Assessment of Personality Disorder

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Assessment of Personality Disorder
Chapter · January 2019

DOI: 10.1017/9781108235433.029
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29 Assessment of Personality Disorder
LEONARD J. SIMMS, TREVOR F. WILLIAMS, AND CHLOE M. EVANS
The classification and assessment of personality disorder In addition, we will address two important topics rele-
(PD) is a topic currently mired in confusion and contro- vant to PD assessment. First, we will discuss the cross-
versy. Over the past decades, evidence has mounted show- cultural PD assessment literature, which is characterized
ing the limitations of the traditional, categorical model of by a relative lack of strong cross-cultural research on the
PD presented in our official diagnostic manuals, culminat- manifestation and measurement of PD. Second, we will
ing in a significant effort to revise the official PD classifica- address the glaring disconnect between research and
tion in the fifth edition of the Diagnostic and Statistical applied measurement of PD.
Manual of Mental Disorders (DSM-5; American
Psychiatric Association, 2013). These efforts have led to
TRADITIONAL CATEGORICAL MEASURES OF PD
a confusing state of affairs in which we have two distinct
systems in place for classifying personality pathology: (1) Traditional PD classification systems, such as those based
the official categorical approach, presented in Section II of in the DSM and the International Classification of
DSM-5, which essentially maintains the approach used to Diseases (ICD), describe PD using a medical model within
classify PDs since 1980, and (2) an alternative model of which pathological syndromes are viewed as being either
personality disorder (AMPD), presented in Section III of present or absent. However, although the inclusion of PDs
DSM-5, which was offered as a categorical-dimensional on Axis II as an independent domain in DSM-III
hybrid method for classifying PDs. Unfortunately, this (American Psychiatric Association, 1980) was regarded
diagnostic confusion has translated into a fractured as an important advance (e.g., reliability of PD diagnoses
assessment picture, with methods available for measuring was supposed to improve relative to previous PD classifi-
PD rooted in more traditional syndromal accounts of PD cations), the categorical model used by that and subse-
or in trait-dimensional conceptualizations of personality quent editions of the DSM repeatedly has been shown to
pathology. suffer from a number of problems that limit its usefulness,
In this chapter, we describe the prominent methods including high rates of diagnostic comorbidity (e.g., Clark,
available to assess PD from both traditions. Our review Watson, & Reynolds, 1995), within-disorder heterogeneity
of traditional methods will take the form of a critical (e.g., Clark et al., 1995; Widiger, 1993), an arbitrary bound-
review, given the limitations of the DSM-based model ary between normal and abnormal personality traits (e.g.,
underlying those measures. In contrast, our goal in pre- Clark et al., 1995; Livesley, Jang, & Vernon, 1998; Widiger
senting the measures rooted in the dimensional, AMPD & Clark, 2000), poor reliability (Dreessen & Arntz, 1998;
tradition is to describe these measures and the future Zanarini et al., 2000), and low convergent validity (see
directions that are needed to improve their traction in Clark, 2007, for a complete review of all of these issues).
applied settings. Notably, the scope of this chapter These limitations led to a significant effort to revise the
includes prominent models and measures and thus will official PD classification in the run-up to the publication of
not represent an exhaustive summary of all possible PD DSM-5. Unfortunately, the efforts to update PD classifica-
assessment methods. Rather, we focus on those methods tion in a way that was responsive to the scientific literature
that have gained traction in clinical or research settings, or were met with resistance from those within the American
that represent promising steps forward that need addi- Psychiatric Association and, indeed, in other sectors of the
tional research and clinical translation efforts. Moreover, mental health community (e.g., Krueger, 2013).
our review is focused on omnibus measures that present Ultimately, the AMPD approach to PD classification – to
a relatively “complete” picture of personality pathology, be described in the “Dimensional Models and Measures”
rather than measures that focus on the features of only one section of this chapter – was not approved by the American
or a limited set of PDs. Psychiatric Association Board of Trustees, who instead
398
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ASSESSMENT OF PERSONALITY DISORDER 399
agreed to publish it in Section III of DSM-5, presumably to PD interviews are semi-structured, which means that they
spark much-needed research into this new model and the permit the interviewer some flexibility in terms of follow-
measures associated with it. The Section II PD classifica- up questions and other aspects of the interview. We briefly
tion, in contrast, essentially represents a copy and paste of describe four semi-structured interviews developed to
the system that was presented in DSM-IV-TR (American measure the official PDs found in DSM-IV-TR and, thus,
Psychiatric Association, 2000). in Section II of DSM-5: (1) the Structured Clinical
Thus, the “official” PD classification in DSM-5 remains Interview for DSM-IV Axis II Personality Disorders (SCID-
the same categorical approach that has been in place, in II; First & Gibbon, 2004), (2) Structured Interview for
various forms, since 1980. In the current instantiation of DSM-IV Personality Disorders (SIDP-IV; Pfohl, Blum, &
this approach, ten purportedly distinct PDs are classified. Zimmerman, 1997), (3) the Diagnostic Interview for DSM-
Section II of DSM-5 includes the following ten PDs: IV Personality Disorders (DIPD-IV; Zanarini et al., 1996),
Borderline PD, Antisocial PD, Narcissistic PD, Histrionic and (4) the International Personality Disorder
PD, Avoidant PD, Dependent PD, Obsessive-Compulsive Examination (IPDE; Loranger, 1999). Notably, these inter-
PD, Schizotypal PD, Paranoid PD, and Schizoid PD. views are quite similar in that they all are keyed to the
These disorders previously were nested within three “clus- official PD criteria as listed in DSM-IV/5. However, each
ters” but that distinction was eliminated in DSM-5. also has unique features – that will be the focus of our
Moreover, in addition to the previously described limita- discussion here – that differentiate them.
tions regarding the categorical PD classification as One way the interviews differ is in the attention they
a whole, it is worth noting that relatively few of the tradi- have been paid in the PD literature. The SCID-II clearly
tional PDs – notably Borderline, Antisocial, and, to a lesser leads the pack in terms of research use. A search of
extent, Schizotypal PD – account for the lion’s share of PsycInfo with the keyword searches of “SCID-II,”
research in the PD literature. That said, interest remains “IPDE,” “SIDP,” and “DIPD” yielded 716, 125, 99, and 15
in measuring these traditional representations of person- published papers, respectively. Although these search
ality pathology. DSM-based PD measures typically take results likely are not exhaustive (additional search terms
the form of both self-report measures and interview- might yield additional hits), the rank-ordering of these
based methods. Self-report measures have the primary results is not likely to charge markedly from that presented
benefit of efficient and cost-effective administration, here. Thus, the SCID-II is the predominant interview used
whereas interview methods are more labor-intensive. to measure PDs keyed to DSM-IV/5 criteria. Notably, the
Moreover, some have argued that individuals with PDs SCID-II recently was updated for DSM-5 (SCID-5-PD;
sometimes lack enough insight into their personality pro- First et al., 2015). Although the PD criteria were
blems to make reliable and valid reports of such, and thus unchanged in DSM-5, the website promoting the SCID-
interviews may be preferable because they permit clinical 5-PD reports that “SCID-5-PD interview questions have
judgments of interviewers to clarify, refine, or confirm the been thoroughly reviewed and revised to optimally cap-
diagnostic picture (e.g., McDermutt & Zimmerman, ture the construct embodied in the diagnostic criteria.”1
2005). Although self-reports of PD symptoms have been That said, only a single peer-reviewed study was evident on
shown to be reliable and valid, interview methods often PsycInfo – using the search term “SCID-5-PD” – at the time
are used in research and applied settings where diagnostic of writing this chapter. Thus, more work clearly is needed
criteria are being assessed, presumably because of their to study this new version.
