14a
Ashley C. Helle, Neil A. Meyer, Jiwon Min, and Stephanie N. Mullins-Sweatt
In their chapter, Evans, Williams, and Simms (this volume) review current measures and methods of assessing personality pathology from a dimensional perspective. The focus of their chapter is two-fold: (1) discussing prominent dimensional measures of traits and impairment and reviewing the clinical utility of these measures, and (2) reviewing timely issues at the center of personality trait assessment, including trait bipolarity, multi-method assessment, and the assessment of dysfunction. Our focus for this commentary is to emphasize the clinical usefulness of these measures. We strongly agree with Evans and colleagues that an important task for the personality disorder (PD) community is to establish the clinical usefulness of measures in order to increase their utility to practitioners.
Transitioning dimensional models into practice is an important and challenging endeavor for the field. The authors discussed relevant concerns and potential roadblocks to this implementation, such as the length of many measures. For example, the Five-Factor Model Personality Disorder (FFMPD) measures (e.g., Five Factor Borderline Inventory, Elemental Psychopathy Assessment) collectively would be quite lengthy, as each full-length measure has more than 100 items. We agree that administration of all of these measures with one client could be logistically problematic and have limited utility within a general therapy setting. Many of the validated FFMPD measures have newly developed and validated short-forms (e.g., Five Factor Obsessive Compulsive Inventory; Griffin et al., 2018), which can improve the ease of usage for practitioners and the experience for clients. Additionally, a number of other dimensional measures (e.g., CAT-PD-Static Form, PID-5) are considerably shorter. In fact, the FFMPD scales themselves can be administered modularly in order to recreate the constructs within the DSM-5 Alternative Model (see Crego, Oltmanns, & Widiger, 2018).
The road to implementation of evidence-based assessment (i.e., utilizing empirically derived personality assessments in practice) can be particularly challenging when attempting to balance various goals of multiple parties. This is a multi-step process, involving the empirical development and validation of the original assessments and then their short-forms, assessment of clinical utility and needs of clients and practitioners, and dissemination and implementation (an area that is often neglected in the assessment realm). This disconnect between the notion of maintaining the empirical structure of a model and implementing core aspects of clinical utility into measure development and application is understandable, given that both validity concerns and clinical utility are competing priorities. It is perhaps noteworthy that these competing concerns mirror those seen when developing diagnostic manuals (Mullins-Sweatt, Lengel, & DeShong, 2016). Responding to and incorporating aspects of feasibility, acceptability, and utility into the empirical development and application of personality assessment is a key aspect of successful implementation and a timely concern, given the integration of primary care health integration models of mental health treatment.
The Role of Adaptive Traits to Treatment
Evans et al. state, “Further research is needed on the role of adaptive traits in PD assessments and how such information can be integrated into broader PD models” (p. 340 in the previous chapter). This is an important point, as maintaining adaptive traits within personality assessment and the application of these models to treatment is consistent with literature related to personality traits and mental health treatment more generally (Lengel, Helle, DeShong, Meyer, & Mullins‐Sweatt, 2016). One benefit of including adaptive traits in assessments is the ability to address the stigmatized nature of pathological traits, particularly within mental health and PDs. Within psychopathology and psychiatric diagnoses, PDs are highly stigmatized, as they have been described as disorders of one’s “personality” or “who you are.” As Widiger and Costa (2012) describe, the inclusion of normal or adaptive traits can be beneficial in personality assessment. We believe that in addition to the robust empirical support for a general trait model, the inclusion of general traits can not only decrease stigma, but assist with the therapeutic assessment process and feedback and treatment planning. For example, a study on client preferences for personality trait feedback found that individuals found adaptive and maladaptive trait feedback to be useful, accurate, and relevant (Lengel & Mullins-Sweatt, 2017).
Utility of Bipolarity within Dimensional Assessment Measures
We agree that bipolarity should continue to be an area of careful consideration – both in research and in applied use of these measures. As Evans et al. discuss, advances in statistical techniques and methodological approaches can improve our ability to detect the actual presence of and correlates of (including impairment) traits at each end of the “pole.” For example, the use of ecological momentary assessment may assist in more accurately capturing behaviors and daily life impairment associated with traits that may be related to high “internalizing” versus the externalizing that is often viewed as the more obvious maladaptive end of the pole. Likewise, with new technologies, we can further assess associated impairment through the use of broader ambulatory assessment to determine health and physiological correlates that may be more strongly associated with these traits (e.g., high conscientiousness and cardiovascular effects) when externalizing behaviors are not as central to the trait or research question of interest.
One challenge with the issue of trait bipolarity relates to assessment (as discussed) and realities of clinical and policy implementation. A structure that includes trait bipolarity has the potential to be challenging for diagnoses, leading to downstream issues with healthcare reimbursement, and thus, presenting a barrier for practitioners. Whereas we agree with Evans et al. that this should not be a reason to not utilize these traits, we recognize some of the legitimate logistical concerns that may exist and agree with the authors that further research is warranted in this area.
