He presented with concerns related to affective lability, substantial impulsivity, dysfunctional relationships, suicidal ideation, and difficulty following through on goal-oriented behaviors. Personal. Figure 5. Washington, DC: American Psychiatric Publishers. Interventions focused on observing Mr. Ds responsibility, or lack thereof, across circumstances, and accurate recognition of Mr. Ds responsibility as it relates to his self-concept, career pursuits, and relationships. doi: 10.1037/abn0000165, Zanarini, M. C., Frankenburg, F. R., Khera, G. S., and Bleichmar, J. Following numerous hospitalizations and substance related legal involvement, Mr. D was referred for individual psychotherapy. doi: 10.1016/j.comppsych.2008.01.007, Krueger, R. F. (2019). Mr. D also met criteria for a severe substance use disorder and recurrent, moderate episodes of major depression. Paradigms of personality assessment and level of personality functioning (Criterion A) in the DSM-5 Alternative Model for Personality Disorders, in The DSM-5 Alternative Model for Personality Disorders: Integrating multiple paradigms of personality assessment, eds C. J. Hopwood, A. L. Mulay, and M. H. Waugh (New York, NY: Routledge), 4859. Ms. B had experienced numerous relationships ruptures with important others leaving her with few relationships on which she could truly depend on. Table 1. Borderline Pers. Ms. Bs change in PID-5 Z-scores by domain. Virginia: American Psychiatric Association. Examining facet scores across the PID-5 domains in Figure 6, Ms. B showed elevations in emotional lability, hostility, and suspiciousness (>2 SDs above the mean) as well as separation insecurity, anhedonia, depressivity, and callousness (>1 SDs above the mean). Mr. D is a White man between the ages of 25 and 30 years old with a history of impulsive gambling, substance abuse, and difficulties maintaining employment. doi: 10.1037/bul0000088, Sharp, C., Wright, A. G. C., Fowler, J. C., Frueh, B. C., Allen, J. G., Oldham, J., et al. Dis. The current study has a number of limitations.
Personal. No use, distribution or reproduction is permitted which does not comply with these terms. Notably, Criterion A identity impairment and Criterion B traits of impulsivity and risk-taking emerged as key differentiating variables distinguishing profiles. Notably, beyond Ms. Bs difficulty recognizing her antagonism and hostility on her own, when the therapist would bring it to her attention, Ms. B was largely unconcerned about others (callousness). Assessing the heterogeneity of BPD using the AMPD, we found that although both patients demonstrated severe levels of personality impairment per the LPFS, Ms. Bs most significant impairment fell within the domain of identity diffusion and Mr. Ds within the domain of self-direction. Bull. Patients diagnostic profiles were assessed with the AMPD framework for their respective time of treatment culminating in ratings across two phases of treatment. Overall, this speaks to the changes observed in self in relation to other functioning and the relative stability of trait level differences. Ferguson, C. J. (2019). J. Treating Borderline Personality Disorder in Clinical Practice. Mr. D repeatedly tested the treatment frame, missing session entirely or arriving late (impulsivity, irresponsibility). Using latent Profile Analysis (LPA) of Criterion A and B facets, they found four distinct profiles: (1) borderline traits (characterized by relatively lower severity albeit impairment in self-direction and empathy as core traits of hostility, impulsivity, and risk-taking), (2) moderative personality severity with impulsivity and risk-taking (characterized by depressivity and increased impulsivity as well as slightly elevated impairment in identity functioning), (3) moderate personality severity with identity problems and depressivity (characterized by increased depressivity and moderate impairment in identity functioning), and (4) severe personality pathology (characterized by severe impairment in self-direction and empathy as well as elevation in hostility and impulsivity). Thus, Mr. Ds treatment goals remained geared toward an increased capacity to integrate a sense of responsibility without shame, tolerance of mutual intimacy in relationships, and setting achievable professional goals. Clinical Utility of the DSM-5 Alternative Model of Personality Disorders: Six Cases from Practice. At Time 1, both Mr. D and Ms. B met criteria for the AMPD legacy BPD diagnosis. Q. The beginning of treatment was marked by frequent intersession phone calls, requests for immediate sessions, and resistance to ending regularly scheduled sessions on time. The Frequency of Personality Disorders in Psychiatric Patients. Despite improvement in overall level of personality functioning, Ms. Bs personality style remained