In the field of mental health, the study of personality and temperament has largely developed separately from the Diagnostic and Statistical Manual of Mental Disorders (DSM) system. This has resulted in implications for assessment methods. For instance, several semistructured interviews have been introduced to assess the diagnostic criteria for specific disorders. The Schedule for Affective Disorders and Schizophrenia (SADS) was the first such interview, providing detailed information on schizophrenia and affective disorders even before the release of DSM-III. Subsequently, the Anxiety Disorders Interview Schedule (ADIS) was developed, focusing on anxiety, depression, and related disorders.
An Overview of Assessment Tools for Neuroticism
The Anxiety Disorders Interview Schedule (ADIS) was initially developed in 1981 to align with the DSM-III (Barlow, 1987; Di Nardo, O'Brien, Barlow, Waddell, & Blanchard, 1983). It was later revised to correspond to the DSM-III-R (Barlow, 1988; Di Nardo, Moras, Barlow, Rape, & Brown, 1993), DSM-IV (Brown, Barlow, & Di Nardo, 1994a; Di Nardo, Brown, & Barlow, 1994), and DSM-5 (Brown & Barlow, 2014). In comparison, the Structured Clinical Interview for DSM Disorders (SCID; Williams et al., 1992) covers a broader range of disorders but offers less detailed information on each specific disorder.
Semistructured diagnostic interviews, which utilize categorical or prototypical classifications, have made significant contributions to the field. Firstly, they have greatly aided the conduction of clinical trials by enabling researchers to accurately define their sample and assess whether patients still meet the criteria for targeted disorders after receiving research treatment. Secondly, in clinical settings, these interviews assist clinicians in making challenging differential diagnoses and facilitate effective communication among professionals. Lastly, structured diagnostic interviews are commonly used in training programs to familiarize trainees with diagnostic criteria, thus embedding symptom-focused categorical conceptualizations of psychopathology within our mental health system.
In addition to comprehensive interview tools, there has been an increase in the availability of more specific clinician-rated and self-report measures for individual diagnoses since the DSM-III era. Examples of interview-based measures for anxiety, depressive, and related disorders include the Panic Disorder Severity Scale (Shear et al., 1997), the Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987), the Yale-Brown Obsessive-Compulsive Scale (YBOCS; Goodman et al., 1989), the Generalized Anxiety Disorder Severity Scale (GADSS; Shear, Belnap, Mazumdar, Houck, & Rollman, 2006), and the Hamilton Depressive Rating Scale (HDRS; Williams, 1988). Moreover, numerous self-report measures assessing the severity of specific DSM disorders have also been developed.
Assessment of Neuroticism in a Categorical Approach
Traditionally, personality assessment and symptom assessment have followed separate paths. While there is a shared nomenclature like the DSM for determining the presence and severity of psychopathology, personality assessment methods have varied widely depending on the assessor's theoretical perspective. In an influential work, Wiggins (2003) outlined five paradigms for personality assessment: personological, psychodynamic, interpersonal, multivariate, and empirical. The absence of a unified system to approach personality has led to fundamentally different interpretations and measurement approaches. Thus, the question "What is personality and how do we measure it?" yields diverse answers across these paradigms (Wiggins, 2003, p. 1).
In the personological tradition, personality assessment focuses on an individual's life story, examining themes derived from personal narratives. On the other hand, the psychodynamic paradigm emphasizes implicit and unconscious dynamics, utilizing indirect methods such as interpreting inkblots (e.g., Rorschach inkblot task; Rorschach, 1942) and storytelling tasks (e.g., Thematic Apperception Test [Murray, 1943], Object Relations Inventory [Blatt, Wein, Chevron, & Quinlan, 1979], and Washington University Sentence Completion Task [Hy & Loevinger, 1996]).
The interpersonal paradigm focuses on studying how individuals interact with others, considering aspects of agency and communion. Various assessment tools have been developed based on an 8-point interpersonal circumplex with two orthogonal axes. Examples of these tools include the Interpersonal Adjectives Scale (Wiggins, 1995), the Inventory of Interpersonal Problems—Circumplex (Alden & Pincus, 1990), and the International Personality Item Pool—Interpersonal Circumplex (Markey & Markey, 2009). These instruments help in understanding interpersonal dynamics and behaviors.
The multivariate approach to personality assessment involves factor analyzing how individuals describe each other, which consistently reveals five broad domains of personality, as discussed in Chapter 1. The Revised NEO Personality Inventory (NEO-PI-R; Costa & McCrae, 1992) is considered the gold-standard assessment tool within this approach. Additionally, Eysenck's Personality Questionnaire (Eysenck & Eysenck, 1975) falls under the multivariate paradigm for understanding individual differences, as described by Wiggins (2003). In contrast, the empirical paradigm identifies important dimensions of personality based on correlations with relevant criterion variables. For instance, items in the Minnesota Multiphasic Personality Inventory (MMPI) were selected based on their predictive ability, regardless of their face validity. The lack of integration between diagnostic and personality assessment approaches may, in part, stem from the absence of a unified framework to understand an individual's character.