greater attention to the exact PD criteria and their diag- A second way the prominent PD interviews differ is
nostic thresholds. whether they include an accompanying questionnaire
In this section of the chapter, we will review DSM-based that can be used either as a screening device or as an
PD measures in several categories: (1) interview-based independent self-report measure of PD symptomatology.
methods, (2) self-report methods solely focused on mea- Of the four prominent measures reviewed here, only two –
suring PD, and (3) self-report methods embedded within the SCID-II and IPDE – include such a questionnaire.
broader omnibus psychopathology measures. In addition, A third way the PD interviews differ is in their ordering
we will briefly review several legacy methods for assessing of questions. The SCID-II, IPDE, and DIPD-IV interviews
personality pathology. All reviewed measures are sum- present questions on a disorder-by-disorder basis, which
marized in Table 29.1 with respect to their basic features, may have the effect of alerting patients and research par-
aspects relevant to clinical translations, and our subjective ticipants to the nature of the disorders being assessed. In
evaluation of the overall quality of the reliability and valid- contrast, the SIDP-IV arranges interview questions topi-
ity evidence that is available. cally rather than by disorder. That is, SIDP-IV interview
questions are presented within topical sections (e.g.,
“work activities” and “interests and activities”), which pre-
Interview-Based Measures of Traditional PD
sumably guards against patients easily inferring the dis-
Categories
orders being assessed. A final way the interviews differ is in
Psychiatric interviews typically come in two basic vari-
eties: fully structured and semi-structured. All prominent 1
See https://tinyurl.com/ya47dk6v
Table 29.1 Summary of personality disorder measures reviewed
Quality of
Variables Reliability Quality of Validity
Measure Citation Measured Validity Scales Norm Samples Related Measures Languages Evidence Evidence
Interview/Clinician Measures Within The DSM Tradition
Structured Interview Pfohl, Blum, & DSM-IV PDs None criterion- – English moderate moderate
for DSM-IV Zimmerman referenced (DSM)
Personality Disorders (1997)
(SIDP-IV)
Structured Clinical First & Gibbon DSM-IV PDs None criterion- SCID-II-PQ English, Mandarin, Korean, excellent moderate
Interview for DSM-IV (2004); First et al. referenced (DSM) Danish, Dutch, French,
Personality Disorders (2015) German, Greek, Hebrew,
(SCID-II) (also Italian, Portuguese,
a version for DSM-5) Romanian, Spanish, Swedish,
Turkish, Zulu
Diagnostic Interview Zanarini et al., DSM-IV PDs None criterion- English, Spanish moderate moderate
for Personality 1996 referenced (DSM)
Disorders (DIPD-IV)
International Loranger (1999) DSM-IV PDs None criterion- screening questionnaire English, Arabic excellent moderate
Personality Disorder referenced (DSM)
Examination (IPDE)
Shedler-Westen Westen & Shedler DSM PDs, None clinical PD sample SWAP-II, SWAP-II-A English, German, French, excellent moderate
Assessment Procedure (2007) alternative PDs, (Westen & Shedler, (Adolescents) Italian, Spanish, Portuguese,
(SWAP-200) and traits 1999a, 1999b) Dutch, Polish, Swedish,
Norwegian, Russian, Hebrew,
Persian, Japanese
Standalone Self-Report DSM Measures

Personality Diagnostic Hyler (1994) DSM-IV PDs None criterion- – English, Spanish, French, fair moderate
Questionnnaire-4 referenced (DSM) Chinese, Italian
(PDQ-4)
SCID-II Personality First & Gibbon DSM-IV PDs None criterion- SCID-II English, Danish, Dutch, fair moderate
Questionnaire (SCID-II- (2004); First et al. referenced (DSM) Greek, German, Italian,
PQ, plus the revised (2016) Korean, Polish, Romanian,
SCID-5-SPQ for DSM-5) Turkish
Multi-Source Oltmanns & DSM-IV PDs None criterion- self-report, other-report English moderate moderate
Assessment of Turkheimer referenced (DSM)
Personality Pathology (2006)
(MAPP)
Continued
Assessment of DSM-IV Schotte et al. DSM-IV PDs None criterion- – English, German, Dutch fair moderate
Personality Disorders (1998) referenced (DSM)
(ADP-IV)
DSM Measures Nested in Broader Measures

SNAP-2 PD scales Clark et al. (2002) DSM-IV PDs + PD Overreporting, community adults, SNAP-Youth, SNAP-Other English moderate moderate
traits underreporting, college students, Rating Form
inconsistency clinical sample,
scales military veterans
(Calabrese et al.,
2012)
OMNI-IV Personality Loranger (2002) DSM-IV PDs + Inconsistency scale community adults OMNI English moderate moderate
Inventory personality traits
Coolidge Axis II Coolidge & DSM-IV PDs, random undergraduate SCATI (Short Form) English, Italian, Bulgarian moderate moderate
Inventory (CATI) Merwin (1992) personality responding, sample
traits, other excessive denial,
clinical malingering scales
syndromes
Minnesota Sellbom, Waugh, DSM-IV PDs, Overreporting, community sample MMPI-2 English, Bulgarian, Chinese, moderate moderate
Multiphasic & Hopwood personality underreporting, Croatian, Czech, Danish,
Personality Inventory- (2018) traits, other inconsistency Dutch, French-Canadian,
2-Restructured Form clinical scales German, Greek, Hebrew,
PD scales syndromes Hmong, Hungarian, Italian,
Korean, Norwegian, Polish,
Romanian, Slovak, Spanish,
Swedish, Ukrainian
PD similarity scores Costa & McCrae DSM-IV PDs, None community sample fair moderate
derived from the (1992); Lynam & personality traits
Revised NEO Widiger (2001)
Personality Inventory
(NEO PI-R/3)
Legacy Measures
Millon Clinical Millon, Grossman, DSM-IV and Overreporting, clinical sample (N = – English, Spanish excellent moderate
Multiaxial Inventory- & Millon, 2015) other PDs, underreporting, 600)
IV (MCMI-IV) personality inconsistency
traits, other scales
clinical
syndromes
Wisconsin Personality Klein et al. (1993) DSM-IV PDs None criterion- – English, Spanish excellent fair
Disorders Inventory referenced (DSM)
(WISPI-IV)
Non-AMPD Trait-Dimensional Measures

Schedule for Clark et al. (2002) DSM-IV PDs + PD Overreporting, community sample SNAP-Youth, SNAP- English excellent excellent
Nonadaptive and traits underreporting, Informant Rating Form, Short
Adaptive Personality inconsistency Form
(SNAP-2) scales
Continued
Table 29.1 (cont.)
