Personality Disorders in 21,Ct

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


2/15

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


3/15

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


4/15

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


5/15

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


6/15

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


7/15

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


8/15

10

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


9/15

PERSONALITY

DISORDERS

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


10/15

12

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


11/15

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


12/15

14

WIDIGER

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