Limitations of Single-Diagnosis Treatment Protocols
The categorical-prototypical approach utilized in DSM-III (American Psychiatric Association, 1980) and its successors has limitations, prompting some experts to propose a return to a more dimensional understanding of psychopathology (Blashfield et al., 2014). One concern is that many diagnoses share similar criteria and often co-occur, suggesting that enhanced diagnostic reliability may come at the expense of validity. In other words, our field may be overly focused on categories that are essentially minor variations of broader underlying syndromes (Andrews, 1990, 1996; Blashfield et al., 2014; Lilienfeld, 2014).
It is widely recognized that many disorders share common biological and psychological mechanisms that contribute to their development and persistence (e.g., Brown et al., 1998; Brown & Barlow, 2009; Cisler, Olatunji, Feldner, & Forsyth, 2010; Deacon & Abramowitz, 2006; Duval, Javanbakht, & Liberzon, 2015; Fledderus, Bohlmeijer, & Pieterse, 2010; McEvoy & Mahoney, 2012). This highlights the possibility that the current categories in the DSM may have limited validity.
Furthermore, with the focus of treatment development and testing primarily centered around the discrete disorders outlined in the DSM, there has been a proliferation of treatment manuals attempting to cover the entire range of psychopathology. This presents several challenges. Firstly, considering the high prevalence of diagnostic comorbidity among DSM disorders (e.g., Brown et al., 2001a; Kessler et al., 1998), it is concerning that protocols designed for single diagnoses offer limited guidance on addressing commonly co-occurring conditions. Research indicates that when comorbid disorders are present, single-diagnosis protocols yield poorer outcomes for the primary targeted disorder (Craske et al., 2007; Gibbons & DeRubeis, 2008; Steketee, Chambless, & Tran, 2001). Additionally, the existence of numerous treatment protocols, each targeting a single disorder, places a significant burden on therapists. To adhere to empirically supported approaches, therapists may require costly training for multiple interventions (McHugh, Murray, & Barlow, 2009), potentially diminishing their enthusiasm for their implementation.
The Dimensional Approach to Diagnosis of Neuroticism
To address the limitations of categorical classification, there have been suggestions to adopt a system that incorporates dimensional elements (e.g., Maser et al., 2009). One prominent example is the alternative model for classifying personality disorders in DSM-5 (American Psychiatric Association, 2013), which will be discussed in detail below. This model was developed in response to overlapping symptoms and high rates of comorbidity among DSM personality disorders, low reliability and significant heterogeneity within specific diagnoses, and an excessive reliance on the unspecified personality disorder category (Krueger, Hopwood, Wright, & Markon, 2014; Widiger & Trull, 2007).
The categorical approach to these disorders has been identified as particularly weak and in need of replacement. The alternative model in DSM-5 introduces severity ratings for a range of traits, allowing for greater specificity in describing the underlying deficits that contribute to symptoms (Hopwood, Thomas, Markon, Wright, & Krueger, 2012). Similar models have been proposed for common Axis I disorders (Brown & Barlow, 2005, 2008), and there are ongoing efforts to develop a comprehensive dimensional taxonomy of all psychopathology (Kotov et al., 2017). These dimensional models highlight specific features such as hostility, grandiosity, and intimacy avoidance, which can then be targeted in individualized treatments instead of relying on a one-size-fits-all approach based on categorical diagnoses.
DSM-5 Alternative Model of Neuroticism
Calls for a dimensional approach to diagnosing personality disorders have been present since the publication of DSM-III (Zachar & First, 2015). During the development of the fifth edition of the manual, the Personality and Personality Disorder Work Group carefully considered the inclusion of dimensional elements. The group examined competing proposals that reflected arguments similar to those seen during the development of DSM-II. On one side, clinical experience supported the existence of discrete personality diagnoses, while emerging empirical data suggested that personality pathology could be better captured through dimensional ratings. To address this debate, the Work Group proposed a hybrid approach that incorporates dimensional elements while maintaining the existing DSM categories with established clinical support (Krueger, Skodol, Livesley, Shrout, & Huang, 2007b).
The alternative model of personality disorders (AMPD) is presented as an empirical and pantheoretical approach to comprehending personality pathology and making diagnoses (American Psychiatric Association, 2013). Despite receiving approval from the DSM-5 Task Force, the Board of Trustees of the American Psychiatric Association opted to maintain the traditional categorical approach in the latest edition of the manual, essentially replicating the Personality Disorders section of DSM-IV. Consequently, the AMPD was designated as an "alternative model" that would be subject to further investigation in the future.