Quality of
Variables Reliability Quality of Validity
Measure Citation Measured Validity Scales Norm Samples Related Measures Languages Evidence Evidence
Dimensional Livesley & Jackson PD traits None community and DAPP-BQ-A (Adolescents), English, French, Spanish, excellent excellent
Assessment of (2009) patient samples DAPP-BQ-SF (Short Form), Portuguese
Personality DAPP-DQ (Differential
Pathology-Brief Questionnaire)
Questionnaire (DAPP-
BQ)
Personality Butcher et al. PD traits Overreporting, community sample English, Dutch, Chinese, excellent excellent
Psychopathology Five (1989); Harkness, underreporting, Croatian, Spanish, Arabic,
(PSY-5) scales of the McNulty, & Ben- inconsistency Farsi, French, Greek, Hebrew,
MMPI-2 and MMPI- Porath (1995); scales Hmong, Icelandic, Italian,
2-RF Ben-Porath & Japanese, Korean,
Tellegen (2008) Norwegian, Russian, Thai,
Turkish, Vietnamese
NEO Personality Costa & McCrae Personality traits None community sample self, observer forms 50+ languages moderate excellent
Inventory-R/3 (NEO-PI (1992); McCrae,
-R/3) Costa, & Martin
(2005)
Structured Interview Trull & Widiger Personality traits None clinical sample – English, French, German moderate excellent
of the Five-Factor (1997) (Bagby et al., 2005)
Model (SIFFM)
AMPD-Aligned Trait Measures

Personality Inventory Krueger et al. PD traits No official validity community and Full, Short Forms (100 & 25 English, Dutch, Norwegian, excellent excellent
for DSM-5 (PID-5) (2012) scales patient samples items), Informant, Child German, Arabic, Portuguese,
French, Spanish
Personality Busch, Morey, & PD traits + full Overreporting, community and Adult & Adolescent English, Spanish fair moderate
Assessment Inventory Hopwood (2017) range of other underreporting, patient samples
(PAI) AMPD trait personality and inconsistency
scoring clinical scales scales
Comprehensive Simms et al. PD traits Overreporting, community and Adaptive Form, Static Form, English, Dutch, Norwegian, moderate moderate
Assessment of Traits (2011) underreporting, patient samples Informant Report, Interview Spanish
relevant to inconsistency
Personality Disorder scales
(CAT-PD)
PD Functioning Measures
Levels of Personality Bach & Hutsebaut PD functioning None outpatient, – English, Dutch moderate excellent
Functioning Scale – (2018) inpatient
Brief Form 2.0 (LPFS-
BF 2.0)
Continued
Level of Personality Morey (2017) PD functioning None MTurk (mechanical – English excellent moderate
Functioning Scale – turk) sample
Self-Report (LPFS-SR)
DSM-5 Levels of Huprich et al. PD functioning None psychiatric and – English moderate moderate
Personality (2017) medical outpatient
Functioning sample
Questionnaire
(DLOPFQ)
Severity Indices of Verheul et al. PD functioning None personality- Short Form (SIPP-SF 64 items) English, Dutch, Norwegian, excellent excellent
Personality Problems (2008) disordered, Argentinian, Italian
(SIPP) psychiatric
outpatient
Measure of Parker et al. PD functioning None Italian community English, Italian (Fossati et al., moderate fair
Disordered (2004) sample (Fossati 2017)
Personality et al., 2017)
Functioning Scale
(MDPF)
General Assessment Livesley (2006) PD functioning None Canadian English, Dutch, German moderate moderate
of Personality community
Disorder (GAPD) sample, Dutch
clinical sample
Inventory of Alden, Wiggins, & Interpersonal None community sample IIP-32 (short circumplex) English, Finnish, Greek, excellent excellent
Interpersonal Pincus (1990) functioning Malay, Polish, Spanish
Problems-Circumplex
(IIP-C)
404 LEONARD J. SIMMS, TREVOR F. WILLIAMS, AND CHLOE M. EVANS
their cost, which is a nontrivial characteristic in many DSM PDs that are rooted in specific theories of personality
research and applied settings. The SCID-II, IPDE, and pathology rather than the specific PD criteria per se. Like
SIDP-IV interviews all include start-up costs and per-use the clinical interviews, a blanket critique about these self-
charges to various degrees, whereas the DIPD-IV appears report measures is that their validity is compromised to
to be available for use simply by requesting it from the the extent that they adhere to a flawed PD classification
author. system. Nonetheless, given the nature of the official PD
Although not an interview in the strictest sense, an addi- classification in DSM-5, these measures remain relevant
tional measure deserves mention in this section, given its for research and applied practice and thus deserve men-
reliance on clinician judgments of personality pathology. tion in this section of the chapter.
The Shedler-Westen Assessment Procedure 200 (SWAP-
200; Westen & Shedler, 2007) is a measure of DSM-IV/5 Primary PD measures. Four prominent self-report mea-
PDs that is completed by clinicians after they have had sures are available whose primary purpose is the assess-
sufficient experience with a given client (e.g., Shedler and ment of DSM-IV/5 PDs: (1) the Personality Diagnostic
Westen [2007] recommend that clinicians complete the Questionnaire-4 (PDQ-4; Hyler, 1994), (2) the Structured
SWAP-200 only after at least six hours of clinical contact Clinical Interview for DSM-IV PDs Personality
with a given patient). For each SWAP-200 assessment, Questionnaire (SCID-II-PQ; First & Gibbon, 2004), (3)
clinicians are required to sort 200 personality descriptive the Multi-Source Assessment of Personality Pathology
items – developed from a psychodynamic perspective on (MAPP; Oltmanns & Turkheimer, 2006), and (4) the
PD – into eight categories from most descriptive to least Assessment of DSM-IV Personality Disorders (ADP-IV;
descriptive. A computer program then reports DSM-IV/5 Schotte et al., 1998). The PDQ-4 (Hyler, 1994) consists of
PD diagnoses, personality diagnoses for alternative, ninety-nine items that measure all ten of the DSM-IV PDs.
empirically derived personality syndromes (Westen et al., The measure has been widely used in research, is concise,
2012), and dimensional trait scores. Shedler and Westen and has shown evidence of reliability and convergent
(2007) report reliability and validity evidence. Notably, validity (e.g., Okada & Oltmanns, 2009). However, it also
much of the research supportive of the SWAP-200 include has been criticized for having a higher-than-ideal rate of
one of the measure’s authors. Independent research is false positive (i.e., high sensitivity and low specificity) PD
much less common and has been decidedly more mixed diagnoses (e.g., Abdin et al., 2011). As such, the PDQ likely
regarding the measure’s reliability and validity (e.g., is best used as a screening instrument rather than
Davidson et al., 2003; Smith, Hilsenroth, & Bornstein, a definitive diagnostic measure.
2009). The SCID-II includes a personality questionnaire (i.e.,
Notably, clinical utility is an important consideration the SCID-II-PQ) that can be used as a screening measure
for all of these interviews and the SWAP-200, for several for the full SCID-II interview. In addition, many studies
reasons. First, given the mass of evidence mounting have opted to use this measure as a standalone measure of
against categorical representations of PD symptomatology the ten primary PDs in DSM-IV. Notably, a version of this
and the rise of dimensional alternatives, the long-term measure that has been updated for DSM-5 is now available
need for interviews keyed to DSM-IV/5 PD criteria is ques- (SCID-5-SPQ; First et al., 2016) but few data are available
tionable. It is reasonable to argue that measures are only on how the revised version compares to the original ver-
as valid as the model they purport to measure. Second, sion or to other measures of personality pathology.
these interviews all are relatively time- and labor-intensive Interestingly, the name of this revised measure was chan-
relative to their self-report counterparts, which can be ged from “personality questionnaire” to “screening per-
administered and scored much more efficiently. sonality questionnaire,” presumably to make explicit that
Although lore in the research world drives many to argue the measure is not intended to make diagnoses absent the
for the superiority of interview methods over self-report full interview.
methods (e.g., McDermutt & Zimmerman, 2005; Segal & The MAPP (Oltmanns & Turkheimer, 2006) originally
Coolidge, 2007), there is no clear evidence for such relative was developed for use in Oltmanns and Turkheimer’s peer
superiority (Widiger & Boyd, 2009). Moreover, interviews nomination studies of college students and air force
have no control for the validity of the self-reports on which recruits in the 1990s (e.g., Thomas, Turkheimer, &
they are based. Oltmanns, 2003). The MAPP includes 105 items, 81 of
which that refer to the features of the 10 DSM-IV PDs
and 24 supplementary items that describe additional per-
Self-Report Measures of Traditional PD Categories
sonality traits. The PD items were written to be lay transla-
There are many self-report measures designed to measure tions of the PD criteria and to refer to others because it was
the traditional PDs as represented in DSM-IV/5. These can developed to collect data from informants. Later, a self-
be placed into several categories: (1) measures whose pri- report version of the MAPP was developed by revising the
mary purpose is the assessment of the DSM PDs, (2) same items to refer to the self. Okada and Oltmanns (2009)
broader psychopathology measures that include scales compared the MAPP to the SCID-II-PQ and PDQ-4 with
measuring the DSM PDs, and (3) legacy measures of the respect to convergent validity and diagnostic thresholds.
