The DSM-5 Levels of Personality Functioning and Severity of Iranian Patients With Antisocial and Borderline Personality Disorders

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1 Irn Red Crescent Med J August; 17(8): e Published online 2015 August 15. DOI: /ircmj.17(5) Reserch Article The DSM-5 Levels of Personlity Functioning nd Severity of Irnin Ptients With Antisocil nd Borderline Personlity Disorders Mehdi Amini 1 ; Abbs Pourshhbz 2,* ; Prvneh Mohmmdkhni 2 ; Mohmmd Rez Khodie Ardkni 3 ; Mozhgn Lotfi 4 1 Behviorl Sciences Reserch Center, Bqiytllh University of Medicl Sciences, Tehrn, IR Irn 2 Deprtment of Clinicl Psychology, University of Socil Welfre nd Rehbilittion Sciences, Tehrn, IR Irn 3 Deprtment of Psychitry, University of Socil Welfre nd Rehbilittion Sciences, Tehrn, IR Irn 4 Mentl Helth Reserch Center, Tehrn Institute of Psychitry, School of Behviorl Sciences nd Mentl Helth, Irn University of Medicl Sciences, Tehrn, IR Irn *Corresponding Author: Abbs Pourshhbz, Deprtment of Clinicl Psychology, University of Socil Welfre nd Rehbilittion Sciences, Tehrn, IR Irn. Tel: , E-mil:.pourshhbz@uswr.c.ir Received: April 30, 2014; Revised: June 24, 2014; Accepted: July 5, 2014 Bckground: Fundmentl problems with Personlity Disorders (PD) dignostic system in the previous version of DSM, led to the revision of DSM. Therefore, multidimensionl system hs been proposed for dignosis of personlity disorder fetures in DSM-5. In the dimensionl pproch of DSM-5, personlity disorders dignosis is bsed on levels of personlity functioning (Criteri A) nd personlity trit domins (Criteri B). Objectives: The purpose of this study ws firstly, to exmine the DSM-5 levels of personlity functioning in ntisocil nd borderline personlity disorders, nd second, to explore which levels of personlity functioning in ptients with ntisocil nd borderline personlity disorders cn better predicted severity thn others. Ptients nd Methods: This study hd cross sectionl design. The prticipnts consisted of 252 individuls with ntisocil (n = 122) nd borderline personlity disorders (n = 130). They were recruited from Tehrn prisoners, nd clinicl psychology nd psychitry centers of Rzi nd Tleghni Hospitls, Tehrn, Irn. The smple ws selected bsed on judgmentl smpling. The SCID-II-PQ, SCID-II nd DSM-5 levels of personlity functioning were used to dignose nd ssess personlity disorders. The dt were nlyzed by correltion nd multiple regression nlysis. All sttisticl nlyses were performed using the SPSS 16 softwre. Results: Firstly, it ws found tht DSM-5 levels of personlity functioning hve strong correltion with ntisocil nd borderline personlity symptoms, specilly intimcy nd self-directedness (P < 0.001). Secondly, the findings showed tht identity, intimcy nd selfdirectedness significntly predicted ntisocil personlity disorder severity (P < ). The results showed tht intimcy nd empthy were good predictors of borderline personlity disorder severity, s well (P < ). Conclusions: Overll, our findings showed tht levels of personlity functioning re significnt predictor of personlity disorders severity. The results prtilly confirm existing studies. Keywords: Antisocil Personlity Disorder; Borderline Personlity Disorder; Severity; DSM-5 1. Bckground The fundmentl problems with the Personlity Disorders (PD) dignostic system in the previous version of DSM, such s ll-or-nothing dignostic ctegories, considerble heterogeneity within ctegories, extensive overlp or comorbidity mong ctegories, indistinct boundries with norml personlity, nd incomplete coverge of personlity psychopthology, led to the revision of the DSM pproch (1, 2). Since 2000, fter the revision of DSM-IV, PD reserchers lrgely gree tht personlity pthology should be represented dimensionlly rther thn ctegoriclly (3). Thus, mny lterntive dimensionl models of personlity hve been considered (4-7), nd ongoing reserch hs been performed to delinete the conceptul nd empiricl structure of personlity trits in the pthologicl rnge (6, 8). Finlly, multidimensionl system ws proposed for representing nd dignosis of