–TR. They instead cobbled together new criterion sets for the antisocial, avoidant, borderline, narcissistic, obsessive–compulsive and schizotypal personality disorders, that combined maladaptive traits from the dimensional trait model proposal (i.e., Criterion B) with specific deficits in self and interpersonal functioning from the level of personality functioning proposal (Criterion A). An obvious assumption of this hybrid proposal is that neither Criterion A nor B are sufficient for the diagnosis of a personality disorder and that each provides separate, independent information. An important focus of future research will be the extent to which this is actually true. Discussed herein is the assessment of personality disorders primarily on the basis of maladaptive personality traits, followed by a discussion of the integration of the maladaptive traits with the self and interpersonal deficits.

FIVE-FACTOR MODEL MALADAPTIVE TRAIT SCALES The DSM–5 dimensional trait model consists of the five broad domains of negative affectivity, detachment, psychoticism, antagonism, and disinhibition. As stated in DSM–5, “these five broad domains are maladaptive variants of the five domains of the extensively validated and replicated personality model known as the ‘Big Five,’ or the Five Factor Model of personality” (American Psychiatric Association, 2013, p. 773). A common criticism of the Five-factor model (FFM), at least with respect to providing a description or assessment of personality disorders, has been that existing FFM measures

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ASSESSMENT OF DSM–5 PERSONALITY DISORDER have lacked fidelity for the assessment of its maladaptive variants (e.g., Krueger et al., 2011; Reynolds & Clark, 2001). This concern no longer applies, as the field now has a number of alternative measures with which to assess maladaptive variants of the FFM (e.g., De Clercq, De Fruyt, Van Leeuwen, & Mervielde, 2006; Krueger et al., 2012; Lynam, 2012; Rojas & Widiger, 2014; Simms et al., 2011). The self-report NEO Personality Inventory–Revised (NEO PI–R; Costa & McCrae, 1992) does provide an assessment of maladaptive variants of high neuroticism, low extraversion, low openness, high antagonism, and low conscientiousness (Haigler & Widiger, 2001), and these are the poles of the FFM that are primarily involved for most (but not all) of the personality disorders (Lynam & Widiger, 2001). It is largely for this reason that the NEO PI–R, a measure of normal (or general) personality functioning, has in fact been quite effective for the assessment of most of the personality disorders (Miller, 2012). The exceptions tend to be the assessment of the dependent, obsessive–compulsive, schizotypal, and histrionic personality disorders (Miller, 2012), as these personality disorders include significant components of maladaptive agreeableness, conscientiousness, openness, and extraversion, respectively (Lynam & Widiger, 2001; Samuel & Widiger, 2004), and the NEO PI– R is sorely limited in its coverage of the maladaptive variants of these poles of the FFM domains (Haigler & Widiger, 2001; Shedler & Westen, 2004). In fact, the NEO PI–R is also limited in its coverage of the maladaptive variants of some of the other poles. For example, absent from its assessment of neuroticism is affective instability as well as the full range of borderline personality disorder anger, vulnerability, and depressiveness (Mullins-Sweatt, Edmundson, et al., 2012). The Structured Interview for the Five-Factor Model (SIFFM; Trull et al., 1998) was modeled after the NEO PI–R (Costa & McCrae, 1992), albeit developed in part to increase somewhat the coverage of maladaptive variants of low neuroticism, high extraversion, high openness, high agreeableness, and high conscientiousness. However, the SIFFM has not been used that often, given perhaps the preference within general personality research for self-report inventories relative to structured interviews. In addition, although the SIFFM provides more coverage of maladaptive variants of the FFM than is provided by the NEO PI–R, the SIFFM does not provide as much coverage as would be needed for all of the DSM–IV (now DSM–5) personality disorders. De Clercq et al. (2006) modeled the development of the Dimensional Personality Symptom Item Pool (DIPSI) after the SIFFM. They constructed items to assess maladaptive variants of facets within the Hierarchical Personality Inventory for Children (HiPIC; Mervielde & De Fruyt, 2002), which is a parental rating scale for the assessment of personality traits in children. The HiPIC provides an assessment of FFM traits within children and adolescents but it is confined to the normal range, comparable to the NEO PI–R. The DIPSI provides an assessment of the maladaptive variants of HiPIC items and scales. Together they provide an integrative assessment of normal and abnormal personality functioning in children and adolescents from the perspective of the FFM (De Clercq & De Fruyt, 2003). The original version of the DIPSI did not include an assessment of maladaptive variants of HiPIC imagination. However, a revised version of the DIPSI now includes