consistent, albeit with a reduction in intensity of expression. At Time 1, Ms. Bs personality pathology had been clarified and adjusted to reflect comorbid borderline and dependent personality disorders, and the generalized anxiety disorder diagnoses was retained. doi: 10.1001/archpsyc.1994.03950030051005, Markon, K. E., Quilty, L. C., Bagby, R. M., and Krueger, R. F. (2013). Dysregul. Personal. Ms. B suffered from an impoverished and unstable identity which depended on overt validation and caretaking from others for cohesion. Patients were first seen for an extensive psychodiagnostic assessment including psychosocial history, the Anxiety Disorders Interview Schedule for DSM-5 Lifetime Version (ADIS; Di Nardo et al., 1994), and the International Personality Disorders Examination (IPDE; Loranger et al., 1994). J. Abnorm. Notably, one of the four traits must be either impulsivity, risk-taking, or hostility (American Psychiatric Association, 2013). Additionally, Ms. B benefited from local case management services. Criterion B of the AMPD and the interpersonal, multivariate, and empirical paradigms of personality assessment, in The DSM-5 Alternative Model for Personality Disorders: Integrating multiple paradigms of personality assessment, eds C. J. Hopwood, A. L. Mulay, and M. H. Waugh (New York, NY: Routledge), 6076. North Am. J. Psychiat. Thus, Ms. B continued to seek out others for self-definition, regulation, and care to a somewhat lesser degree as her insight into this process and general levels of emotional instability (emotional lability) increased as previously noted. doi: 10.1016/j.psc.2008.03.015, Zimmermann, J., Kerber, A., Rek, K., Hopwood, C. J., and Krueger, R. F. (2019). doi: 10.1016/S0140-6736(14)61394-5, Bender, D. S., Morey, L. C., and Skodol, A. E. (2011). Ms. B demonstrated growing willingness to consider others perspectives, catching her aggression in the moment and taking a step back to consider how the other person was feeling. AMPD diagnostic profiles differentiated patients with BPD in both severity and style, and captured within-patient change beyond within-therapist response bias. CB and LR rated and analyzed the data, and contributed to the interpretation of the data and drafting of the work. Skodol et al. (2001).
A systematic review of the clinical utility of the DSM5 section III alternative model of personality disorder. (2015) contrasted six clinical cases to illustrate how AMPD profiles provide individualized assessment, clarify diagnoses, and refine case conceptualization (p. 19). Ms. B has continued to engage in individual TFP, a skills group, and case management services. The same pattern was reported to occur within the work setting and Mr. D often struggled to take responsibility for this, becoming hostile and dismissive when his own responsibility for the treatment was confronted (hostility). TFP is an empirically supported treatment for BPD organized around the theory that core deficits in BPD stem from the individuals incoherent and split mental representations of self and other. Ms. Bs aggression was wholly compartmentalized, and she would deny hostility while loudly interrupting and speaking over the therapist. Personal. Rev. This is consistent with their diagnoses per the categorical section II DSM-5 criteria that were determined upon intake when presenting for treatment. doi: 10.1176/appi.ajp.161.6.946, Gamache, D., Savard, C., Leclerc, P., Payant, M., Ct, A., Faucher, J., et al. Specifically, bids to mentalize and perspective take were utilized frequently in session. To help Ms. B achieve her self-generated goals of feeling happier and developing more meaningful relationships, early interventions focused on maintaining a consistent treatment frame and helping Ms. B notice the vacillation between overly dependent and intensely aggressive behavior. Comprehen. Clinician-rated level of personality functioning over time. Shown in Figure 6, her PID-5 facet level elevations included separation anxiety, hostility, emotional lability, suspiciousness, and callousness (>2 SDs above the mean) as well as depressivity, impulsivity, anxiousness, and anhedonia (>1 SD above the mean). Comprehens. Although at Time 1 neither Mr. D nor Ms. B seemed to fit these profiles exactly, both patients were rated as exhibiting severe identity impairment, particularly Ms. B, and struggling with impulsivity and risk-taking, particularly Mr. D. As such, the ratings seen here within a clinical setting appear to be in line with research on the translation of heterogeneous presentations of BPD to the AMPD framework. doi: 10.1159/000506313, Pincus, A. L., Dowgwillo, E. A., and Greenberg, L. S. (2016). Psychol. The Importance of Considering Clinical Utility in the Construction of a Diagnostic Manual. B. W., Ustun, B., and Peele, R. (2004). Front.
