Premiere Date: July 20, 2016
Expiration Date: January 20, 2018
This activity offers CE credits for:
1. Physicians (CME)
The focus of this article is on diagnostic issues in borderline personality disorder.
At the end of this CE activity, participants should be able to:
• Discuss the traditional DSM approach to personality disorders
• Recognize the changes in DSM-5 and ICD-11 criteria for personality disorders
• Describe the integrative dimensional model approach to borderline personality disorder
This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.
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CME Outfitters designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Peter Fonagy, OBE, FMedSci, FBA, PhD, reports that he has received a personal Senior Investigator Award from the UK National Institute for Health Research and is Principal Investigator on a trial funded by the UK National Institute for Health Research Health Technology Assessment researcher-led stream.
Chloe Campbell, PhD, has no disclosures to report.
Anthony Bateman, MA, FRCPsych, reports that he is Senior Investigator on a trial funded by the UK National Institute for Health Research Health Technology Assessment researcher-led stream.
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The diagnosis of mental illness and the structure of psychopathology in classification systems such as DSM are cross-sectional and rely on reported symptoms within a specified period. This fails to address why psychiatric illnesses persist in some people and why clinical presentations change so radically over time. These weaknesses are relevant to proposed changes to the diagnostic systems of DSM and ICD-11, and particularly to personality disorders that change over time, recur, and are comorbid and complex.
In this article we discuss the traditional DSM approach to personality disorder, the alternative approach set out in Section III of DSM-5, and the new approach proposed for the forthcoming ICD-11. We suggest what may be a way forward for thinking about the conceptualization of personality disorder, concluding that an integrative dimensional model may be the most clinically valuable and theoretically coherent approach.
The traditional DSM model
DSM-5 promised to revolutionize the practice of psychiatric diagnosis. However, in the eyes of many clinicians and researchers it continues to struggle because it retained diagnosis on the basis of clinical observation and patient phenomenological symptom reports—that is, the disease is diagnosed as the constellation of symptoms, despite the fact that neuroscience, behavioral science, and genetic science do not support this. Moreover, it kept the polythetic and dichotomous (categorical) diagnostic system (eg, 5 out of 9 symptoms for borderline personality disorder [BPD]), which gives symptoms equal weight and results in the same symptoms being manifest across a range of possible disorders.
For example, in DSM-IV, 1750 combinations of symptoms could culminate in a diagnosis of PTSD. In DSM-5, the possible combinations of symptoms increased to more than 10,000. The mental disorders as per DSM are not biologically valid disease entities. Moreover, diagnostic systems cannot be based purely on phenomenology.
The criticism of the DSM categorical model is particularly pertinent in the case of personality disorders. The typal approach to personality disorders, as presented in Section II of DSM, provides 10 discrete diagnostic categories of personality disorder. However, the attempt to categorize in this way, for example, a category such as BPD is undermined by excessive comorbidity, excessive within-diagnosis heterogeneity, marked temporal instability, the lack of a clear boundary between normal and pathological personality, and poor convergent and discriminant validity.1 This creates problems for clinicians and researchers alike. For example, the various available evidence-based treatments may have been studied in different populations and may not be equally applicable to all subtypes of BPD. However, there is a degree of consensus that BPD incorporates 3 related core features: emotion dysregulation, impulsivity, and social-interpersonal dysfunction. These core features are significant because they suggest general difficulties in social communication that may cut across psychopathology.
The categorical model for personality disorder reproduced in DSM-5 Section II is not empirically supported, which has been confirmed in meta-analyses.2,3 As a recent review concluded, “. . . not only do personality disorder categories covary due to shared and correlated latent dimensions but at least most of them fall apart once symptoms are analyzed.”4,5
DSM-5 Section III: the alternative model for personality disorders
In an attempt to resolve these difficulties, Section III of DSM-5 proposes an alternative model for personality disorders that consists of 3 components:
1) Level of personality functioning. This has 4 subcomponents of identity and self-direction (both relating to the relationship to the self) and empathy and intimacy (both relating to interpersonal functioning). The severity of impairment predicts whether the individual meets the general criteria for personality disorder. More severe impairment predicts whether there is more than one personality disorder diagnosis, or whether one of the more typically severe forms of personality disorder is present.