457 maladaptive variants of imagination (De Fruyt & De Clercq, 2013, 2014). Simms et al. (2011) developed a self-report measure of maladaptive variants of the FFM, titled the Computerized Adaptive Test–Personality Disorder (CAT–PD). The instrument includes 33 scales, such as Manipulativeness (from antagonism), Romantic Disinterest (from introversion), Exhibitionism (from extraversion), and Perfectionism (from conscientiousness). Initial validation research suggests that its scales align well with the FFM domains, albeit not surprisingly, the convergence of the schizotypal thinking scales with FFM openness were relatively weaker (Wright & Simms, 2014). The Personality Inventory for DSM–5 (PID–5; Krueger et al., 2012) assesses the DSM–5 maladaptive personality trait domains of negative affectivity, detachment, psychoticism, antagonism, and disinhibition via self-report. “These domains can be understood as maladaptive variants of the domains of the five-factor model of personality (FFM)” (Krueger & Markon, 2014, p. 487). Beneath the five domains are 25 trait scales that align closely with the CAT–PD scales (Wright & Simms, 2014). In fact, all but 3 of the 25 PID–5 scales are included in the CAT–PD. The CAT–PD has more coverage, in that it includes 33 scales, relative to the 25 of the PID–5, although the CAT–PD does not appear to have scales that are equivalent to PID–5 Attention-Seeking, Perseveration, or Distractibility. The PID–5, in turn, does not appear to have scales equivalent to the CAT–PD Cognitive Problems, Domineering, Exhibitionism, Fantasy Proneness, Health Anxiety, Rudeness, SelfHarm, Norm-Violation, or Workaholism scales. Some of this reflects not only the greater number of scales within the CAT– PD, but also its inclusion of maladaptive variants of extraversion (i.e., Domineering and Exhibitionism) and conscientiousness (i.e., Workaholism). A potential limitation of the PID–5 is that it is confined largely to just 5 of the 10 poles of the FFM. In this regard the PID–5 is well aligned with the NEO PI–R. Both the PID–5 and the NEO PI–R are confined largely to maladaptive variants of high neuroticism, low extraversion, low agreeableness, and low conscientiousness, with little to no representation of maladaptive variants of low neuroticism, high extraversion, high agreeableness, or high conscientiousness. However, unlike the NEO PI–R, the PID–5 assesses for maladaptive high openness, rather than maladaptive low openness, contributing to the weaker convergence of PID–5 Psychoticism with NEO PI–R Openness (Gore & Widiger, 2013). The PID–5, though, does include one scale for maladaptive high conscientiousness (i.e., Rigid Perfectionism). It also includes Restricted Affectivity as a maladaptive variant of low neuroticism (Krueger et al., 2012), although this scale is perhaps more accurately placed within introversion (Widiger, Costa, & McCrae, 2013). It also includes a Submissiveness scale that can be understood as a maladaptive variant of agreeableness (Gore & Pincus, 2013; Lowe, Edmundson, & Widiger, 2009), albeit placed within negative affectivity in the DSM–5 dimensional trait model (Krueger et al., 2012) and, finally, Attention-Seeking, which might be understood as a maladaptive variant of extraversion (Gore, Tomiatti, & Widiger, 2011), albeit placed within antagonism in DSM–5. Nevertheless, despite these potential exceptions, there remains relatively little representation of low neuroticism, high

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458 extraversion, low openness, high agreeableness, or high conscientiousness, which perhaps limits the ability to cover significant traits of some personality disorders, such as obsessive–compulsive (Crego, Samuel, & Widiger, 2015) and psychopathy (Crego & Widiger, in press). There is also a Clinician Rating Form for a clinician’s assessment of the DSM–5 dimensional trait model on the basis of an unstructured clinical interview (American Psychiatric Association, 2010a). However, this measure is no longer posted on the DSM–5 Web site. There are also other abbreviated measures of the FFM, such as the Five-Factor Model Rating Form (FFMRF; Mullins-Sweatt, Jamerson, Samuel, Olson, & Widiger, 2006). The FFMRF is a one-page rating form that includes an assessment of all 30 of the NEO PI–R FFM facets. The FFMRF has been used in a number of studies as a clinician rating form and as a self-report inventory (Samuel, Mullins-Sweatt, & Widiger, 2013). A limitation of the FFMRF is that it does not provide adequate coverage of the maladaptive variants of the FFM. Rojas and Widiger (2014) therefore developed the Five Factor Form (FFF). The FFF is again a one-page rating form that can be used by clinicians to describe their patients or as a self-report. It includes all 30 NEO PI–R FFM facets and, unique to this measure, maladaptive variants for all 60 poles of all 30 facets. For example, for the facet of modesty (from Agreeableness), a score of 5 indicates “self-effacing, self-denigrating,” a score of 4 is “humble, modest, unassuming,” 3 is neutral, 2 is “confident, self-assured,” and 1 is “boastful, vain, pretentious, arrogant.” For the facet of achievement-striving (from Conscientiousness), 5 indicates “workaholic, acclaim-seeking,” 4 is “purposeful, diligent, ambitious,” 3 is neutral, 2 is “carefree, content,” and 1 is “aimless, shiftless, desultory.” Rojas and Widiger (2014) provided initial research concerning its validity as a measure of the FFM. There are also eight self-report inventories constructed to assess DSM–IV–TR (now DSM–5) personality disorders from the perspective of the FFM. The FFM of personality disorder does not suggest or imply that the personality traits included within the DSM–IV–TR diagnostic categories do not exist, only that they might be better understood dimensionally rather than categorically and, more specifically, as maladaptive variants of the more normal traits within the FFM (Widiger & Costa, 2013). To the extent that a DSM–IV–TR personality disorder can be understood as a maladaptive variant of FFM personality structure, a natural step is to develop a measure of that personality disorder from this theoretical perspective (Lynam, 2012). Lynam et al. (2011) developed the Elemental Psychopathy Assessment (EPA) as a measure of psychopathy from the perspective of the FFM. Working from a consensus profile of psychopathy in terms of 18 facets of the FFM, the authors developed relatively brief scales to assess more maladaptive, extreme, or psychopathy-specific manifestations of each respective FFM facet. The EPA was then validated against the NEO PI–R and measures of psychopathy (Lynam et al., 2011). The development of the EPA was followed by a measure of schizotypal personality disorder from the perspective of the FFM (i.e., Five Factor Schizotypal Inventory [FFSI]; Edmundson, Lynam, Miller, Gore, & Widiger, 2011) and then a measure of histrionic personality disorder from the perspective of the FFM (Five

