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7/27/2019 Personality Disorders in 21,Ct
1/15
Journal
of
Personality
Disorders,
14 1 ,
3-16,
2
2000
The Gu ilf ord
Press
PERSONALITY
DISORDERS
IN
THE
2
1ST
CENTURY
Thomas
A.
Widiger,
PhD
The
diagnosis
and classifica tion
of
personality
disorders have
ome
long
way
since the
beginning
of the 20th
century.
Per
haps
by
this time
next
century,
the
diagnostic
manua l
of
men
ta l disorders will be
using
dimensional
model of
classification
that
will
provide
more
reliable
and
meaningful
points
of
demar
cation
between normal
and abnormal
personality
functioning.
This a rtic le
offers
suggestions
fo r the
form, content,
and
place
ment
of
such
dimensional
model .
The
particular
mode l em
phasized
herein
is the five-factor
mo del of
personality
functioning,
but
the
optimal
diagnostic
system
will
probably
in
volve n
integration
of a lt erna tive dimens iona l models .
The
diagnosis
and classification of
personality
disorders
have
come
a
long
way
since the
beginning
of
the 20th
century.
Many significant
innovations
have occurred since the
days
of
Freud,
Schneider,
Kraepelin,
and others
Millon
et
al.,
1996 .
Foremos t
among
them
has
been
the
increased
sophisti
cation
and cumulat ive
foundation
of
empirical
research
documenting
the
importance
of
personality
traits
to
the
development
of
and
resilience to men
tal disorder
Basic
Behavioral Science
Task
Force,
1996
It
is
difficult
to
pre
dict
what
will
transpire
over
the
next
100
years.
Perhaps
by
the
end of this
new
century
the human
species
will
be
destroyed
by
great
plague
or
by
devastating
meteor
strike,
in
which
se
there
will
be little
interest
among
the
surviving
species
for
revision to the
American
Psychiatric
Association s
APA
Diagnostic
and
Statistical
Manual
of
Menta l Disorders
DSM .
In
the
meant ime,
it is still
meaningful
to
propose
revisions
to the
diagnostic
m n
ual
that
will
hopefully
continue its
progress
toward
becoming
scientifically
valid
classification
of
personality
disorders .
The
diagnosis
of
personality
disorders in the
21st
century
hopefully
will
consist
of dimensional
mode l o f
classification that
acknowledges
the artifi
cial
boundar ies
with
normal
personality
functioning, yet
also
provides
more
explicit,
reliable,
and
meaningful
points
of
demarcation.
The
many
argu
ments
favoring
dimensional
model will
not
be
reiterated
here,
s
they
have
7/27/2019 Personality Disorders in 21,Ct
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4
WIDIGER
1985,
1998;
Widiger,
1993;
Widiger
&
Frances,
1985).
The
purpose
of
this
article is
to
offer
suggestions
fo r the
form,
content ,
and
placement
of
this
di
mensional
model.
AN
INTELLIGENT
MODEL OF
PERSONALITY
DISORDER
In
DSM-IV,
the
decision
w s made to
return th e
Specific
and Pervasive
Develop
menta l Disorders to
Axis
I
and to retain
only
Mental Retardat ion
and
Personality
Disorders
on Axis II. There is
no
very
compelling logic
behind.. .
these
decisions.
(Frances,
First,
&
Pincus, 1995,
p.
72)
Perhaps
it
w s
n
appropriate
accident
that
mental
retardation
and
per
sonality
disorde rs rem ained
together
on
this
axis,
s
the
latter
n
learn
lo t
from the
former.
A useful
model
for
the
classification of
personality
disor
ders
is
provided by
the
diagnosis
ofmenta l
retardation
Widiger,
1997a).
In
telligence,
like
personality,
is
characterist ic
level
of
functioning
that is
relatively
stable
throughout
most
persons'
lives
(Neisser
et
al.,
1996).
This
level
of
functioning,
like
personality,
is
evident
wi thin
everyday
behavior and
has
impor tant implications
for su ess
(adaptivity)
and
failure
maladaptivity)
ross
wide
variety
of
social
and
occupational
contexts. In
telligence,
like
personality,
is multifactorial
const ruct ,
including many
varied
but correlated
components
of
cognitive
functioning
that
have re
sulted
from
variety
of
complexly interacting etiologies.
And
intelligence,
like
personality,
is
best described
s
continuous variable
with
no discrete
break
in its distribution thatwould
provide
a
qualitative
distinction
between
normal
and abnormal
levels.
A
clinically
significant degree
of
maladaptive intelligence
is
currently
de
fined
in
large
part
s
the
level
of
intelligence
below
n
intelligence quotient
IQ)
of 70
APA, 1994).
This
point
of
demarcation
does
not
rve nature
at
discrete
joint, distinguishing
the
presence
versus
absence of
discrete
pa
thology.
It is n
arbitrary
point
of
demarcation
along
continuous distribu
tion of
cognitive
functioning
Szymanski
&
Wilska,
1997).
There re
persons
with n
IQ
below
70
for
whom
qualitatively
distinct disorder
is
evident,
but
the d iso rde r
in such ses is notmental
retardation;
it is
physical
disorder
e.g.,
Down's
syndrome)
that n
be
traced to
specific
biological
event.
Mental
retardation,
in
contrast ,
is menta l
disorder
for which
there
re
more than
200
recognized biological
syndromes.
..entailing
disruptions
in
virtually any
sector
ofbrain
biochemical
or
physiological
functioning
Pop
per
&
Steingard,
1994,
p.
777).
The
numbe r of
contributing etiologies
and
pathologies
is even
greater
when
one includes
the
many
psychosocial
deter
minants.
Approximately
40
of
ses
of
menta l
retardation
lack
known
etiology,
in
part
because
its
determinants,
s in
the
se
of
personality
,
re
7/27/2019 Personality Disorders in 21,Ct
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PERSONALITY
DISORDERS
5
ingless, inappropriate,
or unreasonable On the
contrary,
substantial
amount of
thought
and research has
supported
the
selection of
n
IQ
of
70
s
providing
meaningful
and
reasonable
point
at
which
to characterize
lower
leve ls o f
intelligence
s
resulting
in
clinically
significant
level
of
im
pairment
that
warrants
professional
intervention
Personality
disorders could
l ikewise
be
diagnosed
at that
point
on
the
on
tinuum of
personality
functioning
that indicates
clinically
significant
level
of
impairment
Widiger,
1994).
