However, less is known about the AMPDs utility over the course of treatment. This incoherence leaves the individual struggling to regulate emotions and behaviors in an adaptive manner and TFP aims to increase a patients capacity for accurate and coherent reflection on self and other (Clarkin et al., 2006; Caligor et al., 2018). Looking at domains of the LPFS shown in Figure 4 at Time 2 (yellow bars), Ms. B continued to show severe impairment in self-direction, intimacy, and identity, and moderate impairment in empathy. 143, 117141. doi: 10.1037/a0027953, Hopwood, C. J. Psychodynamic therapy for personality pathology: Treating self and interpersonal functioning. Ratings were discussed with the supervising clinician and each therapist was blind to the others ratings. Mr. Ds change in PID-5 Z-scores by domain. Dis. 4:16. doi: 10.1186/s40479-017-0066-4, Torres-Soto, J.-F., Moya-Faz, F.-J., Giner-Alegra, C.-A., and Oliveras-Valenzuela, M.-A. Am. Assessment 100, 565570. (2016) employed AMPD profiles to differentiate diagnostic profiles, case conceptualization, and specific interventions across three clinical cases of patients diagnosed with DSM-5 Section II narcissistic personality disorder. Mr. D still struggled to hold that others may have thoughts, motivations, and reactions that were different from his own, and he lacked close relationships built on mutuality and transparency. doi: 10.1017/S0033291711002674, Lenzenweger, M. F., Clarkin, J. F., Yeomans, F. E., Kernberg, O. F., and Levy, K. N. (2008). Professional Psychol. When patients shift in and out of therapy from one provider to another, the potential for assessment of patient change over time is often complicated or thwarted. Overall, treatment goals continued to focus on helping Ms. B to acknowledge and observe her tendency to vacillate between dependency and hostility so that she could build and maintain the types of relationships and closeness that she desired. doi: 10.1037/pro0000071, Wnuk, S., McMain, S., Links, P. S., Habinski, L., Murray, J., and Guimond, T. (2013). Toward a Model for Assessing Level of Personality Functioning in DSM5, Part I: A Review of Theory and Methods. Using latent Profile Analysis (LPA) of Criterion A and B facets, they found four distinct profiles: (1) borderline traits (characterized by relatively lower severity albeit impairment in self-direction and empathy as core traits of hostility, impulsivity, and risk-taking), (2) moderative personality severity with impulsivity and risk-taking (characterized by depressivity and increased impulsivity as well as slightly elevated impairment in identity functioning), (3) moderate personality severity with identity problems and depressivity (characterized by increased depressivity and moderate impairment in identity functioning), and (4) severe personality pathology (characterized by severe impairment in self-direction and empathy as well as elevation in hostility and impulsivity). Skodol et al. Although she showed a reduction in anxiousness and impulsivity (<1 SD above the mean), Ms. Bs AMPD profile continued to meet criteria for the legacy BPD category at Time 2 with all four LPFS domains within the moderate to severe level of impairment and continued elevation in four maladaptive traits including emotional lability, separation insecurity, depressivity, and hostility. Since its inception, AMPD research has boomed with focus on the psychometric properties, validity, and reliability of Criterion A and Criterion B (e.g., Krueger et al., 2012; Few et al., 2013; Morey, 2017; Zimmermann et al., 2019; Bliton et al., 2021). Although the LPFS model is understood as a unidimensional index of severity (Bliton et al., 2021), nuanced clinical information regarding personality functioning can be gleaned from the four domains of identity, self-direction, intimacy, and empathy. The beginning of treatment was marked by frequent intersession phone calls, requests for immediate sessions, and resistance to ending regularly scheduled sessions on time. B., Williams, J. Criterion B aligns with the multivariate and empirical personality traditions and specifies interindividual differences in maladaptive style, or the characteristic, patterned expression of traits across contexts (Waugh et al., 2017; Krueger, 2019). Personal. A recent study conducted by Gamache et al. Even still, Mr. Ds trait level impulsivity and Ms. Bs trait level