WIDIGER Factor Histrionic Inventory [FFHI]; Tomiatti, Gore, Lynam, Miller, & Widiger, 2012). A special section of the Journal of Personality Assessment (Widiger, Lynam, Miller, & Oltmanns, 2012) was devoted to the initial validation studies for the Five Factor Borderline Inventory (FFBI; Mullins-Sweatt, Edmundson, et al., 2012), the Five Factor Avoidant Assessment (FFAvA; Lynam, Loehr, Miller, & Widiger, 2012), the Five Factor Dependency Inventory (FFDI; Gore, Presnall, Lynam, Miller, & Widiger, 2012), the Five Factor Narcissism Inventory (FFNI; Glover, Miller, Lynam, Crego, & Widiger, 2012), and the Five Factor Obsessive Compulsive Inventory (FFOCI; Samuel, Riddell, Lynam, Miller, & Widiger, 2012). Each of these FFM personality disorder (FFMPD) scales was constructed by first identifying which facets of the FFM (as included within the NEO PI–R) appear to be most relevant for each respective personality disorder. The source for this information was obtained from researchers’ descriptions of each respective personality disorder in terms of the FFM (i.e., Lynam & Widiger, 2001), clinicians’ FFM descriptions of each personality disorder (i.e., Samuel & Widiger, 2004), and FFM personality disorder research (e.g., Samuel & Widiger, 2008). FFMPD scales were then constructed to assess the maladaptive variants of the facets that were specific to each respective personality disorder (e.g., for the FFOCI, perfectionism, workaholism, punctiliousness, and doggedness as maladaptive variants of facets of conscientiousness). The FFMPD scales were subsequently validated by demonstrating their convergence with both their respective parent FFM facet and alternative measures of the respective personality disorder. Finally, each of the FFMPD measures was shown to have incremental validity over normal personality assessment in accounting for personality disorder pathology, as well as incremental validity over alternative measures of the respective personality disorder. Additional validation studies have been published concerning the EPA (Miller et al., 2011; Wilson, Miller, Zeichner, Lynam, & Widiger, 2011), the FFNI (Miller, Few, et al., 2013; Miller, Gentile, & Campbell, 2013; Miller et al., in press), the FFOCI (Crego et al., 2015), and the FFBI (DeShong, Lengel, SauerZavala, O’Meara, & Mullins-Sweatt, in press). The approach taken in the construction of these FFMPD scales, to disambiguate DSM–IV–TR personality disorders in terms of FFM facets, helps to ensure that all of the maladaptive personality traits included within a respective DSM–IV– TR personality disorder are adequately covered within the FFM measures. It is evident that there remains considerable interest in these personality syndromes (Mullins-Sweatt, Bernstein, & Widiger, 2012; Shedler et al., 2010). These FFMPD scales provide a bridge, or a means of translation, between the DSM–IV–TR (now DSM–5) and the FFM. If future research with these FFMPD scales is confined to just their total scores, these scales will re-create much of the problems for the existing categories (e.g., heterogeneity of membership and diagnostic overlap), but a strength of these measures relative to many other DSM–IV self-report inventories is that these instruments can also be broken down into their subscales, thereby dismantling the heterogeneous syndromes into more distinctive component parts. It is evident, for example, that clinicians, when treating a personality disorder, do not address the entire personality structure with each intervention (Paris, 2006).

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ASSESSMENT OF DSM–5 PERSONALITY DISORDER Clinicians focus on underlying components, such as the dysregulated anger, the fragility, or the oppositionality of persons diagnosed with borderline personality disorder. These various components are assessed independently and specifically by the scales of the FFBI (Mullins-Sweatt, Edmundson, et al., 2012), providing considerably greater utility in clinical practice than the more global measures of borderline personality disorder (Mullins-Sweatt & Lengel, 2012). Table 1 provides a list of the FFMPD scales for the borderline (Mullins-Sweatt, Edmundson, et al., 2012), narcissistic (Glover et al., 2012), and obsessive–compulsive (Samuel et al., 2012) personality disorders, organized with respect to FFM domains and facets. Across the eight personality disorders covered to date, there is a maladaptive variant for all but 2 of the 30 NEO PI–R FFM facets. The two exceptions are activity from extraversion and aesthetics from openness to experience. The lack of a maladaptive variant of high or low activity reflects the lack of coverage of all possible maladaptive traits provided by the eight DSM–IV–TR personality disorders. With respect to aesthetics, there is perhaps unlikely to be a clinically meaningful maladaptive variant of high or low aesthetics. As is evident from Table 1, there are times when there is more than one scale for a respective FFM facet, such as Dysregulated Anger and Reactive Anger from the FFBI and FFNI, respectively (i.e., two different variants of FFM angry hostility), and Acclaim-Seeking and Workaholism from the FFNI

459 and FFOCI, respectively (two different variants of FFM achievement-striving). This reflects the fact that any particular FFM facet will be expressed or appear differently for a respective personality disorder. The anxiousness of dependency is not the same as the anxiousness of schizotypia. In fact, there are indeed five alternative variants of anxiousness: Social Anxiousness from the FFSI, Anxious Uncertainty from the FFBI, Relationship Anxiety from the FFDI, Evaluation Apprehension from the FFAvA, and Excessive Worry from the FFOCI. An important focus of future research would be to determine whether these measures of different variants of anxiousness do in fact have sufficient discriminant or incremental validity. The coverage across all of the personality disorders is substantial, with more than 100 total scales, far too many to include within any one particular study. Lack of adequate coverage is unlikely to be an issue for the full set of FFMPD scales. However, to facilitate usage, Lynam et al. (2013) developed an abbreviated version of the EPA. Research is currently in progress with respect to the development of abbreviated versions of the other measures. There are a number of cases wherein only one pole of a respective facet is represented, reflecting again the limited coverage provided by the eight personality disorders considered to date. Nevertheless, both poles of all five FFM domains are represented. It is anticipated that researchers and clinicians will want to select subsets of scales reflecting their particular interests. For example, a clinician or

