The new ICD-11 Personality Disorder (PD) classification introduces a global severity classification (i.e., mild, moderate, and severe) of personality dysfunction, which may be further accompanied by up to five trait domain specifiers delineating individual manifestations of personality disturbance (i.e., Negative affectivity, Detachment, Dissociality, Disinhibition, and Anankastia). Although these trait domains are conceptualized as dimensions, the ICD-11 only allows clinicians to code them as being categorically present versus absent. It is therefore appropriate to examine the ability of clinicians' judgements in capturing variance in trait domains using dichotomous trait ratings. A total sample of 238 patients was characterized by their clinicians using both dimensional and dichotomous single-item ratings for each trait domain. Subsequently, clinicians filled out the Informant Personality Inventory for ICD-11 (IPiC) as a standardized criterion-measure for trait domains. The dichotomous ratings were all moderately associated with their corresponding IPiC score, except for Negative Affectivity, which only showed a small but statistically significant association. The dimensional ratings were all moderately to strongly associated with their corresponding IPiC scores. However, only the dimensional single-item ratings of Disinhibition and Dissociality were significantly superior to the dichotomous single-item ratings in capturing the IPiC trait domain scores. Findings overall support the use of categorical assignment of trait domain specifiers in the ICD-11 although dimensional formats improve the accuracy of clinicians' judgements.
Personality disorders (PDs) are associated with significant clinical and societal consequences and are highly comorbid with other psychiatric conditions. In forensic mental health settings, PD diagnoses are particularly relevant because they are linked to antisocial behavior, recidivism risk, and specific treatment needs. However, empirical knowledge about the prevalence of PD diagnoses in outpatient forensic mental health (OFMH) care is limited. We aimed to conduct a comprehensive study of the prevalence of PD diagnoses in OFMH institutions and to describe the demographic, clinical, and legal characteristics of individuals with PD diagnoses. Data were collected from OFMH institutions across the Netherlands for all adult individuals who received treatment in 2023. Fifteen institutions provided usable data, resulting in a total sample of 10,560 individuals. Descriptive analyses were conducted to estimate the prevalence of PD diagnoses and to examine differences across individual characteristics and treatment variables. Overall, 19.3% of all individuals were diagnosed with at least one PD. PD was the primary diagnosis in 12% of all individuals and an additional diagnosis in 7.3%, which seems to indicate that PD diagnoses are under-recognized. The most frequently recorded specific PD diagnoses were other specified or unspecified PD, followed by borderline PD and antisocial PD. PD diagnosis prevalence was higher among female individuals, middle-aged individuals, individuals receiving voluntary treatment, and those involved in more serious violent offenses. These findings provide large-scale prevalence data on PD diagnoses in Dutch OFMH and highlight the importance of systematic assessment of personality pathology in forensic outpatient populations.
Childhood trauma has been linked to personality pathology, including impairments in personality functioning and maladaptive personality traits. However, studies applying contemporary dimensional models such as the Alternative Model for Personality Disorders (AMPD) remain limited in South Korea. The aim of this study was to examine associations between childhood trauma and personality pathology using the AMPD in 800 South Korean adults. Latent variable structural equation modeling was conducted while controlling for age and gender and allowing covariances among trauma subtypes. Childhood trauma showed significant associations with both impairments in personality functioning (Criterion A) and maladaptive personality trait domains (Criterion B), with stronger associations observed for Criterion B. Compared with the Five-Factor Model, pathological personality traits showed greater sensitivity to childhood trauma. Physical neglect and emotional abuse exhibited the strongest associations across both domains. These findings support the applicability of the AMPD for understanding the impact of childhood trauma in South Korea.
