DSM V - eliminates HPD as a PD

DSM V (due out in a year or so) looks to greatly simplify personality disorders. One objective may be to cast them all into the same category as regular disorders and thereby get them covered by insurance companies? Or, they want to simplify the diagnosis for other reasons? (Make these "big" 5 better understood generally? More consistent "scoring" among professionals on larger scale studies?).

Note - they also add 37 specific "traits" - I'll discuss that in a separate post. These traits do not constitute a "diagnosis" by themselves. Only the big 5 "rise" to that level.

Here are the "big five" personality disorders that made the cut:

• Antisocial/Psychopathic Type
• Avoidant Type
• Borderline Type
• Obsessive-Compulsive Type
• Schizotypal Type

I believe they put HPD in under Borderline.

Here they are with descriptions and the 1-5 rating scale. Perhaps all PDs would get a 1-5 rating on each scale, then a diagnosis for the dominate one or more?

SOURCE: APA website for DSM 5

Antisocial/Psychopathic Type

Individuals who match this personality disorder type are arrogant and self-centered, and feel privileged and entitled. They have a grandiose, exaggerated sense of self-importance and they are primarily motivated by self-serving goals. They seek power over others and will manipulate, exploit, deceive, con, or otherwise take advantage of others, in order to inflict harm or to achieve their goals. They are callous and have little empathy for others’ needs or feelings unless they coincide with their own. They show disregard for the rights, property, or safety of others and experience little or no remorse or guilt if they cause any harm or injury to others. They may act aggressively or sadistically toward others in pursuit of their personal agendas and appear to derive pleasure or satisfaction from humiliating, demeaning dominating, or hurting others. They also have the capacity for superficial charm and ingratiation when it suits their purposes. They profess and demonstrate minimal investment in conventional moral principles and they tend to disavow responsibility for their actions and to blame others for their own failures and shortcomings.

Individuals with this personality type are temperamentally aggressive and have a high threshold for pleasurable excitement. They engage in reckless sensation-seeking behaviors, tend to act impulsively without fear or regard for consequences, and feel immune or invulnerable to adverse outcomes of their actions. Their emotional expression is mostly limited to irritability, anger, and hostility; acknowledgement and articulation of other emotions, such as love or anxiety, are rare. They have little insight into their motivations and are unable to consider alternative interpretations of their experiences.

Individuals with this disorder often engage in unlawful and criminal behavior and may abuse alcohol and drugs. Extremely pathological types may also commit acts of physical violence in order to intimidate, dominate, and control others. They may be generally unreliable or irresponsible about work obligations or financial commitments and often have problems with authority figures.

5 = Very Good Match: patient exemplifies this type
4 = Good Match: patient significantly resembles this type
3 = Moderate Match: patient has prominent features of this type
2 = Slight Match: patient has minor features of this type
1 = No Match: description does not apply


Avoidant Type

Individuals who match this personality disorder type have a negative sense of self, associated with a profound sense of inadequacy, and inhibition in establishing intimate interpersonal relationships. More specifically, they feel anxious, inadequate, inferior, socially inept, and personally unappealing; are easily ashamed or embarrassed; and are self-critical, often setting unrealistically high standards for themselves. At the same time, they may have a desire to be recognized by others as special and unique. Avoidant individuals are shy or reserved in social situations, avoid social and occupational situations because of fear of embarrassment or humiliation, and seek out situations that do not include other people. They are preoccupied with and very sensitive to being criticized or rejected by others and are reluctant to disclose personal information for fear of disapproval or rejection. They appear to lack basic interpersonal skills, resulting in few close friendships. Intimate relationships are avoided because of a general fear of attachments and intimacy, including sexual intimacy.

Individuals resembling this type tend to blame themselves or feel responsible for bad things that happen, and to find little or no pleasure, satisfaction, or enjoyment in life’s activities. They also tend to be emotionally inhibited or constricted and have difficulty allowing themselves to acknowledge or express their wishes, emotions – both positive and negative – and impulses. Despite high standards, affected individuals may be passive and unassertive about pursuing personal goals or achieving successes, sometimes leading to aspirations or achievements below their potential. They are often risk averse in new situations.

