The DSM-5 Alternative Model for Personality Disorders

Integrating Multiple Paradigms of Personality Assessment

Christopher J. Hopwood, Abby L Mulay, Mark H Waugh, Christopher J. Hopwood, Abby L Mulay, Mark H Waugh

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781351792929
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

The DSM-5 Alternative Model for Personality Disorders reviews and advances this innovative and increasingly popular scheme for diagnosing and evaluating personality disorders. The authors identify the multiple clinical, theoretical, and research paradigms that co-exist in the Alternative Model for Personality Disorders (AMPD) and show how the model can aid the practicing mental health professional in evaluating and treating patients as well as its importance in stimulating research and theoretical understanding of this domain. This work explores and summarizes methods of personality assessment and psychiatric evaluation, research findings, and clinical applications of the AMPD, highlighting its usefulness to clinical teaching and supervision, forensic application, and current research. It is a go-to reference for experienced professionals and researchers, those who wish to learn this new diagnostic system, and for clinicians in training.

1 Construct and Paradigm in the AMPD¹

Mark H. Waugh

About 2,300 years ago, Theophrastus described 30 personality types. The depictions in Theophrastus’ Characters (Bennett & Hammond, 1902), beginning with the duplicitous “Dissembler,” to the cruel, antisocial “Vicious Man,” are surprisingly modern. Theophrastus also notably contributed to the science of classification, but for botany, not psychiatric disorders. His organization of flora persisted until Carl Linnaeus developed a botanical taxonomy built on binomial nomenclature in 1753 (de Queiroz & Gauthier, 1994). The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013) Alternative Model for Personality Disorders (AMPD) is a psychiatric nosology for personality disorders (PD) contained in an officially promulgated system for classifying mental disorders. Like the classifications of Theophrastus and Linnaeus, the AMPD embodies principles of taxonomy, and its nosology has its own binomial nomenclature. As Pincus (2011) stated, Criterion A may be likened to genus, and Criterion B to species of PD.

Classification is a human activity. We naturally categorize objects, tasks, and experiences. We find a task easy or difficult, feel that a new food is tasty or unpalatable, and regard a new acquaintance as a pleasant type of person or not. Similarly, natural categorization becomes formalized for objects of professional and scientific study such as medical conditions (e.g., International Classification of Diseases-10; ICD-10; WHO, 1992), chemical elements (e.g., the Periodic Table), and books (e.g., the Dewey Decimal System; Wiegand, 1998). Scientific taxonomy condenses and organizes information by certain principles. Classifications are human products. As such, they have complicated histories. This is the case for chemistry, biology, and medicine, as well as the mental health disciplines. Amongst others, Blashfield (1984), Berrios (1999), Millon (1994), and Kendler (2009) outline the history and many nuances within the classification of psychopathology and PD. They note the imprint of precedent and unarticulated assumptions are salient in classification. These perspectives, along with the notion of paradigm (Kuhn, 1962/2012), help us to take the measure of the AMPD.

A major theme of this book is that many models and methods apply in the scientific investigation of and in clinical practice with PDs. Wiggins (2003) used the Kuhnian idea of paradigm to illustrate pluralism in personality assessment. Waugh and colleagues (2017) extended Wiggins’ (2003) scheme to the AMPD, noting that multiple paradigms inhere within the AMPD. This is more than an academic observation. That is, the nature of people and of the enterprise of diagnostic nosology should inform our methods of assessment. Issues of measurement are very relevant to the AMPD. Advancing this idea in psychometrics, Loevinger (1993, p. 1) invoked Herman Melville and likened rigorous measurement of psychological concepts to a “white whale.” For Loevinger (1993), pursuit of scientific understanding is guided by methods that conform to the nature of the object of the search (Loevinger, 1957). In other words, epistemology and ontology reciprocally inform each other. The elusive “whale” is unlikely to be found by a single method or a single model. Similarly, for PD, multiple conceptual and methodological approaches pertain.

As a point of departure, we start with Theophrastus’ inventory of 30 “characters” and then quickly move the clock forward to Phillippe Pinel in the 18^th Century. Pinel advanced the humanitarian treatment of the mentally ill, and he also established an early psychiatric nosology. This nosology was the first to describe a category for what we now call PD (manie sans délire [mania without delusion; at the time, mania referred to agitation, not psychosis]; Crocq, 2013). Psychiatric classifications evolve and reflect important scientific and sociological concerns of their times (Blashfield, Keeley, Flanagan, & Miles, 2014; Kendler, 2009). Contemporary conceptions of PD also are built from antecedent understandings. Sir Isaac Newton’s aphorism about progress and standing on the shoulders of giants applies to the field of PD as well.