Identifying
the
optimal point
of
demarcation
would be
difficult,
s
it
has
been
fo r
the
diagnosis
of menta l
retardation
However,
the
discussion,
consideration,
and
research that
wou ld h av e to oc
ur in order to determine
meaningful
point
of demarcat ion
would
itself
represent
substantial
improvement
over the
virtual
absence
of
any
re
search
or rationale
to
justify
the current
diagnostic
thresholds
for
the de
pendent,
avoidant, histrionic,
obsessive-compulsive,
narcissistic, schizoid,
and other
personality
disorders
A
F IVE-FACTOR
MODEL
OF PERSONAL ITY
DISORDERS
To the
extent
that
dimensional model of
personality
disorders
would b e
on
continuum
with
norma l
personality
functioning,
it
would
be
reasonable
for it to be
coordinated
with
the five-factor
mode l
FFM),
s
the
FFM
is the
predominant
mode l
of norma l
personality
functioning
Wiggins
Pincus,
1992).
This is
not
to
say
that
there
is
onsensus
support
for the FFM
Block,
1995),
but
none of
the alternative
models has
nearly
s
much
consistent em
pirical
support
Costa
McCrae, 1995;
Goldberg
Saucier,
1995).
The FFM
has
demonstrated
robustness ross
peer,
spouse ,
and
self-reports;
longi
tudinal
stability
ross the
lifespan;
robustness ross
cultures;
and
com
pelling genetic
heritability
Wiggins,
1996).
ts
predictive validity
and
utility
have been
demonstrated
ross
wide
variety
of f ie lds o f
interest,
including
aging,
health
psychology,
and
industrial-organizational
psychology
Costa
McCrae,
1992).
The
su ess
of
the
FFM
is
due
in
part
to
the
rat ionale
for
its
original
deriva
tion
The
FFM
w s not
constructed
on the
basis of
the
insights
of
particular
theorist
or
group
of
expert
clinicians.
The FFM
w s
developed
on
the
basis
of
the
compelling
rationale
that
the most
important
traits
of
personality
could
be
identified
through
n
empirical
lexical)
analysis
of
the natural
language.
Those
individual differences that
re the
most
significant
in
the
daily
trans
actions
of
persons
with
each
other
will
eventually
become encoded
into their
language
Goldberg,
1982,
p.
204).
The
relative
importance
of
trait is indi
cated
by
the number of
terms
that
have been
developed
to
describe the vari
ous
degrees
and
nu n es
of
that
trait,
and the
structure of
the
traits is
evident
by
the
relationship
among
the
trait terms
To the
extent
that
theo
rist is
n dimension of
it
would
be
7/27/2019 Personality Disorders in 21,Ct
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6
WIDIGER
must
be
used
by
persons
from
wide
variety
of
theoret ical
orientations,
in
cluding
(but
not l imited
to)
psychodynamic,
neurochemical ,
cogni
tive-behavioral,
and
interpersonal-systems.
It is
impossible
to be
entirely
atheoretical,
but
classification
systems
n
be
distinguished
in
part by
the
extent to which
they
re
compatible
with
alternative
theoret ical models .
A
face-validity
limitation
of
the
FFM is
that its
current
description places
relatively
more
emphasis
on the norma l
(adaptive)
variants of
personality
functioning.
For
example,
the
severely dysfunctional
borderl ine
personality
disorder is
not
described
well
by
simply
referring
to
excessive
neuroticism;
nor
is
the
evil,
heinous
psychopath
described
well
by
simply referring
to low
agreeableness.
However,
it is unrealistic to
expect
any
single
term to
de
scribe
well a ll of
the
many specific
degrees
and variants
within
broad
do
main
of
personality
functioning.
The
facets
of neuroticism
identified
by
Cos ta
and
McCrae
(1992),
such
s
angry
hostility,
impulsivity,
vulnerabil
ity,
anxiousness,
and
depression,
do
describe
well fundamental
compo
nents of borderline
personality
disorder. Persons who
re
the most
highly
elevated
on
neuroticism
would be
excessively
vulnerable to
stress
repeat
edly angry
and
hostile,
highly
anxious,
destructively impulsive,
and
often
terribly
depressed,
and would
likely
receive
the
borderline
diagnosis,
s
demons t ra ted
empirically
by
Clarkin,
Hull,
Cantor,
and
Sanderson
(1993)
in
sample
of
inpatient
borderlines at
Cornell
University
Medical
Center.
The
s me n
be
said
for
psychopathy.
For
example,
the
glib
charm of
the
psychopath
is
primarily
reflection of
low
self-consciousness.
The
person
who is at the
normative,
average
level of
self-consciousness
will be
sensitive
to
ridicule,
prone
to some
degree
of embarrassment and
insecurity.
The
psy
chopath,
on th e o th er
hand,
is
at
the lowest
level
of
self-consciousness:
more
than the
average
person,
he is
likely
to seem fr ee f rom social or
emo
tional
impediments,
from
the
minor
distortions,
pecularities,
and
awkward
ness so ommon even
among
the successfu l
(Cleckley,
1941,
p.
205).
If
one
identifies the
person
who is
at
the lowest level
possible
fo r
feelings
ofvulner
ability,
one
would
identify
person
who
is
fearless;
at
the
highest
level
possi
ble
for
tough-mindedness
would
be
callousness;
at
the
far thest
opposite
pole
of altruism
wou ld b e cru el
exploitation;
at the farthest
opposite
pole
of
modesty
would b e
arrogance
and
grandiosity.
All
of the
fundamental
traits
of
psychopathy
re extreme variants
of
ommon
personality
traits,
s dem
onstrated
empirically
by
Miller,
Lynam,
Widiger,
and Leukefeld
(in
press).
Identifying
this
profile
with
specific
te rm,
psychopathy,
is
useful
to
focus
social and clinical
attention,
s
long
s
one
recognizes
that the
profile
is in
deed
collection
of
personality
traits rather
than
homogeneous,
qualita
tively
distinct
condition
(Widiger
Lynam,
1998,
p.
185).
EMPIRICAL
SUPPORT
FOR A
FIVE-FACTOR
MODEL O F
7/27/2019 Personality Disorders in 21,Ct
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PERSONALITY
DISORDERS
7
the FFM
personality
disorder
studies is
beyond
the
scope
of
this
article,
but
it is
worthwhile to
provide
few illustrations.