Ms. B had difficulty observing this process, showing a capacity to briefly reflect on this dynamic but quickly vacillating when this became threatening to her.
Emot. Assessment 100, 565570. Looking at domains of the LPFS shown in Figure 4 at Time 2 (yellow bars), Ms. B continued to show severe impairment in self-direction, intimacy, and identity, and moderate impairment in empathy. doi: 10.1017/S0033291711002674, Lenzenweger, M. F., Clarkin, J. F., Yeomans, F. E., Kernberg, O. F., and Levy, K. N. (2008). Both patients met criteria for DSM-5 Section II BPD.
He struggled to mentalize his own behavior particularly when it came to treatment engagement and occupational functioning. Psychol. Given that Ms. B had limited awareness into her interpersonal impact, it was difficult for her to see beyond her own needs and observe the damaging impact her emotional cascades had on others. 2021, 133. Caligor, E., Kernberg, O. F., Clarkin, J. F., and Yeomans, F. E. (2018). Although Mr. D and Ms. B struggled with empathy, particularly at Time 1, Mr. D and Ms. B each pulled for unique countertransferential reactions that were similarly experienced by both therapists. (2016) illustrated how initial therapeutic interventions, including the timing and delivery of diagnostic feedback, may differ across patients with varying levels of severity and trait constellations. doi: 10.1521/pedi_2021_35_531. At Time 2, Mr. Ds LPFS score illustrated moderate to severe impairment in personality functioning (Table 1). Washington, D.C: American Psychiatric Publishing, Inc, 511544. doi: 10.1002/pmh.1414, Johnson, B. N., and Levy, K. N. (2020). Waugh, M. H., Hopwood, C. J., Krueger, R. F., Morey, L. C., Pincus, A. L., and Wright, A. G. C. (2017). Clinical case examples exemplifying how Criterion A and Criterion B guide interventions across sessions and subsequently engender personality change are warranted. One major reason for this is discontinuity in treatment due to misdiagnosis and inconsistent case conceptualization, as it is not uncommon for individuals with BPD to only be properly diagnosed several years after first treatment contact (Biskin and Paris, 2012; Kjr et al., 2016). Dis. Mental Health 12, 107125. Early treatment goals largely centered on containing acting out behaviors such as substance use, risky sexual behavior, and inconsistent attendance, increasing Mr. Ds capacity to integrate a sense of responsibility without risk of shame, helping Mr. D to tolerate imperfection in intimate relationships, and to set reasonable proximal and distal goals for himself in terms of employment. J. Boston, MA: Center for Stress and Anxiety Related Disorders, Boston University. Assess. (2015). When patients shift in and out of therapy from one provider to another, the potential for assessment of patient change over time is often complicated or thwarted. In comparison, Mr. D showed elevation in impulsivity, risk-taking, hostility, and depressivity. Importance of self and other in defining personality pathology. Diagnostic and statistical manual of mental disorders: DSM-5, 5th Edn. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. However, with Ms. B., her inability to see beyond the immediacy of her own affect and needs left both therapists feeling dismissed and ineffective when clinician responses to her repeated bids for help were promptly rejected. doi: 10.1521/pedi_2013_27_106, Wright, A. G. C., Hopwood, C. J., Skodol, A. E., and Morey, L. C. (2016). The structure of personality pathology: Both general (g) and specific (s) factors? doi: 10.1177/1073191113486513.