5 = Very Good Match: patient exemplifies this type
4 = Good Match: patient significantly resembles this type
3 = Moderate Match: patient has prominent features of this type
2 = Slight Match: patient has minor features of this type
1 = No Match: description does not apply

Borderline Type

Individuals who match this personality disorder type have an extremely fragile self-concept that is easily disrupted and fragmented under stress and results in the experience of a lack of identity or chronic feelings of emptiness. As a result, they have an impoverished and/or unstable self structure and difficulty maintaining enduring intimate relationships. Self-appraisal is often associated with self-loathing, rage, and despondency. Individuals with this disorder experience rapidly changing, intense, unpredictable, and reactive emotions and can become extremely anxious or depressed. They may also become angry or hostile, and feel misunderstood, mistreated, or victimized. They may engage in verbal or physical acts of aggression when angry. Emotional reactions are typically in response to negative interpersonal events involving loss or disappointment.

Relationships are based on the fantasy of the need for others for survival, excessive dependency, and a fear of rejection and/or abandonment. Dependency involves both insecure attachment, expressed as difficulty tolerating aloneness; intense fear of loss, abandonment, or rejection by significant others; and urgent need for contact with significant others when stressed or distressed, accompanied sometimes by highly submissive, subservient behavior. At the same time, intense, intimate involvement with another person often leads to a fear of loss of an identity as an individual. Thus, interpersonal relationships are highly unstable and alternate between excessive dependency and flight from involvement. Empathy for others is severely impaired.

Core emotional traits and interpersonal behaviors may be associated with cognitive dysregulation, i.e., cognitive functions may become impaired at times of interpersonal stress leading to information processing in a concrete, black-and white, all-or-nothing manner. Quasi-psychotic reactions, including paranoia and dissociation, may progress to transient psychosis. Individuals with this type are characteristically impulsive, acting on the spur of the moment, and frequently engage in activities with potentially negative consequences. Deliberate acts of self-harm (e.g., cutting, burning), suicidal ideation, and suicide attempts typically occur in the context of intense distress and dysphoria, particularly in the context of feelings of abandonment when an important relationship is disrupted. Intense distress may also lead to other risky behaviors, including substance misuse, reckless driving, binge eating, or promiscuous sex.

5 = Very Good Match: patient exemplifies this type
4 = Good Match: patient significantly resembles this type
3 = Moderate Match: patient has prominent features of this type
2 = Slight Match: patient has minor features of this type
1 = No Match: description does not apply

Obsessive-Compulsive Type

Individuals who match this personality disorder type are ruled by their need for order, precision, and perfection. Activities are conducted in super-methodical and overly detailed ways. They have intense concerns with time, punctuality, schedules, and rules. Affected individuals exhibit an overdeveloped sense of duty and obligation, and a need to try to complete all tasks thoroughly and meticulously. The need to try to do things perfectly may result in a paralysis of indecision, as the pros and cons of alternatives are weighed, such that important tasks may not ever be completed. Tasks, problems, and people are approached rigidly, and there is limited capacity to adapt to changing demands or circumstances. For the most part, strong emotions – both positive (e.g., love) and negative (e.g., anger) – are not consciously experienced or expressed. At times, however, the individual may show significant insecurity, lack of self confidence, and anxiety subsequent to guilt or shame over real or perceived deficiencies or failures. Additionally, individuals with this type are controlling of others, competitive with them, and critical of them. They are conflicted about authority (e.g., they may feel they must submit to it or rebel against it), prone to get into power struggles either overtly or covertly, and act self-righteous or moralistic. They are unable to appreciate or understand the ideas, emotions, and behaviors of other people.

5 = Very Good Match: patient exemplifies this type
4 = Good Match: patient significantly resembles this type
3 = Moderate Match: patient has prominent features of this type
2 = Slight Match: patient has minor features of this type
1 = No Match: description does not apply

Schizotypal Type

Individuals who match this personality disorder type have social deficits, marked by discomfort with and reduced capacity for interpersonal relationships; eccentricities of appearance and behavior, and cognitive and perceptual distortions. They have few close friends or relationships. They are anxious in social situations (even when they have the time to become familiar with the situation), feel like outcasts or outsiders, find it difficult to feel connected to others, and are suspicious of others’ motivations, including their spouse, colleagues, and friends.

