Personality Disorders. New Developments in Our Thinking about Personality Disorders. Dimensional vs Categorical. Example of Dimensional System

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1 Personality Disorders New Developments in Our Thinking about Personality Disorders Dimensional or Categorical? An old story! John M. Oldham, MD, MS Professor of Psychiatry Robertson Endowed Chair for Personality Disorders Baylor College of Medicine Houston, Texas Dimensional vs Categorical Dimensional Continuous, along a spectrum eg, height or weight Example of Dimensional System Categorical Points of discontinuity Features shared by a distinct group eg, males, females, pregnant women The Interpersonal Circumplex Examples: Leary (1957) and Kiesler (1983) Mistrusting Hostile Competitive Cold Aloof Inhibited Unassured Dominant Submissive Assured Deferent Exhibitionistic Trusting Sociable Friendly Warm Leary T. Interpersonal Diagnosis of Personality. New York, NY: Ronald Press; Kiesler DJ. Psychological Review. 1983;90(3): The Five-Factor Model of Personality Neuroticism Calm Worrying Even-tempered Temperamental Self-satisfied Self-pitying Comfortable Self-conscious Unemotional Emotional Hardy Vulnerable Extraversion Reserved Affectionate Loner Joiner Quiet Talkative Passive Active Sober Fun-loving Unfeeling Passionate Openness to Experience Down-to-earth Imaginative Uncreative Creative Conventional Original Prefer routine Prefer variety Uncurious Curious Conservative Liberal Agreeableness Ruthless Soft-hearted Suspicious Trusting Stingy Generous Antagonistic Acquiescent Critical Lenient Irritable Good-natured Conscientiousness Negligent Conscientious Lazy Hardworking Disorganized Well-organized Late Punctual Aimless Ambitious Quitting Persevering Adapted from Costa PT Jr, et al. Clinical Psychology Review. 1986;6:

2 Example of Categorical System DSM-IV-TR Personality Disorders (A dimensionally-flavored categorical system) A. Cluster A (odd/eccentric) Paranoid Schizoid Schizotypal B. Cluster B (dramatic/emotional/impulsive) Antisocial Borderline Histrionic Narcissistic C. Cluster C (anxious/fearful) Avoidant Dependent Obsessive-Compulsive D. Personality Disorder Not Otherwise Specified Well-informed clinicians and researchers have suggested that variation in psychiatric symptomatology may be better represented by dimensions than by a set of categories, especially in the area of personality traits Bruce J. Rounsaville, MD James S. Jackson, PhD Renato D. Alarcon, MD Robert E. Kendell, MD Gavin Andrews, MD Kenneth Kendler, MD Rounsaville BJ, et al. Basic nomenclature issues for DSM-V. In: Kupfer DJ, et al (Eds). A research agenda for DSM-V. Washington, DC: American Psychiatric Association; 2002:1-29. Final Board Decision Final Personality Disorders Proposal Presented to DSM-5 Task Force in October 2012 Alternative Model for DSM-5 Personality Disorders (AMPD) placed in Section III of DSM-5 ( Emerging Measures and Models ) Strongly and unanimously endorsed and approved

3 Elements of Normal Personality Functioning Current DSM-5 Alternative Personality Disorders Model Section III Self Identity Self-direction Interpersonal Empathy Intimacy Elements of Normal Personality Functioning Self Identity: Experience of oneself as unique, with clear boundaries between self and others; stability of self-esteem and accuracy of selfappraisal; capacity for, and ability to regulate, a range of emotional experience. Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of constructive and prosocial internal standards of behavior; ability to self-reflect productively. Elements of Normal Personality Functioning Interpersonal Empathy: Comprehension and appreciation of others experiences and motivations; tolerance of differing perspectives; understanding the effects of own behavior on others. Intimacy: Depth and duration of connection with others; desire and capacity for closeness; mutuality of regard reflected in interpersonal behavior. DSM-5 General Criteria for Personality Disorder (GCPD) The essential features of Personality Disorder are: Moderate or greater impairment in personality (self / interpersonal) functioning AND The presence of 1 pathological personality traits Criterion A: (Level of Impairment in Personality Functioning) Moderate or greater impairment in personality (self / interpersonal) functioning, manifest by characteristic difficulties in 2 of the following 4 areas: 1. Identity 2. Self-direction 3. Empathy 4. Intimacy American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.