Contemporary researchers tend to invoke psychoanalytic theories to support the view of personality functioning as a "unitary capacity" involving "psychological maturity." In this piece, I argue against this false equivalence by raising three points. First, I show that psychoanalysis is not a homogenous discipline that converged on a shared developmental ontology, but rather a deeply heterogenous tradition marked, if anything, by persistent disagreement. Second, I briefly review commonly-cited psychoanalytic theories (including classic Freudian, ego psychological, and object relational theories) to illustrate how none of them supports the view of personality functioning as a "unitary capacity." Third, I argue that the origins of the construct "personality functioning" are rooted more in descriptive empirical findings rather than traditional psychoanalytic perspectives. Finally, I conclude by suggesting that researchers should stop flattening psychoanalytic theory to support their "unitary" perspective and should instead conduct rigorous empirical tests to determine whether there is any merit in their otherwise theoretically empty viewpoint.
This study addresses the need for an examination of the criterion validity of a highly popular self-report instrument which is used to gain a quick first impression of personality dysfunction: the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF 2.0). To this end, the relationship between LPFS-BF 2.0 scores and SCID-5-AMPD-I scores rated by trained clinicians was investigated in a clinical Norwegian sample (N = 155). Moreover, we investigated the relationship between the Norwegian version of the LPFS-BF 2.0 and other self-report instruments (the WSAS, GAD-7, and PHQ-9). Correlations, a linear regression model, as well as sensitivity and specificity for cut-off values proposed in the literature, were estimated. The results of the linear regression analysis with SCID-5-AMPD-I scores as the dependent variable, showed a strong and significant relationship between LPFS-BF 2.0 scores and SCID-5-AMPD-I scores, also when controlling for other variables. The LPFS-BF 2.0 showed moderate to high correlations with all other instruments. The sensitivity values for cut-off scores suggested in the literature for the LPFS-BF 2.0 were too low. In sum, we found support for the concurrent and criterion validity of the LPFS-BF 2.0. Additionally, we tentatively suggest that the cut-off values currently in use may need to be lowered.
This letter responds to Pingani et al.'s validation of a questionnaire on clinical confidence and psychodynamic skills in personality disorder care. It argues that confidence should be interpreted at the team level, where formulation, boundaries, risk communication, and emotional containment shape the patient's experience of care.
Limited research has examined how personality constructs within the alternative model of personality disorders (AMPD) framework are related to intrapsychic processes such as emotion regulation difficulties and metacognitive beliefs and how these components jointly interact as an integrated system across developmental stages. The present study addressed this gap by applying a network analytic approach to investigate the structural interrelations among these domains in adolescent and adult community samples. Participants included 470 adolescents aged 14-17 years and 740 adults from the general population (total N = 1210), all of whom completed validated self-report measures assessing personality functioning, maladaptive personality traits, emotion regulation difficulties, and metacognitive beliefs. Age-adjusted networks were estimated using regularized partial correlations. Network structure, centrality, and clustering indices were examined and compared across age groups. Across both samples, personality functioning, maladaptive traits, emotion dysregulation, and metacognitive beliefs formed a densely interconnected network, indicating substantial overlap and mutual association among domains. Network architectures were broadly similar between adolescents and adults, suggesting substantial structural continuity across development. At the same time, differences in centrality and clustering metrics indicated age-related shifts in the relative prominence of specific traits, emotion regulation difficulties, and metacognitive processes. Overall, the findings support a systems-based view of personality pathology in which core dysfunctions, traits, and intrapsychic processes dynamically interact from adolescence into adulthood. By integrating multiple domains within a unified network framework, this study contributes to a more comprehensive and developmentally informed understanding of personality pathology.