personlity disorder fetures in DSM-5. The new pproch for the ssessment of personlity pthology identifies core impirments in levels of personlity functioning, pthologicl personlity trits, nd prominent personlity pthology types (9). All prts needed for PD dignosis. However, there is wide consensus tht severity ssessment is essentil for ny dimensionl system of personlity psychopthology (10). Moreover, the DSM-5 Personlity Disorders Work Group hs proposed impirments in personlity functioning s the centrl element of PD (11). Thus, in the dimensionl model of personlity disorder ny PD (schizotypl, ntisocil, borderline, nrcissistic, obsessive-compulsive nd voidnt) is ssocited with fundmentl disturbnces Copyright 2015, Irnin Red Crescent Medicl Journl. This is n open-ccess rticle distributed under the terms of the Cretive Commons Attribution-NonCommercil 4.0 Interntionl License ( which permits copy nd redistribute the mteril just in noncommercil usges, provided the originl work is properly cited.

2 of self nd interpersonl reltions, problems with identity, self-direction, empthy nd intimcy. The review of literture showed tht levels of personlity functioning or self-other pproch for dignosis re informtive in determining both the type nd the severity of personlity pthology (12-14). The severity of impirment in personlity functioning hs lso been shown to be importnt in plnning tretment nd predicting its outcome. Despite the good dvntges nd empiricl bckground of levels of personlity functioning, prcticl studies in clinicl settings with specific PDs nd cross-culturl studies in this field re continuously needed (9, 12, 14, 15). Also, reserchers need to determine which levels of personlity functioning better predict nd explin severity thn others. 2. Objectives The purpose of the current study ws firstly, to exmine the reltionship between DSM-5 levels of personlity functioning on n Irnin smple with ntisocil nd borderline personlity disorders, nd second, to explore which levels of personlity functioning in ptients with ntisocil nd borderline personlity disorders cn better predict severity. 3. Ptients nd Methods 3.1. Study Popultion nd Smpling This study hd cross sectionl study design. Of the 300 prticipnts, 252 individuls with ntisocil (n = 122) nd borderline personlity disorders (n = 130) were selected from September to November With regrd to α = 0.05 nd β = 80%, four vribles were tested by multiple regression nlysis. Bsed on prtil R 2 = 0.095, the smple size for Antisocil Personlity Disorder (ASPD) ws clculted to be 119. For Borderline Personlity Disorder (BPD), α nd β were 0.05 nd 80%, respectively, nd four vribles were tested by multiple regression nlysis. Bsed on prtil R 2 = 0.1, the dequte smple size for BPD ws 113. Prticipnts were selected from prisoners (48.8%), outptients (16.5%) nd inptients (7.5%). They were recruited from Tehrn prisons, nd clinicl psychology nd psychitry centers of Rzi Psychitric Hospitl nd Tleghni Generl Hospitl, Tehrn, Irn. The smple ws selected bsed on judgmentl smpling (Expert smpling). Inclusion criteri were dignosis of ntisocil nd borderline personlity disorders (for personlity disorders), being t lest 18 yers old, hving t lest secondry eduction, nd the exclusion criteri were presence of psychotic disorder, presence of severe mood disorder, presence of mentl retrdtion, nd presence of physicl condition tht impirs the person's mentl stte. Prticipnts were 90.5% mles nd 9.5% femles, ged 18 to 60 yers (SD = ± 1.37), with guidnce school degree eduction level or higher. Disorders of Axis I; 106 ptients (42.06%) hd no impirment, 78 ptients (30.97%) hd history of substnce-relted disorders, 35 ptients (13.88%) hd mood disorder, 15 ptients (5.96%) hd nxiety disorders, 8 ptients (3.17%) hd hd history of psychotic spectrum disorder nd 10 ptients (3.96%) hd other disorders Mterils Dt gthering mesurements included psychologicl reports, SCID-II-PQ, SCID-II, nd DSM-5 levels of personlity functioning checklist SCID The SCID nd its versions re considered to be the most comprehensive of the structured