Blais
(1997)
provided
results
from
a nat ionwide
survey
of 100 clinicians.
The
clinicians
were
asked
to rate
one of
their
patients
who
carried
primary
diagnosis
of
personality
disorder
and had
been
in treatment
fo r
at
least
10
sessions
average length
of
treatment was 3.4
years).
The
clinicians
rated
each
patient
on
each of the DSM-1V
personality
disorder
diagnostic
criteria
A full
range
of
symptomatology
was ob ta ined . Each clinician also
rated each
patient
on 40
single-term
adjectives representing
the FFM . It has
been
r
gued
that
the
language
of
the
FFM
fails to
capture clinically
important
s
pects
of
personality functioning
and
that
clinicians
will
have
difficulty
applying
this model to their
patients
Blais,
1997,
p.
388).
Nevertheless,
Blais
(1997)
reported
that their
findings
[were]
highly
consistent with the
results
from
previous
research
that
[used]
different
samples
and
me sure
ment
instruments
p.
391).
Blais
1997)
concluded
that
their data
suggest
that clinicians n
meaningfully
apply
the
FFM
to their
patients
and
that the
FFM
of
personality
has
utility
fo r
improving
our
understanding
of the DSM
personality
disorders
p.
392).
McCrae, Cos ta ,
and Busch
1986)
demonstrated how the
items within
the
California
Q-Set
CQS;
Block,
196
1
n be
readily
understood from the
per
spective
of the
FFM.
The
CQS
items were
developed by
successive
panels
of
psychodynamically
oriented
clinical
psychologists seeking
ommon
lan
guage
for
the
description
of
psychological functioning.
McCrae
et
al. admin
istered the
CQS
and the NEO-PI
(Costa
McCrae,
1992)
to
participants
of
the Balt imore
Longitudinal
Study
of
Aging.
A
factor
analysis
of the
complete
set
of
items
yielded
five
factors that
corresponded
closely
to
the five
doma ins
of the
FFM. The neuroticism factor
contrasted
such
CQS
items
s
thin-skinned,
irritable,
extrapunitive,
self-defeating,
and
brittle
ego
defenses,
with
socially
poised,
sati sf ied wi th
self,
and
calm,
relaxed.
Extraversion
contrasted such
items
s
talkative,
behaves
assertively,
initiates
humor,
and
self-dramatizing,
with
submissive,
avoids close
relationships,'
and
emotionally
bland.
Openness
contrasted
values
intel
lectual
matters,
rebellious
nonconforming,
unusual
thought
processes,
introspective,
and
engages
in
fantasy,
daydreams,
with
moralistic,
uncomfortable
with
complexities,
and favorsconservative
values.
Agree-
ableness
contrasted
sympathetic,
considerate,
behaves in
giving
way,
and
warm,
compassionate,
with
basically
distrustful,
expresses
hosti l
ity
directly,
and
critical,
skeptical.
Last,
conscientiousness
contrasted
dependable, responsible,
productive,
and has
high
aspiration
level
with
enjoys
sensuous
experiences,
self-indulgent,
and
unableto
delay
gratification.
The
CQS
FFM
s ores
correlated well with
the
self-report, peer
report,
and
spouse report
NEO-PI
ratings,
yielding
quite
impressive
convergent
and
discriminant
validity.
It
has been
that
the
of
natural
7/27/2019 Personality Disorders in 21,Ct
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8
WIDIGER
that
very
similar
factors
n be found
in it
provides
striking
support
for
the
five-factor
model
McCrae
et
al.,
1986,
p.
442).
John,
Caspi,
Robins,
Moffitt,
and
Stouthamer-Loeber
1994)
updated
the
McCrae
et al.
1986)
study using
the California Child
Q-Set
CCQS)
descrip
tions of
35
boys
provided
by
their
mothers
s
part
of
the
Pittsburgh
Youth
Study,
longitudinal
investigation
of
the
antecedents
and correlates of de
linquency.
A
factor
analysis
of the
100
CCQS
items resulted
in
seven-factor
solution,
five of
which
clearly represented
the five domains
of
the
FFM.
The tw o
remaining
factors
were
interpreted
s
irritability
e.g.,
cries, whines,
or
pouts)
and
positive activity e.g.,
energetic, physically
tive,
or
fast-paced).
John etal
1994)
noted that researchwith adults has
in
dicated that
irritability
is
component
of
neuroticism,
and
positive activity
component
of extraversion
(Costa
McCrae,
1992).
They discouraged
re
searchers
from
placing
much
importance
on
the
tw o
addi tional factors
until
they
were
replicated
in
subsequent
studies
Until this is
done,
we re om
mend
that researchers
use
the
Big
Five
scales
(John
et
al., 1994,
p.
174).
It
is their
expectation
that
positive activity
and
irritability
will
eventually
merge
with
sociability
and anxious
distress,
respectively,
to form the
superordinate
dimensions of
extraversion
and neuroticism
in
adul thood
(Robins,
John,
Caspi,
1994,
p.
280).
Trull, Useda, Costa,
and McCrae
1995)
reported
substantial
convergence
of the
FFM
with
the MMPI-2
Personality
Psychopathology
Five
PSY-5)
devel
oped
by
Harkness,
McNulty,
and
Ben-Porath
1995).
Fo r
example,
PSY-5
positive
emotionality
and
negative
emotionality
strongly
resembled the
NEO-PI dimensions of extraversion and
neuroticism,
respectively
Trull
et
al., 1995,
p.
514).
The o the r th ree PSY-5
scales,
aggressiveness,
constraint,
and
psychoticism
had
more
complex relationships
but
were
nevertheless
clearly convergent: aggressiveness appears
to combine
some
aspects
of
low
agreeableness
and
high
extraversion;
constraint
m ay
be character ized
by
high
agreeableness
and
high
conscientiousness;
and
psychoticism
w s
pos
itively
related
to neuroticism
and
negatively
related to
some
facets of
agree
ableness
Trull
et
al., 1995,
p.
514).
Trull et al.
also
compared
the
tw o
models w ith
respect
to
their
ability
to
account for
personality
disorder
symptomatology
s
assessed
by
semistructured
interview
and
self-report
inventory.