Individuals with this type are eccentric, odd, or peculiar in appearance or manner (e.g., grooming, hygiene, posture, and/or eye contact are strange or unusual). Their speech may be vague, circumstantial, metaphorical, overelaborate, impoverished, overly concrete, or stereotyped. Individuals with this type experience a limited or constricted range of emotions, and are inhibited in their expression of emotions. They may appear detached and indifferent to other’s reactions, despite internal distress at being “set apart.”

Odd beliefs influence their behavior, such as beliefs in superstition, clairvoyance, or telepathy. Their perception of reality can become further impaired, often under stress, when reasoning and perceptual processes become odd and idiosyncratic (e.g., they may make seemingly arbitrary inferences, or see hidden messages or special meanings in ordinary events) or quasi-psychotic, with symptoms such as pseudo-hallucinations, sensory illusions, over-valued ideas, mild paranoid ideation, or transient psychotic episodes. Individuals with this personality disorder type are, however, able to “reality test” psychotic-like symptoms and can intellectually acknowledge that they are products of their own minds.

5 = Very Good Match: patient exemplifies this type
4 = Good Match: patient significantly resembles this type
3 = Moderate Match: patient has prominent features of this type
2 = Slight Match: patient has minor features of this type
1 = No Match: description does not apply

From Wisdom's post, above

"19~ Behaving so as to attract and be the focus of others’ attention; admiration seeking; flamboyance; audacity; inappropriate sexualization of interpersonal relationships"

"Here are the "big five" personality disorders that made the cut:

•Antisocial/Psychopathic Type
•Avoidant Type
•Borderline Type
•Obsessive-Compulsive Type
•Schizotypal Type

I believe they put HPD in under Borderline."

Wisdom interesting the new description of BPD seemingly didn't include or even allude to "19~ Behaving so as to attract and be the focus of others’ attention; admiration seeking; flamboyance; audacity; inappropriate sexualization of interpersonal relationships."

Also their general description of BPD was new and strange - BPD categorically exhibits extremely impared empathy? If you go to the BPD forum and look up the thread "BPD and Empathy" <or title words to that effect> you will see that most posters agreed that BPD by itself was a condition characterized by normal levels of, or even by too much, empathy. Aren't BPD people too sensitive, too empathic?

Good post wisdom...

Too many of the pd's overlap (which is why there are so many bpd/npd, or bpd/hpd, or hpd/npd, etc) in their traits.

I just call them "cluster b".

My bpd ex, for example, didn't exibit every single trait of the borderline (she didn't cut herself), but she did specific acts that were 'crazy' that only a histrionic would do.

However, I did meet a real full life blooded histrionic...(why I found this site because she didn't fit bpd or npd).

Concerning the other posters question about empathy...no, borderlines rarely show empathy (when they do is it simply to get you back under their control and to prevent you from leaving them), and when they do show it, it is rare. They may show it at first, but once they feel you are hooked, they stop showing it because they feel you love them which makes them think "control".

In my opinion, the hpd's and npd's don't show empathy. The hpd, for example, plays roles (as if they were actors...this is why 'histrionic' comes from the greek language which literally means 'theatrics')....and once their role switches, their new mask has nothing left of the old mask. New emotions (they are emotionally unstable, right) do not include empathy, true empathy, for theri old roles which they have discarded.

Think, sometimes they are your lover (the love role), then, out of the blue, they just want friendship (just like that..a new role). The roles they decide to keep are still roles...(such as their fake image at the workplace or in public situations where they feed their NS).

A bpd, on the other hand, can revert back to her old role quickly (thus the "I love you I hate you" books that are about borderline women). One day you're the devil, the next day you are the perfect man. This is why borderlines are so poisonous, because it can be difficult for you to leave them due to the fact that borderlines will "revert" directly back to the woman you want (they don't always stay evil for long periods of time).