Table 1.—Five-factor model scales for the borderline, narcissistic, and obsessive–compulsive personality disorders. DSM–IV Personality Disorder FFM Facets Neuroticism Anxiousness Angry hostility Depressiveness Self-consciousness Impulsivity Vulnerability Extraversion Warmth Gregariousness Assertiveness Excitement seeking Openness Fantasy Feelings Actions Values Agreeableness Straightforwardness Altruism Compliance Modesty Tender-mindedness Conscientiousness Competence Order Dutifulness Achievement striving Self-discipline Deliberation

Borderline

Narcissistic

Obsessive–Compulsive Excessive Worry

Dysregulated Rage Despondence Self Disturbance Behavioral Dysregulation Affective Dysregulation

Reactive Anger Shame, Indifference Need for Admiration Detached Coldness Exhibitionism Authoritative Risk Aversion

Dissociative Tendencies

Grandiose Fantasies Constricted Inflexibility Dogmatism

Manipulative

Manipulation Entitlement

Oppositional Arrogance Lack of Empathy

Acclaim-Seeking Rashness

Perfectionism Fastidious Punctilious Workaholism Doggedness Ruminative Deliberation

Note. FFM D Five-factor model. Scale titles shown in bold indicate high levels of a respective facet. Scales titles shown in italics indicate low levels of a respective facet.

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Table 2.—Maladaptive Five-factor model trait scales: Agreeableness versus antagonism. Agreeableness FFM Facet

Scale

Instrument

Trust

Suggestibility FFHI Gullibility FFDI Straightforwardness — Altruism Selflessness FFDI Compliance Modesty

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Tendermindedness

Antagonism

Subservience FFDI Self-Effacing FFDI Timorous FFAvA — —

Scale Cynicism Suspiciousness Manipulative Exploitative Entitlement Oppositional Vanity Arrogance Callous Lack of Empathy

Instrument EPA FFSI FFBI FFNI FFNI FFBI FFHI FFNI EPA FFNI

Note. FFM D Five-factor model; FFHI D Five Factor Histrionic Inventory (Tomiatti et al., 2012); EPA D Elemental Psychopathy Assessment (Lynam et al., 2011); FFDI D Five Factor Dependent Inventory (Gore et al., 2012); FFSI D Five Factor Schizotypal Inventory (Edmundson et al., 2011); FFBI D Five Factor Borderline Inventory (MullinsSweatt, Edmundson, et al., 2012); FFNI D Five Factor Narcissism Inventory (Glover et al., 2012); FFAvA D Five Factor Avoidant Assessment (Lynam et al., 2012).

researcher might be interested in assessing only for maladaptive variants of agreeableness, and would thereby confine the test administration to the FFDI Gullibility, Selflessness, Subservience, and Self-Effacing scales (Gore et al., 2012), as well as Suggestibility from the FFHI (Tomiatti et al., 2012). Table 2 provides illustrative scales organized with respect to the domain of agreeableness versus antagonism. Note that there are scales for both poles of the FFM, agreeableness as well as antagonism. Alternatively, the clinician or researcher might wish to consider only maladaptive variants of extraversion, including, for instance, the EPA Dominance and Thrill Seeking scales (Lynam et al., 2011), the FFNI Exhibitionism and Authoritativeness scales (Glover et al., 2012), or the FFHI Attention-Seeking, Social Butterfly, and Flirtatiousness scales (Tomiatti et al., 2012). Table 3 provides illustrative scales organized with respect to the domain of extraversion versus introversion, including again maladaptive variants of both poles. In sum, these FFMPD scales can be understood as measures of the respective personality disorders as well as measures of the FFM.

An additional advantage of these scales is indeed their conceptual and empirical coordination with the FFM, allowing researchers and clinicians who use them to relate their findings for a respective personality disorder to the FFM. Considering personality disorders from the perspective of the FFM is useful in the development of a more integrative understanding of normal and abnormal personality (Clark, 2007; Widiger & Trull, 2007). To the extent that disorders of personality are understood as maladaptive variants of FFM personality structure, one can bring to these personality disorders the extensive construct validity research concerning the genetics, childhood antecedents, course, universality, and positive and negative life outcomes identified for the FFM (Widiger & Costa, 2012, 2013).

FFM, MALADAPTIVE TRAITS, AND PSYCHODYNAMIC CONSTRUCTS In the DSM–5 hybrid model proposal, specific personality disorders are defined by the presence of both Criterion A, deficits in self and interpersonal relatedness, and Criterion B, maladaptive personality traits (American Psychiatric Association, 2013), as if these are distinct constructs. This proposal might reflect in part that work group members worked independently of one another, yielding two separate, perhaps even competing, models (i.e., the prototype narratives and the dimensional trait model). In the end, the two independent models were conjoined together in a “hybrid” model. The maladaptive personality traits are well understood from the perspective of the FFM (Krueger & Markon, 2014; Widiger, 2011). Although the deficits in sense of self and interpersonal relatedness were obtained from a psychodynamic theoretical perspective (Bender et al., 2011; Kernberg, 2012; Pincus, 2011), perhaps these deficits or impairments in self and interpersonal functioning might also be understood from the perspective of the FFM. The FFM of Costa and McCrae (1992) was derived from the Big Five lexical model of personality (Goldberg, 1993), The Big Five is an atheoretical descriptive model of personality, derived originally from the trait terms within the language, thereby representing what persons who have used this