As
hypothesized,
these trait
me sures
were
system
atically
related to
personality
disorder
symptom
counts,
whether
based
on
interviews or on
self-reports
(Trull
et
al., 1995,
p.
515).
For
example,
the
MMPI-2
PSY-5 scales
correlated
significantly
with 7
of
the
13
self-report
scales
after
controlling
for mo od
and
anxiety;
the NEO
PI-R
correlated with
all
13
no
differences were
reported
with the
semistructured
interview).
Soldz, Budman,
Demby,
and
Merry
1993)
compared
the
ability
of
the FFM
and
the
interpersonal
circumplex
to
account
fo r
personality
disorder
symptomatology
in
sample
of
102
patients
referred
fo r
group psychother
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PERSONALITY
DISORDERS
9
tory
oflnterpersonal
Problems
(IIP;
Alden,
Wiggins,
Pincus,
1990).
Despite
the rather
limited
power provided by
single-term
adjectives
in
comparison
to
the
comprehensive
set of
clinically
relevant
interpersonal
problems
s
sessed
by
the
IIP,
th e
use of the
Big
Five
model le d to
even
better
placement
for
severa l d i so rder s
(p.
41),
consistent
with the
earlier
study by Wiggins
and
Pincus
(1989).
Soldz
et
al.
(1993)
concluded
that
our
results
lend
strong
support
to
the
position
that
the
Big
Five
personality
factors
n ade
quately represent
the distinctions
among
the
personality
disorders
(p.
5
.
Two
personality
disorder
models
that re
comparable
to
the FFM
in
the
spirit
and
method
of their construction
re
Livesley s
18-factor
model,
s
assessed
by
the
DimensionalAssessment of
Personality
Pathology-Basic
Questionnaire
(DAPP-BQ;
Livesley,
Jackson,
Schroeder,
1989)
and Clark's
22-factor
model,
s assessed
by
the
Schedule fo r
Nonadaptive
and
Adaptive
Personality
(SNAP;
Clark
et
al.,
1993).
Both
of
these d imens iona l models
were
developed
through
systematic
and
comprehensive
searches
of the clinical and
empirical
l i terature
fo r
virtually
every
personality
disorder trait
concept,
followed
by
ex
tensive
analyses
of the
correlations
among
the traits
to
reduce them to a m n
ageable
set of fundamenta l
dimensions.
In direct
comparison,
Clark,
Livesley,
Schroeder and Irish
(1996)
ind icated considerable
convergence,
with
only
few,
relatively
minor
differences
(e.g.,
DAPP-BQ
Intimacy
Problems
may
not be well
represented
within
the
SNAP,
and SNAP Workaholism
may
not
be
well
represented
within the
DAPP-BQ).
Equally
important,
higher
order
fa c
tor structure of the
joint
set of instruments
yielded
four
factors
whichorre
sponded
to
the
wel l- es tab li shed d imens ions of
neuroticism,
introversion,
(dis)agreeableness
(aggression-hostility),
and
(low)
conscientiousness
(impul
sive sensation
seeking)
(Clark
et
al., 1996,
p.
300).
Clark, Vorheis,
and
McEwen
(1994)
assessed
the
convergence
of
the
FFM
with
the SNAP
22-factor
model,
and
reported
that the SNAP
scalesthat
s
sess
maladaptive personality
traits were shown to be
related
to
me sures
of
all five
factors,
which
indicates the
general
relevance
of
the FFM fo r Axis II
phenomena
(p.
109).
The
factor
analytic
results
l end cons iderab le
support
to
related
hypotheses.
First,
the
s me
underlying
personality
trait
structure has
been
shown
to
emerge
from
analyses
of
normal
and
maladaptive
personality
traits
Once
again,
these
data
provide
evidence
of
structural
continuity
ross
normal
and
abnormal
personal
ity.
Second
and more
specifically
comprehensive
(although
perhaps
not
ex
haustive)
set
of
maladaptive
traits
has
been
shown
to
correlate
signiflcandy
with
all
of
the
dimensions
of the
FFM,
which
supports
the
notion
that
this
particular
model
of
personality
has
relevance fo r
understanding personality
disorder.
(Clark
etal. ,
1994,
p.
110)
Schroeder,
Wormworth,
and
Livesley
(1992)
adminis tered
the
NEO-PI
and
the
DAPP-BQ
to 300 adult
members
of
the
factor
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WIDIGER
well within
the f ive -fac tor mode l
of
normal
personality p.
51).
Livesley,
Jang,
and Vernon
1998)
factor
analyzed
the
18 lower-order
traits
included
within
the
DAPP-BQ
in
samples
of
656
personality
disordered
patients,
939
general
population
subjects,
and
686 twin
pairs.
Principal
components
analysis yielded
fou r b road doma ins
that
Livesley
et
al.
(1998)
identified
s
emotional
dysregulation,
dissocial
behavior , inhibitedness
and
compulsivity.
They
i nd ic a ted the
convergence
of
these
four
factors with four
of the
five
domains of
the
FFM,
wi th emo tiona l
dysregulation
convergent
with
neuroticism,
d is soc ia l behav io r
defined
by
interpersonal hostility,
judgmental
attitudes,
callousness,
and conduc t
problems)
coordinating
well with
antagonism,
inhibition
(characterized
by intimacy problems
and
restricted
affect)
aligning
well with FFM
introversion,
and
compulsivity
with
conscientiousness.
Livesley
et
al.
did
emphasize
that
they
did
not
obtain
factor
that
would
correspond
to
FFM
openness
but,
s
noted
by
n om
panying commentary,
four
out of five ain t
bad
Widiger,
1998,
p.
865).
In
perhaps
on e of
the more
thorough
and
extensive
comparisons
of alter
native dimensional
models,
O Connor and
Dyce
1998)
conducted 12 inde
pendent
principal-axes
ommon factor
analyses
on the correlation matrices
among
the
personality
disorders
using
variety
of
samples
and
assessment
instruments
provided
by
nine
previously published
studies.
The
personality
disorder
matrices were
rotated to least
squares
fi t to
the
target
matrices
generated
by
variety
of alternative
dimens iona l models .
As
emphasized
by
O Connor
and
Dyce
1998),
their
analyses
were
not
exploratory
searches
of
data
sets,
obtaining
wha teve r fa cto r
analytic
solution
might
capitalize
on
the
particular
me sures
and
samples
that were
used. Their
confirmatory
analyses
were
powerful,
support-seeking attempts
to find the
view
on
correlational
structure
that w s most consistent
with
given
model .
