Criteria A of the DSM-5 Alternative Model for Personality Disorders (AMPD) defines personality pathology in terms of impairments in “self” (identity, self-direction) and “interpersonal” (empathy, intimacy) functioning. Articulated as a set of dynamic regulatory and relational processes that are stratified in the Level of Personality Functioning Scale, these impairments involve how individuals think and feel about themselves and others and how they relate to others. Defining personality pathology in terms of regulatory and relational processes involving self and other, and distinguishing severity of personality pathology from individual differences in its expression (Criteria B), offers the AMPD several advantages. First, it distinguishes the nature and severity of personality pathology from other forms of psychopathology. Second, it allows the AMPD to integrate personality structure and personality processes. Third, it is highly suitable for synthesis with the Contemporary Integrative Interpersonal Theory of personality. Finally, beyond the interpersonal perspective, it facilitates even broader theoretical and treatment integration.

In discussing the clinical science of personality disorders in the post-DSM-III/IV era, Pincus [1] distinguished defining what personality pathology is from describing individual differences in its expression, and further suggested that improvements in the classification of personality disorders “will require greater coordination of definitional theories and systems for describing variation in expression of personality pathology” (p. 287). This approach, which can also be conceived of as distinguishing the genus of personality pathology and the species of personality disorder [2, 3], is also reflected in the DSM-5 Alternative Model for Personality Disorders (AMPD) [4, 5]. Criteria A of the AMPD assesses what is common among all patients with personality pathology (genus) and Criteria B assesses individual differences in the expression of personality disorder (species).

Criteria A of the AMPD defines personality pathology in terms of impairments in “self” (identity, self-direction) and “interpersonal” (empathy, intimacy) functioning. Articulated as a set of dynamic regulatory and relational processes that are stratified in the Level of Personality Functioning Scale (LPFS) [4], these impairments involve how individuals think and feel about themselves and others and how they relate to others [6]. Although AMPD Criteria A semantics differentiates self and interpersonal impairments, self and other are intertwined throughout Criteria A diagnostic features (e.g., “Depends excessively on others for identity, self-esteem, and emotion regulation with compromised boundaries”; “Hyper-attuned to others, but only with respect to perceived relevance to self”) and the LPFS renders a single rating of the severity of personality pathology. Conceptualizing the genus of personality pathology in terms of regulatory and relational processes involving self and other offers the AMPD several advantages. First, it distinguishes the nature and severity of personality pathology from other forms of psychopathology [7]. Second, it allows the AMPD to integrate personality structure and personality processes [8]. Third, it is highly suitable for synthesis with the Contemporary Integrative Interpersonal Theory (CIIT) of personality [9]. Finally, beyond the interpersonal perspective, it facilitates even broader theoretical and treatment integration [10, 11]. In the remainder of this paper, we discuss and elaborate these advantages.

Self and interpersonal functioning deficits are the core feature of personality pathology, and it is the centrality of these impairments in self and other functioning that distinguishes personality pathology from other classes of psychopathology (e.g., eating, mood, anxiety, psychotic, substance use disorders, etc.) [7]. A growing number of empirical studies support this distinction. Scores on measures of psychosocial functioning significantly differ between those who do and those who do not have personality disorders [12-14], and scores on the LPFS itself reliably distinguish those who have a diagnosed personality disorder from those who do not [15]. In addition, using a bottom-up approach, factor analysis of diagnostic criteria for personality disorders yields a general personality disorder factor that maps well onto concepts in Criteria A [16]. Criteria A is often referred to as the “severity” indicator of the AMPD. Defining the severity of personality pathology in terms of impairments in self and other functioning common to all personality disorders, and distinguishing severity of personality pathology from individual differences in expression of personality disorder, are improvements over the DSM-5 Section II categorical diagnostic system for personality disorders where high severity is likely to lead to the undesirable outcome of meeting criteria for multiple personality disorder diagnoses [17].