The clinical trajectory of patients with borderline personality disorder. 122, 10571069. doi: 10.1037/a0034878, First, M. B., Pincus, H. A., Levine, J. Anxiety Disorders Interview Schedule for DSMIV. Despite some improvements, Mr. D still had difficulty honoring interpersonal and professional obligations and commitments (irresponsibility) which further complicated important relationships and goal-directed behavior. B., Williams, J. Clinicians rated patients on each item ranging from (0) Very False or Often False to (3) Very True or Often True. Subtypes of borderline personality disorder patients: A cluster-analytic approach. Care was taken to alter identifying information and case material to protect the confidentiality of the patients. We aimed to demonstrate the clinical utility of the AMPD model across therapists and phases of treatment. Di Nardo, P. A., Brown, T. A., and Barlow, D. H. (1994). doi: 10.1146/annurev-clinpsy-021815-092954, Pincus, A. L., Cain, N. M., and Halberstadt, A. L. (2020). The Level of Personality Functioning Scale (LPFS; American Psychiatric Association, 2013) operationalizes Criterion A and rates the personality pathology severity. Psycholog. Ms. Bs negative affectivity fueled behavior toward others that vacillated from infantile dependence to indignant hostility. Clin. Assessment 93, 332346. doi: 10.1176/appi.ajp.2012.12030341, Bateman, A. W., Gunderson, J., and Mulder, R. (2015). J. Psychiatry 161, 946954. Ms. B would evade bids to reflect on her thoughts, emotions, and behavior and would instead revert to detailing past experiences that she felt justified her current experience and emotions.
Ms. Bs Time 2 AMPD profile shifted to show moderate to severe levels of personality functioning. CMAJ 184, 17891794. Vrije Universiteit Brussel (VUB), Belgium, Medical University of South Carolina, United States. doi: 10.1080/00223891.2018.1477787, Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., and Skodol, A. E. (2012). Integr. Disord. When Ms. Bs needs for self-regulation or her expectations for care were not met, she continued to engage in aggressive behavior such as yelling and name calling (hostility). Taken together, the AMPD unites process and structure to offer a nuanced conceptualization of personality as severity of difficulties in self and relatedness that is further clarified by characteristic style. The development and psychometric properties of an informant-report form of the personality inventory for DSM5 (PID-5). The AMPD BPD profiles largely were distinguished by increasing severity level; however, results also pointed to the importance of Criterion A identity and Criterion B depressivity, impulsivity, and risk-taking in differentiating profiles. These differences in AMPD profiles, although yielding a similar diagnostic picture at first glance (i.e., BPD), mirror the patients stark differences in presentation that were seen clinically in session. doi: 10.1037/per0000408, Morey, L. C. (2017). However, less is known about the AMPDs utility over the course of treatment. Dis. Initial Construction of a Maladaptive Personality Trait Model and Inventory for DSM-5. Taken together, efforts to understand BPDs heterogeneity largely emphasize either severity or style. Ratings were discussed with the supervising clinician and each therapist was blind to the others ratings. doi: 10.1037/pri0000025, Pincus, A. L., and Roche, M. J. 31, 405420. Psychoanal. Looking at trait constellations per the PID-5, Ms. B showed elevation in emotional lability, separation insecurity, anxiousness, hostility, impulsivity, and depressivity. Psychol. Milton Park: Routledge, 147. Existing AMPD case examples provide illustrations of the AMPDs clinical utility spanning case conceptualization, differential diagnosis, treatment planning, and intervention. Prior literature has defined clinical utility of a model by three main features: (1) communicative value; (2) implementation characteristics; and (3) usefulness in selecting proper interventions and making clinical decisions (Reed, 2010; Mullins-Sweatt et al., 2016). doi: 10.1503/cmaj.090618, Bliton, C. F., Roche, M. J., Pincus, A. L., and Dueber, D. (2021). doi: 10.1097/01.pra.0000460618.02805.ef, Bateman, A. W. (2012). Mr. D floated from one job to the next, either getting fired for poor performance or quitting prior to being let go. 41, 457464. Nervous Mental Dis. Psychiatry 49, 380386. doi: 10.1521/pedi.2008.22.4.313, Loranger, A. W., Sartorius, N., Andreoli, A., Berger, P., Buchheim, P., Channabasavanna, S. M., et al. Mr. Ds difficulty observing and tolerating the impact of his behavior on others, tended to leave both therapists feeling parentified in moments of his irresponsibility and rebelliousness. To remain faithful to the AMPD, patients AMPD diagnostic profiles are assessed using the Level of Personality Functioning Scale (LPFS) and the Personality Inventory for the DSM-5 Informant Form (PID-5-IRF) as specified within Section III of the DSM-5. 3, 228246. As illustrated in Figure 4 at Time 1 (orange bars), Ms. B exhibited extreme impairment in identity and severe impairment in self-direction, empathy, and intimacy.