negative affectivity continued to be unique challenges, albeit with lesser intensity and disruption to functioning. Boston, MA: Center for Stress and Anxiety Related Disorders, Boston University. Treating clinicians rated patients for their respective treatment phases using the Level of Personality Functioning Scale (LPFS), capturing severity, and the Personality Inventory for the DSM-5 (PID-5), capturing style. Psychol. Therefore, as noted by Hopwood (2018), it follows that a treatment targeting BPD would yield changes to Criterion A of the AMPD. B. W., Ustun, B., and Peele, R. (2004). A systematic review of the clinical utility of the DSM5 section III alternative model of personality disorder. The PID -5 Inventory: The dimensional profile of DSM5 to guide diagnosis and therapeutic needs in personality disorders. Dysregul. For example, at Time 1 Mr. D had elevated levels of irresponsibility (>4 SDs above the mean) and at Time 2 the irresponsibility facet remained elevated but had reduced (>2 SDs above the mean). Psychiatry 49, 380386. doi: 10.1080/21674086.1988.11927218, Kjr, J. N., Biskin, R., Vestergaard, C., Gustafsson, L. N., and Munk-Jrgensen, P. (2016). At the diagnostic assessment, Ms. Bs presenting concerns included a long history of treatment-resistant depression and anxiety related to relationship difficulties, specifically an estranged relationship with her daughter, employment difficulties, and a generally unfulfilling life. Vrije Universiteit Brussel (VUB), Belgium, Medical University of South Carolina, United States. As such, the AMPD profile accounts for BPD as general personality pathology severity (i.e., genus) further explicated by characteristic symptom expression (i.e., species), a combination that seems necessary to understand BPD. Similarly, Ms. B showed elevated levels of separation insecurity (>2 SDs above the mean) at Time 1 that remained elevated but reduced at Time 2 (>1 SDs above the mean). Psychoanalytic diagnosis: Understanding personality structure in the clinical process, 2nd Edn. Received: 13 October 2021; Accepted: 03 January 2022;Published: 14 February 2022. Washington, D.C.: American Psychiatric Publishing. Both patients were seen for psychodynamic psychotherapy over the course of three years provided by two doctoral-level training clinicians supervised by a licensed clinical psychologist specializing in personality disorder treatment and assessment. Aligning with psychodynamic, interpersonal, and personological traditions (Waugh et al., 2017; Pincus and Roche, 2019), Criterion A reflects an underlying dimension of personality pathology severity defined by difficulties in self and interpersonal relatedness (Bender et al., 2011; Pincus et al., 2020). Thus, Ms. B seemed to desperately approach others for self-definition, regulation, and care despite the intense fear of harm. CMAJ 184, 17891794. doi: 10.1037/pri0000025, Pincus, A. L., and Roche, M. J. Bach et al. At Time 2, Mr. Ds LPFS score illustrated moderate to severe impairment in personality functioning (Table 1). Second, the application of class or cluster analyses to DSM criteria or key symptom expressions of BPD (e.g., interpersonal difficulties and affective dysregulation) derive subgroups of individuals with BPD. Depicted in Figure 1 at Time 1 (green bars), Mr. D showed extreme impairment in self-direction and severe impairment in identity, intimacy, and empathy. Thus, investigating BPD through an AMPD lens as it directly applies to case conceptualization and treatment course offers importance insights into the AMPDs clinical utility. J. Mr. D often exhibited the idealized self via irresponsibility and recklessness, while associating being responsible with the risk of exposing incompetence and being shamed. Clinical case examples exemplifying how Criterion A and Criterion B guide interventions across sessions and subsequently engender personality change are warranted. Comprehen. Dysregul. Dis. Although she demonstrated minimal concern for others when feeling deprived or rejected (callousness), Ms. Bs improving capacity for perspective taking and empathy allowed her to reflect on this in the moment.
Milinkovic, M. S., and Tiliopoulos, N. (2020). Personal. In The American Psychiatric Publishing textbook of personality disorders, 2nd Edn. doi: 10.1503/cmaj.090618, Bliton, C. F., Roche, M. J., Pincus, A. L., and Dueber, D. (2021). 57, 481504.