Table 3.—Maladaptive Five-factor model trait scales: Extraversion versus introversion. Extraversion FFM Facet

Scale

Introversion Instrument

Warmth

Intimacy Needs

FFDI

Gregariousness

Attention-Seeking Exhibitionism Authoritative Domineering — Thrill-Seeking Social Butterfly — —

FFHI FFNI FFNI EPA

Assertiveness Activity Excitement-seeking Positive emotionality

EPA FFHI

Scale

Instrument

Detached Coldness Social Anhedonia Social Dread Social Withdrawal Unassertive Shrinking — Risk Aversion

FFOCI FFSI FFAvA FFSI FFDI FFAvA FFOCI

Physical Anhedonia Joylessness

FFSI FFAvA

Note. FFM D Five-factor model; FFDI D Five-Factor Dependent Inventory (Gore et al., 2012); FFOCI D Five Factor Obsessive–Compulsive Inventory (Samuel et al., 2012); FFSI D Five Factor Schizotypal Inventory (Edmundson et al., 2011); FFHI D Five Factor Histrionic Inventory (Tomiatti et al., 2012); FFAvA D Five Factor Avoidant Assessment (Lynam et al., 2012); FFNI D Five Factor Narcissism Inventory (Glover et al., 2012); EPA D Elemental Psychopathy Assessment (Lynam et al., 2011).

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ASSESSMENT OF DSM–5 PERSONALITY DISORDER language consider to be the most important traits, features, or components of personality for describing oneself and other persons (Goldberg, 1993). McCrae and Costa (2003) proposed a particular theoretical model for the development of FFM traits, but their proposal is not the only possible understanding. In Wiggins (1996), five alternative theoretical models are provided. The Big Five can indeed accommodate alternative theoretical perspectives. For example, an alternative model to the Big Five and FFM is the interpersonal circumplex, which provides a rich theoretical model for understanding the etiology and pathology of personality disorders (e.g., Pincus & Hopwood, 2012). However, the two domains of the interpersonal circumplex, agency and communion, can be understood as 45degree rotations of the FFM domains of extraversion and agreeableness (McCrae & Costa, 1989; Wiggins & Pincus, 1989). In sum, the Big Five is itself simply a descriptive model of personality structure (Goldberg, 1993), with no presumption as to how the traits are formed. Hereafter, when reference is made to the FFM, the intention is to refer to simply the five domains and underlying traits, without embracing or endorsing any one particular theoretical model for their origin. Psychodynamically oriented constructs have been understood within the structure of the FFM. For example, McCrae, Costa, and Busch (1986) demonstrated how the 100 items within the California Q-Sort (CQS; Block, 2008) could be understood from the perspective of the FFM (Widiger, Samuel, Mullins-Sweatt, Gore, & Crego, 2012). The CQS items were developed by successive panels of psychodynamically oriented clinicians seeking a common language (Block, 2008). A factor analysis of the complete set of items yielded five factors that corresponded closely to the FFM. The neuroticism factor contrasted such CQS items as “thin-skinned,” “extrapunitive,” and “brittle ego defenses,” with “socially poised” and “calm, relaxed.” Extraversion contrasted such items as “talkative,” “behaves assertively,” and “self-dramatizing,” with “avoids close relationships” and “emotionally bland.” Openness contrasted “values intellectual matters,” “rebellious nonconforming,” “unusual thought processes,” and “engages in fantasy, daydreams,” with “moralistic,” “uncomfortable with complexities,” and “favors conservative values.” Agreeableness contrasted “behaves in giving way” and “warm, compassionate, with “basically distrustful,” “expresses hostility directly,” and “critical, skeptical.” Conscientiousness contrasted “dependable, responsible” and “has high aspiration level” with “self-indulgent,” and “unable to delay gratification.” Support for their interpretation of these factors was obtained from convergent and discriminant correlations with self and peer NEO PI scales (Costa & McCrae, 1992). In sum, McCrae et al. (1986) demonstrated a close correspondence of a sophisticated psychodynamic nomenclature with the FFM. Mullins-Sweatt and Widiger (2007) reported similar results for the Shedler–Westen Assessment Procedure–200 (SWAP– 200; Shedler & Westen, 2004), a psychodynamically oriented clinician Q-sort comparable to the CQS. They related SWAP– 200 scales with the FFM, the latter assessed via the NEO PI–R (Costa & McCrae, 1992). Medium to large effect size relationships were obtained for SWAP–200 Obsessionality with conscientiousness, Psychopathy with antagonism and low conscientiousness; Emotional Dysregulation and Dysphoria with neuroticism; Schizoid Orientation with introversion;