The genealogy of the AMPD Criterion B includes the lexical tradition. This derives from the early work of Allport and Odbert (1936) on trait names and Cattell’s (1933) multivariate study of personality temperament. This path travels through the Big Five (Goldberg, 1993), alongside Five Factor Model (FFM) connections with PD (Widiger & Trull, 2007), to quantitative psychology (Achenbach, 1966; Blashfield, 1984; Krueger, 1999) and the trait-facets of Criterion B (Krueger & Markon, 2014). And if our lens is clear and strong, the tracings of Theophrastus appear within the lexical tradition.

Criterion A, level of personality impairment, starts with the notion of personality itself and emerges from concepts of constitution, self, and character (Berrios, 1996; Zachar, 2015). The ideas of self and character originated in art, literature, theater, and philosophy. Scientific psychology uses different terms and methods, but aspires to map the same terrain of personality, self, will, and consciousness (Gardner, 1992). Recognizing these shared goals underscores the wisdom of ensuring that both objective and subjective dimensions are included in a model of PD. Criterion A derives from psychodynamic, attachment, and social-developmental theory (Bender, Morey, & Skodol, 2011) and schematizes PD functioning on a dimension of impairment. The broad purview of Criterion A is suggested in the metaphors McAdams (2015) uses to characterize personality within a life-history framework: actor, agent, and author. Actors do, agents exercise will, and authors narrate. These ideas are examined closely later in this chapter, but at this juncture, we note McAdams and Pals (2006) organized personality constructs into five broad heuristic domains. The three domains most relevant to PD are dispositional traits (e.g., psychometric traits), characteristic adaptations (e.g., contextualized, dynamic patterns of motivation and adapting), and narrative identity (e.g., development of a life story). The scope of Criterion A spans these domains and points to agentic and narrative aspects of PD.

Understanding PD must address subjectivity. Symptom checklists, structured interviews, psychophysiological, and pharmacogenetic assays provide important information and may further consistency of agreement in diagnoses of PD. But, these approaches are not sufficient for a comprehensive science of psychopathology (Jaspers, 1912/1968; Kendler, 2005; Marková & Berrios, 2009; Meehl, 1986). For this, a broader repertoire of concepts and methods is needed. This would span neuroscience and molecular psychiatry on one end, and range to the narrative domain and subjective experience of the person on the other end. Zachar and Kendler (2007) point out that any classification model that uses the idea of self must permit narrative models and narrative data. After all, the self (person) is the terrain of PD. The arts of Homer, Shakespeare, and Faulkner alongside the narrative psychological science of the individual life story (McAdams, 1993) speak to the nature of self and self-experience. Of course, this is not a new idea, as is found in the writings of William James (James, 1890/1950). But, how may the clinician or psychopathologist know another’s subjectivity? The philosopher Nagel (1974, p. 435) asked “what is it like to be a bat,” and concluded this seems an impossible quest. Indeed, the study of reflective functioning (RF) and mentalization (Fonagy et al., 1991), an important line of investigation in personality and PD, posits this is the case. Yet, we can infer others’ mental states with degrees of confidence, aided by knowledge, experience, and empathy. Building on this idea, Fonagy, Luyten, and Allison (2015) theorized the common core of PD is a tacit, closed-off quality of personality functioning. This core reflects implicit distrust, a generalized foreclosure of normal, evolutionarily acquired processes of human social openness and reciprocity wherein we learn and grow from experiences with others. This closed-off quality underlies nosologically defined PD: the “…enduring pattern of inner experience and behavior…manifested in…cognition, affectivity, interpersonal functioning, (or) impulse control… (that) is inflexible and pervasive…” (DSM-5; APA, 2013, p. 646). Furthermore, this core of PD, often characterized as ego syntonic, is the “ground” of subjective experience, if considered within the Gestalt figure-ground heuristic. This existential ground is sometimes enacted in fears of rejection, loss, emptiness, attack, negation, shame, intimacy, or self-usurpation. As well, it may manifest in vulnerability to piercing emotional pain, a sense of falling apart, or de-stabilizing hypersensitivity to humiliation. To understand PD, this subjective side of experience must be coordinated with objective observation (Parnas, Sass, & Zahavi, 2012). Scientist and clinician alike seek to make sense of inferences about others’ mental states, and many types of data and points of view are needed.