Am. Ms. Bs diffuse sense of identity and poor self-esteem primarily presented as extreme vacillations in affect and intense fears of abandonment leading first to hostility and anger and then urgent dependency when these needs were not met. Personal. Although retrospective ratings are a limitation, the pattern of profile associations within patients relative to therapists supports the validity of the ratings. Identifying unstable and empty phenotypes of borderline personality through factor mixture modeling in a large nonclinical sample. Figure 1. Figure 3. New York, NY: Guilford Press. Personal.
A recent study conducted by Gamache et al.
Per the previously mentioned criteria, Ms. Bs Time 1 AMPD profile also meets criteria for the BPD legacy category with all four LPFS domains at a moderate or greater level of severity and at least four elevated maladaptive traits including emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, and hostility. However, exploring the clinical application and utility of the AMPD has received comparatively less attention. He received a primary diagnosis of borderline personality disorder with antisocial traits. The AMPD aimed to improve upon the well-documented limitations of the DSMs categorical model of personality disorders (PDs), a model left unrevised since 1980 (Skodol et al., 2014; Bender et al., 2018; Waugh, 2019). As illustrated in Figures 2, 3, 5, 6, there was not a reconfiguration of Criterion B trait domains and facets from Time 1 to Time 2 but rather a reduction in the maladaptive manifestations for both patients. Prof. Psychol. Knowledge of a patients severity of personality impairments and the specific style in which they manifest aids the new clinician beginning work with these challenging patients by providing useful information to guide treatment planning. Borderline pathology accounts of approximately 1020% of patients in outpatient settings (Korzekwa et al., 2008; Zimmerman et al., 2008); however, it remains difficult to follow patient treatment trajectory and associated symptom change over time. Dis. Although both patients were diagnosed with BPD at intake assessment, the AMPD framework shed light on each patients distinct core deficits in functioning and style of presentation that were experienced in therapy. Although she demonstrated minimal concern for others when feeling deprived or rejected (callousness), Ms. Bs improving capacity for perspective taking and empathy allowed her to reflect on this in the moment. The Personality Inventory for DSM-5 (PID-5; Krueger et al., 2012) operationalizes Criterion B as five dimensional trait domains and 25 dimensional trait facets. (2021) found four AMPD profiles for BPD: (i) borderline traits, (ii) moderate pathology with impulsivity, (iii) moderate pathology with identity problems and depressivity, and (iv) severe pathology. (1994). J. Abnorm. 12, 133155.
Mr. Ds identity still tended to vacillate between an idealized, care-free self and an incapable and flawed self; however, Mr. D demonstrated an improved capacity to reflect on this vacillation in therapy. As a set, the present aims will join extant efforts to demonstrate the AMPDs clinical utility. doi: 10.6018/analesps.35.1.333191. Although there is some overlap in traits between these two patients, Mr. Ds trait profile was most elevated in the domain of disinhibition while Ms. Bs was most elevated in the domain of negative affectivity. Anales de Psicologa 35, 4757. Competing Theories of Borderline Personality Disorder. Attunement to the patients overall severity of dysfunction informs broad clinical decision-making regarding the need for structure within session and boundaries across session, identification of patterns of relatedness, and flexibility in responding to acute distress, to name a few (Bateman, 2012; Bateman et al., 2015; Clarkin et al., 2015). Thus, Ms. B seemed to desperately approach others for self-definition, regulation, and care despite the intense fear of harm. A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders. The LPFS includes the indicators of identity, self-direction, intimacy, and empathy. Ideally such ratings would be made at an optimal point following initiation of treatment with each therapist. Psychiatry 42, 144150. Given the lack of clarity and contention surrounding BPD conceptualization (Gunderson et al., 2018), empirical efforts have focused on parsing apart the heterogeneity of BPD. The patients style directs how interventions are adapted and delivered to best meet the patients needs (McWilliams, 2011; Torres-Soto et al., 2018). Psychiatry 48, 329336. In The DSM-5 Alternative Model for Personality Disorders: Integrating Mulitple Paradigms of Personality Assessment. Diagnosing borderline personality disorder. doi: 10.1037/a0027953, Hopwood, C. J. Longitudinal validation of general and specific structural features of personality pathology.