His sense of self largely vacillating between an idealized care-free, excitable self and a deeply loathed incapable and flawed self. Gen. Psychiatry 51, 215224. Psychiatry 48, 7078. Thus, there is a need to examine changes in AMPD diagnostic profiles and personality expression within treatment and across time. Individuals with BPD utilize significantly more treatment resources than individuals with mood, anxiety, or other personality disorders (Ansell et al., 2007). Emot. doi: 10.1001/archpsyc.1994.03950030051005, Markon, K. E., Quilty, L. C., Bagby, R. M., and Krueger, R. F. (2013). doi: 10.1037/a0021701, Roberts, B. W., Luo, J., Briley, D. A., Chow, P. I., Su, R., and Hill, P. L. (2017).
Focusing on Object Relations. Ms. B had difficulty observing this process, showing a capacity to briefly reflect on this dynamic but quickly vacillating when this became threatening to her. Stemming from psychoanalytic models (Kernberg, 1988), borderline can also be considered a spectrum of personality organization that undergirds all PDs and speaks to the dimensional severity of identity integration, maturity of defenses, and reality testing. Disord. (2021). doi: 10.1037/a0018770, Few, L. R., Miller, J. D., Rothbaum, A. O., Meller, S., Maples, J., Terry, D. P., et al. Ms. B was caught in a vicious cycle of heavily depending on others for regulation, experiencing others as withholding and rejecting, and not recognizing that her own aggressive and dependent responses drove away and burned out others. Annu. *Correspondence: Chloe F. Bliton, email@example.com, The AMPD in Clinical & Applied Practice: Emerging Trends and Empirical Support, View all The current case reports demonstrate that assessment of the AMPD, particularly for patients cycling through numerous therapists over time, appears to be fruitful. A unique facet of the present study was the transfer between two clinicians allowing for patient assessment over time and across raters within a naturalistic clinical setting. doi: 10.1037/a0034878, First, M. B., Pincus, H. A., Levine, J. Taken together, the AMPD unites process and structure to offer a nuanced conceptualization of personality as severity of difficulties in self and relatedness that is further clarified by characteristic style. Results indicated greater improvements in personality severity while personality style remained more stable. Upon diagnostic assessment, it became apparent that Mr. Ds symptoms and experiences could be best understood through the lens of personality pathology. Curr. Figure 2. The editor and reviewer's affiliations are the latest provided on their Loop research profiles and may not reflect their situation at the time of review. At Time 1, Ms. Bs LPFS score illustrated severe impairment in personality functioning (Table 1).
doi: 10.1037/abn0000165, Zanarini, M. C., Frankenburg, F. R., Khera, G. S., and Bleichmar, J. American Psychiatric Association (eds) (2013). Ms. B presented for services after a former provider recommended a thorough diagnostic assessment for suspected personality pathology. Ideally such ratings would be made at an optimal point following initiation of treatment with each therapist.
As Ms. B demonstrated a growing willingness to consider others perspectives, catching her aggression more readily in the moment, she began to see her impact on others. The development and psychometric properties of an informant-report form of the personality inventory for DSM5 (PID-5). Ms. B appeared to have some insight into the intensity of her unstable emotions (emotional lability) though she greatly struggled with affect regulation. To remain faithful to the AMPD, patients AMPD diagnostic profiles are assessed using the Level of Personality Functioning Scale (LPFS) and the Personality Inventory for the DSM-5 Informant Form (PID-5-IRF) as specified within Section III of the DSM-5. The patients style directs how interventions are adapted and delivered to best meet the patients needs (McWilliams, 2011; Torres-Soto et al., 2018). Arch. Mr. Ds change in LPFS severity. doi: 10.1002/pmh.1337, Korzekwa, M. I., Dell, P. F., Links, P. S., Thabane, L., and Webb, S. P. (2008).
