Clinical Utility of Dimensional Models for Personality Pathology

Abstract

Clinical utility is defined as the extent to which the DSM assists clinical decision makers in fulfilling the various clinical functions of a psychiatric classification system. Distinction is made between elements of diagnostic validity that are more or less conditional to utility (i.e., coverage, and consistency with etiology and prognosis) and components of clinical utility in the narrow sense of the term (i.e., user acceptability and accuracy, communication, reliability, subtlety, and clinical decision making). Clinical utility is often considered the driving force behind the respective revisions of the DSM system, yet it has been difficult if not impossible to obtain reasonable levels of clinical utility within categorical classifications of personality disorders. This paper presents evidence that a dimensional diagnostic system will substantially improve clinical utility, especially with respect to coverage, reliability, subtlety, and clinical decision making. In addition, some evidence suggests that the purely dimensional models outperform the so-called hybrid models (i.e., dimensional profiling of categories) with respect to coverage, consistency with etiology, subtlety, and clinical decision making. Several research options that might inform future revisions, including the choice or development of a dimensional classification, are suggested.

Development and Validation of Personality Disorder Spectra Scales for the MMPI–2–RF

“…; American Psychiatric Association, 2013) Section III approach offers an alternative model of personality disorder (AMPD) that allows for the diagnosis of PD types via assessments of personality dysfunction and trait dimensions. Overall, the field shows increasing interest in a more dimensional approach to PD diagnosis (e.g., Bernstein, Iscan, & Maser, 2007;Verheul, 2005), consistent with some of the aims of this study. Yet, it is important to note that the typological approach persists for reasons including familiarity, clinical tradition (Gunderson, 2010), concerns about the pace of nosological change (Applebaum, 2017), and its status as the official operational approach of the DSM.…”

Assessment and Diagnosis of Personality Disorder: Perennial Issues and an Emerging Reconceptualization

“…Arguing that simply selecting one is scientifically unacceptable www.annualreviews.org • Personality Disorder Assessment and Diagnosisbecause each has strengths and weaknesses, they presented a common integrative, hierarchical model topped by two "superfactors" (essentially Digman's 1997 alpha and beta factors or Block's 2001 ego resiliency and control), with middle layers of three to seven broad dimensions, which in turn are composed of facets (basic personality traits), all anchored at yet lower levels in specific affects, behaviors, and cognitions. Such a model has its detractors (Block 2001) and limitations in describing personality comprehensively (Hooker & McAdams 2003), and would need further specification to have clinical utility (Verheul 2005), but the common model presented emerges from substantial research and represents a solid base around which to develop a reliable, valid, and scientifically and clinically useful dimensional system.…”

“…Verheul (2005), however, turned the complexity argument around, noting that dimensions provide diagnostic richness and subtlety not afforded by the DSM categories, which are criticized for oversimplicity. Moreover, he argued that the current diagnostic system does not direct either treatment selection or planning; rather, severity is the primary determinant of the decision to treat (see also Tyrer 2005).…”

The DSM-5 Personality Disorder Proposal and Future Directions in the Diagnostic Classification of Personality Disorder

“…This discontinuity makes it difficult to evaluate clinical utility. Although the construct of clinical utility has multiple components, including user acceptability, accuracy of application, value in professional communication, and so on [37], all aspects of clinical utility are dependent on validity. Earlier, serious questions were raised about the validity of both the typal and dimensional classifications, especially the typal component.…”