2) Specific personality disorder diagnoses are reduced to 6 (as opposed to 10 in the existing model).
3) A system of pathological personality traits. These traits are organized into 5 domains: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. Within these domains, there are 25 trait facets.
From this perspective, people with BPD are identified by impairment in personality functioning, characterized by difficulties in 2 or more of the following 4 areas:
• Identity: impoverished, poorly developed self-image, often excessive self-criticism; chronic feelings of emptiness; dissociative states under stress
• Self-direction: instability in goals, aspirations, values, career plans
• Empathy: impoverished ability to recognize the feelings and needs of others, especially as a result of hypersensitivity (feeling rejected or insulted; perceptions of others are negatively biased)
• Intimacy: intense, unstable, and conflicted close relationships characterized by mistrust and neediness; close relationships often viewed in extremes of idealization and devaluation, reflected in a pattern of over-involvement or withdrawal
The trait stage of diagnosis for BPD requires fulfillment of 4 or more of the following 7 traits: emotional lability, anxiousness, separation anxiety, depressivity, impulsivity, risk-taking, and hostility (Figure). Of the 4 or more traits fulfilled, at least 1 of these must be impulsivity, risk-taking, or hostility.
This alternative model is dimensional in nature, which is in keeping with research evidence that indicates that “personality disorders are continuous with normal personality,”6 and the personality functioning scale accommodates a severity factor, which is a good predictor of outcome. The main criticism has been that the new model, with its use of dimensional and trait approaches, is an “unwieldy conglomeration of disparate models that cannot happily coexist and raises the likelihood that many clinicians will not have the patience and persistence to make use of it in their practices.”7 Clinicians should not be expected to regard their patients in terms of so many subcomponents.
However, it also keeps a categorical/typal model (in the form of the 6 specific personality disorder diagnoses) alongside the dimensional model. This hybridization requires 2 incompatible assumptions—that psychopathology is continuous with normality, and that a diagnosis is “a distinct type that is either present or absent, which is also discontinuous with related constructs and, in the case of personality disorder, with normal personality”6—which disregards the lack of empirical evidence for discontinuous types.
ICD-11, which is currently in development, proposes a dimensional approach to the classification of personality disorders. There will be one general diagnosis for personality disorder: the criteria for this are described as “a relatively enduring and pervasive disturbance in how individuals experience and interpret themselves, others, and the world that results in maladaptive patterns of cognition, emotional experience, emotional expression, and behaviour.”8 These patterns are entrenched and result in significant difficulties in psychosocial functioning, particularly in interpersonal relationships; the disturbances range across personal and social situations and are relatively stable over time.
Once the general diagnosis of personality disorder has been made, the level of impairment is identified as mild, moderate, or severe. In addition, there is the subthreshold category of personality difficulty; this is not a disorder and refers to a disturbance that might manifest sporadically or in particular contexts. The emphasis, therefore, is on personality disorder in general and its severity, rather than on categories of personality disorder. Severity is assessed on the extent of social dysfunction, the level of risk to self and others, and the overlap of trait domains that capture an individual’s personality disorder profile. These domain traits are “not categories, but rather represent a set of dimensions that correspond to the underlying structure of personality dysfunction.”8 The proposed domain traits are negative affective features, dissocial features, features of disinhibition, anankastic features, and features of detachment. In individuals with more severe personality disorder, more than one domain trait is likely to be present.