The borderline has a back and forth type of life...they are cold and hot, and they mutate just like a virus does to maintain its existence. So, one day a bdp will demonstate this trait, whilst another day it is an entirely different trait. This makes it hard to label them or identify them at first, because they exibit new traits often. One bpd is not like all the others...but when you notice her behavior 'clustering' with the bpd traits, you know she is a cluster b.

I've only heard of one real, full blooded npd woman. She was addicted to receiving rewards at charity organizations. She spent so much time away from home trying to feed her NS, that her husband never saw her. She always was doing charity work trying to receive more 'recognition'. A lot of guys take hpd women and label them as npd, or they take bpd women and label them as npd, but a pure npd woman I have rarely heard of (personally).

Plus, it is a known fact that bpd women have narcissistic traits as a defense mechanism. So, these pd's often overlap.

Anyway, these are just my experiences and opinions...

Cheers.

Even when hpd's are diagnosed...many times it is just a new 'role' for them to play (the "I'm working on myself" or the "I need help role"). Hell, they even may go into the helping profession and use the fact that they have a pd to get a bunch of attention from others, saying stuff like,

"I know what this feels like...listen to me...".

What better way for the hpd to get attention than to acknowledge an illness? It is a common trait of theirs once they are diagnosed with any illness, physical or mental. I never trust hpd's...even when they are playing the "their getting help role".

That role gets them gobs of attention, which is the hpd's goal in life. In fact, they are rarely cured, but I guess its better for them to play the "I'm sick and getting help role" than the other destructive roles.

the thing is, even when the "ill" hpd gets into a relationship, they still almost always screw things up and hurt the person. So, they may take a new public role on (the I need help role) but in a relationship, it's all the same thing all over again.

Same story, different town.

Overall Personality Functioning / level of impairment

I forgot to mention one important component of DSM 5 - Severity. APA kicks things off by saying "how severe is the PD overall"? This is how they measure that. (Note the perennial "index array numbering" question. They started with a 0 here...) You need a 3 or 4 to have a PD.


Source: APA DSM 5 web site

Personality disorder reflects adaptive failure: (on two dimensions)

• Impaired sense of self-identity
• and/or
• Impaired sense of interpersonal functioning.

Andrew E. Skodol, M.D. wrote:The assessment is designed to “telescope” the clinicians attention from a global rating of the overall severity of impairment in personality functioning through increasing degrees of detail and specificity in describing personality psychopathology that can be pursued depending on constraints of time and information and on expertise.

Here are the measures for Global Severity. Next clicks in "on the telescope" are: 2. how the individual lines up against the "Big 5" PD Prototypes, and 3. (most granular) the ratings on each of the 37 individual Traits (see separate topic for Traits).


Self:
Identity Integration
Integrity of Self-concept
Self-directedness
_____ 0 = No Impairment
_____ 1 = Mild Impairment
_____ 2 = Moderate Impairment
_____ 3 = Serious Impairment
_____ 4 = Extreme Impairment

Interpersonal:
Empathy
Intimacy and Cooperativeness
Complexity and Integration of Representations of Others
_____ 0 = No Impairment
_____ 1 = Mild Impairment
_____ 2 = Moderate Impairment
_____ 3 = Serious Impairment
_____ 4 = Extreme Impairment

Continuing to unravel what APA is doing with DSM V - here are some good notes from a "backgrounder" type conference that proceeded work on the draft changes. It includes comments from three of the work group members on the PD section and explains much of what they are driving at with the proposed changes.

Admittedly this stuff is a bit "thick" and far upstream from typical HPD BBS content. I post it here to show that the thought process that goes into a DSM revision is indeed intense! Even with that however, it shows no system is perfect. No "label" fits any individual with 100% precision. For those willing to dig, I believe these few paragraphs also provide some nuggets and the "rational" behind the 37 traits (described in a separate Topic) and where they are headed with that.

