7a
Filip De Fruyt and Barbara De Clercq
Miller and Widiger (this volume) provide a comprehensive and up-to-date review of the current status of trait-based models to describe personality disorders, with a particular emphasis on the Five-Factor Model (FFM) of personality. Their summary makes clear that considerable progress has been made for a trait-based description of personality disorders, although the Diagnostic and Statistical Manual of Mental Disorders in its current edition (DSM-5; American Psychiatric Association, 2013) still only proposes the ten categorical personality disorders in its official section. The trait-based DSM-5 alternative model has been put in the waiting-room (Section III), as a model requiring additional research and guidelines for practical implementation, reflecting the long way to go before trait-based models will be formally accepted in established diagnostic taxonomies and – related to this – be routinely used in professional diagnostic practice.
Besides pointing to the potential and benefits of a trait-based description of personality disorders, Miller and Widiger (this volume) underscore that, by adopting the trait perspective, considerable knowledge from the field of general personality was infused in the field of personality disorders, which was previously kept distinct from the clinical field. Indeed, increasing empirical evidence points to the biological (Riccelli, Toschi, Nigro, Terracciano, & Passamonti, 2017) and genetic (Vukasovic & Bratko, 2015) underpinnings of general traits, how they naturally develop across the life course (Roberts, Walton, & Viechtbauer, 2006; Soto, John, Gosling, & Potter, 2011), and whether traits can be the subject of intentional change (Allan, Leeson, De Fruyt, & Martin, 2018; Hudson & Fraley, 2015; Roberts et al., 2017). Likewise, the relatively new trend to also investigate more fluctuating and state-like within-individual differences (Hofmans, De Clercq, Kuppens, Verbeke, & Widiger, 2019; Jayawickreme, Zachry, & Fleeson, 2019) beyond the traditional perspective on between-individual differences, has shown its potential for research on personality disorder symptoms (e.g., in borderline personality disorder pathology; Wright, Hopwood, & Simms, 2015). Finally, also the consequential outcomes of traits have been described well during the past years both in adulthood (Skodol, 2018) and at younger ages (De Fruyt, De Clercq, & De Bolle, 2017), increasing our knowledge on the daily and potential long-term impact of traits on the development and course of personality pathology.
Moreover, the field of mental disorders, including personality disorders and their symptoms, further benefited from a more integrative consideration of its phenotypic manifestations, by research examining the underlying structural properties in association with personality traits. Such approaches may better account for the arbitrary boundaries between what is considered adaptive or maladaptive, the observed comorbidities among different disorders and their symptoms (e.g., substance abuse and borderline personality disorder), heterogeneity within particular diagnoses, and instability of diagnoses due to fluctuating symptoms (Kotov, Krueger, & Watson, 2018; Kotov et al., 2017). Research initiatives like the Hierarchical Taxonomy of Psychopathology (HiTOP; Kotov et al., 2018) or Caspi and colleagues’ work on the general P-(sychopathology) factor (Caspi et al., 2014) are promising avenues to redesign our thinking on the structure of psychopathology and its relationship with personality (Widiger et al., 2019). Together, these new directions also contribute to a more holistic consideration of the individual patient, integrating findings from various research disciplines into clinical practice.
Personality Pathology: Disentangling Description from Dysfunction
Personality disorders are disorders of personality traits. This statement is a fundamental assumption of the dimensional perspective on personality disorders, implying that personality disorders share variance with nearly all general personality descriptive models. This will certainly be the case with the FFM (Widiger, Trull, Clarkin, Sanderson, & Costa, 2002), considered to be a comprehensive model of personality description, for which empirical overlap has been hypothesized already decades ago, generating a successful stream of research describing DSM-based personality disorders in terms of (facets of) the FFM (Bastiaansen, Rossi, & De Fruyt, 2013; Samuel & Widiger, 2008). Widiger, with various collaborators (for an overview, see: Crego, Oltmanns, & Widiger, 2018), took this approach a step further, describing several personality disorders in terms of specific configurations of maladaptive traits. These various sources of evidence have in common, however, that they still treat the DSM-based personality disorders as the prime targets to assess, although there is abundant evidence that the categorical conceptualization of personality disorders is fundamentally flawed (Widiger, 2000; Widiger, Livesley, & Clark, 2009). In this respect, one could argue that it may be better to talk about personality pathology, instead of referring to personality disorders, because the disorder concept is too strongly bound to the questionable categorical DSM-tradition. In the comment of this chapter, we therefore prefer to talk about the assessment of personality pathology, because the comment exceeds the focus on the familiar personality disorder constructs, and also includes for instance the personality disorder trait-specifier.
