19a
Shannon Sauer-Zavala
In their compelling chapter, Bach and Presnall-Shvorin provide a comprehensive reminder of the importance of considering patients’ personality profiles when building a therapeutic alliance and selecting treatment approaches. Although, as the authors note, the notion of using personality to inform treatment is not new (e.g., Allport, 1961; Cattell, 1943; Eysenck, 1947; Harkness & Lilienfeld, 1997), they provide a practical guide to understanding how various maladaptive manifestations of the Five-Factor Model (FFM; e.g., Costa & McCrae, 1992) affect alliance and suggest how existing treatment approaches map on to several FFM domains.
A conceptual point that warrants further discussion is the authors’ assertion that there is a clear distinction between personality traits themselves and their phenotypic expression that, in extreme cases, constitutes a clinical disorder (e.g., Allport, 1961; Leising & Zimmermann, 2011). They further note that personality cannot be altered in response to treatment, and that the problematic, observable manifestations of traits should be the focus of care. Unfortunately, the characteristic thoughts and behaviors associated with traits often correspond to Diagnostic and Statistical Manual (DSM) disorders, resulting in an unwieldy proliferation of treatment approaches geared toward each discrete diagnosis. For example, within their treatment recommendations for negative affectivity, Bach and Presnall-Shvorin describe seven distinct treatment models that correspond to the facets of neuroticism (e.g., for emotional lability, provide dialectical behavior therapy; for depressivity, provide self-compassion training). Although an examination of personality profiles at the facet level allows for increased treatment specificity over DSM classification, it also likely results in a large training burden for clinicians who must become familiar with numerous interventions in order to provide coverage for the FFM.
Despite these challenges, the FFM may still provide a useful frame for streamlining treatment planning that reaches beyond a descriptive taxonomy. An understanding of the core, functional processes that underscore evolution from trait to disorder may point to a limited number of treatment elements with bidirectional impact on both traits and their phenotypic manifestations. A proposal for developing functional models of DSM disorders based on the FFM is provided in the following commentary; neuroticism and its associated disorders will be used as the illustrative example, followed by a summary of how presented principles may be applied to additional dimensions of personality.
A FFM-Based Functional Model of Disorders
Neuroticism predicts a range of public health problems, including a variety of mental disorders and their co-occurrence (Clark, Watson, & Mineka, 1994; Henriques-Calado, Duarte-Silva, Junqueira, Sacoto, & Keong, 2014; Khan, Jacobson, Gardner, Prescott, & Kendler, 2005; Krueger & Markon, 2006; Sauer-Zavala & Barlow, 2014; Trull & Sher, 1994; Weinstock & Whisman, 2006). Moving past a descriptive taxonomy, a functional model characterizing the processes through which neurotic temperament evolves into the distress and interference associated with a broad range of DSM disorder symptoms can be used to develop robust treatment elements that may simultaneously address disorder symptoms along with neuroticism itself. Specifically, there is ample support for the notion that disorders falling along the traditional neurotic spectrum (e.g., anxiety disorders, depressive disorders) result from three interacting components (see: Barlow, Sauer-Zavala, Carl, Bullis, & Ellard, 2014; Sauer-Zavala & Barlow, 2014): (1) the trait-like tendency to experience negative emotions (neuroticism), (2) aversive reactions to these emotional experiences when they occur, and (3) subsequent attempts to suppress or otherwise avoid them. Although avoidant strategies may be effective in the short term, there is compelling evidence to suggest that suppressed emotions return with greater frequency and intensity (e.g., Campbell-Sills, Barlow, Brown, & Hofmann, 2006), maintaining emotional disorder symptoms in the long term (Purdon, 1999).
Emerging research suggests that treatments explicitly designed to address this functional model are associated with promising reductions in a range of clinical presentations, as well as neuroticism itself (e.g., Armstrong & Rimes, 2016; Carl, Gallagher, Sauer-Zavala, Bentley, & Barlow, 2014; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005, 2010). An examination of the components included in these treatments suggests commonalities. Specifically, all three provide psychoeducation on the adaptive function of emotions and encourage an approach oriented stance toward these experiences. Reduced avoidant coping in the face of strong emotions limits the paradoxical rebound effects that maintain both negative affectivity and DSM disorder symptoms. Targeting underlying functional processes in this manner is consistent with the National Institute of Mental Health’s Research Domain Criteria (RDoC) initiative that tasks researchers to look beyond diagnoses to identify core processes implicated in the development and maintenance of symptoms across a range of disorders (Insel et al., 2010).
With regard to heterogeneity in presentations within high levels of neuroticism (e.g., high self-conscientiousness, low depressivity), a comprehensive functional model may help clinicians conceptualize these differences. For example, social withdrawal associated with depressivity, discomfort with somatic sensations associated with anxiousness, and non-suicidal self-injury associated with mood lability may all be conceptualized as aversive, avoidant reactions to emotional experiences per the functional model described above – perhaps warranting only minor variations on a unified treatment approach. As a result, clinicians with a strong understanding of this functional model of neurotic spectrum disorders can address varied clinical presentations with a streamlined treatment approach. Thus, treating neuroticism itself with a limited number of treatment strategies, rather than its individual facets or downstream clinical correlates, may represent a more efficient and cost-effective means of addressing the wide swath of public health problems associated with this trait.
Of course, it is important to note that neurotic spectrum disorders represent just one functional class of psychopathology, and it may be possible to identify additional broad classes characterized by their own unique shared mechanisms. Specifically, a similar perspective can be taken with regard to addressing the clinical disorders that may arise from falling at the extreme poles on the other four dimensions of the FFM. For example, low levels of extraversion have been shown to confer added risk, beyond neuroticism, for depressive disorders, social anxiety, and agoraphobia (e.g., Brown, Chorpita, & Barlow, 1998), whereas high levels of this trait (along with high levels of openness) are associated with bipolar disorder (Bagby et al., 1996; Quilty, Sellbom, Tackett, & Bagby, 2009). Similarly, maladaptive variants (both high and low levels) of agreeableness, conscientiousness, and openness have each been linked to specific forms of psychopathology (Widiger, Lynam, Miller, & Oltmanns, 2012). Some theoretical and empirical work has already been done to establish functional models accounting for the relationship between traits and DSM disorder symptoms, along with suggesting corresponding streamlined interventions strategies (e.g., extraversion: Carl, Soskin, Kerns, & Barlow, 2013; conscientiousness: Roberts, Hill, & Davis, 2017). Overall, these efforts may result in fewer diagnostic categories, along with a smaller number of more broad-based psychological interventions.
Conclusions
Identifying shared functional mechanisms that apply to broader groups of disorders may inform more efficient strategies designed to explicitly target the processes that maintain symptoms across diagnostic boundaries. It is possible that the FFM may provide a framework for understanding and addressing the majority of psychopathology included in the DSM system, along with the traits themselves. The bulk of the literature elucidating how personality features evolve into clinical diagnoses has been conducted in the context of neuroticism. However, understanding the functional processes that account for how the other FFM traits evolve into the distress and impairment that characterize a mental disorder is an important step in identifying effective treatment strategies that may move these personality features. Using the FFM as the basis for intervention selection may result in a limited number of treatment elements, each mapping on to one of the five dimensions of temperament that confer risk for a wide swath of psychopathology. In other words, this dimensional approach to treatment may lead to a more manageable number of evidence-based treatment components, reducing therapist training burden while also providing coverage to the full range of DSM disorders.
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