Source:
Dimensional Aspects of Psychiatric Diagnosis
July 26-28, 2006
Seventh in a series of 12 conferences on "The Future of Psychiatric Diagnosis: Refining the Research Agenda" convened by the American Psychiatric Institute for Research and Education (Affiliate of APA, funded by NIH)
http://www.dsm5.org/Research/Pages/DimensionalAspectsofPsychiatricDiagnosis%28July26-28,2006%29.aspx

John Helzer, MD (Burlington, VT – one of four conference co-chairs) wrote:opened the conference with a description of its rationale and goals These were 1) to review the advantages and drawbacks of offering a quantitative "dimensional" component in DSM-V and ICD-11; 2) to discuss various alternative dimensional approaches; and 3) to discuss a research agenda relevant to designing and testing dimensional alternatives. He stressed that the six diagnostic areas scheduled for formal presentation - i.e., substance use disorders, mood disorders, psychotic disorders, anxiety disorders, childhood disorders, and personality disorders - were illustrative examples and that it was not the intention of the conference to confine discussion to these areas. Dr. Helzer noted that although DSM-III was a revolutionary paradigmatic shift, the diagnostic progress it fostered revealed the inadequacies of a strictly categorical diagnostic model. He then offered four recommendations for DSM-V: 1) that the DSM-V criteria should include options for dimensional approaches; 2) that the categorical approach of DSM should be retained given the ongoing need for diagnostic categories for clinical work and research; 3) that the content of DSM-V dimensional components be determined by categorical definitions given the need to be able to relate the dimensional scales back to the categorical definitions; and 4) that DSM-V should be structured to ensure maximum utility for future taxonomic needs.

Helena Kraemer, PhD (Palo Alto, CA – one of four conference co-chairs) wrote: presented on the clinical and research contexts of categories and dimensions. She first distinguished between the term "disorder," which she defined as "something wrong in the patient that is of clinical relevance," and "diagnosis of a disorder," which is an expert opinion that a disorder is present. The decision to use a dimensional versus categorical diagnosis has nothing to do with the nature of the disorder itself but everything to do with the quality of the diagnosis for a disorder. A dimensional diagnosis has three or more ordinal values, which can range from a three point scale (at a minimum) up to continuum (e.g., BMI for eating disorders). A categorical diagnosis has only two possible values: present and absent. Further elaborating the purpose of the conference, she said the key issue is to consider whether to add a dimensional component to the DSM-V categorical diagnoses rather than to try to replace categorical diagnoses with dimensional constructs. Every dimensional diagnosis can be made categorical by setting a cut-point; conversely, every categorical diagnosis can be made dimensional a cross any of a number of possible dimensions, including - but not limited to - symptom count, symptom duration, symptom severity, degree of impairment, and certainty of diagnosis. Dr. Kraemer illustrated the advantages of dimensional over categorical diagnoses in research settings by describing a randomized controlled trial of cognitive-behavioral therapy vs. self-help for the treatment of eating disorders. The actual trial, which used the presence or absence of a categorical diagnosis of bulimia nervosa as the outcome variable, showed no statistically significant differences in the two groups. However, if a dimensional measure of frequency of binges and purges were to have been used instead, a statistically significant moderator effect would have been detected, indicating that the treatment worked in low-risk but not high-risk groups. From a statistical perspective, advantages of using dimensional vs. categorical outcomes include greater power to detect treatment effects, less attenuation and greater precision in estimates of effect sizes, and better ability to detect signals Dr. Kraemer recommended that any proposed DSM-V dimensional diagnosis correspond well with the respective categorical diagnosis, be transparent to clinicians, and have clinical validity and test-retest reliability. She concluded that the time to add dimensional diagnosis to DSM has come and that a dimensional approach is needed in order to prepare for the future inclusion of genetic, imaging, biochemical elements to psychiatric diagnoses. A dimensional approach can be as simple or as complicated as is appropriate for each disorder, but most importantly, clinicians must be able to use it.