461 Narcissism with antagonism and extraversion; and Hostility with antagonism. There were some SWAP–200 scales that did not correlate well with the FFM, such as Dissociation, Oedipal Conflict, and Sexual Conflict. However, these scales included many items that do not appear to be strongly related to personality disorder. For example, the SWAP–200 Sexual Conflict scale includes such items as “Experiences a specific sexual dysfunction during sexual intercourse or attempts at intercourse (e.g., inhibited orgasm or vaginismus in women, impotence or premature ejaculation in men),” and “Tends to see sexual experiences as somehow revolting or disgusting” (Shedler & Westen, 2004, p. 1750). SWAP–200 Sexual Conflict is perhaps better understood as a measure of sexual dysfunction rather than as a measure of personality disorder. Shedler and Westen (2004) developed an FFM measure using SWAP–200 items, but it was couched in an intention of demonstrating “that the five-factor model is not sufficiently comprehensive” (p. 1753). They suggested that only 30% of the SWAP–200 items had any relevance to the FFM. McCrae, L€ockenhoff, and Costa (2005), however, coded 93% of the SWAP–200 items in terms of the FFM. Mullins-Sweatt and Widiger (2008) compared the convergent (and discriminant) validity of the Shedler and Westen and McCrae et al. SWAP– 200 FFM scales with respect to their relationship with the NEO PI–R (Costa & McCrae, 1992). There was no difference in convergent validity for their respective extraversion scales, but the McCrae et al. conscientiousness scale had better convergent validity than the Shedler and Westen conscientiousness scale, and substantially higher convergent validity was obtained for the McCrae et al. neuroticism, agreeableness, and openness scales. The convergent validity for the McCrae et al. SWAP–200 scales with respective NEO PI–R scales was .74 for neuroticism, .72 for extraversion, .51 for openness, .77 for agreeableness, and .76 for conscientiousness. DSM–5 Personality and Personality Disorder Work Group members have developed two self-report measures of self and interpersonal deficits: the General Assessment of Personality Disorders (GAPD) by Livesley (2006) and the Severity Indices of Personality Problems–118 (SIPP–118) by Verheul et al. (2008). These are not official measures of the self and interpersonal deficits of DSM–5 Section III, but they involve very similar and closely aligned constructs. Berghuis, Kamphuis, and Verheul (2012) conducted a factor analysis of the 30 facet scales of the NEO PI–R (Costa & McCrae, 1992), along with the 19 GAPD scales and the 16 SIPP–118 scales. Consistent with an FFM conceptualization, the SIPP–118 scales concerning self-control loaded with FFM conscientiousness and the GAPD and SIPP–118 interpersonal scales loaded with agreeableness and extraversion (although three NEO PI–R extraversion scales split off to form their own factor). Inconsistent with the view that self-pathology would load on neuroticism (DeShong et al., in press; Mullins-Sweatt, Edmundson, et al., 2012), the 15 GAPD self-pathology scales along with the four SIPP–118 identity integration scales formed a separate factor. The authors concluded that their results indicate that selfpathology lies outside of the general personality structure as described by the FFM. However, an alternative understanding for the findings of Berghuis et al. (2012) is that the results reflect a potential artifact of factor analytic principles. Factor analysis structures a set of scales in terms of the relative binding that

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462 exists among them, considering as well the relative number of scales that potentially exist for a respective factor (Haynes, Smith, & Hunsley, 2011). For example, few persons would disagree with the position that social withdrawal belongs within FFM introversion. However, as a hypothetical study, consider the likely result if one conducted a factor analysis of the 30 facet scales from the NEO PI–R (Costa & McCrae, 1992), along with Social Isolation and Withdrawal from the FFSI (Edmundson et al., 2011), Social Dread from the FFAvA (Lynam et al., 2012), Social Withdrawal from the PID–5 (Krueger et al., 2012), Social Withdrawal from the CAT–PD (Simms et al., 2011), No Friends from the Schizotypal Personality Questionnaire (Raine, 1991), Social Avoidance from the Dimensional Assessment of Personality Pathology–Basic Questionnaire (Livesley & Jackson, 2009), and Detachment from the Schedule for Nonadaptive and Adaptive Personality–2 (Clark, Simms, Wu, & Casillas, in press). These seven variants of social withdrawal scales are all well understood by their authors to lie within the FFM domain of introversion. Yet, if they were all included within a factor analysis with the 30 facet scales of the NEO PI–R, it might be the case that these seven scales, along with perhaps NEO PI–R gregariousness, would all tightly bind together to form their own separate factor, distinct from introversion. This might occur because they would all correlate much more highly with each other than they would with the other facets of extraversion (e.g., excitement-seeking, warmth, positive emotionality, and activity). However, such a finding should not suggest that social withdrawal falls outside of the FFM (introversion in particular), as it clearly does lie within introversion (Costa & McCrae, 1992; Edmundson et al., 2011; Krueger et al., 2012; Lynam et al., 2012; Wright & Simms, 2014). Of course, this is speculation, and this hypothesis should be tested in future research. A comparable finding perhaps occurred within Berghuis et al. (2012). The 19 scales of the GAPD include 15 different variants of self-pathology, such as lack of self-clarity, sense of inner emptiness, self-state disjunctions, fragmentary self– other representations, defective sense of self, and poorly differentiated images of others. The SIPP–118 includes four scales that assess different aspects of identity integration (e.g., self-reflexive functioning and stable self-image). These very closely related variants of self-pathology would naturally correlate more highly with one another than they would with other facets of neuroticism (e.g., angry hostility, depressiveness, and anxiousness), thereby binding together into their own tight factor. If only one or two self-pathology scales had been included in the analysis, perhaps they would have loaded cleanly on neuroticism, consistent with the findings for FFBI Self Disturbance by DeShong et al. (in press) and MullinsSweatt, Edmundson, et al. (2012). In sum, one can separate any construct from the FFM by simply overloading its representation within a factor analysis so that the respective scales will bind together to form their own factor, separate from the others. A simple inspection of the self and interpersonal impairments within the DSM–5 Section III hybrid model would appear to suggest that these impairments cover the same ground that is covered by maladaptive personality traits. Consider, for example, the deficit in empathy for antisocial