Fail
ures
to
find
support
re thus more
likely
due
to
shortcomings
with mode l
than to
shortcomings
with
the method
(O'Connor
Dyce,
1998,
p.
14).
The
highest
and most consistent levels
of
fi t were
obta ined
for the
five-factor
model
(O'Connor
Dyce,
1998,
p.
14),
along
with
Cloninger
and
Svrakic's
1994)
seven-factor model.
Ball,
Tennen,
Poling,
Kranzler,
and
Rounsavil le
1997)
compared
the
FFM,
assessed
by
the NEO-FF I
(Costa
McCrae,
1992),
with the
dimensional
model
of
Cloninger
and
Svrakic
1994),
assessed
by
the
Temperament
and
Character
Inventory
TCI),
in
sample
of
370
substance
dependent patients
(188
outpatients;
182
inpatients)
diagnosed
with
personality
disorders
by
semistructured
interview. Ball
et
al.
1997)
reported
that the
FFM
outper
formed
the TCI
ross
all of
their
analyses.
The
proportion
of
variance
counted
for in all
personality
disorders w s
higher
fo r
the NEO than
the TCI
scales with NEO
neurot ic ism,
extraversion,
and
agreeableness
being
on
sistently
stronger predictors
ross
several
disorders
than
the
TCI
d imen
sions
Ball
et
al.,
1997,
p.
549).
The
NEO
dimensions
were
related to
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PERSONALITY
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11
AXIS
II
PLACEMENT
The
FFM
provides
description
of
the
continuous
and multi fac tor ia l
n ture
of
norma l
ndabnormal
personality
functioning
in
m nner
analogous
nd
complementary
to
comparable
descriptions
of
the continuous nd
multifactorial n ture
of
norm al and abnorm al
intellectual
functioning.
Placed
together
on Axis
II,
they
could
become
model
fo r
the
reliable,
pre
cise,
nd
valid
diagnosis
of menta l disorders
s
clinically
significant
points
of dem rc tion
along
continuous domains
of
cognitive,
emotional,
interper
sonal,
nd behaviora l
functioning.
However,
one of the
issues
to be
ad
dressed
in
this series of
p pers
is
whether the
personality
disorders
should
continue to
be
diagnosed
on n
xis
separate
from other ment l
disorders .
The
placement
of the
personality
disorders on
separate
xis
may
have
on
tributed
to
number
of
problematic
perceptions
e.g.,
th t
personality
dis
orders
re
untre t ble or
th t
they
re
qualitatively
distinct from other
menta l
disorders).
A
proposed
solution
to
these
misunderstandings
is
to
b ndon
the
distinction
by
moving
the
personality
disorders to
Axis
I
Livesley,
1998 .
Abandoning
the
multiaxial
placement
of
personality
disorders, however,
might
not be
advisable,
s it would
not
resolve
ny
of the
diagnostic
bound
ries
th t
re
of
concern
would
lose
the
benefit s obta ined
by
the
multiaxial
placement,
ndwould
likely
result in more losses th n
gains.
The
problem
tic
distinctions
between
void nt
personality
disorder
nd
generalized
so
cial
phobia
or
depressive
personality
disorder
nd
early
onset
dysthymia
would
still
rem in after the
personality
disorders were
moved
to A xis
I.
The
differentiation
of
personality
disorders from other
men ta l d is o rde rs
w s
problematic
long
before there
were
separate
xes
and
would
rem in
after
the multiaxial
system
w s
abandoned.
A
widely
cited
nd influential
reli
ability
study
in
the
days
of DSM-I
by
Ward, Beck,
Mendelson, Mock,
nd
Erbaugh
1962
concluded
th t
the
largest
single
sour e of
disagreement
among
practicing
clinici ns
w s
determining
w he the r
the
neurotic
symptomatology
or
the
characterological
pathology
is
more
extensive or ba
sic
p.
202).
Ward
et
al.
were
critical
of
the
DSM-I
fo r
encouraging
clinicians
to
choose between
neurotic
condit ion
nd
personality
d is ord er when
both
were
in
fact
present.
The
placement
of
the
personality
disorders
on
separate
xis
w s
compelling
approach
to this
problem.
Personality
disor
ders
were
placed
on
separate
xis
in
DSM-III to
encourage
clinicians to di
agnose
these
disorders
along
with
other menta l
disorders
rather th n
being
forced
to
arbitrarily
and
unreliably
make
choice
between
them
(Frances,
1980,
p.
1050 .
A
return to
Axis
I
would
likely
incre se
r ther
th n
decrease
artificial
distinctions
between
personality
nd
other
ment l
disorders
by
once
again
compelling
clinicians
to
make
arbitrary
nd
illusory
differential
diagnoses.
The
placement
of the
personality
disorders on
xis
in
e ch
of
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WIDIGER
Loranger
(1990)
compared
all
diagnoses
provided
by
clinicians
before
nd
after the
implementation
of DSM-III . Themost
dr m tic
difference
be
tween
the DSM-II
nd
DSM-III
st tistics
w s the
more
th n
twofold
in
re se
in
the
diagnosis
of
personality
disorders,
from
19.1
to 49.2
Loranger,
1990,
p.
674).
The subst nti l interest
in
the
study
nd
tre t
ment
of
personality
disorders th t
we re
currently experiencing
is due
in
part
to the
appropriate
ttention
generated
by
their
presence
on
sep
r te
xis The existence
of this
journal
is itself
test ment
to the
growth
of
the field of
personality
disorders
th t owes much to the
recognition
pro
vided
by
the
m ultiaxial
system
of
DSM-III .
As
st ted
by
the
founding
edi
tors in
the
initial
issue of this
journal:
W ith
the
dvent of this official
classification,
personality
not
only
gained
place
of
consequence
among
syndromal categories
but bec me
centr l
to its
multiaxial
schema
(Millon
&
Frances,
1987,
p.
ii .
There
might
in fact
be
compelling
re son
fo r
placing personality
disor
ders
on
separate
xis
There is
no
patient
who
lacks
personality,
nd
there
may
be
no
patient
who
lacks
clinically
significant
maladaptive
person
ality
tr its
Widiger,
1993 .