The Five-Factor Narcissism Inventory-Short Form (FFNI-SF) is specifically developed to assess narcissism at the two- (grandiose and vulnerable narcissism) and three-factor level (agentic extraversion, self-centered antagonism, and narcissistic neuroticism). To date, however, no psychometrically validated Dutch language version has been available in research or clinical settings. This study developed and validated the Dutch version of the 60-item FFNI-SF (FFNI-SF-NL), examining its reliability, factor structure, and convergent and discriminant validity following a preregistered analysis plan. A sample of 223 adult Dutch-speaking participants, comprising 80 patients with personality disorders or individuals receiving mental health care and 143 non-clinical participants, completed the FFNI-SF-NL. While strict confirmatory factor analysis showed poor model fit for the proposed two- and three-factor models, subsequent exploratory factor analysis and exploratory structural equation modeling supported a three-factor structure that closely replicated the modern trifurcated conceptualization of narcissism. The FFNI-SF-NL vulnerable and grandiose composites and agentic extraversion, self-centered antagonism, and narcissistic neuroticism factors demonstrated adequate to good reliability and strong external construct validity, with correlations between its dimensions and other narcissism measures, personality traits, and psychological distress aligning closely with theoretical expectations specified a priori. Clinical participants showed higher vulnerable narcissism and narcissistic neuroticism scores, whereas non-clinical participants showed higher grandiose narcissism and agentic extraversion scores, providing preliminary support for the clinical relevance of distinguishing FFNI-SF-NL narcissism dimensions. These results support the FFNI-SF-NL as a reliable and valid multidimensional measure capturing nuanced expressions of narcissistic traits in both clinical and non-clinical Dutch-speaking populations, facilitating future research and clinical practice.
We conducted a randomized clinical trial assessing the beneficial and harmful effects of short-term versus long-term mentalization-based therapy (MBT) for outpatients with borderline personality disorder (BPD) and found no evidence of a difference on BPD symptom severity, functional impairment, quality of life, global functioning, and severe self-harm. In this paper, we assessed the effects of short-term versus long-term MBT on the exploratory outcome, psychiatric symptoms, assessed with the Symptom Checklist-90-Revised (SCL-90-R). Participants included the full intention-to-treat sample of the original trial of N = 166 randomized outpatients with subthreshold or a diagnosis of BPD (short-term MBT n = 84, long-term MBT n = 82), who were randomly assigned to short-term MBT (5 months) or long-term MBT (14 months). Psychiatric symptoms were assessed with the SCL-90-R at baseline, 8, 16, and 24 months after randomization. The 16-month time point was predefined as our time point of primary interest. Regression analyses showed no evidence of a difference when assessing general symptom severity (MD -0.02, 95% CI -0.24-0.20; p = 0.841) or any of the subscales, including anxiety, depression, hostility, interpersonal sensitivity, obsession/compulsion, paranoid ideation, phobic anxiety, psychoticism, and somatization. At the exploratory 24-month follow-up time point, similar results were obtained. In conclusion, short-term MBT neither weakened nor improved patients' psychiatric symptoms compared with long-term MBT for outpatients with BPD. Trial Registration: ClinicalTrials.gov: NCT03677037.
We critically appraise the study by de Bruin et al., which examined whether avoidant personality traits and avoidant coping predict differential outcomes of cognitive-behavioral therapy (CBT) versus short-term psychodynamic psychotherapy (STPP) in adult depression. Although the authors address an important clinical question regarding dimensional personality assessment in treatment selection, several methodological issues may limit the strength of their conclusions. First, avoidant personality traits were operationalized using a composite score derived from subtracting extraversion from neuroticism on the NEO-FFI. Although dimensional models are increasingly encouraged, this approach may not adequately capture the multifaceted construct of avoidant personality pathology, which includes features such as rejection sensitivity, shame, social inhibition, and feelings of inadequacy, and may instead reflect broader negative affectivity or introversion. Second, the study may have been underpowered to detect moderation effects, which typically require larger samples than main effect analyses. Attrition and participant exclusion may have further reduced statistical power, limiting the ability to identify meaningful treatment interactions. Therefore, the absence of significant moderation effects should be interpreted cautiously and not taken as definitive evidence of equivalent treatment efficacy across levels of avoidant pathology. Despite these limitations, the study contributes to growing research on dimensional personality approaches in depression treatment, and further well-powered studies using validated measures are warranted.
Personality functioning (PF) is the defining criterion for personality disorder in contemporary diagnosis and a popular topic in research. However, research and dialogue on PF has been uneven and often ideologically driven, in part because semantic differences are often conflated with substantive differences in the way PF is conceptualized. Here, I distinguish four ways to conceptualize PF: a psychodynamic developmental dimension, a descriptive summary of whatever all personality disorders or maladaptive traits have in common, a multidimensional model of traits, and a multidimensional model of adaptive capacities distinct from traits. I articulate the underlying assumptions and consequences for research and practice of each of these four approaches. I argue that conflating these assumptions has led to miscommunication about PF in the literature and describe how these models can be distinguished to provide more rigorous tests of the existence, nature, and utility of PF for personality theory and clinical assessment.