This approach also has implications for patients’ current and prospective functioning. Research supports the criterion validity and predictive validity of personality pathology severity [18]. Several studies demonstrate that general severity of personality pathology exhibits significant concurrent negative associations with psychosocial functioning in a broad range of domains, and many find that severity exhibits stronger and more pervasive associations with functional impairments than stylistic features of personality disorders [17, 19-22]. Importantly, longitudinal studies also support the predictive validity of general personality pathology severity over years [17, 19, 22] and the LPFS itself over days or weeks [23, 24]. Here we emphasize research that finds severity of personality pathology (including Criteria A LPFS) distinguishes personality disorders from other disorders and relates to current and prospective functioning regardless of, and sometimes more strongly than, stylistic features of personality disorders. Our discussion of severity does not address the contentious issue of overlap between Criteria A impairments and Criteria B traits [for reviews see 25, 26]. However, we believe the additional advantages of defining personality pathology and its severity with reference to self and other impairments discussed below further support DSM-5 AMPD Criteria A.

Integrating between-person personality trait structure and within-person dynamic personality processes can provide a more evidence-based and clinically useful model for conceptualizing and diagnosing personality disorders than using models based on structure or process alone [8, 27]. Personality traits are a fundamental component of personality disorders and are optimal for describing individual differences between patients. However, profiles of maladaptive trait elevations are not the clinical entities seen in the consulting room. Clinicians providing treatment primarily focus on regulatory and relational processes that unfold over time and serve as etiological and maintenance mechanisms for psychopathology. Individual differences in personality traits provide important information about the evoking contexts and style of expression of personality impairments, differentiating the species of personality disorder across patients. This added specificity can help focus and tailor psychotherapy given that most techniques of evidence-based treatments for personality disorders broadly target the impaired processes of the personality pathology genus, such as promoting accurate perceptions of self and other via mentalization in Transference-Focused Psychotherapy or improving emotion regulation via mindfulness in Dialectical Behavior Therapy. A patient’s trait profile can help the clinician better predict how, and under what circumstances, the patient is likely to exhibit personality impairments [23], further informing intervention [11, 28]. A comprehensive approach that integrates assessment of individual differences with intensive repeated assessments of psychosocial functioning [e.g., 29-31] helps bring personality traits from bench to bedside [32, 33].

The AMPD attempts to integrate clinical theories of pathological personality processes (found in Criteria A) with an empirically derived dimensional trait model (found in Criteria B). However, this system is not well integrated into a cohesive framework sufficiently buttressed by clinical theory and research. Fortunately, the emphasis on self and other impairments in Criteria A allows for integration with existing theories of personality and paradigms of personality assessment with their rich empirical and clinical foundations [34]. One well-established theoretical framework that is highly compatible with an emphasis on self and other impairments is CIIT [9]. According to CIIT, agency and communion are the two core metaconstructs that underlie interpersonal experience. Together, agency and communion form a superordinate structure referred to as the Interpersonal Circumplex. This empirically derived structure is a focus of convenience that coordinates CIIT’s dispositional (personality trait) and dynamic (personality process) features through the interpersonal situation framework [27, 35] (Fig. 1).

Fig. 1.

The interpersonal situation.

Fig. 1.

The interpersonal situation.

Close modal

Interpersonal theory understands normal and disturbed interpersonal functioning in terms of the level and pervasiveness of distortion and dysregulation in interpersonal situations [1, 10]. Dysfunctional interpersonal styles reflect consistent patterns of regulatory and relational processes in interpersonal situations. Several potential foci are elaborated in Figure 1. Self-regulation involves the ability to effectively manage one’s social cognition and self-concept, or how one thinks about oneself in relation to others in interpersonal situations. Affect regulation involves the ability to modulate one’s inner emotional states and affective expression, or how one feels in interpersonal situations. Field regulation involves modulating the processes by which one relates to others in social transactions, or how one behaves and impacts others’ behavior in interpersonal situations. Table 1 creates a crosswalk between AMPD Criteria A and the contemporary interpersonal model of personality pathology.

Table 1.