dignostic interviews, which re currently vilble. In fct, in 1987 they were new nd wide rnge of instruments, by Spitzer, Gibbon, Willims nd built in complince with the criteri of the DSM-IV (16). This instrument hs been estblished s the gold stndrd for relible ssessment of psychitric disorders. Inter-rter relibility for SCID-I ws bove 70 for mood, nxiety, schizophrenic disorders nd lcohol buse; it ws somewht lower for few other disorders (17), while for SCID-II it ws reported between 0.48 nd 0.98 for the ctegoricl dignoses (Cohen s κ) nd 0.90 to 0.98 for the dimensionl judgments (intr-clss correltion coefficient) (18). Cronbch s α ws found between 0.71 nd 0.94 for the SCID-II personlity disorder scles (18). Due to high ccurcy of the dignostic criteri nd extrordinry complince with DSM-IV criteri, trnslted to nd dpted with different lnguges. In Irn SCID-II nd SCID-II-PQ hve been trnslted nd dpted by Mohmmdkhni et l. (19). The durtion of the SCID-I is 30 to 90 minutes, the durtion of the SCID-II is 30 to 60 minutes. Severity ws determined in this study by the scores obtined from SCID-II The DSM-5 levels of personlity functioning scle levels of personlity functioning refer to the core cpcities of personlity-relted self nd interpersonl functioning nd determining the severity of ny impirment in these res (12). The DSM-5 levels of personlity functioning include identity, self-direction, empthy nd intimcy. If there is no impirment of these functions, personlity disorders re not considered. The levels of personlity functioning scle use ech of these elements to differentite five levels of impirment on continuum of severity rnging from no impirment, i.e. helthy functioning (Level = 0), to extreme impirment (Level = 4) (11). The more impirment in these res, the more likely tht person hs PD. In preliminry nlysis of smple of 424 psychitric ptients, Morey et l. (14) found tht score of greter thn three (out of five) on short five-item scle, 2

3 hd sensitivity of 79% nd specificity of 54% for semistructured interview dignosis of PD. Amini et l. (20) hve trnslted DSM-5 levels of personlity functioning scle to Frsi, nd developed semi-structured interview. Inter-rter relibility for semi-structured interview of DSM-5 levels of personlity functioning items ws bove The DSM-5 levels of personlity functioning scle domins correltion with DSM-IV ws between 0.30 nd The durtion of the semi-structured interview for DSM-5 levels of personlity functioning is 15 to 25 minutes Procedure In the implementtion process, the reserchers included three post-grdutes of clinicl psychology. To void probble bis outcome from these people, they were not informed of the exct gol of the reserch in detil nd they were told tht the reserch gol ws to study personlity disorders. They were entirely uninformed of the concerned disorder types. To control the probble bis, the reserch ssocites begn to collect dt periodiclly per step while they were blinded to the outcome of the previous or next step. The collegues were trined to use these instruments. After trining under the supervision of the resercher, some people were ctully interviewed, nd the interviewers bug ws fixed. As mentioned bove, there were two groups of ptients (ptients with personlity disorders nd norml subjects). Prior to the reserch onset, the prticipnts were fully informed nd provided written consent. To void ftigue nd to increse motivtion in subjects, study for ech subject ws conducted during two dys. In the dys following the completion of the demogrphic questionnire, prticipnts completed the SCID-II-PQ. Furthermore, cses, which hd both symptoms of ntisocil nd borderline personlity disorders, were exmined by the Structured Clinicl Interview for Personlity Disorders (SCID-II). After the definitive dignosis of ntisocil personlity disorder nd borderline, they were invited to ttend the next stge of the interview process bsed on DSM-5 levels of personlity functioning. Ethics pprovl ws obtined from the University of Socil Welfre nd Rehbilittion Sciences Reserch Ethics Committee, nd the registered ethicl code ws 92/801/3110/2/A Sttisticl Anlysis The normlity of dt ws tested nd confirmed by the Kolmogorov-Smirnov test. We computed bivrite correltions between the DSM-5 levels of personlity functioning nd ASPD, nd BPD symptoms. To exmine which levels of personlity functioning in ptients with ntisocil nd borderline personlity disorders cn better predicted severity, stepwise regression nlysis ws used, in which SCID-II results (ASPD nd BPD severity) were the dependent vribles nd levels of personlity functioning were the predictors. The nlysis ws done using the SPSS 16 nd NCSSPASSII. 