Andrew Skodol, MD (New York, NY – Chair of DSM-5 PD section) wrote: in his discussion, raised several issues and questions that will need to be addressed in the future: 1) although the dimensional models for PD converge on broad domains, they differ at trait/lower item levels, so ascertaining which of the many existing models to choose will be challenging; 2) how should comorbidity that occurs both within and across broad spectra be interpreted (e.g., comorbidity between mood disorders in the internalizing dimension and substance use in the externalizing dimension); 3) although traits long have been presumed to be stable over time, there is some evidence of change over time, raising the question of how to incorporate such change into conceptualizations of traits; 4) identifying and achieving consensus on the core features of any new global definition of PD; numerous features of such a definition that could be dimensionalized - e.g., duration of traits, pervasiveness, inflexibility, distress, and functional impairment; and 5) given that personality disorders vary in dimensional complexity, it will be necessary to determine which traits are the most important and most useful. . Dr. Skodol concluded by suggesting that a personality disorder might possibly be reconceptualized as a combination of both enduring predispositions (static phenotypes) and characteristic behaviors (dynamic processes) and that it will be important to incorporate both static and dynamic elements when formulating a hybrid model for DSM-V.

At least one of the members of the WG is studying how PD traits change over long periods of time.

Robert Krueger, PhD (Minneapolis, MN – Member of DSM-5 PD section) wrote: presented on the research base for a dimensional approach to personality diagnosis in the DSM, noting that the first of the research planning conferences in the "Future of Psychiatric Diagnosis" series (which took place in December 2004) focused on dimensional models of personality disorders. Eighteen alternative dimensional models for personality were summarized at the meeting, raising the question about which dimensional system would be best for diagnosing personality disorders. Although the various models appear to be superficially diverse, extensive evidence documents systematic links between the models, leading many investigators to believe that a hierarchical model can be developed that that integrates these models.

Internalizing

• emotional dysregulation
• introversion vs. extraversion

Externalizng

• impulsivity vs. constraint
• antagonism vs. compliance

The top level of the hierarchy would have two dimensions, internalizing and externalizing, each of which would have two lower dimensions, emotional dysregulation and introversion vs. extraversion under internalizing, and impulsivity vs. constraint and antagonism vs. compliance under externalizing. Beneath the four dimension level would be lower-level traits akin to the current personality disorder items (e.g., difficulty with intimacy may lie under the introversion/extraversion factor) which would facilitate clinically optimal conceptualization of specific patients. This hierarchical structure reflects not only observable variation but also the underlying genetic risk factors, is also applicable to children and adolescents, and is applicable cross-culturally. Dr. Krueger recommended that an integrative dimensional structure should be a starting point for the classification of personality disorders in DSM-V. He proposed, however, that ultimately it will be necessary to reconsider the deeper structural aspects of the DSM given that the Axis I-II distinction is not highly compatible with the empirical organization of mental disorders. Also, he said, augmenting DSM-V with dimensions would help to generate the data needed to formulate a "bottom-up" structural organization for DSM-VI.

John Livesley, MD, PhD (Vancouver, Canada – Member of DSM-5 PD section) wrote: presented on the clinical relevance of a proposed dimensional classification of personality disorder (PD). He argued against just taking the DSM categories and converting them to a set of dimensions because they are not "natural kinds," not clinically useful, and provide poor coverage. He proposed a two component structure for classifying PD: 1) developing diagnostic criteria for general PD; and 2) developing a system for representing individual differences in PD (different forms of disorder). The DSM-IV definition of PD as maladaptive traits would be extended by defining the individual disorders as categories of primary traits. For example, borderline personality disorder could be defined in terms of the primary traits of affective lability, impulsivity, cognitive dysregulation, insecure attachment, and self-harm. Dr. Livesley then presented an example of this approach using the Dimensional Assessment of Personality Pathology (DAPP) Model, which contains 28 primary traits and four higher-order factors

• Emotional dysregulation
• Dissocial behavior/psychopathy
• Inhibitedness
• Compulsivity

He argued for the clinical utility of this dimensional approach on several grounds: 1) that it corrects coverage problems in the DSM (e.g., it includes sadism and pessimistic anhedonia), 2) it allows for flexibility in assessment on either the higher-order factor level or the primary trait level, 3) most interventions for PD focus on specific symptom or behavior clusters (i.e., the primary traits) rather than global diagnoses; and 4) psychotherapeutic interventions are typically organized around incidents, scenarios, recurrent themes, and maladaptive cognitions which may represent the behavioral expressions of primary traits.