Results indicated greater improvements in personality severity while personality style remained more stable. Therefore, as noted by Hopwood (2018), it follows that a treatment targeting BPD would yield changes to Criterion A of the AMPD. Although she showed a reduction in anxiousness and impulsivity (<1 SD above the mean), Ms. Bs AMPD profile continued to meet criteria for the legacy BPD category at Time 2 with all four LPFS domains within the moderate to severe level of impairment and continued elevation in four maladaptive traits including emotional lability, separation insecurity, depressivity, and hostility. 25, 312. At Time 1 during the initial phase of treatment, Mr. Ds AMPD profile was defined by severe impairment in personality functioning which indicates significant difficulties in self and relational functioning. Construct and Paradigm in the AMPD. Ms. Bs change in LPFS severity.
Ms. B had difficultly observing and understanding her inner world as she experienced contradictory internal standards for behavior which clouded her ability to observe the impact of her own oscillating aggressive and overly dependent behavior on others.
(2012). To ensure patients AMPD profile changes were not an artifact of within-clinician rating bias and to examine the stability of AMPD profiles across time and therapist, we compared the associations between AMPD profiles within patients and within therapists. Psychoanalytic diagnosis: Understanding personality structure in the clinical process, 2nd Edn. (2013). Of note, Mr. Ds AMPD profile at Time 2 no longer meets criteria for the BPD legacy category. The international personality disorder examination: the World Health Organization/alcohol, drug abuse, and mental health administration international pilot study of personality disorders. Personal. Targeting his deeply rooted and critical self-concept became a new therapy goal. Dis. (2018). Stemming from psychoanalytic models (Kernberg, 1988), borderline can also be considered a spectrum of personality organization that undergirds all PDs and speaks to the dimensional severity of identity integration, maturity of defenses, and reality testing. This article demonstrates the utility of the AMPD for two clinical cases in three distinct ways: (i) highlighting heterogeneity in BPD between patients, (ii) comparing improvements in personality severity and style over time, and (iii) elucidating profile change across therapist ratings. Refining the Borderline Personality Disorder Phenotype through Finite Mixture Modeling: Implications for Classification. Aligning with her tendency to experience herself as deprived by a withholding other and incapable of caring for herself (separation anxiety), Ms. B continued to experience expectations of interpersonal harm (suspiciousness). Health 10, 181190. 48, 7989. Although Mr. D had several people in his life with whom he socialized, he lacked intimacy in close relationships where a similar conflict between wanting closeness and fearing being fully seen contributed greatly to his difficulties experiencing himself and others as consistent, and he frequently pushed others away. This unstable and unintegrated sense of self largely impacted Mr. Ds capacity for self-directedness. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). (2019). Emot. Aligning with identity consolidation, Mr. Ds goal-directed functioning had improved as he was consistently maintaining employment. Toward ICD-11: Improving the clinical utility of WHOs International Classification of mental disorders. Toward a Model for Assessing Level of Personality Functioning in DSM5, Part I: A Review of Theory and Methods. 6:18. doi: 10.1186/s40479-019-0116-1, Mullins-Sweatt, S. N., Lengel, G. J., and DeShong, H. L. (2016). Clinical utility pertains to practical application of a clinical construct and is generally evaluated across three domains: (1) the communicative value among clinicians and patients, (2) practical implementation spanning accuracy, ease of use, and feasibility; and (3) usefulness in treatment planning and intervention (First et al., 2004; Reed, 2010; Mullins-Sweatt et al., 2016).