4 Guidance in estimating moderate or greater impairment : Level of Personality Functioning Scale 0 Little or No Impairment 1 Some Impairment 2 Moderate Impairment 3 Severe Impairment 4 Extreme Impairment DSM-IV and DSM-5 Section II general criteria for any Personality Disorder include the following: Why impairment in functioning? D. The pattern is stable and of long duration But in fact, CLPS data and MSAD data demonstrate otherwise. CLPS = Collaborative Longitudinal Personality Disorders Study; MSAD = McLean Study of Adult Development. 100 BPD Remission (cumulative): Lifetest survival estimates 90 NIMH Collaborative Longitudinal Personality Disorders Study (CLPS) Remitted (%) Remission definition: BPD > 12 months Years of Follow-up BPD = borderline personality disorder. Gunderson JG, et al. Arch Gen Psychiatry. 2011;68(8):

5 Functional Remission (GAF > 70 for 12 months): Remitted (%) Lifetest survival estimates BPD Stability of BPD Remission: MSAD: A 16-year Prospective Follow-Up Study BPD patients slower to remit or recover than Axis II comparison subjects By year 16, high rates of remission by both groups, but less so for BPD recovery (defined as good social and vocational functioning) Sustained remission and recovery substantially more difficult for BPD than other personality disorders Years of Follow-up GAF = Global Assessment of Functioning. Gunderson JG, et al. Arch Gen Psychiatry. 2011;68(8): Zanarini MC, et al. Am J Psychiatry. 2012;169(5): Criterion B: (Patterns of Pathological Personality Traits) Trait Domains Negative Affectivity Detachment Antagonism Disinhibition Psychoticism Negative Affectivity (vs emotional stability) 1. Emotional lability 2. Anxiousness 3. Separation insecurity 4. Submissiveness 5. Hostility 6. Perseveration 7. Depressivity 8. Suspiciousness 9. Restricted affectivity American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; Detachment (vs extraversion) 1. Withdrawal 2. Intimacy avoidance 3. Anhedonia 4. Depressivity 5. Restricted affectivity 6. Suspiciousness Antagonism (vs agreeableness) 1. Manipulativeness 2. Deceitfulness 3. Grandiosity 4. Attention seeking 5. Callousness 6. Hostility

6 Disinhibition (vs conscientiousness) 1. Irresponsibility 2. Impulsivity 3. Distractibility 4. Risk-taking 5. (lack of) Rigid perfectionism Psychoticism (vs lucidity) 1. Unusual beliefs and experiences 2. Eccentricity 3. Cognitive and perceptual dysregulation Personality Disorders Personality Disorder Trait Specified Antisocial Avoidant Borderline Narcissistic Obsessive-Compulsive Schizotypal Personality Disorder Trait Specified Criterion A: Moderate or greater impairment in personality functioning, manifest by characteristic difficulties in 2 of the following 4 areas: 1. Identity 2. Self-direction 3. Empathy 4. Intimacy Criterion B: 1 pathological personality trait domains OR specific trait facets within domains, considering ALL of the following domains: 1. Negative Affectivity 2. Detachment 3. Antagonism 4. Disinhibition 5. Psychoticism American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; Clinician Assessment of DSM-5 Personality Disorders A Hierarchical Model of Personality Psychopathology Moderate or Greater Impairment in Personality Functioning Personality Disorder(s) or PD Trait-Specified Meets All Other General PD Criteria PD Diagnosis Confirmed Krueger RF, et al. Annu Rev Clin Psychol. 2014;10:

7 The Five Domains of the NIMH Research Domain Criteria (RDoC) Possible Domain Correlations 1. Negative Valence Systems 2. Positive Valence Systems 3. Cognitive Systems 4. Systems for Social Processes 5. Arousal / Regulatory Systems RDoC Negative Valence Systems Cognitive Systems Systems for Social Processes DSM-5 Negative Affectivity Psychoticism Detachment Self / Interpersonal Functioning Fowler JC, et al. In press. ICD-11 Personality Disorder Proposal Single Diagnostic Category: Personality Disorder Definition: A pervasive disturbance in how an individual experiences and thinks about the self, others, and the world, manifested in maladaptive patterns of cognition, emotional experience, emotional expression, and behavior. DSM-5, Section III Negative affectivity Detachment Antagonism Disinhibition Psychoticism (Trait facets of restricted affectivity, rigid perfectionism, perseveration) ICD-11 Negative affectivity domain Detachment domain Dissocial domain Disinhibited domain (Schizotypal disorder) Anankastic domain Tyrer P, et al. Lancet. 2015;385(9969): Adapted from Newton-Howes G, et al. Lancet. 2015;385(9969): Patients with BPD Have Severe Impairment in Functioning Example Borderline Personality Disorder Common history of childhood trauma Mistrustful of others, yet cling to others for life support High internal levels of anxiety and distress Stormy interpersonal relationships High family stress Difficulty keeping jobs Overemotional and impulsive Self-injurious behavior

8 Heritability of DSM-IV Personality Disorders Brain Structure and Function in BPD Review of neuroimaging studies of BPD Main findings: volume of hippocampus, amygdala amygdala activity 2 to emotion-related stimulus Kendler KS, et al. Psychol Med. 2006;36(11): Reichborn-Kjennerud T, et al. Psychol Med. 2007;37(5): Torgersen S, et al. Psychol Med. 2008;38(11): O Neill A, et al. Brain Struct Funct. 2012;217(4): Normal: BPD: Amygdala Prefrontal Disconnection in BPD Prefrontal cortex inhibitory control over amygdala Absence of normally tight coupling = disconnect between orbital frontal cortex and amygdala failure to downregulate amygdala in response to aversive stimuli New AS, et al. Neuropsychopharmacology. 2007;32(7): Social Baseline Theory and BPD Assumption: People are hardwired to assume close proximity to others, and to utilize social proximity as a baseline affect regulation strategy Social Baseline Theory Principles: 1. Early attachment = initial source of co-regulation (fostering neural links between prefrontal cortex and limbic system) 2. These neural structures support capacity for self-control, and for attachment and maintenance of friendship bonds 3. Frontolimbic circuits implicated in adult attachment formation, trust, affiliation, and attraction These crucial neural structures are impaired in patients with BPD Hughes AE, et al. J Abnorm Child Psychol. 2012;40(1): Sequential Theoretical Model of BPD Pathogenesis Theoretical Model of BPD Symptom Expression Insecure Attachment Unstable Interpersonal Relationships Heritable Risk Mistrust Emotional sensitivity Impulsivity Stimulus Social stress Interpersonal interactions Excessive intensity Endophenotypes Impulsive aggression Affect instability Overvalued expectations Unfounded anxieties Cognitive-perceptual symptoms Compensatory (?) Efforts to Control Distress Self-inflicted pain Dissociation Rejection of / distancing from others Suicide Highly Symptomatic State Emotional distress Paranoid thinking Suicidal ideation / behavior Impulsive behavior Oldham JM. Am J Psychiatry. 2009;166(5): Oldham JM. Borderline personality disorder. In: Bhugra D, et al (Eds). Troublesome Disguises: Managing Challenging Disorders in Psychiatry. Second Edition. West Sussex, UK: Wiley Blackwell; 2015:57-66.

9 APA Practice Guideline Work Group on Borderline Personality Disorder John Oldham, MD (Chair) Glen Gabbard, MD Marcia Goin, MD, PhD John Gunderson, MD Paul Soloff, MD David Spiegel, MD Michael Stone, MD Katherine Phillips, MD APA Treatment Recommendations for Patients with BPD Evidence-based Treatment Strategies for BPD Psychotherapy (core treatment) Pharmacotherapy (adjunctive, symptom-targeted) Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. October Accessed June 8, Types of Psychotherapy for BPD (published randomized controlled trials) 1. Mentalization-Based Therapy (MBT) 2. Dialectical Behavior Therapy (DBT) 3. Schema-Based Therapy (SBT) 4. Transference-Focused Therapy (TFT) 5. Generalized Psychiatric Management (GPM) 6. Cognitive-Behavioral Therapy (CBT) 7. Systems Training for Emotional Predictability and Problem Solving (STEPPS) European Guidelines and Algorithms British 2009 Dutch 2008 German 2009 Summary International scope of BPD Practice Guidelines (United States, The Netherlands, Germany, United Kingdom, Australia) Consistent recommendations: 1. Core treatment = psychotherapy 2. Adjunctive treatment = pharmacotherapy