They reported evidence that the MAPP provides a more MMPI-2 Restructured Form (MMPI-2-RF; Tellegen &
conservative threshold for diagnosing the DSM-IV PDs Ben-Porath, 2008), which is a compelling and efficient
than the other two measures. Moreover, they reported update (total items = 338) to the venerable MMPI-2.
only low to moderate agreement among these three mea- These scales (Sellbom, Waugh, & Hopwood, 2018) demon-
sures, which replicates a general finding in this literature: strated evidence of construct validity in relation to exter-
Self-report and interview measures of PDs tend to corre- nal PD, trait, and chart data in a range of clinical,
late at rates lower than would be ideal given that they community, and forensic samples.
purport to be measuring the same PD constructs (see
Clark, 2007, for a discussion of this and other problems Legacy measures tied to specific theoretical models of
in the PD assessment literature). PD. Finally, two measures are available that measure the
Finally, the ADP-IV (Schotte et al., 1998) is a ninety- ten traditional DSM PDs but do so from a particular the-
four-item questionnaire that is designed to assess the ten oretical perspective rather than as a strict representation
primary DSM-IV PDs and two appendix diagnoses. The of the DSM criteria. These include the Millon Clinical
ADP-IV first investigates the self-rated typicality of each Multiaxial Inventory-IV (MCMI-IV; Millon, Grossman, &
criterion by means of a seven-point trait scale. Next, for Millon, 2015) and the Wisconsin Personality Disorders
each criterion rated positively, the impairment asso- Inventory (WISPI; Klein et al., 1993). The MCMI-IV is
ciated with that criterion is assessed using a three-point a 195-item true/false questionnaire that consists of 15 PD
distress scale. Thus, this measure attempts to distinguish scales, 10 clinical syndrome scales, 5 validity scales, and 45
between PD severity and style at the level of each criter- Grossman personality facet scales (3 per each PD scale).
ion, something that is unique among self-report PD mea- The primary characteristic that differentiates the MCMI-
sures. Research has tended to support the convergent IV (and its earlier versions) from other mainstream PD
validity of the ADP-IV at levels roughly similar to that of measures is its theoretical foundation. The MCMI-IV is
other PD self-reports. For example, Schotte and collea- based on Millon’s evolutionary theory of PD. This back-
gues (2004) found low to moderate correlations between ground likely has influenced the MCMI’s convergent valid-
ADP-IV PD ratings and those obtained using the full ity with respect to other PD measures, which has varied
SCID-II interview in a sample of Flemish community considerably across studies (e.g., Millon, Davis, & Millon;
participants and psychiatric patients. 1997; Retzlaff, 1996). The MCMI-IV is described in detail
in Chapter 18 of this volume. The WISPI-IV (Klein et al.,
Secondary PD measures. Five broader omnibus psycho- 1993) is a 204-item self-report measure of the DSM-IV/5
pathology and personality measures include scales PDs. The WISPI-IV has its roots in object relations theory
designed to measure all ten traditional DSM-IV/5 PDs: and Lorna Benjamin’s Structural Analysis of Social
(1) the Schedule for Nonadaptive and Adaptive Behavior model (SASB; Benjamin, 1996). Its validity
Personality-2 (SNAP-2; Clark et al., 2002), (2) the OMNI- against the SCID-II interview has been studied in psychia-
IV Personality Inventory (Loranger, 2002), (3) the tric patients, showing poor convergence at the level of
Coolidge Axis II Inventory (CATI; Coolidge & Merwin, categorical diagnoses but better convergent and discrimi-
1992), (4) the PD scales of the Minnesota Multiphasic nant validity for five out of eleven WISPI-IV dimensional
Personality Inventory-2 (MMPI-2; Somwaru & Ben- PD scales (Smith et al., 2011).
Porath, 1995), and (5) PD similarity scores derived from
the Revised NEO Personality Inventory (NEO PI-R, Costa
& McCrae, 1992; Lynam & Widiger, 2001). Notably, these DIMENSIONAL MODELS AND MEASURES
methods all are considerably longer than those measures In contrast to categorical systems of classification,
whose sole purpose it is to measure the DSM-IV/5 PDs, a dimensional model conceptualizes psychopathology as
with total items of 390, 375, 250, 567, and 240, respec- lying on a continuum with normal psychological function-
tively. Thus, these measures likely are less favorable in ing, such that psychopathology is quantitatively, as
research or applied settings in which time is scarce and opposed to qualitatively, different from psychological
all that is desired is a tight measure of the DSM-IV/5 PDs. health. Furthermore, dimensional models are based on
That said, all of these measures, to various extents, underlying theoretical models that have undergone
include scales of more basic personality and/or PD traits empirical scrutiny (e.g., Harkness & McNulty, 1994;
that might be of interest to some users. For example, the Widiger & Trull, 2007), as opposed to categorical models
SNAP-2 is a prominent measure of PD traits, and the NEO that derive their structure mainly from expert psychiatric
family of measures have been heavily studied with respect opinion. Dimensional classification is especially relevant
to their normal-range trait links to PD. Moreover, the to the PD domain, for at least two reasons. First, there is
MMPI-2 is the most heavily studied personality and psy- extensive evidence that PD symptoms vary continuously
chopathology measure and includes a diverse array of between clinical samples and the general population, sug-
validity scales, features that makes it particularly useful gesting a shared, dimensional latent structure (e.g.,
in high-stakes assessment contexts. Notably, PD “spectra Livesley et al., 1994). Second, a dimensional model
scales” recently were developed using the item pool of the would potentially ameliorate some of the well-
documented limitations of the categorical model of PD in & Jackson, 2009) is similar to the SNAP in that it was
the various editions of the DSM (e.g., Clark, 2007). For developed as an early attempt to represent and measure
example, categorical PD models have been roundly criti- the traits underlying PD. The DAPP-BQ includes 290
cized for their excessive comorbidity. Dimensional trait items and measures eighteen lower-order traits nested
models alleviate this concern to the extent that the seek within four higher-order dimensions – Emotional
to identify the underlying traits that arguably drive the co- Dysregulation, Dissocial Behavior, Inhibition, and
occurrence of PDs that we see clinically. Compulsivity. Items were rationally written to capture
In this section of the chapter, we review the prominent the DSM-III PD criteria. All eighteen of the DAPP-BQ
PD models and measures that are rooted in the dimen- trait scales have documented evidence of internal consis-
sional approach. As noted, dimensional models recently tency, test-retest reliability, and construct validity, and
have been formalized in the AMPD, which includes two include strong clinical norms (e.g., Bagge & Trull, 2003;
primary components – Criterion A focused on personality van Kampen, 2002).