Livesley has some very cool other research going I hope to probe fairly soon.

Found something published by one of the key guys on the DSM 5 PD revision committee W. John Livesley, MD. It shows they knew over ten years ago that the 10 PDs in DSM4 had huge overlaps. His research also shows a lot of the thinking that seems to be going into the current DSM 5 revision thinking. In his research on PD structure Livesley follows closely anything related to genetics and heritability.

Phenotypic and Genetic Structure of Traits Delineating Personality Disorder
W. John Livesley, MD, PhD; Kerry L. Jang, PhD; Philip A. Vernon, PhD
Arch Gen Psychiatry. 1998;55:941-948.
http://archpsyc.ama-assn.org/cgi/content/full/55/10/941

He found at the "macro" level there are only three "factors" that count in PD.

Dissocial Disorder
Antisocial/Psychopathic Type

Emotional Dysregulation Disorder
Borderline Type

Inhibited Disorder
Schizotypal Type
Avoidant Type

Not found to be significant personality disorder at this macro level
Obsessive-Compulsive Type

Some interesting conclusions

higher-order factors can co-occur and that they are not mutually exclusive - they exist in a multidimensional space

hierarchical structure of personality disorder traits is not simply one in which each superordinate trait is subdivided into several lower-order traits because these traits are only partly explained by their superordinate trait.

for example "The lower-order trait of Compulsivity appears to be distinct from other traits both genetically and phenotypically and hence it emerges as a separate factor in [more detailed analysis.] This does not mean, however, that it should be included as a higher pattern in a dimensional classification of personality disorder traits."


Examples of lower order traits - all found reasonably independent and significant at a "closer in" zoom:

• Compulsivity
• Suspiciousness
• Oppositionality
• Narcissism

Moreover, some specific traits [e.g. perhaps even the proposed trait #19 "pure HPD"] are unrelated to higher-order patterns. This suggests that both levels of the trait hierarchy are required for a comprehensive account of personality for clinical and research purposes.

For some purposes such as epidemiological studies, higher-order descriptions are appropriate. For research on etiology, however, the lower-order traits will be required to provide more detailed information.

In the above study, all personality disorders "shook out" to the following three factors.


Emotional Dysregulation - broader than "neurotic" and broader than DSM 4 Borderline in that it also includes: identity Problems, cognitive dysregulation (schizotypal cognition and cognitive disorganization under stress), insecure attachment, oppositionality, suspiciousness and narcisism. Close to "Harm Avoidance" (Cloninger) and Eysenck's Neuroticism.

Dissocial Disorder - Close to psychopathy (Hare) and negative pole of agreeableness (5-factor model. Close to Eysenck's Psychoticism. Includes impulsivity/sensationseeking/antisocial traits.

Inhibited Disorder- Similar but more specific that introverted (vs. extroverted). Consistent with inhibited temperament (Kagan)

Note: Livesley's work here seems corroborates Kernberg's and Linehan's view that "Borderline" really incorporates many specific personality disorders - its really a "supra" level description. You can attack a disorder from that level. Also there are different "flavors" of borderline - including NPD, HPD...etc. You can drill down from that supra level to the specific factors a the 'close in" level of granularity, then and go after those specifically, one at a time, or in clusters.

My take away for HPDs and Nons looking to help (or cope)is this: be sure to occasionally tour through borderline and "sister" PD areas for concepts and ideas. Something that works great there is likely to work here too. Looking at the Livesley "Big Three" dimension called "Emotional Dysregulation" above and note how broad it is. If a single emotional area screws up, this dimension goes high and you are likely to see some "borderline" symptoms, as uniquely expressed by the specific individual. To get the jester back in the box and keep the lid on, they probably need to attack any "Emotional Dysregulation" on multiple fronts, all at once. Of course prioritize weak areas and things that specifically set the person off. But also consider too, working at a "macro" level to strengthen overall emotional regulation. Get the entire emotional system well functioning so it takes more alarm signal from any one (or more) of the potential sources to set off the big bell.