WIDIGER personality disorder, consisting of “a lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another” (American Psychiatric Association, 2013, p. 764). It is difficult to understand what is different for this deficit in empathy when compared to the maladaptive trait of callousness, which involves a “lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions” (American Psychiatric Association, 2013, p. 764). One can, of course, also identify examples in which the DSM–5 self or other impairments specific for a particular personality are not contained within the trait list for that respective personality disorder (and vice versa), but these might reflect differences in coverage rather than differences in the nature of what is being assessed. The most compelling answer to the question of whether the deficits in self and interpersonal relatedness are independent from maladaptive personality traits would be studies that demonstrate that they account for a substantial proportion of variance in personality disorder pathology that is not already covered by the maladaptive personality traits. However, the existing research does not appear to support this hypothesis. Perhaps the most informative study to date in this regard was provided by Berghuis, Kamphuis, and Verhuel (2014) using the same data set of Berghuis et al. (2012). As noted earlier, Berghuis et al. (2012) administered the GAPD (Livesley, 2006) and the SIPP–118 (Verheul et al., 2008) to a large sample of 261 patients. The GAPD and the SIPP–118 contain 35 self-report inventory scales (19 and 16, respectively) that assess for deficits in sense of self and interpersonal relatedness. They also administered the DAPP–BQ (Livesley & Jackson, 2009), a self-report measure of maladaptive personality traits that align closely with four of the five domains of the FFM (Widiger, 1998) that is quite comparable to the PID–5 (Krueger et al., 2012) and the FFMPD (Widiger, Lynam, et al., 2012) scales. Finally, they also administered the Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II; First, Spitzer, Williams, & Gibbon, 1995), which they used as a criterion measure of personality disorder pathology. Berghuis et al. (2014) reported on the extent to which the maladaptive personality traits and the self and interpersonal deficits were able to account for variance in personality disorder pathology. They considered five criterion measures: the total sum of personality disorder pathology as assessed by the SCID–II, as well as four individual personality disorder scales of the SCID–II (i.e., Paranoid, Avoidant, Borderline, and Obsessive–Compulsive). The GAPD and SIPP–118 accounted for 34% and 32% of the variance within the SCID–II total score, respectively, whereas the DAPP–BQ accounted for 42%. With respect to individual personality disorders, the GAPD accounted for only 1% (avoidant) to 2% (borderline) additional variance in personality disorder pathology beyond the variance accounted for by the DAPP–BQ. The SIPP–118 did better, accounting for 3% (avoidant) to 7% (borderline) additional variance. In contrast, the DAPP–BQ accounted for considerably more variance in personality disorder pathology than both measures of self and interpersonal deficits. With respect to individual personality disorders, the DAPP–BQ accounted for 4% (paranoid) to 15% (avoidant) of additional

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Table 4.—Illustrative traits from Stone (1993) and the Five Factor Form. Trait Stone: Assertive FFF: Assertiveness Stone: Trusting FFF: Trust Stone: Fair FFF: Tender-minded Stone: Modest FFF: Modesty Stone: Honest FFF: Straightforward

Maladaptively Low

Low

High

Maladaptively High

Submissive Resigned, uninfluential Paranoid Cynical, suspicious Ruthless Merciless, ruthless Pretentious Arrogant, pretentious Unscrupulous Deceptive, dishonest

Unassertive Passive Suspicious Cautious, skeptical Exploitative Strong, tough Affected Confident, self-assured Devious Savvy, cunning, shrewd

Bossy Assertive, forceful Naive Trusting Deferential Empathic, gentle Humble Humble, modest Scrupulous Honest, forthright

Domineering Dominant, pushy Gullible Gullible Meek Overly soft-hearted Self-effacing Self-effacing, self-denigrating Overscrupulous Guileless

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Note. Stone traits obtained from Stone (1993); FFF D Five Factor Form traits (Rojas & Widiger, 2014).

variance in the SCID–II relative to the GAPD, and 4% (paranoid) to 12% (avoidant) additional variance relative to the SIPP–118. With respect to the total sum of personality disorder pathology, the GAPD accounted for 0% of additional variance in the SCID–II relative to the DAPP–BQ; the SIPP–118 accounted for only 1%. In contrast, the DAPP–BQ accounted for 7% additional variance over the GAPD and 4% additional variance over the SIPP–118. In sum, despite the presence of an extensive set of 35 scales of self and interpersonal impairments, they do not appear to be adding much additional information than what is already being provided by a measure of maladaptive personality traits. A dimensional trait model need not be considered incompatible with a psychodynamic perspective. Stone (1987) has long been recognized as a well-regarded psychoanalyst, as well as a psychodynamically oriented personality disorder researcher and clinician. Stone (1990) recognized, “to do justice to the clinician, who must confront the seemingly infinite variety of personality types that patients (and nonpatients) display, a large vocabulary of descriptors is essential” (pp. 416– 417). He approached this task in much the same manner that the personality psychologists created the FFM, by compiling all of the trait terms within the English language. “To this end I began jotting down all the words I could think of . . . that pertained to personality” (Stone, 1990, p. 417). He eventually accumulated a master list of 530 trait terms, which he felt would provide a comprehensive lexicon for the description of both the normal and abnormal variants of personality. He organized this list into a structure that closely parallels the FFF (Rojas & Widiger, 2014), in which there are five variants of each trait, with the inner terms being largely normal variants (or at least less maladaptive), and the outermost terms at both poles representing the most maladaptive variants. For example, for one trait, punctual, the outermost terms were “irresponsible” at one pole and “punctilious” at the other (Stone, 1993, p. 96). The two traits just to the left and right of punctual were “procrastinating” (a less maladaptive variant than being irresponsible) and “compulsive” (a less maladaptive variant, he felt, than being punctilious). This lexical structure, which includes personality disorder constructs, presaged the eventual development of the FFF (Rojas & Widiger, 2014). The comparable item within the FFF contrasts being rigidly principled with being irresponsible, undependable, and immoral. Another Stone item is “fair.” The two traits at the far opposite poles are “ruthless” (i.e., maladaptively low in fairness) and “meek” (maladaptively high in fairness). Its parallel

FFF item contrasts being merciless and ruthless with being overly soft-hearted. Table 4 provides additional examples wherein items from the FFF parallel closely the lexical trait structure developed by Stone for his clinical practice. Stone (1993) became familiar with the FFM and recognized that it closely paralleled his lexical structure of personality. “Much of the variance in our current typology could be accounted for via a five-factor model” (Stone, 1993, p. 119). He graciously contributed a chapter for a text concerning personality disorders and the FFM (i.e., Stone, 2013), in which he presents nine case studies from his psychodynamically oriented clinical treatment, explicating the richness of the FFM in characterizing and understanding the adaptive and maladaptive personality traits of his patients.