functioning and Criterion B focused on personality traits –
as well as a range of other inclusion and exclusion criteria MMPI-2-RF Personality Psychopathology Five Scales
that are similar to the traditional approach. To meet cri- (PSY-5). The PSY-5 model (Harkness & McNulty, 1994) –
teria for a PD using the AMPD, one must demonstrate both which includes the five broad traits of Aggressiveness,
deficits in personality functioning and the presence of at Psychoticism, Constraint, Negative Emotionality, and
least one maladaptive personality trait.2 Thus, measures Positive Emotionality – represents both a measure of
have been developed to measure each of these compo- broad traits thought to be relevant to adaptive and mala-
nents. We organize this review into three subsections daptive personality and a model of such traits that has
focused on (1) measures that predate the AMPD, (2) mea- gained traction in recent years as a basis for the AMPD.
sures aligned with the traits presented in Criterion B of the The PSY-5 traits first appeared as a cohesive set of scales
AMPD, and (3) measures designed to represent PD-specific developed for the Minnesota Multiphasic Personality
functioning (or impairment) that currently is represented Inventory-2 (MMPI-2; Butcher et al., 1989; Harkness,
in Criterion A of the AMPD. McNulty, & Ben-Porath, 1995) and, later, as a refined set
in the restructured form of the MMPI-2 (MMPI-2-RF; Ben-
Porath & Tellegen, 2008). Items originally were chosen
Non-AMPD Dimensional Models and Measures
from the full MMPI-2 item pool via replicated rational
Schedule for Nonadaptive and Adaptive Personality-2. The selection procedures, followed by rational and psycho-
SNAP-2 (Clark et al., 2002) provides a means for assessing metric pruning (Harkness et al., 1995). The scales have
trait dimensions relevant to PD. Clark initially developed demonstrated good reliability, as well as convergent and
the SNAP in the early 1990s based on the assumption that discriminant validity with respect to the PID-5 and various
the problems associated with the DSM approach to PD external criteria (e.g., Harkness et al., 2013). However, the
classification (e.g., comorbidity, heterogeneity) were due lack of integrated PSY-5 facet scales is a notable limitation
to shared personality traits across the purportedly distinct of the PSY-5 model and scales (however, see Quilty &
DSM PDs. The SNAP-2 includes 390 items and measures Bagby, 2007, for a post hoc set of PSY-5 facet scales).
three broad temperament dimensions corresponding to
a Big Three personality model (i.e., negative temperament,
Five-Factor Model Measures
positive temperament, and disinhibition vs. constraint), as
well as twelve lower-order facets that were developed via Five-factor model (FFM) measures do not assess patholo-
an iterative bottom-up series of factor- and content- gical traits per se; rather, they assume that extremely low
analytic procedures applied to PD diagnostic criteria and or high levels of the FFM normal-range personality traits –
related features. The clinical utility of the measure is rela- neuroticism, extraversion, agreeableness, conscientious-
tively strong, as it also includes a comprehensive set of ness, and openness – constitute personality pathology
validity scales and a set of scales keyed to the DSM-IV/5 and are associated with psychosocial impairment. The
PDs for clinicians who desire a bridge between categorical FFM has its roots in two distinct traditions. First, the
and trait-dimensional PD conceptualizations. Moreover, FFM is rooted in the lexically based Big Five literature
the measure has strong community and clinical norms (e.g., Goldberg, 1993). That said, clinical applications of
and considerable evidence in support of its reliability and the FFM are rooted in the work of Costa and McCrae, who
validity (e.g., see Simms & Clark, 2006). formalized the FFM in the NEO family of measures (Costa
& McCrae, 1992; McCrae, Costa, & Martin, 2005) as the
The Dimensional Assessment of Personality Pathology – five broad traits listed above and their nested thirty lower-
Basic Questionnaire (DAPP-BQ). The DAPP-BQ (Livesley order facets. Although the NEO measures were designed
to measure normal-range variants of personality, they
2
have been the basis of a large literature linking FFM traits
Note that the AMPD also includes trait-based criteria for assessing
six of the traditional PDs – Borderline, Antisocial, Schizotypal, and PD (e.g., Widiger & Trull, 2007). Moreover, there now
Avoidant, Narcissistic, and Obsessive-Compulsive PDs. is good evidence that FFM traits represent normal-range
variants of at least four of the five PSY-5 domains (e.g., on an ambitious series of projects to develop FFM-inspired
Suzuki et al., 2015). measures of the traits relevant to eight of the ten DSM-
The full NEO-FFM model first emerged in the revised based PDs. These measures collectively represent the Five-
NEO Personality Inventory (NEO-PI-R; Costa & McCrae, Factor Model of Personality Disorder (FFM-PD). Each of
1992). A minor revision was published in 2005 (NEO-PI-3; these FFM-PD measures is limited to those facets of the
McCrae, Costa, & Martin, 2005) but the NEO-FFM model FFM that have shown empirical relevance to a given PD
has remained remarkably consistent for more than twenty- based on extant research. Space constraints do not permit
five years. Notably, the work of Tom Widiger and his collea- a full description of each FFM-PD measure; interested
gues and students has greatly enhanced our understanding readers are referred to a recent special issue of
of PD traits, using the FFM model as a foundation. The Psychological Assessment that focuses on the measures
primary strength of the NEO measures is the strong within this collection (Bagby & Widiger, 2018). Although
research base documenting evidence of their psychometric the early evidence is promising regarding these measures’
features and links with PD. Limitations include the lack of reliability and validity, it is unclear how this collection of
integrated validity scales, a pay-per-use model, and a focus measures is meant to be used in clinical work, especially
on normal-range variation in personality traits, which since these measures collectively include too many items
together make the NEO a tough sell in resource-poor clinical and numerous overlapping scales to be efficiently used by
settings. However, a public domain parallel version of the practicing clinicians. Moreover, strong normative data are
NEO has been published in the International Personality lacking. If the FFM-PD is to become a clinically useful
Item Pool (Goldberg et al., 2006), which helps reduce costs measure, work is needed to integrate these eight measures
associated with using the official NEO measures. However, into a single, efficient FFM-PD measure.
clinical utility remains a concern.
Notably, Widiger and his colleagues have developed
AMPD-Aligned Trait Measures
several FFM-based measures designed to explicitly extend
the normal-range NEO traits into the maladaptive range, Personality Inventory for DSM-5 (PID-5). The PID-5
presumably making them more amenable to clinical- (Krueger et al., 2012) is the official measure of the AMPD
psychiatric research and practice. This work has moved as represented in Section III of DSM-5. It includes 220 self-
in several directions. First, they have developed a series of report items that assess the twenty-five maladaptive traits
short rating scale methods that attempt to explicitly model of the AMPD. Traits are distributed across five higher-
both adaptive and maladaptive variants of the FFM’s thirty order domains that are isomorphic with the PSY-5
facets. The most recent of these, the Five Factor Form model: Negative Affectivity, Detachment, Antagonism,
(FFF; Rojas & Widiger, 2014), consists of one item for Disinhibition, and Psychoticism (Krueger et al., 2012).