The
m nner
and
extent to which
patient's
per
sonality
facilitates
nd
hinders clinical
treatment,
nd
the
extent
nd
m nner
in which
they
result in
clinically significant maladaptive
function
ing,
should be
routine
consider tion
of
every
clinician
(Harkness
&
Lilienfeld,
1997 .
The
logic
for
assigning
personality
its
own xis
is
not
merely
m tter
of
differenti
ating
syndromes
of
more
cute
and d rama tic
form
from
those of
long-standing
nd
prosaic
character .
More
relevant
to this
partitioning
decision
w s
the
sser
tion
th t
personality
tr its
nd
disorders
n serve
usefully
s
dynamic
sub
str te
from
which
clinicians
n better
grasp
the
significance
and
meaning
of
their
patients'
tr nsient nd
florid disorders.
In
th e
DSM-III,
then,
personality
not
only
tt ined
nosological
st tus
of
prominence
in
its
own
right
but
w s
assigned
contextual
role
th t made it fundamenta l to th e
understanding
nd
interpreta
tion
of other
psychopathologies.
Millon
&
Frances,
1987,
p.
ii
CONCLUSIONS
My
recommenda t ion for the
diagnosis
of
personality
disorders
in
future
edi
tions of
the m nu l
is
to
recognize explicitly
the
continuous
n ture
of
per
sonality functioning;
th t
personality
disorders re
maladaptive
v ri nts
of
ommon
personality
tr its
A
diagnosis
of
personality
disorder
could
be
made on
the b sis of
specified
cutoff
points
on
e ch of
the 30
facets
of
the
FFM,
representing
those
points
t
which
the
degree
of
self-consciousness,
tough-mindedness,
or
deliberation
for
example
resulted in
clinically
sig
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PERSONALITY DISORDERS
13
that
adaptive
s
well
s
maladaptive
traits
would
be
recognized.
Traits
that re
helpful
to
treatment
e.g.
,
adaptive
levels of
openness
or
conscien
tiousness)
wou ld in fo rm c lin ic al
decisions,
s well s the
traits
that
re
problematic e.g.,
excessive
self-consciousness,
impulsivity,
or
gullibil
ity .
It
m ay
also be
the
se
that
all
personality
traits
re
to
some
extent
po
tentially maladaptive
within some
situational
context(s).
This
perspective
is
readily compatible
with
the
FFM.
One
simply
obtains
n
FFM
profile
de
scription
of
n
individual
and
then ssesses the m nner
and
extent to
which
that
person s
traits re
helpful,
problematic,
harmful ,
or
maladaptive
within
the
social cultural
contexts
in
which that
person
must
funct ion
(McCrae,
1994;
Widiger,
1994).
Single diagnostic
labels,
such s
dependent,
borderline,
or
psychopathic,
could
still
be
obta ined
by
determining
the
extent to which
n
individual s
particular
constel lat ion
of
FFM
traits
is consistent
with
prototypic
profile
for
particular
disorder. Miller et al.
in
press
demonstrated this
procedure
using
n intraclass
Q-correlation
of
the
extent to which
respondent s
NEO-PI-R
profile
matched the
profile
of
prototypic
se of
psychopathy.
Al
gorithms
for other
harmful,
virulent,
or l etha l cons te l la tions
of
personality
traits
that
overlap
with
or
shade into the
prototypic
psychopath
re also
be
ing developed e.g.,
for
the DSM-IV
antisocial
personality
disorder,
narcis
sistic
personality
disorder,
aberrant
self-promoter,
successful
psychopath,
or abus ive
personality
disorder).
An
advantage
of
any
comprehensive
d i
mensional model
of
personality
disorder
is the
ability
to
generate
precise
profile representations
of and
diagnostic algorithms
fo r a
variety
of
overlap
ping,
alternative
diagnostic
categories.
A
dimens ional
model
of
personality
disorders need
not,
however,
be
syn
onymous
with the five-factor
model
to
be
the
optimal
diagnostic
system.
or
example,
the
FFM domain of
openness may
not
have
sufficient
utility
or relevance
to be included
(Clark
etal.,
1996;
Livesley
etal.,
1998).
Open
ness
w s
the
last
and the
smal les t of
the
domains to
be
extracted from
the
lexical
studies;
it
is
the
least
important
of the
five. Its
exclusion
might
be
problematic
to
c lin ic ians concerned
with
eccentric
perceptions,
aberrant
fantasies, alexithymia,
and
other
maladaptive
variants
of
this
domain
Widiger,
1998 ,
but
its
exclusion from DSM-V
might
be no
more contro
vers ial
than the exclusion of
social,
emot iona l
intelligence
from
official
conceptualizations
of
intelligence. Perhaps
the mode l
that
is
given
official
recognition
in
future
edit ion
of
the DSM will
be
n
integration
of
the
vari
ety
of
compelling
alternatives
that
re
currently
being generated
Widiger
Sanderson,
1995).
Research to date has
indicated
substantial onver
gence
among
the
alternative
dimensional
models,
particularly
the
DAPP-BQ,
FFM, PSY-5,
and
SNAP
(Clark
Livesley,
1994;
Clark
et
al.,
1996;
Livesley
et
al.,
1998;
Schroeder et
al.,
1992;
Trul l
et
al.,
1995 .
These
models re not
equivalent
to one
another,
but their
compatibility
is
far
more
than their
differences
The
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WIDIGER
REFERENCES
Alden,
L. E.
Wiggins,
J.
S.,
Pincus,
A. L.
1990).
Construction
of
circumplex
scales
fo r the
Inventory
of
Interper
sonal Problems. Journal
of
Personality
Assessment,
55 ,
521 536.
Amer ican
Psychiatric
Association.
1994).
Di
agnostic
and
statistical
manual
of
men
ta l
disorders
4th ed.).
Washington,
DC:
Author.
Ball.
S.
A.,
Tennen,
H.,
Poling,
J.
C Kranzler,
H.
R.,
Rounsaville,
B.
J.
1997).
Per
sonality,
temperament,
and character
dimensions
and
the
DSM-IV
personal
ity
disorders
in
substance abusers.
Journal
of
Abnorma l
Psychology,
106,
545 553.
Basic
Behavioral
Science Task
F orce of
th e
National
Advisory
Mental
Health Coun
cil.
1996).
Basic
behavioral
science re
search fo r
mental health.