10 BPD APA DSM-IV / DSM-5 (Section II) Criteria (At least 5 must be present) 1. Fear of abandonment 2. Difficult interpersonal relationships 3. Uncertainty about self-image or identity 4. Impulsive behavior 5. Self-injurious behavior 6. Emotional changeability or hyperactivity 7. Feelings of emptiness 8. Difficulty controlling intense anger 9. Transient suspiciousness or disconnectedness BPD APA DSM-5 Alternative Model Typical features of Borderline Personality Disorder are instability of self-image, personal goals, interpersonal relationships, and affects, accompanied by impulsivity, risk-taking, and/or hostility. Characteristic difficulties are apparent in identity, self-direction, empathy, and/or intimacy, as described below, along with specific maladaptive traits in the domain of Negative Affectivity, and also Antagonism and/or Disinhibition. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; BPD Criterion A (abbreviated): Moderate or greater impairment in personality functioning in 2 of the following areas: 1. Identity: Marked instability of self-image, strong self-criticism, feelings of emptiness, stressinduced dissociative states 2. Self-direction: Unstable goals and values 3. Empathy: Limited ability to see things from another s point of view, sensitivity to real or imagined criticism 4. Intimacy: Conflicted relationships, difficulty trusting others, separation insecurity, patterns of over involvement/withdrawal BPD Criterion B (abbreviated): 4 of the following pathological personality traits (requiring at least one of #5, #6, or #7) 1. Emotional Lability (a facet of Negative Affectivity) 2. Anxiousness (a facet of Negative Affectivity) 3. Separation Insecurity (a facet of Negative Affectivity) 4. Depressivity (a facet of Negative Affectivity) 5. Impulsivity (a facet of Disinhibition) 6. Risk-taking (a facet of Disinhibition) 7. Hostility (a facet of Antagonism) BPD, Alternative Model, Shorthand A. Moderate or greater impairment in personality functioning B. Pathological personality traits in the domains of negative affectivity, disinhibition, and/or antagonism Clinical Usefulness of the DSM-5 Diagnostic Criteria for Personality Disorders

11 Morey et al WG Study A recent empirical study involving 334 clinicians found that in 14 of 18 comparisons, DSM-5 is perceived as more clinically useful than DSM-IV with respect to: Ease of use Communication of clinical information to other professionals Communication of clinical information to patients Comprehensiveness in describing pathology Treatment planning Clinicians in Academic and Routine Clinical Practice Field Trials Over 80% of clinicians in the Academic and Routine Clinical Practice field trials found the new PD criteria moderately to extremely useful compared to DSM-IV. Morey LC, et al. J Abnorm Psychol. 2014;123(2): DSM-5 Personality Disorders Frequently heard concerns It s too complex, and clinicians won t use it. Reality check DSM-5 proposed 25 traits, compared to 94 criteria in DSM-IV (43% reduction) Interpretation It s more complicated than what I now do. Freedman R, et al. Am J Psychiatry. 2013;170(1):1-5. Top 5 Take-Aways Practical Take-Aways for the Busy Clinician 1. Personality Disorders are best conceptualized as dimensional constructs.

12 Top 5 Take-Aways Top 5 Take-Aways 2. The basic elements of personality functioning are: A Sense of Self Identity Self-direction Interpersonal Relationships Empathy Intimacy 3. The criteria for any PD in the new AMPD are: Moderate or greater impairment in personality (self/interpersonal) functioning AND The presence of 1 pathological personality traits Top 5 Take-Aways Top 5 Take-Aways 4. In the AMPD, the 5 pathological trait domains are: 1) Negative Affectivity 2) Detachment 3) Antagonism 4) Disinhibition 5) Psychoticism 5. The bones of the criteria for BPD in the AMPD are: A. Moderate or greater impairment in personality functioning B. Pathological personality traits in the domains of Negative Affectivity, Disinhibition, and/or Antagonism