Comparison of alternative models for personality disorders, II: 6-, 8- and 10-year follow-up.

The DSM-IV-TR (APA, 2000) conceptualization of personality disorders as a group of categorical entities has led to an appreciable research base on a number of these constructs (e.g, Blashfield Intoccia, 2000), pointing to their clinical utility and predictive validity. Nonetheless, there is broad dissatisfaction with this representation of personality disorders (Krueger et al., 2007; Widiger et al., 2009), and various studies have indicated that dimensional alternatives may be more reliable (Heumann Morey, 1990; Widiger Coker, 2002) and valid (Morey et al., 2007; Markon et al., 2011) than DSM-IV categories. However, agreement on the selection of a particular dimensional model to replace the DSM-IV concepts remains limited. Among the alternative proposals are a) modifying categorical DSM-IV constructs with dimensional representations (Skodol et al., 2005); b) replacing personality disorder diagnoses with an assessment of normative traits thought to underlie personality disorder symptomatic expression (Widiger Trull, 2007), such as those of the Five-Factor Model (FFM); and c) assessing traits that are thought to span normal and abnormal personality processes, such as those represented on the Schedule for Nonadaptive and Adaptive Personality (SNAP: Clark, 1993) or the Dimensional Assessment of Personality Pathology (DAPP: Livesley et al., 1998) systems. In an earlier article (Morey et al., 2007), we examined the criterion validity of five different models for representing personality disorder in the Collaborative Longitudinal Personality Disorders Study (CLPS, Gunderson et al., 2000), examining validating variables that included antecedent variables of potential relevance to etiology and pathogenesis, variables assessing baseline functioning, as well as 2- and 4-year outcomes. The results of that investigation yielded two broad conclusions. First, there was consistent evidence that dimensional characterizations of personality disorder demonstrated greater concurrent and predictive validity relative to DSM-IV categorical diagnoses. Second, it appeared that models of personality pathology could be distinguished between those that more heavily represent normative trait dispositions (such as the FFM) and those that focus on more maladaptive behavioral manifestations of personality pathology (such as the DSM-IV concepts), and that the latter tended to demonstrate greater concurrent validity, whereas the former demonstrated superior predictive validity. Such findings have led to a proposal for personality disorders DSM-5 that reflects a “hybrid” combination of personality traits and disorder types (Skodol et al., 2011). The purpose of the present report is to present findings from this project at six, eight, and ten years of follow-up, to determine whether the trends observed over the first four years of this longitudinal study generalize to more distal outcomes. For example, it is possible that some personality characteristics might be predictive of remission, and thus informative for understanding intermediate outcome, but different features might be related to relapse and consequently predictive of longer-term outcomes. As in the previous paper (Morey et al., 2007), we provide a comprehensive comparison of these personality models with respect to predictive and incremental validity, using validating markers such as functioning, treatment utilization, suicidal behavior, and Axis I psychopathology. We hypothesized that results would extend our previous observation that normative personality traits and maladaptive behavioral features represent related but incompletely overlapping phenomena that are each incrementally important in understanding dysfunction related to personality. Furthermore, we examine implications of our findings for the integration of traits and disorders as formulated for the representation of personality disorders in DSM-5.