Personality pathology is a multi-layer condition, including the traits around which the pathology develops, but also encompassing an aspect of dysfunction, arising from an interaction between a trait vulnerability and a relevant context. This interactional viewpoint on the development of psychopathology, including personality disorders, forms a cornerstone of psychological science and points to the importance of including context in evaluating the level of functioning of the individual. In our developmental model on personality pathology (De Fruyt & De Clercq, 2014), we have consistently argued that a clinical diagnosis of personality pathology requires a separate evaluation of the functioning of the young individual, i.e., whether her/his standing on personality traits is associated with an impaired functioning in three significant contexts: (a) functioning within the family, (b) interaction with peers and friends, and (c) functioning at school. These contexts not only represent relevant sources of cues that may trigger maladaptive traits at a certain age, but also create an important avenue for evaluating the consistency of maladaptation across situations, which is useful for clinical decision-making in terms of the trait-based nature of the symptoms (De Clercq, 2018). This model is directly applicable to adulthood by orienting the evaluation of functioning towards (a) family and intimate relationships, (b) interpersonal relationships, and (c) functioning at work. This conceptual model is to some extent also in line with the alternative model of personality disorders in DSM-5 (American Psychiatric Association, 2013), although the prerequisite of dysfunction (Criterion A) before moving on to the trait description (Criterion B) may be inconsistent with the idea that it is the traits that form the heart of personality pathology, with the dysfunction resulting from a person’s trait vulnerabilities in their encounter with environmental challenges.
Personality Pathology: Coverage
Besides a consideration of the evaluation of dysfunction, diagnostic task forces for DSM or other mental disorder classification systems will also have to (re)define the content of the field they ultimately want to cover. For example, DSM-5 Section III attempts to considerably redefine the content field of personality disorders, providing only trait configurations for six of the previous ten personality disorders. In addition, one can also make trait-specified diagnoses (Personality Disorder – Trait-Specified) when criteria for individual personality disorders are not fully met, and the individual has an extreme standing on some of the DSM-5 traits and shows significant dysfunction. The trait-specified diagnoses have the potential to go beyond the traditional categorical personality disorder concepts, to accommodate the large number of diagnoses of Personality Disorders Not Otherwise Specified (PDNOS) in DSM-IV (American Psychiatric Association, 2000). The field hence needs to think carefully about the content domain it wants to represent. Such decisions may be most fruitful when based on our improved knowledge on the structure of psychopathology in general, taking findings from HiTOP or the general P-factor research into account, but also findings on the development of personality and maladaptive traits in particular.
Challenges
A crucial question for this field is how to go from here and move the trait-based approach (with or without amendments) from Section III to DSM’s Section II. Although there was strong dissatisfaction with the categorical personality disorders, its replacement by a particular trait system, i.e., the DSM-5 trait set (Krueger, Derringer, Markon, Watson, & Skodol, 2012), turned out to be complex and demanding. On top of a particular trait set (Criterion B) also a Criterion A was proposed, that involves a separate assessment of the individual’s functioning of the Self (identity and self-direction) and Interpersonal (empathy and intimacy) areas. Although there seems to be more consensus on the usefulness of the DSM-5 trait set, there are divergent opinions on whether we still need to retain (some) personality disorder concepts and propose trait configurations that maximally account for variance in these (Herpertz et al., 2017; Hopwood et al., 2018). In addition, there is discussion on the utility and necessity of Criterion A, and especially the way this criterion is operationalized. Bastiaansen and colleagues (Bastiaansen, De Fruyt, Rossi, Schotte, & Hofmans, 2013; Bastiaansen et al., 2016), for example, examined this two-fold diagnosis of personality disorder, operationalizing personality dysfunction using the Severity Index of Personality Problems (SIPP; Verheul et al., 2008) and using the NEO-PI-R (Costa & McCrae, 1992) or the DAPP-BQ (Livesley & Jackson, 2009) to assess general or maladaptive traits respectively. They (Bastiaansen, De Fruyt, et al., 2013; Bastiaansen et al., 2016) concluded that both criteria overlapped substantially though had some added value to explain traditional personality disorder concepts.
In sum, it is likely that a successful transition to trait-based systems to describe personality pathology will have to rely on the available empirical evidence regarding the taxonomic representation of (personality) pathology and its suitability and utility in clinical practice. We hope that this transition process can be conducted in an open dialogue with all stakeholders where participants to the debate are willing to learn from each other, adapt opinions or even reconsider positions so trait-based assessment becomes a reality in clinical assessment.
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