Although Mr. D and Ms. B struggled with empathy, particularly at Time 1, Mr. D and Ms. B each pulled for unique countertransferential reactions that were similarly experienced by both therapists. Personal. Specifically, Pincus et al. No use, distribution or reproduction is permitted which does not comply with these terms. Ms. B had difficultly observing and understanding her inner world as she experienced contradictory internal standards for behavior which clouded her ability to observe the impact of her own oscillating aggressive and overly dependent behavior on others. Although Ms. B largely continued to view others as sources of emotional regulation and feared rejection, her ability to observe this process began to emerge, allowing Ms. B to attempt to repair relationships following ruptures. Notably, beyond Ms. Bs difficulty recognizing her antagonism and hostility on her own, when the therapist would bring it to her attention, Ms. B was largely unconcerned about others (callousness). However, each patient presented with differing manifestations of this pathology, capturing the heterogeneity of BPD. Washington, D.C: American Psychiatric Publishing, Inc, 511544. Notably, one of the four traits must be either impulsivity, risk-taking, or hostility (American Psychiatric Association, 2013). Clinical case examples have offered a unique perspective of the AMPDs ability to translate from bench to bedside. Mr. D also met criteria for a severe substance use disorder and recurrent, moderate episodes of major depression. The AMPD aimed to improve upon the well-documented limitations of the DSMs categorical model of personality disorders (PDs), a model left unrevised since 1980 (Skodol et al., 2014; Bender et al., 2018; Waugh, 2019). doi: 10.1016/S0140-6736(14)61394-5, Bender, D. S., Morey, L. C., and Skodol, A. E. (2011). Prof. Psychol. Patients diagnostic profiles were assessed with the AMPD framework for their respective time of treatment culminating in ratings across two phases of treatment. 8:4. doi: 10.1186/s40479-021-00146-w, Gunderson, J. G., Fruzzetti, A., Unruh, B., and Choi-Kain, L. (2018). Personal. doi: 10.1016/j.comppsych.2007.02.001, PubMed Abstract | CrossRef Full Text | Google Scholar, Bach, B., Markon, K., Simonsen, E., and Krueger, R. F. (2015). Clin. Comprehen. Psychoanal. doi: 10.1037/bul0000088, Sharp, C., Wright, A. G. C., Fowler, J. C., Frueh, B. C., Allen, J. G., Oldham, J., et al. This article demonstrates the utility of the AMPD for two clinical cases in three distinct ways: (i) highlighting heterogeneity in BPD between patients, (ii) comparing improvements in personality severity and style over time, and (iii) elucidating profile change across therapist ratings. An integrated approach to treatment of patients with personality disorders. For example, as Mr. D gained insight into his difficulties in self and relatedness, he began to better understand the protective nature of his tendency to devalue in an effort to maintain an idealized self-image and protect against the risk of shame. Mr. D is a White man between the ages of 25 and 30 years old with a history of impulsive gambling, substance abuse, and difficulties maintaining employment. This dependency held true even as Ms. B frequently experienced the therapist as withholding and rejecting. 125, 11201134. 124, 387398. McWilliams, N. (2011). In addition to providing a useful framework for understanding improvement, easy implementation of the LPFS and PID-5 on the part of the clinician allows for a rich clinical profile and description to be created with little time or cost. Ms. Bs central impediments in self and other functioning were further complicated by her personality style. Results have ranged from identifying subgroups differentiated by severity (Clifton and Pilkonis, 2007), internalizing versus externalizing subgroups (Smits et al., 2017; Johnson and Levy, 2020), and two to four classes of subgroups demarcated by core symptoms (e.g., Lenzenweger et al., 2008; Hallquist and Pilkonis, 2012; see Gamache et al., 2021 for a review). doi: 10.1080/00223891.2018.1477787, Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., and Skodol, A. E. (2012). In a study comparing outpatients with BPD to those with other personality disorders and those with schizophrenia, 97% of the individuals with BPD reported a history of prior outpatient treatment compared to 33% of those with other personality disorders and 80% of those with schizophrenia (Skodol et al., 1983). First, therapists made retrospective ratings on the LPFS and PID-5 based on the patients presentations in the early months of each treatment phase. Emot. Anxiety Disorders Interview Schedule for DSMIV. To ensure patients AMPD profile changes were not an artifact of within-clinician rating bias and to examine the stability of AMPD profiles across time and therapist, we compared the associations between AMPD profiles within patients and within therapists. Mr. Ds change in PID-5 Z-scores by facet. All authors contributed to the article and approved the submitted version. J. Notably, Criterion A identity impairment and Criterion B traits of impulsivity and risk-taking emerged as key differentiating variables distinguishing profiles. Although both patients struggled to understand the perspective of others, these difficulties manifested