4. Results The demogrphic chrcteristics of the two groups re presented in Tble 1. The two groups hd no significnt differences in demogrphic chrcteristics. The men nd stndrd devition scores of the levels of personlity functioning in ntisocil nd borderline personlity disorder groups re showed in Tble 2. Bivrite correltion between DSM-5 levels of personlity functioning (identity, self-directedness, intimcy, empthy) nd ntisocil nd borderline personlity symptoms re presented in Tble 3. Tble 1. Demogrphic Chrcteristics of the Two Groups Antisocil Borderline Personlity Disorder Personlity Disorder Age, y ± ± 8.8 Gender Mle 118 (96.7) 116 (89.2 ) Femle 4 (3.3) 14 (10.8) Eduction Levels Under diplom 62 (50.8) 64 (9.2) Diplom 45 (36.9) 36 (45.4) Post diplom 7 (5.7) 54 (56.8) Bchelor nd higher 6 (6.6) 33 (34.7) Dt re presented s Men ± Stndrd Devition (SD) or No (%). Tble 2. The Men nd Stndrd Devition Scores of the Levels of Personlity Functioning in the Two Groups ASPD BPD Identity 0.86 ± ± 0.76 Self-directedness 2.18 ± ± 1.27 Intimcy 2.28 ± ± 1.06 Empthy 2.04 ± ± 1.04 Abbrevitions: ASPD, Antisocil personlity disorder; nd BPD, Borderline Personlity Disorder. Tble 3. The Correltion Between DSM-5 Levels of Personlity Functioning nd Antisocil nd Borderline Personlity Symptoms ASPD Symptoms BPD Symptoms Identity 0.46 b 0.08 Self-directedness 0.44 b 0.16 c Intimcy 0.45 b 0.40 b Empthy 0.42 b Abbrevitions: ASPD, Antisocil personlity disorder; nd BPD, Borderline Personlity Disorder. b P vlue < c P vlue <

4 As seen in Tble 3, positive nd significnt correltions were found between ntisocil personlity symptoms nd DSM-5 levels of personlity functioning. The totl levels re highly correlted with ASPD symptoms (P vlue < 0.001). In borderline personlity disorder, except identity nd empthy, other vribles hd significnt correltions with BPD symptoms (P vlue < nd < 0.05). To exmine the reltionship between DSM-5 levels of personlity functioning nd ASPD nd BPD severity, stepwise regression nlysis ws conducted, where ASPD nd BPD severity were the dependent vribles nd levels of personlity functioning (identity, self-directedness, intimcy, empthy) were the independent vribles. The results of regression nlysis for levels of personlity functioning nd ASPD severity re presented in Tble 4. As demonstrted by Tble 4, the effects of three vribles were significnt. These results indicte tht pproximtely 21.7%, 31.4%, nd 33% of the vrince of the ASPD severity could be ccounted by identity, intimcy nd self-directedness, respectively. Empthy ws excluded from the tble. The dt showed tht identity, intimcy, nd self-directedness significntly predicted ntisocil personlity disorder severity. The results of regression nlysis for levels of personlity functioning nd BPD severity re displyed in Tble 5. As indicted by Tble 5, the effects of both vribles were significnt. The results showed tht intimcy nd empthy were good predictors of borderline personlity disorder severity. The R squre of regression model ws 16.5% nd 25%. This mens tht pproximtely 16.5% nd 25.1% of the vrince of the BPD severity could be ccounted for by these vribles. Tble 4. Regression Anlysis for Levels of Personlity Functioning nd Antisocil Personlity Disorder Severity (n = 122) Unstndrdized Coefficients Effect (men ± SD) t Vlue Identity 0.62 ± Intimcy 0.56 ± Self-directedness 0.24 ± Dependent : Antisocil Personlity Disorder severity. Tble 5. Regression Anlysis for Levels of Personlity Functioning nd Borderline Personlity Disorder Severity (n = 130) Unstndrdized Coefficients Effect (men ± SD) t vlue Intimcy 0.59 ± Empthy ± Dependent : Borderline Personlity Disorder severity. 