Thomas A. Widiger

The borderline diagnosis I: psychopathology, comorbidity, and personaltity structure

Borderline personality disorder (BPD) is a complex and serious mental disorder associated with severe functional impairment, substantial treatment utilization, and a high rate of mortality by suicide. Recently, BPD has become a focus of intensifying study. In Part I of this three-part article meant to provide a foundation to researchers on the current status of the borderline diagnosis and prospects for its future development, we examine the psychopathology, comorbidity, and personality structure of BPD. Although the descriptive characteristics of BPD are well-represented by DSM-IV diagnostic criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria in conjunction with semistructured interviews have, however, increased the ability of investigators to diagnose BPD as reliably as many Axis I disorders. Frequent comorbidity of BPD with Axis I disorders necessitates a broad assessment of psychopathology to help account for clinical heterogeneity. Because of the absence of evidence of the validity of the diagnostic threshold for a categorical diagnosis of BPD, and because of the heterogeneity within the diagnosis, investigators should also supplement their DSM-IV diagnoses with assessments of underlying personality trait structures. Although there are a number of competing models of personality structure, they have remarkable convergence on a set of three to five basic personality dimensions.

A Meta-Analytic Review of the Relationships Between the Five-Factor Model and DSM-IV-TR Personality Disorders: A Facet Level Analysis

Theory and research have suggested that the personality disorders contained within the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) can be understood as maladaptive variants of the personality traits included within the five-factor model (FFM). The current meta-analysis of FFM personality disorder research both replicated and extended the 2004 work of Saulsman and Page (The five-factor model and personality disorder empirical literature: A meta-analytic review. Clinical Psychology Review, 23, 1055-1085) through a facet level analysis that provides a more specific and nuanced description of each DSM-IV-TR personality disorder. The empirical FFM profiles generated for each personality disorder were generally congruent at the facet level with hypothesized FFM translations of the DSM-IV-TR personality disorders. However, notable exceptions to the hypotheses did occur and even some findings that were consistent with FFM theory could be said to be instrument specific.

Plate tectonics in the classification of personality disorder: shifting to a dimensional model.

The diagnostic categories of the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders were developed in the spirit of a traditional medical model that considers mental disorders to be qualitatively distinct conditions (see, e.g., American Psychiatric Association, 2000). Work is now beginning on the fifth edition of this influential diagnostic manual. It is perhaps time to consider a fundamental shift in how psychopathology is conceptualized and diagnosed. More specifically, it may be time to consider a shift to a dimensional classification of personality disorder that would help address the failures of the existing diagnostic categories as well as contribute to an integration of the psychiatric diagnostic manual with psychologys research on general personality structure.

Personality and psychopathology

Personality and psychopathology can relate to one another in three different ways: personality and psychopathology can influence the presentation or appearance of one another (pathoplastic relationships); they can share a common, underlying etiology (spectrum relationships); and they can have a causal role in the development or etiology of one another. Each of these possible forms of inter-relationship is considered in this paper.

Personality Disorders as Extreme Variants of Common Personality Dimensions: Can the Five Factor Model Adequately Represent Psychopathy?

The present study examined Widiger and Lynams (1998) hypothesis that psychopathy can be represented using the Five-Factor Model (FFM) of personality. Participants in the study consisted of 481 21-22-year-old men and women who are part of an ongoing longitudinal study. Psychopathy was assessed by the degree of similarity between an individuals NEO-PI-R and an expert-generated FFM psychopathy prototype. The expert-based prototype supported the account of Widiger and Lynam (1998), as did the correlations between the NEO-PI-R Psychopathy Resemblance Index (PRI) and the individual personality dimensions. The PRI was also related in predicted ways to measures of antisocial behavior, drug use, and psychopathology. The results support the contention that psychopathy can be understood as an extreme variant of common dimensions of personality, and underscore the utility of a dimensional model of personality disorders.

Personality and Personality Disorders

The mental disorders that most clearly relate to personality are the personality disorders. The purpose of this article is to review the support for the hypothesis that the personality disorders of the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) represent variants of normal personality traits. We focus in particular on the efforts to identify the dimensions of personality that may underlie the personality disorders. We then illustrate the relationship of personality to personality disorders using the five-factor model, discuss conceptual issues in relating normal and abnormal personality traits, and consider methodological issues that should be addressed in future research.