each FFM facet, each rated on a five-point scale including Items were conceptually generated by expert consensus
the following anchors: 1 (maladaptive low), 2 (normal low), and psychometrically pruned over two rounds of data
3 (neutral), 4 (normal high), and 5 (maladaptive high). In collection. The PID-5 has demonstrated adequate to good
addition, each item also includes exemplar descriptors of convergent and discriminant validity with respect to nor-
both the maladaptive and the normal-range options. For mal-range trait measures, other maladaptive trait mea-
example, for the facet of Warmth, 1 = “cold, distant” and 2 sures, and the traditional DSM-IV PD categories (e.g.,
= “formal-reserved” on the low end and 4 = “affectionate, Wright & Simms, 2014; Yam & Simms, 2014). Moreover,
warm” and 5 = “intense attachments” on the high end. the measure has demonstrated adequate test-retest relia-
Thus, options 1 and 5 reflect maladaptively low and high bility and a replicable factor structure (e.g., Al-Dajani,
manifestations of warmth, respectively, whereas options 2 Gralnick, & Bagby, 2016). The PID-5’s status as the official
and 4 reflect normal-range variations in warmth. Although measure of the AMPD and its large research base are
only limited research has been published on the FFF thus features that improve its clinical utility; however, the lack
far, some early work has demonstrated evidence for its of integrated validity scales limits its usefulness in high-
convergent and discriminant validity relative to a range stakes contexts. However, see papers by Bagby and
of measures, including other FFM measures (e.g., Rojas & Sellbom (2018) and Sellbom, Dhillon, and Bagby (2018)
Widiger, 2018). That said, the explicit adaptive- for reports of inconsistency and overreporting scales,
maladaptive structure of the FFM has shown only mixed respectively, that have been developed by other research-
support thus far in the literature and deserves further ers, derived from the PID-5 item pool. In addition, the PID-
scrutiny (Rojas, 2017). 5 now has two brief versions: a 25-item version (American
Second, for FFM researchers and practitioners who Psychiatric Association, 2013) that permits users to assess
desire a non–self-report assessment method, Trull and only the five trait domains of the AMPD, and a 100-item
Widiger developed the Structured Interview for the short-form (Maples et al., 2015) of the full measure that
Assessment of the Five-Factor Model of Personality permits scoring of the facets as well (albeit with compro-
(SIFFM; Trull & Widiger, 1997), which is a semi- mised reliability). A final concern with the PID-5 is that
structured interview measure of the thirty NEO-FFM strong, representative norms are not yet available (e.g., Al-
facets. Finally, Widiger and his colleagues have embarked Dajani et al., 2016)
Notably, the AMPD trait model also can be scored using New York; broader norms representative of the full US
the items of the Personality Assessment Inventory (PAI; population would be desirable.
Morey, 1991), which is a relatively popular self-report
measure consisting of 344 items that assess a broad
Personality Functioning Measures
range of psychopathology constructs, including personal-
ity pathology. Busch, Morey, and Hopwood (2017) pub- As noted in the preceding sections, personality trait
lished a scoring algorithm by which the PAI scale scores measurement in the PD literature dates back several
can be used to assess the AMPD traits via regression esti- decades. In contrast, assessment of “personality dys-
mated scales. These PAI-estimated AMPD traits were ade- function” is a younger and less developed area of
quately correlated with PID-5–estimated AMPD trait research (Ro & Clark, 2009). However, there has been
profiles and reproduced the five factors of the AMPD with an increased focus on conceptualizing and measuring
good fidelity (Busch et al., 2017). The primary advantage personality dysfunction in recent years in the wake of
of using the PAI to estimate AMPD traits is that the PAI has the publication of DSM-5, particularly in response to
a robust research literature and includes features that AMPD’s inclusion of a specific criterion requiring the
improve its clinical utility (e.g., strong norms and validity presence of deficits in personality functioning, an
scales). Disadvantages include that these scales have yet to attempt to codify PD impairments as something distinct
be cross-validated or validated against other measures by from both personality traits and impairment due to
an independent group of researchers. other psychiatric conditions. Criterion A in the AMPD
describes two broad areas of personality functioning –
Comprehensive Assessment of Traits relevant to Personality self and interpersonal functioning – each of which also
Disorder-Static Form (CAT-PD-SF). The CAT-PD-SF (Simms are divided into two narrower domains of functioning.
et al., 2011) is a National Institute of Mental Health–funded Taken together, the AMPD describes four aspects of
measure that was developed to identify a comprehensive personality functioning – intimacy, empathy, self-
model and efficient measure of PD traits. Although devel- direction, and identity – as well as a prototype-based
oped independently, the CAT-PD facets are similar to those rating scale for measuring each (i.e., the Levels of
represented in the AMPD. The CAT-PD-SF is a brief mea- Personality Functioning Scale [LPFS; American
sure drawn from the full CAT-PD item pool. The CAT-PD Psychiatric Association, 2013]).
project yielded thirty-three facet scales measuring an inte- In this section, we review the measures designed to
grative set of PD traits. These scales were formed following measure personality functioning, both those based
data collection through an iterative series of factor- and directly on the LPFS and those that predated the formal
content-analytic procedures. The full CAT-PD scales are introduction of the LPFS. However, an important issue in
long by design (1,366 total items; M scale length = 44 this literature, one that goes beyond the scope of this
items) so as to be amenable for computerized adaptive chapter, is whether PD functioning and PD traits can be
testing. However, a static form (CAT-PD-SF) was developed meaningfully differentiated. Indeed, evidence indicates
using a combination of statistical and content validity con- that maladaptive personality trait measures tend to over-
siderations to facilitate quick and standardized assessment lap substantially with a range of personality dysfunction
across studies and in clinical settings. The static form mea- measures (e.g., Hentschel & Pukrop, 2014; Berghuis,
sures all thirty-three traits using 216 items. In addition, Kamphuis, & Verheul, 2014) and that such findings are
a 246-item version exists that includes validity scales consistent with conceptual overlap rather than measure-
designed to detect inconsistent responding, overreporting, ment redundancy. Thus, despite the existence of separate
and underreporting. measures to assess these constructs, recent literature has
The static scales demonstrate good internal consistency, openly questioned whether PD traits and impairments are
test-retest reliability, and evidence of convergent and dis- psychometrically differentiable (see Widiger et al., 2019,
criminant validity (e.g., Wright & Simms, 2014) and have for a critical review).
been used in a growing number of PD trait studies.
Notably, the CAT-PD has been shown to tap additional LPFS-based measures. The LPFS is designed to be clin-
variance relevant to PD not directly assessed by the PID- ician-rated using a series of ordinally arranged proto-
5, such as self-harm and antisocial behavior (e.g., Evans & types provided in the AMPD. Its development was
Simms; 2018; Yalch & Hopwood, 2016). Thus, the CAT-PD informed by extant clinician-rated personality dysfunc-
-SF is a promising measure of AMPD traits and offers an tion measures and secondary data analysis (Zimmerman
alternative representation of the PD trait space that should et al., 2015). Research generally has supported the struc-
be useful as the field moves toward a consensual PD trait tural validity of the LPFS, with a handful of notable
model. Moreover, its validity scales make it a strong option exceptions (e.g., see Zimmerman et al., 2015, for
(as compared to the PID-5) for settings in which partici- a strong example of this literature). Despite these chal-
pants or patients might have some motivation to manip- lenges to the LPFS, interest has grown in developing
ulate the test in some way. Notably, the CAT-PD offers efficient, self-report measures of these constructs. We
psychiatric and community norms collected in Western will describe three such measures.