5. Discussion The first im of this study ws to exmine the DSM-5 levels of personlity functioning on n Irnin smple with ntisocil nd borderline personlity disorders. The study findings reveled tht ll levels of personlity functioning hd significnt positive correltions with ASPD. This mens tht DSM-5 levels of personlity functioning hd good reltionship with ntisocil personlity disorder symptoms of n Irnin smple. The present findings re consistent with the findings of Zimmermnn et l. (13), nd Morey et l. (14). Also, the findings indicte tht except identity nd intimcy, other vribles (selfdirectedness nd empthy) hd significnt correltion with borderline personlity symptoms. It seems tht the study popultion could be one of the resons for these findings. Previous studies indicted tht severity is the most importnt single predictor of concurrent nd prospective dysfunction in ssessing personlity psychopthology (11, 21, 22). Therefore, the second im of this study ws to explore which levels of personlity functioning in ptients with ntisocil nd borderline personlity disorders cn better predict severity. The stepwise regression nlysis results showed tht identity, intimcy, nd selfdirectedness re positively nd significntly correlted with ntisocil personlity disorder severity, indicting tht those with higher scores on these vribles tend to hve higher symptoms of ASPD. These findings re consistent with the findings of Zimmermnn et l. (13), Mullins-Swett et l. (23), Yng et l. (24), nd Schmeck et l. (25). In ptients with borderline personlity disorder, the nlysis showed tht intimcy nd empthy hd significnt ssocition with borderline personlity disorder severity. It mens tht interpersonl level of personlity functioning (intimcy nd empthy) could explin the severity on ptients with BPD in this study. In ddition, the results showed tht the DSM-5 levels of personlity functioning re n essentil prt of ntisocil nd borderline personlity disorders. Also, the results reveled tht levels of personlity functioning were the sme in other cultures nd the Irnin smple. The present study is one of the first in which reserchers exmined the DSM-5 levels of personlity functioning reltionship with severity, nd is the first study on Irnin ptients with personlity disorders bsed on the DSM-5 pproch. Overll, our findings showed tht the levels of personlity functioning re significnt predictor of ntisocil nd borderline personlity disorders severity. Nevertheless, there re number of importnt limittions in this work nd future reserch is required to overcome such limittions. Firstly, the results re bsed on reltively smll number of cses nd so cution should be tken in interpreting the dt. Secondly, dt ws gthered by semi-structured interview designed to ssess dimensionl model of personlity disorders, nd future work should focus on other relevnt instruments. The third 4

5 limittion of the current study ws the nture of the smple, which ws drwn from ntisocil nd borderline personlity disorders. Future reserch should replicte findings in lrger smples with multiple personlity disorders. Fourth, xis I disorders were not detected nd controlled in the smple. Thus, future reserch should exmine the role of xis I disorders in personlity disorders severity. Fifth, most prticipnts in this study were mles. Therefore, other reserch is needed to investigte DSM-5 levels of personlity functioning nd severity in femles. Seventh nd finlly, our work focused on the ssessment of DSM-5 levels of personlity functioning nd severity in dults. Further work is needed to determine it in other ge groups. Acknowledgements The uthors would lso like to cknowledge the ssistnce of prticipnts who were involved in the ssessments. Funding/Support The uthors declre tht this study ws not support by ny finncil source. References 1. Kendler KS. An historicl frmework for psychitric nosology. 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