The proposed ICD-11 is clearly a break from previous ICD and DSM systems of diagnosis in that it ceases to use type-specific categories of personality disorder. The single diagnostic category is the presence or absence of personality disorder itself, and discrimination is made on the basis of severity and the expression of domain traits. This resolves the issue of comorbidity across different categories of personality disorders. For example, BPD classically involves an emphasis on negative affect; BPD comorbid with antisocial personality disorder—a frequently used traditional diagnosis—might manifest as moderate or severe personality disorder with dissocial features and features of disinhibition as well as negative affect. The ICD trait domains, although not using the language of typal categorization, can be understood as constituting a way of making sense of a patient’s behaviors in terms of severity and typical styles of behavior and their underlying cognitive processes, which some might think comes perilously close to categories.
At the heart of this discourse is whether personality disorder can be understood as one dimensional continuum or as made up of discrete but overlapping diagnostic categories—or whether a hybrid model that combines dimensional and categorical approaches is the most fitting. To date, there are few data that compare categorical, dimensional, and hybrid models of personality disorder.
We suggest a new direction that combines (1) recent research on the structure of personality pathology and the structure of psychopathology more generally, and (2) developments related to resilience and a theory of social learning—the theory of epistemic trust. The implications of these lines of thinking are that an integrated dimensional model is the most coherent from both a clinical and a research perspective. Personality disorders are best understood as existing on a continuum of persistence of symptoms over time, which encompasses normal personality functioning up to the most severe personality pathology. However, some form of categorization that captures an individual’s profile of behavioral difficulties and forms of distress and social dysfunction is necessary to comprehend the manifestations of pathology, to understand the individual clinically and, ultimately, to make treatment decisions.
The 20-year analysis of the Dunedin longitudinal study by Caspi and colleagues9 suggested the existence of a general factor in psychopathology. The researchers found that vulnerability to mental disorder was more convincingly described by a bi-factor model comprising a general psychopathology factor (labeled “p”) and 3 spectral factors (internalizing, externalizing, and thought disorder), rather than by spectral factors alone. A higher “p” factor score was associated with “more life impairment, greater familiality, worse developmental histories, and more compromised early-life brain function.”9 This work has been confirmed by other studies that extended the validity of the “p” factor concept into childhood and adolescence, where the measure of an overarching psychopathology factor substantially improved the prediction of mental disorder over a 3-year period.10,11 In this context, “p” could stand for the persistence of mental disorder.
The idea of a general construct that underpins vulnerability to psychopathology has also been considered specifically in personality disorder. A recent study by Sharp and colleagues12 at the Menninger Clinic explored whether there is a general personality disorder factor that underlies different diagnoses for personality disorder. Bi-factor analyses of the DSM personality disorder criteria confirmed several different disorders but indicated that they also load on to a general factor that includes all the BPD criteria, rather than the latter representing a separate personality disorder category. It appears that BPD might be better understood as being at the core of personality pathology more generally, rather than as a type of personality disorder; this approach would help make sense of the high levels of comorbidity found in BPD patients.
Caspi and colleagues found that individuals who scored highly on the general psychopathology scale were characterized by “three traits that compromise processes by which people maintain stability—low Agreeableness, low Conscientiousness, and high Neuroticism . . . that is, high-p individuals experience difficulties in regulation/control when dealing with others, the environment, and the self.”9 Such a profile, of course, captures the core features of BPD: emotion dysregulation, impulsivity, and social dysfunction. BPD is similar to high “p” and because BPD features appear to be central to all personality disorders, we may infer that there is at least a superficial association between high “p” scores and the likelihood of a personality disorder diagnosis. This, in turn, predicts an increased likelihood or persistence of a mental disorder.
Thus, moving from a cross-sectional to a developmental psychopathology frame enables us to reverse our lens and shift from investigating the mechanisms that lead to adversity-related illness to investigating the factor that protects against the impact of adversity—resilience. We suggest that the measurement captured in general factors for psychopathology (“p”) is the same construct that determines an individual’s resilience—or lack of it. Can we re-conceptualize the construct of high “p” (suggesting persistence), that is, personality disorder with BPD features, as the relative absence of a capacity to withstand adversity or as a lack of resilience?