Kendler (2005; 2015) argued the path for the psychopathological scientist is different than the chemist, for example. The natural scientist operates within a correspondence theory of truth. This presumes a fixed and independent reality. In contrast, psychiatry and related disciplines cannot assume an independent reality (separate from “mind”) because what psychiatry studies is composed of both third-person (objective) and first-person (subjective) points of view. Furthermore, to report a psychiatric symptom is ipso facto an interpretation of one’s experience (even if “brain-based”), and this is communicated dialogically (Marková & Berrios, 2012). Given this territory, a coherence theory of truth is appropriate. This interpretive attitude is less ambitious, subject to revision, and offers working explanations of phenomena based on the standard of consistency, as opposed to a fully mind-independent reality. Extending this line of reasoning, Kendler (2015) concludes that psychological processes are nested within biological functions, and these (inseparable) domains act bi-directionally. Neither domain trumps the other’s explanatory value (Kendler, 2008). Biological findings require back-translation into the psychological realm, and subjectivity is an emergent domain arising from biology. A similar if heuristic logic may be analogized to the personality scheme of McAdams and Pals (2006). Different realms of personality constructs are interwoven within the person, and they may benefit from different approaches to understanding. Neither trait, characteristic adaptation, or narrative identity provides sufficient explanation. Furthermore, it may be helpful to regard narrative identity, for example, as emerging from or “nested” within domains of characteristic adaptation and trait. A dispositional trait may lend itself to objective observation, but aspects of narrative identity less so. In sum, Kendler’s (2015) explanatory pluralism and the ideas of McAdams and Pals (2006) can inform PD.

To the extent the AMPD aspires to model disorders of personality (self), it must efficiently organize PD constructs, inform science and practice, coordinate with an evidence base, and demonstrate clinical utility—and connect with the lived experience of patients. In discussing clinical utility, Mullins-Sweatt and Widiger (2009) emphasized that a diagnostic system should be easy to use, facilitate communication, and help in the treatment of patients. In other words, a PD nosology with clinical utility looks beyond documentation, description, and science. Optimally, it may help bring the person to life for the clinician, and it surely should not obstruct empathy. These aspirations are not contrary. Concern for subjectivity need not subvert methodological rigor (Rychlak, 1968; 1988) or a priority given to objectivity in psychiatric classification (Cooper, 2012). A robust PD model permits first-person experience (personhood) to be coordinated with the third-person perspectives important in professional work and scientific study. The project thus assumes intentionality and meaning. Parameters like situation, context, history, and random events also are admitted to the table. Such an ecumenical approach means our constructs and methods are proxies rather than statements of reality (Cronbach & Meehl, 1955; Kendler, 2015). Following this line of reasoning, our constructs (informed presumptions) become open concepts (Meehl, 1977). That is, our understandings are approximations, imprecise and provisional, representing our best efforts for the time.

This chapter discusses the AMPD with respect to these caveats and concerns. This involves brief review of the history and principles of psychiatric classification. In addition, ideas of scientific paradigm, metaphor, map, construct, and measurement are applied to PD. This examination concludes that the AMPD provides heuristic advantage for the scientist and the practitioner.

Paradigms and Psychiatric Classification

Kuhn (1962/2012) articulated the idea of paradigm as we commonly understand it. He described science as a discipline and mode of inquiry consisting of evolving patterns of interrelated assumptions, methods, and conclusions (paradigms). Paradigms determine standards, what counts as evidence, and what is considered acceptable to study. Thus, a paradigm is a template or lens through which objects of study are known. Since scientists are people and theories are human constructions, sociological and historical forces affect these templates. The Kuhnian paradigm is a powerful concept. It can be applied very broadly, like Foucault’s notion of epistemes in history (Flynn, 1994). More narrowly, theories of personality (Loevinger, 1987), the field of personality assessment (Wiggins, 2003), and the discipline of psychiatry (Kendler, 2005) display paradigm dynamics. Implicit dynamics of paradigms also affect psychiatric classification (Blashfield et al., 2014).

Zachar and Kendler (2017) argue psychiatric nosology presently is facing a Kuhnian crisis of confidence, in large part generated by the emerging paradigm of dimensionalization of diagnosis. Concerns about the appropriateness of categorical classification for PD diagnosis are not new (e.g., Livesley, 1985; Livesley, 1991; Meehl, 1986; Widiger & Frances, 1985), but they now are changing the landscape of the field. To appreciate the significance of the dimensional paradigm, it is helpful to examine that which it seeks to model.