The integration of personality theory, attachment, and sex differences in recent years has promoted useful insights when assessing and treating personality pathology. Lesser attention has explored the salience of attachment style and sex differences in the relationship between personality pathology within the emerging Alternative Model of Personality Disorders (AMPD). This naturalistic study addresses these gaps in the literature by using a large inpatient sample (N = 1512; 49.7% female) of men and women residing in the United States who were administered the Relationships Questionnaire and Personality Inventory for the DSM-5. Results demonstrated significant effects across several AMPD Criterion B domains, attachment styles, and sex, with attachment most consistently linked with Criterion B domains. Furthermore, an interaction effect between attachment style and sex was not demonstrated across any Criterion B domain. Limitations and future directions are offered with clinical implications for this research as applied to clinical practice and the application of theory to understand personality pathology.
Mentalizing is a socio-cognitive capacity that develops within early attachment relationships, but institutional care may disrupt this process. Although adoption significantly improves developmental outcomes, it remains unclear whether socio-cognitive vulnerabilities observed in children persist in adulthood. This preregistered study aimed to explore (a) socio-cognitive catch-up in adult adoptees, and (b) predictors of reflective functioning (RF) in adulthood with a particular focus on attachment and interpersonal trust. Sixty-eight individuals were followed from infancy to adulthood. Adoptees did not differ from nonadoptees in RF in adulthood (Cohen's d = 0.07, 95% CI [-0.43, 0.57]), and age at adoption was not associated with RF (r = 0.02, p = 0.917). Cross-sectionally, RF was significantly correlated with dismissing (r = -0.58, p < 0.001) and preoccupied states of mind (r = 0.29, p = 0.017). Attachment in infancy (strange situation), preschool (attachment story completion task), and adolescence (child attachment interview) did not predict RF in adulthood. Interpersonal trust in adolescent and adult friendships was not associated with RF in adulthood. Overall, the findings suggest recovery in socio-cognitive development among adoptees with early institutional care and indicate that early attachment may not linearly predict RF. Future research should further explore developmental pathways to better understand the precursors of mentalizing in adulthood.
Clinicians often experience frustration and uncertainty when working with patients with personality disorder (PD). Several evidence-based treatments are available, some deriving from psychodynamic theory. Despite the clinical relevance of confidence in managing such encounters, no validated measure of clinicians' confidence in assessing, structuring treatment, and applying psychodynamic skills in the work with PD patients exists. This study reports the development and validation of the Clinical Confidence and Psychodynamic skills in Personality Disorder Questionnaire (CCPPDQ). The CCPPDQ is a 13-item self-administered questionnaire. 314 psychiatrists and psychiatry residents from the United Kingdom, Italy, India, and Malaysia completed it during applied transference focused psychotherapy (TFP) training (2022-2024). Exploratory and confirmatory factor analyses identified and confirmed the underlying structure. Internal consistency, test-retest reliability, and convergent validity with the Attitudes to Personality Disorder Questionnaire (APDQ) were assessed. Gender differences and predictors of CCPPDQ scores were also analyzed. Analyses supported a two-factor structure: Confidence in Assessment and Structuring Treatment (CAST) and Confidence in Applying Psychodynamic Techniques (CAPT), accounting for 58.5% of total variance. The CCPPDQ showed excellent internal consistency (ω = 0.93) and strong test-retest reliability (ICC = 0.92). Convergent validity was supported by positive correlations with APDQ total and subscale scores, particularly Enjoyment and Security. Regression analyses identified age, gender, and APDQ scores as significant predictors of CCPPDQ outcomes. The CCPPDQ is a reliable tool for assessing clinicians' confidence in working with PD patients. Its subscales capture meaningful aspects of psychodynamic practice, offering utility for training, supervision, and research.