Incremental Utility of Dysfunction
Evans et al. provide a succinct summary of literature describing whether traits and dysfunction can or should be distinguished. They conclude that the question of whether dysfunction provides incremental validity over personality traits and whether traits and dysfunction can be psychometrically differentiated requires further research. Specifically, the authors provided a number of studies that call into question the ability to distinguish between PD traits and personality dysfunction, which we will expand upon here by providing additional studies not included in the Evans et al. chapter.
Wygant and colleagues (2016) found that personality impairment criteria for antisocial personality disorder (ASPD) from the DSM-5 alternative model of personality disorder (AMPD) had incremental validity over the PD traits in predicting PCL-R psychopathy and SCID-II ASPD. Liggett, Sellbom, and Carmichael (2017) also found similar results when examining obsessive-compulsive personality disorder (OCPD) criteria from AMPD; specifically, that the impairment criteria had incremental validity above and beyond the PD traits when operationalizing OCPD. The inconclusive findings when examining whether personality trait and dysfunction can be distinct underscores the necessity of further research.
Additionally, when discussing the utility of personality dysfunction, it is imperative to consider incremental validity over traits in predicting external criteria. Creswell and colleagues (Creswell, Bachrach, Wright, Pinto, & Ansell, 2016) found that personality dysfunction did not have incremental validity over personality traits when predicting problematic alcohol use. On the other hand, Roche (2018) found that both traits and dysfunction provided incremental validity over each other in predicting a trans-theoretical model of personality organization (TTM; Blais, 2010). Clearly, additional research exploring the utility of personality traits and dysfunction with regard to external criteria is needed.
Other Issues in Assessment
Evans et al. discuss the importance of multiple sources of assessment when assessing personality pathology. We strongly agree and want to further highlight research that has documented the importance of utilizing structured and semi-structured assessments when using multiple sources. For example, Samuel et al. (2013) found incremental validity in the prediction of psychosocial functioning over five years for PD diagnoses made by client self-report assessments and semi-structured interviews over naturalistic therapist diagnoses. As a result, they cautioned against the use of PD diagnoses by clinicians, noting that they were outperformed by semi-structured interviews in all cases and by patient self-reports in almost all cases. However, it is important to note that more recent research has found higher agreement between patient self-report and therapist informant report of dimensional PD symptoms, suggesting more convergence than previously suggested by the literature (Samuel, Suzuki, Bucher, & Griffin, 2018).
Moving Forward and Bridging the Gap
The authors highlight an important gap in the implementation of much of what has been discussed in the literature. The research-to-practice gap that occurs is not unique to psychopathology (or, more specifically, personality trait) assessment research or treatment. This can be seen across diagnoses and within many disciplines (e.g., medicine, psychology). When practice and research are segregated, the dilemma no longer becomes what model or measure to use, but how to ensure that these two necessary entities communicate, share ideas, and implement the best evidence-based practices. Evans et al. speak to this, stating, “However, more is probably needed, including efforts to interact directly with clinicians in workshops and continuing education activities, as well as to influence the methods emphasized in training programs for psychologists and allied mental health professionals” (p. 343 in the previous chapter).
Over a decade of research provides evidence that dimensional models indeed provide sufficient clinical utility (e.g., Blais, 1997; Samuel & Widiger, 2004, 2006; Verheul, 2005) and more in-depth information about an individual’s specific personality profile (Widiger & Trull, 2007). Whereas empirical support should theoretically “carry more weight” than practitioners’ preferences for the models or measures to use, measures must be known about, feasible, and acceptable in order to improve dissemination and implementation. Direct interaction, training, feedback, and participation from practitioners are essential at multiple levels (e.g., graduate level training, routine updated trainings in practices). Research has indicated that experts and clinicians agree that PDs can be conceptualized as maladaptive variants of personality traits (e.g., Bernstein, Iscan, Maser, & Boards of the Directors of ARPD and ISSPD, 2007) and that clinicians often prefer dimensional models to categorical models on many aspects of clinical utility (e.g., Morey, Skodol, & Oldham, 2014). However, this support has been equivocal, and there are aspects of clinical utility (e.g., communication with other professionals) on which dimensional models are rated similarly to extant models (Morey et al., 2014). It is areas like this in which training and bridging the gap could assist the field in moving forward. In conclusion, we highlight agreement with Evans et al. that continuing to improve the dimensional assessment of PD is a worthwhile endeavor. As part of this work, researchers must continue to consider the usefulness and incremental validity of such assessments in order to improve their training, implementation, and use.
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Ashley Helle’s work on this chapter was supported by National Institute on Alcohol Abuse and Alcoholism Grant T32 AA–13526 (PI: Kenneth Sher).