ICD-11 will suggest an explicit link between personality disorder and compromised interpersonal or social function. We can readily reverse this and see personality disorder as an inability to adapt to changing social contexts. An individual with personality disorder is impaired in appraising social situations, less able to extract relevant social information from their current interpersonal context, and compromised in evaluating social information to update their interpersonal schemas or expectations. Consequently, they appear rigid, leading to the assumption that their pathology is rooted in the most stable psychic structure we can conceptualize: their personality. Yet, we know from follow-along studies that personality disorder is hardly stable.13
What we do have evidence of is the increased likelihood of persistence of continuous dysfunction in this group. Resilience assumes that protection from adversity is commensurate with the availability of and capacity to make use of social and environmental support. Those least capable of appraising social contexts and learning from social experience will be at greatest risk for managing adversity poorly and most vulnerable to succumbing to social challenge, with mental disorders being triggered by adversity.
Is there a known psychological mechanism that could (at least hypothetically) account for this conceptualization? We suggest that the constructs that represent psychopathology are measurements of an individual’s level of epistemic trust, by which we mean trust in the authenticity and personal relevance of interpersonally transmitted knowledge. This describes an individual’s openness to learning from another person, acquiring information, and receiving and internalizing this new knowledge. To modify a person’s behavior, social information must be coded as personally relevant and generalizable (ie, applicable to a range of social contexts). However, access to this privileged route of communication that leads to learning and change cannot be universal. It is restricted to people whose communication we can trust as accurate and reliable—individuals to whom we extend epistemic trust.14
The evolutionary purpose of epistemic trust is to enable social learning in an ever-changing social and cultural context, by stimulating individuals to be open to acquiring new knowledge from their (social) environment. These individuals update expectations from trustworthy sources but show appropriate suspicion and vigilance. They reject new information as not relevant to them when it comes from those who have not demonstrated their trustworthiness. The epistemic channel cannot be left open by default. It is adaptive for humans to adopt a position of epistemic vigilance unless they are reassured otherwise.
The disruption of epistemic trust, or the emergence of outright epistemic mistrust as a result of environmental adversity, genetic propensity, or both, can lead to a fundamental breakdown in the capacity for the ongoing exchange of social communications. This can create the appearance of rigidity, inflexibility, or being hard to talk to and difficult to help. To be able to trust knowledge, we are biologically programmed to look for cues in the communicator’s behavior that proves their interest in our wellbeing.
We tend to extend trust to those who demonstrate interest in us and can see the world from our perspective. If they show us that they understand our point of view, we will be able to listen to them and not just hear their words. Emotion dysregulation, impulsivity, and social dysfunction interact—it is hard (and possibly pointless) to try to work out which comes first. They are jointly cause and consequence. But they compromise an individual’s capacity to detect genuine interest and to approach social communication with epistemic trust. It follows from this perspective that personality disorder may be a state of profound and chronic epistemic mistrust that bars individuals from social communication, making them appear rigid and “hard to reach.”
Perhaps these patients require longer-term therapy, whatever their presenting symptoms, to help overcome their vigilance in relation to learning from their therapist. The therapist needs to be exceptionally explicit in adopting the patient’s perspective, which will serve to generate epistemic trust and open the patient to social learning. It is only by addressing this limitation of social communication that epistemic vigilance can be lifted so that the benefits of improved social knowledge can be experienced within the wider social environment.
We are all more or less epistemically trustful or distrustful. The epistemic trust model of personality disorder thus requires an integrative and dimensional approach. This involves thinking not in terms of classes of patients based on traditional phenomenological indicators and behavioral trajectories common to different clinical phenotypes, but in assuming an underlying common factor of vulnerability to adverse social conditions and a lack of resilience (too much “p”) as well as additional neurobiological drivers that generate different symptom profiles. Both are relevant and must be examined using state-of-the-art models of the dimensional structure of psychopathology in real-life psychiatric settings.