Invalidating family environments are theorized to undermine youths' emotion socialization and confer risk for psychopathology, yet heterogeneity in how invalidation is expressed within families is rarely examined. This study employed latent profile analysis (LPA) to a sample of 5621 children and adolescents (aged 9 to 18, M = 13.31, SD = 2.00, 53.6% female) to identify distinct profiles of family invalidation and compare mental health outcomes across profiles. Model comparisons supported a four-profile solution: Low Invalidation (54.2%), Moderate Invalidation (32.3%), Paternal Emotional Dysregulation and Denial (5.6%), and Maternal Emotional Dysregulation and Denial (7.9%). Using the BCH procedure, profiles differed in borderline personality features, depression, and anxiety. Across outcomes, the Maternal Emotional Dysregulation and Denial profile showed the highest symptom levels, whereas the Low Invalidation profile showed the lowest levels; anxiety was similarly elevated in the maternal- and paternal-invalidating profiles. Age, gender, living arrangement, and household income also varied descriptively across profiles. These findings emphasize the differential impact of family invalidation on youth mental health, highlighting the critical need for early screening and culturally sensitive, tailored family-based interventions targeting parental invalidation to reduce youth psychopathology.
Research on the significance of comorbid personality disorders (PD) on the outcome of depression treatment has shown inconsistent findings. In addition, it is still unclear whether treatment choice based on personality traits and coping can enhance the efficacy of depression treatment. Aiming to deliver clinically representative results, we use dimensional measures to examine avoidant personality and coping as moderators for the efficacy of cognitive-behavioral therapy (CBT) versus short-term psychodynamic psychotherapy (STPP) for depression. Furthermore, we explored whether these depression treatments reduced avoidant personality traits and coping. Included were 265 patients with major depressive disorder who received 16-week CBT or STPP in a randomized clinical trial. Depression, avoidant personality traits, and avoidant coping were measured with, respectively, the Hamilton Depression Rating Scale, NEO Five Factor Inventory (extraversion and neuroticism subscales), and Utrecht Coping List (avoidance subscale). Multilevel regression analyses estimated the moderating effects of avoidant personality traits and avoidant coping on the relationship between treatment type and depressive symptom change, as well as changes in avoidant personality traits and avoidant coping in CBT and STPP. Avoidant personality traits and avoidant coping did not moderate the efficacy of CBT and STPP. Both treatments resulted in significant reductions in avoidant personality traits, but not in coping. Both CBT and STPP can be offered to patients with avoidant personality traits and avoidant coping and can reduce avoidant personality traits.Trial Registration: ISRCTN31263312 (http://www.controlled-trials.com).
While abundant research has examined parent emotion socialization (PES) in mothers, only two studies have examined PES in mothers with borderline personality disorder (BPD), and none has looked at its relationship with level of personality functioning-defined personality disorder (PD). Further, no study has assessed the moderating effect of reflective functioning (RF) in this context, which may help elucidate the mentalizing conditions under which mothers with PD engage in certain types of PES. The present study aims to examine the relationship between maternal level of personality functioning (LPF) and PES, group differences between mothers with PD and mothers without PD on PES, and the moderating effect of RF on the relationship between LPF and PES. The study sample was comprised of 149 mothers (Mage = 34.88). Of those mothers, 42 met clinical criteria for PD. Study measures included the Level of Personality Functioning Scale Brief Form 2.0, the Coping with Children's Negative Emotions Scale, and the Reflective Functioning Questionnaire-8 item form. Maternal LPF was negatively correlated with supportive PES and positively correlated with nonsupportive PES. Mothers with PD and mothers without PD demonstrated significant differences on supportive and nonsupportive PES. Finally, RF had a significant moderating effect on the relationship between maternal LPF and nonsupportive PES. Taken together, findings suggest similar challenges for mothers with LPF-defined PD to those previously found for mothers with BPD. Results further indicate that increasing supportive PES, decreasing nonsupportive PES, and improving RF capacity could be helpful treatment targets for mothers with PD.