Psychiatric nosology is a branch of medical disease classification, and diseases traditionally have been understood as categorical entities. Consider neurosyphilis, a disease historically highly relevant to psychiatry. One either has or does not have this disease. There is a cause (i.e., the infectious bacterium Treponema pallidum) and, if the disease is not cured, it eventually produces the neuropsychiatric syndrome of general paresis. Philosophical, scientific, methodological, professional, and sociological assumptions accompany categorical diagnosis. In this example of neurosyphilis, assumptions include discrete class, organic etiology, natural course of illness, and belonging to the province of natural science.

The notion of discrete class assumes psychometric zones of rarity (Kendell & Jablensky, 2003). This means symptom variation shows a class (taxon) structure, not a continuous distribution on a dimension. It is important to note that categorical diagnosis itself is a paradigm. Traditional categorical diagnosis, as with disease and symptoms, has a specific organization to its classificatory elements and often an implied etiology. This is the idea of a syndrome, first articulated in Thomas Sydenham’s 17^th Century description of chorea (i.e., Saint Vitus’ Dance; see Martino et al., 2005). A syndrome has a discrete structure and typically assumes a biological cause. Biological etiology is not necessary, however. A cause can be psychological. For example, a psychodynamic etiology is presumed in conversion hysteria. The syndrome concept works well with classic medical diseases (e.g., neurosyphilis, pneumonia), but less so for some illnesses such as hypertension (HTN). HTN has biological causes but fits better with a dimensional model, rather than a syndrome, because HTN represents a summary product of diverse biological processes construed on a gradient. Note, this conception is not simply a way to capitalize on the metric advantage of quantity compared to categorical measurement. Rather, the underlying processes are viewed as inherently dimensional. In the example of HTN, medical convention establishes threshold values for identification of disease presence, with the “category” of HTN serving as a convenient proxy for the underlying dimensional disease processes.

In terms of psychiatric disorders, most empirical studies (e.g., Caspi et al., 2014; Krueger, 1999) and theoretical analyses (Kendler, Zachar, & Craver, 2011; Zachar & Kendler, 2007) question the validity of categorical structure in psychiatric nosology. Research findings suggest psychopathology may include just a few categorical disorders such as autism, substance use, and schizotypy (Haslam, Holland, & Kuppens, 2012). In the realm of PD, categorical structure appears even less likely. The sole exception with some empirical support for a taxon structure is schizotypy (Lenzenweger, 2015; Meehl, 1962). An excellent empirical review is found in Haslam and colleagues (2012), and a thorough conceptual analysis in Meehl (1992). Regarding the issues of the metrics of psychopathology, some suggest the distinction between category and continuum itself may not be sharp and may also lie on a continuum (Borsboom et al., 2016).

The medical model is often implicitly assumed in traditional categorical diagnosis (syndrome). The medical model incorporates several philosophical assumptions with natural science, social, and professional implications (Lilienfeld et al., 2015; Murphy, 2017). A strict or hard medical model is problematic for PD in several ways. These include socio-political and professional aspects of classification, some of which are discussed later. The medical model is problematic also in that cultural, social, normative, and agentic-constructivist concerns are intrinsic with ideas of the self and personality (Zachar & Kendler, 2007). A strict medical model with categorical-syndromic diagnosis fails to do justice to the subjective, constructivist, and nominalist aspects of PD. One classificatory remedy is to emphasize the pragmatic utility of diagnosis rather than assumptions of natural essence as implied in the medical model. This stance views PD as a practical kind, rather than a natural kind, which is the case in a mind-independent natural substance, entity, or condition (e.g., neurosyphilis; Zachar & Kendler, 2007).

Zachar and Kendler (2017) note that as psychiatric nosology moves closer to dimensionalization, scientific and professional debate intensifies, and fundamental assumptions of classification begin to shift. The DSM-5 (APA, 2013) aspired to increased dimensionalization of diagnosis (Regier, Narrow, Kuhl, & Kupfer, 2009), but implementation was limited, falling short of a full transdiagnostic reframing of nosology (e.g., Krueger & Eaton, 2015). The field of PD, however, has made substantial progress toward adopting a dimensional paradigm (Clark, 2007; Widiger & Trull, 2007), and one version is the AMPD. The limitation of categor...