in different ways that are captured by Criterion B of the AMPD: Mr. D presenting as impulsive and Ms. B as affectively dysregulated. Assess. Psycholog. Patients were first seen for an extensive psychodiagnostic assessment including psychosocial history, the Anxiety Disorders Interview Schedule for DSM-5 Lifetime Version (ADIS; Di Nardo et al., 1994), and the International Personality Disorders Examination (IPDE; Loranger et al., 1994). At Time 1 during the initial phase of treatment, Mr. Ds AMPD profile was defined by severe impairment in personality functioning which indicates significant difficulties in self and relational functioning. Although intimacy and empathy remained impaired as she persisted in relying on other relationships for regulation, her capacity to hold and reflect on this within therapy increased. Following patient trajectories across therapists offers a unique opportunity to examine the AMPDs sensitivity to and utility for capturing personality change over time for patients with BPD. Borderline personality disorder diagnosis in a new key. Following patient trajectories across therapists offers a unique opportunity to examine the AMPDs sensitivity to and utility for capturing personality stability and change over time for patients with BPD. Is there a characteristic pattern to the treatment history of clinic outpatients with borderline personality? Mr. Ds difficulty observing and tolerating the impact of his behavior on others, tended to leave both therapists feeling parentified in moments of his irresponsibility and rebelliousness. Shown in Figure 6, her PID-5 facet level elevations included separation anxiety, hostility, emotional lability, suspiciousness, and callousness (>2 SDs above the mean) as well as depressivity, impulsivity, anxiousness, and anhedonia (>1 SD above the mean).
42, 18791890. Longitudinal validation of general and specific structural features of personality pathology. Res. (2018). Impairment within the indicators is stratified across five distinct levels ranging from Little to No Impairment (Level 0) to Extreme Impairment (Level 4). Finally, we expect to see the AMPD profile capture within-patient change beyond within-therapist response bias through both treatment phases. doi: 10.1097/01.pra.0000460618.02805.ef, Bateman, A. W. (2012). As the empirical literature on the clinical utility of the AMPD grows, there is a need to examine changes in diagnostic profiles and personality expression in treatment over time.
Both Ms. B and Mr. D were being treated from a psychodynamic orientation with transference focused psychotherapy (TFP). Treatment of personality disorder. Mr. D demonstrated a tenuous though growing recognition of the consequences and impact of his behavior; however, this insight amplified his experience of shame and guilt. Diagnosing borderline personality disorder. 29, 13021308. Toward ICD-11: Improving the clinical utility of WHOs International Classification of mental disorders. J. Thus, Mr. Ds treatment goals remained geared toward an increased capacity to integrate a sense of responsibility without shame, tolerance of mutual intimacy in relationships, and setting achievable professional goals. Pincus et al. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Both clinicians are white women, 29 and 30 years old, and presently in their 6th year of doctoral training. Existing AMPD case examples provide illustrations of the AMPDs clinical utility spanning case conceptualization, differential diagnosis, treatment planning, and intervention. Innov. North Am.
He began weekly individual transference focused psychotherapy (TFP; Caligor et al., 2018), increasing to twice weekly sessions after several months, with additional medication management and Dialectical Behavior Therapy skills group.
Aligning with her tendency to experience herself as denied by a withholding other, Ms. B appeared stuck between expectations of interpersonal harm (suspiciousness) and a pervasive fear of rejection amplified by an impaired capacity to care for herself (separation anxiety). 12, 133155. Aim 2 of this presentation focused on assessing changes in AMPD Criterion A and Criterion B across treatment periods with two consecutive therapists. Anales de Psicologa 35, 4757. Examining the Structure and Validity of Self-Report Measures of DSM-5 Alternative Model for Personality Disorders Criterion A. J. Although Criterion A and B provide a clear picture of progress as noted above, the AMPD also highlighted emerging targets for treatment. A meta-analysis of normal and disordered personality across the life span. Future exploration of the AMPDs clinical utility in assessing the full spectrum of personality functioning (i.e., non-pathological to pathological) and in conjunction with other diagnostic presentations is warranted. Personal. Early treatment goals largely centered on containing acting out behaviors such as substance use, risky sexual behavior, and inconsistent attendance, increasing Mr. Ds capacity to integrate a sense of responsibility without risk of shame, helping Mr. D to tolerate imperfection in intimate relationships, and to set reasonable proximal and distal goals for himself in terms of employment. 2021, 133. Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure.
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