Vulnerability
and
resi l ience.
American
Psychologist,
51 ,
22 28.
Blais,
M. A.
1997).
Clinician
ratings
of the
five-factor
mod el o f
personality
a nd th e
DSM-IV
personality
disorders.
Journa l
of
Nervous and Menta l
Disease,
185,
388 393.
Block,
J.
1961).
The
Q-Sort
method in
person
ality
assessment and
psychiatric
re
search.
Springfield,
IL :
Charles C.
Thomas .
Block,
J.
1995).
A
contrarian view
of
th e
five-factor
approach
to
personality
de
scription. Psychological
Bulletin,
117,
187-215.
Clark,
L.
A.,
Livesley,
W.
J.
1994).
Two
ap
proaches
to
identifying
th e
dimensions
of
personality
disorder:
Convergence
on
th e
five-factor model. In P. T.
Costa
T .
A.
Widiger
Eds.),
Personality
disor
ders and
thefive-factor
mode l
ofperson
ality
pp.
261-278).
Washington,
DC:
American
Psychological
Association.
Clark,
L.
A.,
Livesley,
W.
J.
Morey,
L.
1997).
Personality
disorder
ssess
ment:
The
challenge
of
construct
valid
ity.
Journal
of Personality
Disorders,
11 ,
205-231.
traits of
personality
disorder: Two
new
methods
fo r
their
assessment.
Psycho
logical
Assessment, 5,
81-91.
Clark,
L.
A.,
Vorhies,
L.,
McEwen,
J. L.
1994).
Personality
disorder
symptomatology
from the
five-factor
model
perspective.
In
P.
T.
Costa
T.
A.
Widiger
Eds.),
Personality
disorders
and
thefive-factor
mode l
of
personality
pp.
95-1
16).
Washington,
DC:
Amer i
c n
Psychological
Associat ion .
Clarkin,
J.
F., Hull,
J.
W., Cantor,
J.
San
derson,
C.
1993).
Borderline
personal
ity
disorder
and
personality
traits:
A
comparison
of SCID II BPD and
NEO-PI.
Psychological
Assessment 5,
472 476.
Cleckley,
H.
1941).
The mask
of sanity.
St.
Louis,
MD:
Mosby.
Cloninger,
C.
R.,
Svrakic,
D.
M.
1994).
Dif
ferentiating
normal and
deviant
per
sonality by
the
seven-factor
personality
model.
In
S. Strack M .
Lorr
Eds.),
Dif
ferentiating
norma l
and
abnormal
per
sonality pp .
40-64) .
New
York :
Springer.
Costa,
P.
T.,
McCrae,
R. R.
1992).
Revised
NEO
Personality
Inventory
NEO-PI-R)
and
NEO
Five Factor
Inventory
NEO-FFI)
professional
manual.
Odessa,
FL:
Psychological
Assessment
Resources .
Costa,
P.
McCrae,
R. R.
1995).
Solid
ground
in
th e
wetlands of
personality:
A
reply
to
Block.
Psychological
Bulletin,
117,
216-220.
Frances,
A.
J.
1980).
The DSM-III
personality
disorders
section:
A
commentary.
American
Journal
of
Psychiatry,
137,
1050-1054 .
Frances,
A.
J., First,
M.
B.,
Pincus,
H. A.
1995).
DSM-IV
guidebook.
Washing
ton,
DC:
Amer ican
Psychiatric
Press .
Goldberg.
L.
R.
1982).
From
ace to
zombie:
Some
explorations
in
th e
language
of
personality.
In
C.
D .
Spielberger
J.
N.
Butcher
Eds.),
Advances
in
personality
assessment
Vol.
1,
pp .
203-234).
7/27/2019 Personality Disorders in 21,Ct
13/15
PERSONALITY
DISORDERS
15
ment
planning:
Personality
traits.
Psychological
Assessment 9,
349-360.
Harkness
A.
R .,
McNulty,
J.
L.,
Ben-Porath,
Y.
S.
1995).
The Personal
ity
Psychopathology
Five
PSY-5):
Con
structs
and
MMPI - 2
scales.
Psychological
Assessment
7,
104-114.
John,
O.
P.,
Caspi,
A., Robins,
R.
W
Moffltt,
T.
Stouthamer-Loeber,
M.
(1994).
The little five :
Exploring
the
nomological
network
of th e
five-factor
m odel of
personality
in
adolescent
boys.
Child
Development.
65 ,
160-178.
Livesley,
W.
J.
(1985).
The
classification
of
personality
disorder:
I. The choice of
category
concept.
Canadian Journal
of
Psychiatry.
30. 353-358 .
Livesley.
W.
J.
1998).
Suggestions
fo r
a frame
work fo r an
empirically
based
classifica
tion
of
personality
disorder. Canadian
Journal
of
Psychiatry,
43,
137-147.
Livesley,
W.
J. Jackson,
D.
N.,
Schroeder,
M.
L.
1989).
A
study
of th e
factorial
structure of
personality
pathology.
Journal
of Personality
Disorders, 3,
292-306.
Livesley,
W.
J.
Jang,
K.
L.,
Vernon,
P. A.
(1998).
Phenotypic
and
genetic
struc
ture of
traits
delineating personality
disorder.
Archives
of
General
Psychia
try,
55 ,
941-948 .
Loranger,
A. W.
1990).
The
impact
of DSM-III
on
diagnostic
practice
in
a
university
hospital.
Archives
of
Genera l
Psychia
try,
47,
672-675.
McCrae,
R. R.
1994).
A
reformulation
of Axis
II:
Personality
and
personality-related
problems.
In P.
T.
Costa
T.
A.
Widiger
(Eds.).
Personality
disorders and th e
five-factor
mode l
of
personality
pp.
303-310).
Washington,
DC: American
Psychological
Associat ion.
McCrae,
R.
R., Costa,
P.
T.,
Busch,
C.
M.
(1986).
Evaluating
comprehensiveness
in
personality systems:
The California
Q-Set
and th e
f ive-fac tor model .
Jour
nal
of Personality.
54 .
430-446 .
Miller,
J.
D.,
Lynam,
D.
R.,
Widiger,
T.
A.,
Leukefeld,
C.
in
press).
Personality
dis
orders
as extreme variants of
common
personality
dimensions:
Can
the
five-factor
model
adequately
represent
Millon, Frances,
A. J.
1987).