The borderline diagnosis II: biology, genetics, and clinical course

In Part I of this three-part article, consideration of the core features of BPD psychopathology, of comorbidity with Axis I disorders, and of underlying personality trait structure suggested that the borderline diagnosis might be productively studied from the perspective of dimensions of trait expression, in addition to that of the category itself. In Part II, we review the biology, genetics, and clinical course of borderline personality disorder (BPD), continuing to attend to the utility of a focus on fundamental dimensions of psychopathology. Biological approaches to the study of personality can identify individual differences with both genetic and environmental influences. The aspects of personality disorder that are likely to have biologic correlates are those involving regulation of affects, impulse/action patterns, cognitive organization and anxiety/inhibition. For BPD, key psychobiological domains include impulsive aggression, associated with reduced serotonergic activity in the brain, and affective instability, associated with increased responsivity of cholinergic systems. There may be a strong genetic component for the development of BPD, but it seems clear, at least, that there are strong genetic influences on traits that underlie it, such as neuroticism, impulsivity, anxiousness, affective lability, and insecure attachment. The course of BPD suggests a heterogeneous disorder. Predictors of poor prognosis include history of childhood sexual abuse, early age at first psychiatric contact, chronicity of symptoms, affective instability, aggression, substance abuse, and increased comorbidity. For research purposes, at least, biological, genetic, and prognostic studies all continue to suggest the need to supplement categorical diagnoses of BPD with assessments of key underlying personality trait dimensions and with historical and clinical observations apart from those needed to make the borderline diagnosis itself.

Comorbidity of Personality Disorders and Depression Implications for Treatment

This article reviews naturalistic and controlled studies of the impact of comorbidity of personality disorders and depression on response to various forms of treatment. The findings support the common belief that personality disorders are associated with a poorer response to treatment for depression. In contrast, the limited data available suggest that the presence of depression may be a positive prognostic indicator for patients with borderline and antisocial personality disorder. There are insufficient data to draw conclusions regarding the influence of specific types of personality disorders on outcome with specific forms of treatment for depression. More specific assessment of personality disorders, particularly of possible underlying dimensions, is likely to be a more fruitful approach than the currently used categorical approach in identifying effective treatments for patients with personality disorders and depression.

Experimental manipulation of NEO-PI-R items.

Research assessing the relationship of the Five-factor model (FFM) of personality to personality disorder symptomatology has generally been consistent with theoretical expectations. Three exceptions, however, have been failures to confirm predicted associations of the NEO-Personality Inventory-Revised (NEO-PI-R; Costa & McCrae, 1992b) Conscientiousness scale with obsessive-compulsive personality disorder symptomatology, the NEO-PI-R Agreeableness scale with dependent symptomatology, and the NEO-PI-R Openness scale with schizotypal symptomatology. It was the hypothesis of this study that these findings might be due in part to a relative emphasis on adaptive rather than maladaptive variants of these domains of personality functioning within the NEO-PI-R. This hypothesis was tested by experimentally altering NEO-PI-R items to reverse their implications for maladaptiveness. The predicted correlations of the FFM were confirmed with the experimentally altered items in a sample of 86 adult psychiatric outpatients.

Assessing the basic traits associated with psychopathy: development and validation of the Elemental Psychopathy Assessment.

A new self-report assessment of the basic traits of psychopathy was developed with a general trait model of personality (five-factor model [FFM]) as a framework. Scales were written to assess maladaptive variants of the 18 FFM traits that are robustly related to psychopathy across a variety of perspectives including empirical correlations, expert ratings, and translations of extant assessments. Across 3 independent undergraduate samples (N = 210-354), the Elemental Psychopathy Assessment (EPA) scales proved to be internally consistent and unidimensional, and were strongly related to the original FFM scales from which they were derived (mean convergent r = .66). The EPA scales also demonstrated substantial incremental validity in the prediction of existing psychopathy measures over their FFM counterparts. When summed to form a psychopathy total score, the EPA was substantially correlated with 3 commonly used psychopathy measures (mean r = .81). Finally, in a small male forensic sample (N = 70), the EPA was significantly correlated with scores on a widely used self-report psychopathy measure, disciplinary infractions, alcohol use, and antisocial behavior. The EPA provides an opportunity to examine psychopathy and its nomological network through smaller, more basic units of personality rather than by scales or factors that blend these elements.