First, the Levels of Personality Functioning Scale – Brief way to understand and measure a broad range of inter-
Form 2.0 (LPFS-BF 2.0; Bach & Hutsebaut, 2018) was personal impairments. Second, the Measure of
developed as a PD screen by a team of four clinicians and Disordered Personality Functioning Scale (MDPF;
consists of twelve items corresponding to each of the Parker et al., 2004) is not linked to any particular theory
twelve LPFS scoring criteria (Hutsebaut, Feenstra, & of personality functioning. Instead item development
Kamphuis, 2016). Among its strengths are empirical sup- was informed by a comprehensive literature review
port for its convergent validity with respect to similar (Parker et al., 2002) from which the research team iden-
measures of personality functioning and evidence that it tified seventeen constructs central to their definition of
empirically differentiates between those with versus with- personality dysfunction. The resulting 141 items were
out PDs in a clinical sample (e.g., Hutsebaut et al., 2016). factor analytically honed to twenty items loading onto
Second, the Level of Personality Functioning Scale – two higher-order factors: Non-Coping and Non-
Self-Report (LPFS-SR; Morey, 2017) is an eighty-item Cooperativeness, which appear to correspond roughly
measure of the LPFS constructs. The measure consists of to AMPD self and interpersonal dysfunction,
one item per “information unit” in the LPFS scoring cri- respectively.
teria. One unique aspect of this measure is that its scoring Third, the General Assessment of Personality Disorder
scheme weighs items according to the LPFS severity level (GAPD; Livesley, 2006) is an eighty-five-item self-report
to which they correspond, such that items that reflect measure intended to assess the broad PD functioning
moderate impairment are weighted +1.5, whereas items domains of self and interpersonal pathology as defined
that reflect severe impairment are weighted +2.5 (Morey, by Livesley’s adaptive failure model of PD (e.g., Livesley
2017). This measure is relatively new on the scene but & Jang, 2000), which notably bear a strong resemblance to
early evidence has provided good evidence of reliability the similarly named functioning domains in the AMPD.
and validity (e.g., Hopwood, Good, & Morey, 2018; The GAPD’s structure is hierarchical, such that eight nar-
Morey, 2017). rower facets are nested within these two broad functioning
Finally, the DSM-5 Levels of Personality Functioning domains. The items for the GAPD were generated on the
Questionnaire (DLOPFQ; Huprich et al., 2017) was basis of both a literature review and therapy sessions with
developed from a larger pool of items written indepen- individuals with a PD; those that failed to differentiate
dently by experts to assess the constructs underlying between individuals with and without a PD were elimi-
the LPFS; the final sixty-six items were those agreed nated (Hentschel & Livesley, 2013).
on by the experts as a team (Huprich et al., 2017). Finally, the Severity Indices of Personality Problems
Each of the sixty-six items is asked twice: (SIPP; Verheul et al., 2008) is a 118-item self-report mea-
Respondents are asked to report how true each item is sure developed using an expert-guided, rational-intuitive
for them across the two distinct contexts of work/school approach to measure five higher-order domains of person-
and social relationships. Thus, the explicit considera- ality functioning: Self-control, Identity Integration,
tion of cross-situational variability is a potential unique Relational Capacities, Social Concordance, and
strength of the DLOPFQ; however, Huprich and collea- Responsibility (Verheul et al., 2008), four of which appear
gues (2017) failed to detect meaningful cross-situational to correspond neatly with the four LPFS components: Self-
differences in item responses in a mixed sample, calling control with LPFS Self-direction, Identity Integration with
into question the utility of this distinction. Notably, all LPFS Identity, Relational Capacities with LPFS Intimacy,
of these LPFS measures lack validity scales and strong and Social Concordance with LPFS Empathy. Verheul and
normative data, features that likely limit their useful- colleagues (2008) described considerable evidence for the
ness in applied clinical settings. construct validity of the SIPP-118, including a replicated
factor structure, test-retest reliability, internal consis-
Pre-LPFS measures. In addition to measures directly tency, and convergent and discriminant validity. These
keyed to the LPFS constructs in the AMPD, several mea- pre-LPFS measures also lack validity scales and strong
sures of personality functioning predated the AMPD’s normative data, features that limit their usefulness in
publication but nonetheless deserve mention here due, applied clinical settings
at least in part, to the similarity to and influence of the
measured constructs to those now codified in the AMPD.
SCID-AMPD: The First Complete Measure
First, the Inventory of Interpersonal Problems-
of the AMPD
Circumplex (IIP-64; Alden, Wiggins, & Pincus, 1990)
directly assesses interpersonal problems that character- None of the measures reviewed thus far provides
ize personality dysfunction. It consists of two orthogonal a complete assessment of the full AMPD (i.e., both the
higher-order dimensions (Dominance and Nurturance) trait and functioning criteria, as well as the revised criteria
and eight subordinate octant scales (Domineering, for the six retained PDs). Without such a complete mea-
Vindictive, Cold, Socially Avoidant, Nonassertive, sure, researchers and clinicians must pull together differ-
Exploitable, Overly Nurturant, and Intrusive) that ent measures if they wish to fully assess the AMPD, which
together provide an elegant and conceptually strong can be cumbersome. A remedy to this problem recently
was published: First and colleagues (2018) developed the developmental stage or sociocultural environment”
Structured Clinical Interview for the DSM-5 Alternative (American Psychiatric Association, 2013, italics added).
Model for Personality Disorders (SCID-AMPD), which is Thus, regardless of approach, PD is defined such that
a semi-structured diagnostic interview that guides assess- individuals should not be diagnosed with a PD if their
ment of the AMPD. As noted, the AMPD is a hybrid dimen- behavior is not considered problematic or impairing in
sional-categorical system that includes criteria requiring the context of their sociocultural context.
the presence of deficits in personality functioning Unfortunately, how exactly to account for such socio-
(Criterion A) and the presence of one of more maladaptive cultural variables is not spelled out in either set of PD
personality traits (Criterion B). In addition, criteria are criteria or in the measures reviewed in this chapter. In
provided, based on combinations of specific personality particular, several questions are relevant to this discus-
impairments and traits, to diagnose the following six PDs: sion. First, are some PD criteria or traits written such
antisocial, avoidant, borderline, narcissistic, obsessive- that they are more impairing in some cultural contexts
compulsive, and schizotypal PDs. relative to others? For example, Asian samples generally
The SCID-AMPD assesses all components of the model, have been characterized as being more introverted and
in three separate modules that can be used separately or reserved relative to Western samples (e.g., McCrae &
together. Module I is provided to assess the LPFS domains Terracciano, 2005). In this context, PDs associated with
of self and interpersonal functioning. Module II assesses social withdrawal or detachment (e.g., Schizoid PD,
the traits of the AMPD at both the broad domain level as Avoidant PD, AMPD traits related to Detachment) might
well as the nested twenty-five trait facets. Finally, Module be expected to be more heavily diagnosed in Asians despite
III provides a complete assessment of each of the six PDs the possibility that these features are more normative (and
retained in the AMPD, as well as Personality Disorder– arguably, thus, less impairing) in such cultures. Research
Trait-Specified, which is a residual category designed to on this point is limited but a recent dissertation from our
capture personality pathology that falls outside the six lab revealed (1) that the literature about such cultural
classified PDs. The SCID-AMPD is a new measure and differences in PD manifestation and impairment is quite
thus little has been written about its psychometric features limited and (2) that Asian samples do not differ in the ways
other than what is included in the manual prepared by the predicted here with respect to disorders and traits related
authors. We could only find a single peer-reviewed paper to social withdrawal (and for most PD straits, for that
about the SCID-AMPD. Christensen and colleagues (in matter) (Yam, 2017). Much more work is needed to exam-
press) reported positive findings regarding the inter-rater ine the impact of cultural differences as they relate to PD
reliability of Module I ratings of the LPFS. Clearly much features, in particular whether such features differ in their
more research is needed on the AMPD and its component associated impairment across cultures.