CONCLUSIONS AND SUGGESTIONS FOR FUTURE RESEARCH The DSM–5 Personality and Personality Disorders Work Group suggested that it was a time for “a major reconceptualization of personality psychopathology” (Skodol, 2010). They argued that the existing diagnostic categories were fundamentally flawed, highlighting in particular the excessive diagnostic cooccurrence and, for some of the personality disorders, inadequate empirical support. However, the American Psychiatric Association Scientific Review Committee (Kendler, 2013) concluded that there was insufficient empirical support for the hybrid proposal. There is, however, a considerable body of research to support the FFM of personality disorder (Widiger, Samuel, et al., 2012). The Big Five is also an atheoretical descriptive model of personality structure (Goldberg, 1993). The same can be said for the FFM. McCrae and Costa (2003) provided a particular theoretical model for understanding the origins of FFM traits, but the FFM can also be understood as simply a descriptive model of personality structure. There are indeed alternative theoretical models for the origins of the FFM domains and traits (Wiggins, 1996). There is no necessary presumption as to how a person might have developed, for instance, affective dysregulation, callousness, or separation insecurity, or what the underlying pathology for these maladaptive traits might entail. It is conceivable that some psychodynamic constructs might not be well understood from the perspective of the FFM (e.g., certain dynamic conflicts), but persons from alternative theoretical perspectives, such as the neurobiological (DeYoung et al., 2010) and the psychodynamic (Stone, 1993, 2013), have worked comfortably within the FFM.

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464 To facilitate a clinical application of the FFM, there are now a number of alternative measures of maladaptive personality functioning from the perspective of the FFM (e.g., De Clercq et al., 2006; Krueger et al., 2012; Lynam, 2012; McCrae et al., 2005; Rojas & Widiger, 2014; Simms et al., 2011). These measures can be useful to clinicians in a number of ways. First, they break down each of the DSM–IV–TR (now DSM–5) personality disorders into component parts. Clinicians can assess for these individual components, such as the separation insecurity, pessimism, shamefulness, helplessness, gullibility, selflessness, and subservience of dependent personality disorder (Gore et al., 2012), which are typically the focus of clinical treatment rather than the global syndrome. The scales also provide a bridge between the DSM–IV–TR personality syndromes and the FFM. The FFM is no longer an abstract, academic model of general personality structure with no clear relevance to the constructs of interest to clinicians. Finally, clinicians can bring to an understanding of the personality disorders the considerable body of research concerning the etiology, developmental antecedents, course, universality, and life outcomes that have been identified for the FFM (e.g., Allik, 2005; Caspi, Roberts, & Shiner, 2005; B. W. Roberts & DelVecchio, 2000; B. R. Roberts, Kuncel, Shiner, Caspi, & Goldberg, 2007; Yamagata et al., 2006). Nevertheless, there is the need for additional research to further address questions concerning the validity and utility of these measures. For example, there are more than 100 FFMPD scales (Widiger, Lynam, et al., 2012). This is clearly too many to include in any one study or clinical assessment. Their further usage would be facilitated not only by the development of abbreviated versions (Lynam et al., 2013), but also by an exploration of the unique utility, discriminant validity, and incremental validity of near neighbor scales (e.g., Social Anxiousness from the FFSI [Edmundson et al., 2011] and Evaluation Apprehension from the FFAvA [Lynam et al., 2012]). There is no hard rule for what would constitute the optimal or maximal number of maladaptive personality trait scales. There are more than 1,000 maladaptive trait terms within the English language (Goldberg, 1993) but surely there is no need to have a scale for each one of them. On the other hand, the existence of distinct trait terms within the language that do have different meanings (e.g., gullibility, subservience, and selflessness) would suggest the potential for valid and useful distinctions in their assessment. It would also be useful to further expand the assessment of these maladaptive personality traits beyond self-report. Some of the FFM measures described herein can be used as clinician rating forms (e.g., the Clinician Rating Form [American Psychiatric Association, 2010a], the FFMRF [Mullins-Sweatt et al., 2006], and the FFF [Rojas & Widiger, 2014]). There is also a semistructured interview for the assessment of adaptive and maladaptive personality traits (i.e., Trull et al., 1998). However, it would also be useful to develop informant versions for the assessment of the maladaptive personality traits. Integral to the presence of a personality disorder is a distortion in the perception of the self and other persons (Bender et al., 2011). It is then questionable whether one can obtain a fully valid assessment relying solely on self-report.

WIDIGER It might also be useful to develop an assessment of these traits via performance or projective tests. Notable in this regard is the Rorschach Construct Scale (RCS; Mihura, Meyer, Bel-Bahar, & Gunderson, 2003), which is a revision of the Rorschach Rating Scale (Meyer, Bates, & Gacono, 1999). The RCS assesses constructs that align well with the FFM, although it does include variance not fully accounted for by the FFM. The alignment of the RCS might prove to be even stronger, though, when it is related to maladaptive variants of the FFM, such as the FFMPD or PID–5 scales.

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