DSM-5 Alternative Model for Personality Disorders (AMPD) Criteria A crosswalk with interpersonal dysregulation and distortion

DSM-5 Alternative Model for Personality Disorders (AMPD) Criteria A crosswalk with interpersonal dysregulation and distortion
DSM-5 Alternative Model for Personality Disorders (AMPD) Criteria A crosswalk with interpersonal dysregulation and distortion

To bring this model to life, consider the individual with paranoid personality disorder and the recurrent interpersonal situation that characterizes their life (Fig. 2). Because the paranoid individual is high on the trait of suspiciousness, they are hypervigilant to threats from others and tend to distort perceptions of their behavior and motivation. For example, the coworker who genuinely offers collaboration is perceived as trying to steal ideas or unfairly take credit. This distorted view of the other as exploitative evokes dysregulated affect (anger), the motive to protect the self (remove the threat), and hostile interpersonal behavior that is consistent with the paranoid distortion and dysregulation but inconsistent with the genuine agentic and communal goals of the rebuffed coworker. In response, the coworker may respond with anger in kind or simply withdraw and not approach again. Regardless, a potentially creative collaboration was thwarted, and employee morale may be damaged. Distortion and dysregulation in interpersonal situations may be episodic and stress-induced (e.g., exhaustion and illness may create transient states of hypersensitivity) or chronic and pervasive (e.g., personality pathology).

Fig. 2.

The paranoid process.

Fig. 2.

The paranoid process.

Close modal

The interpersonal situation coordinates empirically supported structures and processes from the CIIT perspective, and this can be expanded to the AMPD by similarly coordinating Criteria B (structure) and Criteria A (processes). Many of the Criteria A impairments in self and interpersonal functioning conceptually align themselves with agency and communion, respectively [2, 36]. Importantly, research finds that in social interactions in daily life, overall severity of personality impairment [37], stylistic features of personality disorders such as narcissism [38], and AMPD Criteria B traits such as antagonism [39] all impact patients’ perceptions of self and other as agentic and communal, affective experiences, and functioning [for a review see 40]. The interpersonal model of personality pathology appears well suited to the task of integrating structure and process in the AMPD.

Beyond links to CIIT, Criteria A’s focus on self and other impairments has additional advantages for theoretical integration and therapeutic practice. As noted above, many theories and evidence-based treatments for personality disorders already broadly focus on targeting self and other impairments. In fact, the authors of Criteria A drew on psychodynamic, attachment, interpersonal, and social-cognitive perspectives to develop the LPFS [6]. This pantheoretical approach to understanding general personality pathology severity in Criteria A maximizes treatment options for personality pathology across different theoretical models. For example, Transference-Focused Psychotherapy (TFP) [41] specifically targets the self-other dysfunction assessed by Criteria A by understanding and articulating the patient’s mental representations of self, their mental representations of others, and the dominant affects that link these mental representations (e.g., a scared, victimized self representation linked to a sadistic, abusive other representation via fear). Through a series of clarifications, confrontations, and interpretations, the TFP therapist uses the here-and-now therapeutic relationship to increase the patient’s awareness of and capacity to reflect on their self and interpersonal difficulties.

In Mentalization-Based Treatment (MBT) [42], the focus centers on increasing the patient’s capacity for mentalization, or the ability to attend to and understand the mental states of self and other. MBT therapists actively focus on the patient’s current mental state (their thoughts, feelings, wishes, desires) with the aim of building more adaptive internal states as well as better understanding of other’s internal states. Disruptions in mentalization within the therapeutic relationship (i.e., shifts to non-mentalizing modes of experience) are inevitable and serve as key opportunities to work collaboratively to understand the interpersonal situation and affects immediately preceding the disruption.

Cognitive behavioral treatments for personality disorder also focus on the centrality of self-other difficulties found in Criteria A. For example, Schema-Focused Therapy (SFT) [43] argues that personality disorder arises from early maladaptive schemas about self and other that lead to rigid and enduring patterns of avoidance. An SFT therapist would use intervention techniques from behavioral, psychodynamic, and interpersonal treatment models to decrease the patient’s avoidance and develop more adaptive schemas of self and other. Dialectical Behavior Therapy (DBT) [44] uses the biosocial theory to describe how the combination of biological (temperamental) vulnerability and an invalidating social environment leads to emotion regulation difficulties. DBT includes treatment strategies that emphasize more adaptive self and interpersonal functioning, such as mindfulness, validation, acceptance, distress tolerance, emotion regulation skills, and interpersonal skills. The DBT therapist aims to articulate unverbalized emotions, thoughts, or behavior patterns about self and other and communicates how current impairments in self and interpersonal functioning make sense given past social learning in the invalidating environment.