modules. Moreover, like other PD interviews, validity Interestingly, many of the measures reviewed in this
scales do not exist. We were fortunate enough to serve as chapter have been translated into one or more addi-
a pilot testing site for the SCID-AMPD several years ago, tional languages. This is an important step toward the
and our feedback to the development team was that the cross-cultural application of these measures. For exam-
measure, especially when all modules are used, was very ple, the PID-5 – the most visible measure of AMPD
cumbersome and time-consuming to administer. Now traits – already has been translated into Danish,
that the final version has been published, we clearly need Norwegian, Dutch, German, Arabic, Italian,
studies to evaluate not only the reliability and validity of Portuguese, French, and Spanish, and others undoubt-
the measure but also its efficiency and clinical utility. edly are being developed. Similarly, the new SCID-5-PD
already has versions in English as well as the following
languages: Danish, Dutch, German, Greek, Italian,
CURRENT TOPICS IN PD ASSESSMENT
Korean, Polish, Romanian, and Turkish. Although
development of translated versions of these (and
Cross-Cultural Issues
other) PD measures is an important and necessary
The influence of culture, race, and ethnicity on the pre- step, an additional question arises regarding the cross-
sentation and assessment of PD is understudied. Notably, cultural impact of PD features and traits: What should
both the categorical and the AMPD approaches to PD be used for norms for these translated PD scales? One
classification address culture in their PD definitions. For might argue that these measures should collect compre-
the official PD classification in DSM-5, PD is defined, in hensive normative data within each new culture/lan-
part, as “an enduring pattern of inner experience and guage within which the measure is expected to be
behavior that deviates from the expectations of the indivi- used and to use those within-group norms for diagnos-
dual’s culture” (American Psychiatric Association, 2013, tic purposes. This would be relatively straightforward
italics added). Similarly, in the AMPD approach, DSM-5 (although expensive and time-consuming) for trait
requires that impairments in personality functioning and scales such as the PID-5 and CAT-PD given the psycho-
the presence of maladaptive personality traits “are not metric tradition underlying such measures. However, it
better understood as normal for an individual’s is less clear how to explicitly account for cultural
differences in structured interviews of PD criteria, become useful clinical instruments. All too often,
where the criteria and thresholds are codified in the researchers focus on developing research measures only
DSM and not usually interpreted with reference to and neglect adding the features that might make them
local norms. more useful in clinical settings. This is true of some of
Thus, the PD field has much work to do in studying the measures reviewed here, especially the measures of
relative differences in PD symptoms and traits and the PD functioning/impairment, which largely lack adequate
impact of such across cultures. These differences have norms or clear interpretive guidelines.
important implications for our measures of PD, which – Another factor that is important to note here is that
aside from offering translated versions of measures – gen- clinical psychologists and related mental health practi-
erally have not articulated clear procedures for how to tioners often are relatively adherent to the measures on
account for cultural differences in PD diagnoses. The pro- which they were trained in graduate school or initially
blem applies equally to traditional and alternative models elected to use in their clinical practice. For example,
of PD but the solutions might vary across approaches. numerous reviews have documented that practicing
clinicians continue to favor measures such as the
MMPI-2, Rorschach Inkblot Method, and Thematic
Disconnect Between Research and Applied PD
Apperception Test – which collectively represent
Assessment
seventy-, ninety-, and eighty-year-old assessment tech-
Another task for the PD community to address is that of nologies, respectively – despite the information pro-
clinical utility, as currently there is a disconnect between vided in reviews like this and the literature more
research and clinical applications of PD measures. Features broadly that more modern measures are available that
likely to improve the clinical utility of a measure include (1) provide more nuanced and evidence-based methods to
the presence of norms representative of all populations assess personality pathology (e.g., Piotrowski, 1999).
within which the measure is designed to be used (e.g., Why might this be? Although a full treatment of this
community, psychiatric, different cultural and language question is beyond the scope of this chapter, it is clear
groups); (2) validity scales designed to detect a range of that current PD researchers will need to do more than
problematic responding, including inconsistent respond- they are currently doing to counter this phenomenon.
ing, defensive responding, malingering, acquiescence, and Adding features to tests to improve their clinical utility
denial; (3) scoring and interpretative manuals to aid practi- (e.g., strong norms, validity scales, interpretive materi-
tioners use of these measures; (4) other training materials als, scoring services) is an important and necessary first
and seminars aimed to translate research findings into clin- step to improve the state of clinical PD assessment.
ical practice; (5) theoretical models and treatment recom- However, more is probably needed, including efforts
mendations that help practitioners translate modern, to interact directly with clinicians in workshops and
dimensional PD measure into evidence-based treatments continuing education activities, as well as to influence
for their clients. Another factor that influences clinical uti- the methods emphasized in training programs for psy-
lity is cost but this relationship is complex. On the one hand, chologists and allied mental health professionals.
costly measures are difficult to use in cost-sensitive
research and applied settings. However, the features that
SUMMARY, CONCLUSIONS, AND FUTURE
serve to increase clinical utility often cost money to develop
DIRECTIONS
and implement and little grant money currently is avail-
able for measure development in the United States from In this chapter, we have summarized the prominent cate-
traditional funding agencies (e.g., the National Institute gorical and dimensional measures related to PD. We
of Mental Health). Thus, building clinical utility into PD reviewed the problems associated with traditional catego-
measures is an uphill battle for many researchers unless rical approaches to PD classification and their associated
they opt to commercialize their measures and use the measures, and we reported on the progress that has been
profits to fund additional development and validation made in the dimensional assessment of personality traits
work. that are presumed to underlie PD. In addition, we dis-
The measures included in this chapter vary considerably cussed the challenges associated with classifying and mea-
in terms of whether they include features that improve suring PD in a cross-culturally sensitive manner.
their clinical utility. Measures attached to existing bat- Moreover, we discussed the ways that measure developers
teries, such as the MMPI-2/MMPI-2-RF, SNAP-2, and might improve the clinical utility of their PD measures
PAI, are in the best position to have immediate clinical and, thus, gain greater traction in research and applied
impact, given that these measures already have enjoyed settings in which PD assessment is desired. In sum, there is
considerable traction in applied practice and include fea- no shortage of ways to assess the features of personality
tures such as validity scales, strong normative bases, and pathology. Given the recent uptick in research examining
comprehensive interpretive and training materials. the AMPD and related dimensional models, the future
Conversely, more modern measures, such as the PID-5 appears to be moving toward a dimensional PD classifica-
and CAT-PD, appear to have a longer road to travel to tion. For example, Oltmanns and Widiger (2018) recently
published a measure keyed to the new ICD-11 PD classifi- Berghuis, H., Kamphuis, J. H., & Verheul., R. (2014). Specific
cation and thus research on that model and such measures personality traits and general personality dysfunction as pre-
is likely to grow in the coming years. Moreover, grassroots dictors of the presence and severity of personality disorders in
efforts currently are underway to integrate the classifica- a clinical sample. Journal of Personality Assessment, 96(4),
410–416.
tion of PD features in an evidence-based structural model
Busch, A. J., Morey, L. C., & Hopwood, C. J. (2017). Exploring the
of psychopathology (see the Hierarchical Taxonomy of
assessment of the DSM-5 Alternative Model for Personality
Psychopathology [HiTOP] initiative; Kotov et al., 2017). Disorders with the Personality Assessment Inventory. Journal
Researchers in this domain would do well to work toward of Personality Assessment, 99(2), 211–218.
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sures of dimensional PD features. Kaemmer, B. (1989). Minnesota Multiphasic Personality
Inventory – 2 (MMPI-2): Manual for administration and scoring.
Minneapolis: University of Minnesota Press.
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