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Abstract: Introduction: Widespread and long-standing dissatisfaction with the current DSM-IV diagnostic system for the personality disorders (PDs) revolves around five specific issues: use of a dichotomous, categorical model; extremely high rates of comorbidity within the PDs, as well as with Axis I disorders; excessive heterogeneity within the PDs; nonempirically derived diagnostic cut-offs and limited coverage of the personality pathology seen by clinicians. Many critics have suggested that the personality pathology might be better characterized using a dimensional trait model of general or pathological personality. Much research documents support relations between the PDs and the five-factor model of personality (FFM), a prominent model of general personality functioning. Recent research has examined the ability of FFM trait configurations to assess the DSM-IV PDs. Initial work focused on matching individual FFM profiles to prototypical PD profiles derived from expert ratings. Although this initial work showed that these FFM-assessed PDs performed like explicit PD assessments, the prototype matching approach was deemed cumbersome and a simpler, alternative count technique derived from the expert profiles was developed. The FFM PD counts sum the facets rated as being particularly prototypic (high or low) of a PD. The current study: The current study tests the FFM PD counts by examining their convergent and discriminant validity correlations with explicit measures of DSM-IV PD symptomatology in two clinical samples (one French; one Belgian). In addition, “receiver operator characteristics” (ROC) analyses are used to provide information on the clinical utility of the FFM PD counts. Method: The French clinical sample consisted of 100 female inpatients hospitalized for treatment of an eating disorder, whereas the Belgian clinical sample consisted of 130 psychiatric inpatients (47% women) with diverse presenting problems. Translated versions of the NEO PI-R were used to assess the FFM in each sample and to generate the FFM PD counts. DSM-IV PD symptom counts and diagnoses were obtained via structured interview in the French sample and via self-reports in the Belgian sample. Results: In the French sample, convergent validity correlations between the FFM PD counts and DSM symptom counts ranged from 0.20 to 0.65 with a median r of 0.47. In the Belgian sample, these correlations ranged from 0.17 to 0.61 with a median r of 0.45. For the French sample, the median discriminant correlations for each FFM PD ranged from −0.23 to 0.35; for the Belgian sample they ranged from −0.13 to 0.28. Finally, ROC analyses were conducted for the PDs in which 10 or more individuals met the DSM diagnosis. ROC analyses provide “areas under the curve” (AUC), as well as other diagnostic efficiency statistics. An AUC of 0.50 indicates that the FFM PD count is no better at distinguishing between those with and without a given PD diagnosis than chance. AUCs were significant for all PDs examined except for the OCPD, ranging from 0.57 to 0.94 with a mean of 0.75. Average diagnostic efficiency statistics were also generally good. Discussion: The FFM PD counts adequately assess the majority of extant DSM PDs. With the recent development of normative data and scoring sheets, these FFM counts can be applied in most clinical settings. Importantly, FFM data can be used flexibly with a focus either on the role of specific domains and facets or on specific trait configurations. Additionally, there are theoretical benefits to conceiving of PDs as constellations of FFM trait. Comorbidity is to be expected to the degree that the PDs include the same traits. The FFM PD counts are inherently dimensional, representing approximations to a prototype; thus, concerns surrounding the PDs as categories are rendered inert. Using the FFM to conceptualize the PDs allows basic research on personality to inform research on the etiology, course and treatment of the PDs. [Copyright &y& Elsevier]

Abstract: The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) describes the more stable and trait-liked aspects of psychopathology as “personality disorders” (PDs) and places them on a separate Axis (Axis II). Ten specific PDs (e.g., borderline) are articulated; each involves cognition, affect or behaviour that deviates from cultural norms is stable over time and causes impairment or distress for the individual and/or the immediate environment. PDs are distinguished from one another by the particular pattern of cognition, affect and behaviour. Numerous critiques of the DSM PDs have been published over the last 25 years. One of the most egregious problems is caused by the use of a categorical approach to the diagnosis of PDs in which individuals receive a diagnosis if they surpass a certain “cut-point” (e.g., five of nine borderline symptoms), but do not receive a diagnosis if they fall below the cut-off (e.g., four or fewer symptoms). These cut-points were not based on empirical data and there is little evidence to suggest that they capture distinct groups of individuals. The use of a categorical model causes a number of problems including the assumptions of homogeneity within the groups (e.g., nondisordered individuals should “look” alike) and heterogeneity across the groups (e.g., those with the disorder should not look like those without the disorder). Another concern with the PD diagnoses is the extremely high level of co-occurrence found among the PDs (e.g., avoidant and dependent PDs) and across Axes (e.g., borderline PD and major depression). If the PDs are independent, nonoverlapping constructs, then the disorders should not co-occur at the rates typically found. Opponents of the current PD diagnostic system argue that PDs need to be reconsidered using dimensional models of normal and abnormal personality traits. One increasingly popular perspective on personality pathology with empirical support involves considering PDs as extreme variants of the dimensions of the five-factor model (FFM). Many trait psychologists agree that five dimensions (i.e., neuroticism, extraversion, openness to experiences, agreeableness, conscientiousness) are both necessary and sufficient to represent the underlying structure of personality traits. Within this perspective, differences between abnormal and normal functioning are thought to be more gradual and quantitative, rather than reflecting qualitative distinct categories. Numerous individual studies have suggested that measures of the FFM relate to the DSM-IV PDs in a consistent manner and that the use of the narrower facets or traits provides a richer, more discriminating description of the PD constructs. The facets of the FFM have been used successfully to translate the DSM-IV PD criteria and describe the prototypical individual with a specific PD. The considerable overlap between the FFM dimensions and PDs has led some to suggest that the latter should be conceptualized as disorders of personality. Widiger et al. suggested a four-step process to assess personality pathology, involving: assessment of an individual''s standing on the domains and traits of the FFM; screening for problems relevant to high or low standing on FFM traits; judging if the problems are of clinical significance and optionally, summarizing the personality profile in terms of a DSM-IV PD pattern. While it is unclear whether or when the FFM or a similar model of personality will be adopted for use in the DSM nosology, there is substantial evidence that such a model can be used to understand and assess personality pathology in a valid and useful manner. The ability of the FFM to resolve issues of dimensionality and comorbidity, as well as provide improved clinical utility and treatment planning, suggests significant advantages can be gained through the use of such a model. [Copyright &y& Elsevier]