Editorial.
Journal
of
Personality
Disorders.
J
111
Neisser,
U.,
Boodoo,
G., Bouchard,
T.
J.
Boykin,
A.
W.,
Brody,
N., Ceci,
S.
J.
Halpem,
D.
F. ,
Loehlin,
J.
C
Perloff,
R.,
Sternberg,
R.
J.
Urbina,
S.
1996).
Intelligence:
Knowns
and un
knowns.
American
Psychologist,
51,77-101.
O'Connor,
B.
P. ,
Dyce,
J. A.
1998).
A test of
models
of
personality
disorder
configu
ration.
Journal
of
Abnormal
Psychol
ogy,
107,
3-16 .
Popper,
C.
W.,
Steingard,
R.
J.
1994).
Dis
orders
usually
first
diagnosed
in in
fancy,
childhood,
or
adolescence.
In R.
E.
Hales,
S.
C.
Yudofsky,
J. A.
Talbot t
Eds.),
Textbook
ofpsychiatry
(2nd
ed.,
pp.
729-832).
Washington,
DC: Amer i
can
Psychiatric
Press.
Robins,
R. W.
John,
O.
P.
Caspi,
A.
1
994)
Major
dimensions
of
personality
in
early
ado lescence: The
big
five
and be
yond.
In
C.
F.
Halverson,
G.
A.
Kohnstamm,
R. P.
M art in
(Eds.),
The
developing
structure
of
temperament
and
personality
from
infancy
to
adult
hood
pp.
267-291). Hillsdale,
NJ:
Er lbaum.
Schroeder,
M.
L.,
Wormworth,
J.A.,
Livesley,
W.
J.
1992).
Dimens ions of
personality
disorder and
their
relationship
to th e
Big
Five dimens ions of
personality. Psycho
logical
Assessment
4,
47-53.
Soldz,
S.
, Budman,
S.
Demby
A.
Merry,
J.
1993).
Representation
of
personality
disorders
in
circumplex
and
five-factor
space:
Explorations
with
a
clinical
sample.
Psychological
Assessment
5,
41-52 .
Szymanski,
L.
S.,
Wilska,
M.
1997).
Menta l
retardation.
In
A.
Tasman,
J.
Kay,
J.
A.
Lieberman
Eds.),
Psychiatry
Vol. 1,
pp.
635).
Philadelphia,
PA:
W.B.
Saunders.
Trull,
T.
J., Useda,
J.
D.,
Costa,
P.
Mc
Crae,
R.
R.
1995).
Comparison
of
th e
MMPI-2
Personality
Psychopathology
Five
PSY-5),
the
NEO-PI,
and the
NEO-PI-R.
Psychological
Assessment
7.
508-516.
Trull,
T.
J .,
Widiger,
T.
A.,
Useda,
J.
D.,
7/27/2019 Personality Disorders in 21,Ct
14/15
16 WIDIGER
Ward,
C.
H., Beck,
A.
T
Mendelson, M.,
Mock,
J.
E.,
Erbaugh,
J. K.
1962).
The
psychiatric
nomenc la ture .
Rea
sons fo r
diagnostic
disagreement.
A r
chives
of
General
Psychiatry,
7,
198-205.
Widiger,
T. A.
1993).
The DSM-III-R
categori
cal
personality
disorder
diagnoses:
A
critique
and
n
al ternat ive.
Psychologi
cal
Inquiry,
4,
75-90.
Widiger,
T.
A.
994)
Conceptualizing
a disor
der
of
personality
from
th e five-factor
model .
In
P. T.
Costa
T. A.
Widiger
Eds.),
Personality
disorders
and
th e
five-factor
mode l
of personality pp.
311-317).
Washington,
DC:
American
Psychological
Association.
Widiger,
T. A.
1997a).
Mental disorders s
discrete clinical
conditions:
Dimen
sional
versus
categorical
classification.
In
S.
M.
Turner M. Hersen
Eds.),
Adult
psychopathology
and
diagnosis
3rd
ed.,
pp.
3-23).
New York:
Wiley.
Widiger,
T.
A.
1997b).
Personality
disorders
s
maladaptive
variants of
ommon
personality
traits:
Implications
fo r
treatment.
Journal
of Contemporary
Psychotherapy,
27,
265-282.
Widiger,
T. A.
1998).
Four
out of five ain t
bad.
Archives
of
General
Psychiatry,
55,
865-866.
Widiger,
T.
A.,
Corbitt,
E.
1994).
Normal
versus abnormal
personality
from
th e
perspective
of th e DSM. In S. Strack
M.
Lorr
Eds.),
Differentiating
normal
and
abnormal
personality
pp.
158-175).
New
York:
Springer.
Widiger,
T.
A.,
Costa,
P.
T .
1994).
Personal
ity
and
personality
disorders.
Journal
of
Abnorma l
Psychology.
103,
78-91.
Widiger,
T.
A,
Frances,
A. J.
1985).
The
DSM-III
personality
disorders:
Per
spectives
from
psychology.
Archives
of
General
Psychiatry,
42,
615-623.
Widiger,
T.
A.,
Lynam,
D. R.
1998).
Psy
chopathy
from the
perspective
of the
fiv e-fa cto r model o f
personality.
In T.
Millon,
E.
Simonsen,
M.
Birket-Smlth,
R.
D.
Davis
Eds.),
Psychopathy:
anti
social criminal,
and violent behaviors
pp.
171-187).
New York:
Guilford.
Widiger,
T.
A.,
Sanderson,
C. J.
1995).
To
wards
a
dimensional mod el of
person
ality
disorders
in
DSM-IV and DSM-V.
InW. J.
Livesley
Ed.),
The
DSM-IV
per
sonality
disorders
pp.
433^158).
New
York:
Guilford.
Wiggins,
J.
S.
Ed.). 1996).
Thefive-factor
model
of
personality.
Theoretical
per
spectives.
New York:
Guilford.
Wiggins,
J.
S.,
Pincus,
H. A.
1989).
Con
ceptions
of
personality
disorder
and
di
mensions of
personality. Psychological
Assessment
1,
305-316.
Wiggins,
J.
S.,
Pincus,
H.
A.
1992).
Person
ality:
Structure and
assessment. An
nual
Review
of
Psychology,
43,
473-504.
7/27/2019 Personality Disorders in 21,Ct
15/15
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