Having noted that multiple theories and treatment models specifically address self and other impairments, we also wish to highlight how the pantheoretical approach of the AMPD is consistent with the tenets of psychotherapy integration. Clarkin and colleagues [45] describe an integrated modular approach to the treatment of personality pathology that emphasizes (a) the individuality of the patient, not the category of the disorder; (b) the severity of dysfunction (Criteria A) and the specific expressions of dysfunction (Criteria B); (c) the therapeutic use of modules of intervention from existing evidence-based clinical approaches; and (d) intervention in the context of a developing alliance between therapist and patient. In this way, clinicians can integrate different evidence-based treatment techniques to address general personality severity and specific expressions of dysfunction. For example, a therapist might use the skills of DBT to help their patient to better understand and change their emotions while also using interventions from MBT to increase the patient’s awareness of and mentalization about how their maladaptive views of self and other are contributing to their emotion dysregulation. As clinicians from diverse theoretical backgrounds begin to use the AMPD for treatment planning, research should focus on the genus (Criteria A) of personality pathology and the species of personality disorder (Criteria B) and how an integrated treatment approach can be used to target both severity of impairments and the specific expressions of dysfunction.

The clinical science undergirding classification, diagnosis, and treatment of personality disorders has become increasingly energized and diversified since the recognition of serious limitations of the DSM categorical nosology. By defining personality pathology in terms of self and other impairments and distinguishing severity of personality pathology from individual differences in its expression, the DSM-5 AMPD is a significant, if imperfect, step forward. The centrality of self and other impairments in Criteria A provides a focus that (a) distinguishes the core features of personality pathology from peripheral psychopathological symptoms that commonly co-occur with personality pathology (e.g., depressed mood, binge eating), (b) allows for an organic pantheoretical integration of perspectives on normal and abnormal personality, and (c) aligns with the intervention targets of evidence-based treatments for personality disorders and those of practicing clinicians more generally. Finally, when combined with the Criteria B traits, the Criteria A self and other impairments can be functionally linked within emerging frameworks integrating personality structure and personality processes [10, 46-48].

Additional work is needed to take full advantage of the AMPD’s potential. First, we note that one area that has been extensively investigated is the cross-sectional overlap and incremental validity of Criteria A and Criteria B [25, 26]. Our view is that battles for cross-sectional incremental validity of traits and personality functioning measures have their place but generate negligible clinical insights. Why would we expect or require personality dysfunction and individual differences in personality to be orthogonal? Extraversion and neuroticism are known to be aspects of well-being for nearly 40 years [49], yet there are not calls to reduce the concept of well-being to profiles of trait elevations. We see such links as necessary not problematic, as personality traits and personality processes are not orthogonal. Thus, we agree with Hopwood’s assertion that “further work focused on validating cross-sectional PD assessments and/or debating which traits underlie different PDs will not move the field forward” [32, p. 499]. Fortunately, the AMPD provides an ideal focus for clinical personality science to move forward by employing new longitudinal methodologies and dynamic statistical analyses that can truly model personality structure and personality processes [31, 37, 50-53]. Such work should also inform and be informed by clinical practice as efforts to develop more effective interventions for personality pathology continue. Future therapy approaches that target core self and other impairments and maladaptive traits, as well as tailor interventions with reference to severity of personality pathology and the patient’s trait profile would serve to advance the next generation of treatment models [54-56]. These and related future advancements are facilitated by defining personality pathology in terms of personality processes reflecting impairments in self and other functioning and distinguishing the severity of personality impairment from individual differences in its expression [1].

We are grateful to our colleagues Dr. Christopher Hopwood and Dr. Aidan Wright for their continuing scholarly contributions to Contemporary Integrative Interpersonal Theory and the interpersonal situation framework.

The authors have no conflicts of interest to declare.

Each author contributed original drafts of specific sections of the manuscript.

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