In DSM-5, the alternative model of personality disorders (AMPD) can be applied through the diagnosis of "Other Specified Personality Disorder" (301.89). The AMPD requires the satisfaction of seven general criteria. The first criterion, Criterion A, involves evaluating the level of personality function, which includes assessing aspects of self such as identity and self-direction, as well as interpersonal functioning such as empathy and intimacy. These areas of functioning are considered crucial in defining the shared features of personality disorders that differentiate them from healthy personality and other types of psychological disorders (Pincus, 2011).
Psychodynamic, Interpersonal, and Personological Approaches on Neuroticism
Criterion A encompasses elements from Wiggins's psychodynamic, interpersonal, and personological approaches to personality assessment, as discussed earlier in this chapter. It focuses on factors such as self-other boundaries, dynamics of self-esteem regulation, and interpersonal relatedness (Hopwood, Schade, Krueger, Wright, & Markon, 2013). Moving on to Criterion B, it involves evaluating dimensional personality traits that are grouped into five overarching domains, each consisting of 25 specific facets. The levels observed on these facets help determine the presence of a particular personality disorder.
Criterion B in the AMPD aligns with Wiggins' empirical, multivariate approach to personality assessment. It incorporates five broad traits: negative affectivity, detachment, antagonism, disinhibition, and psychoticism. These traits are similar to the dimensions of the five-factor model (FFM), although they are labeled differently. The developers of the AMPD consider this nosological scheme to be a combination of traditional and innovative approaches, benefiting from the wisdom of various paradigms of personality assessment (Waugh et al., 2017, p. 4).
Criteria C through E in the AMPD introduce additional factors to consider when making a mental health diagnosis. These include the pervasiveness and stability of the personality disorder, the age of onset, differentiation from other mental disorders, and the ability to distinguish it from the effects of substances, developmental stages, or sociocultural factors. These criteria contribute to a comprehensive understanding of the individual's condition and help guide the diagnostic process.
In the AMPD, a hybrid categorical/dimensional approach is used to diagnose specific personality disorders. By combining trait ratings through algorithms, six personality disorder categories can be identified: antisocial, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal personality disorders (American Psychiatric Association, 2013). For instance, in the case of antisocial personality disorder, after confirming the presence of Criterion A, the disorder can be represented by a combination of trait facet dimensions such as manipulativeness, callousness, deceitfulness, hostility, risk taking, impulsivity, and irresponsibility (Waugh et al., 2017).
It is important to note that maladaptive personality functioning can exist beyond these six categories. In such cases, the AMPD allows for the coding of "personality disorder-trait specified." This approach involves describing clinically significant traits rather than using shorthand categories that represent specific constellations of traits. This provides a more nuanced understanding of personality pathology and allows for a comprehensive assessment of individuals.
Understanding Neuroticism in the Alternative Model of Personality Disorders
Negative affectivity in the AMPD represents excessively high levels of neuroticism. In DSM-5, this construct is defined as the frequent and intense experience of various negative emotions, including anxiety, depression, guilt/shame, worry, and anger (American Psychiatric Association, 2013, p. 779). The negative affectivity domain is further divided into specific facets, which include emotional lability, anxiousness, depressiveness, perseveration, submissiveness, and separation insecurity.
In the context of the six personality disorder categories retained in DSM-5, facets of negative affectivity play a role in the identification of avoidant personality disorder (specifically anxiousness), borderline personality disorder (involving anxiousness, depressivity, emotional lability, and separation insecurity), and obsessive-compulsive personality disorder (specifically perseveration). These facets help capture the unique features and manifestations of these personality disorders within the framework of the AMPD.
The majority of research on the facets of the Alternative Model of Personality Disorders (AMPD) has focused on their relationship with traditional personality disorder categories. A recent meta-analysis conducted by Watters, Bagby, and Sellbom (2019) examined 25 different studies that measured the AMPD traits and at least one traditional personality disorder diagnosis. The results of the meta-analysis indicated overall support for the proposed facets of each personality disorder within the AMPD. However, it was also found that some categorical diagnoses were associated with additional facets beyond those proposed by the AMPD, suggesting weak discriminant validity for these diagnoses.
A Tool for Measuring Severity of Neuroticism
The Levels of Personality Functioning scale (LPFS), utilized in DSM-5, serves as a measure for operationalizing and assessing the self and interpersonal dysfunction described in Criterion A. This scale, developed by Bender, Morey, and Skodol (2011), consists of four constructs: identity, self-directedness, empathy, and intimacy. Raters are required to match patient behavior to prototypical manifestations of each construct, which are ordered by severity. This allows raters to determine the overall severity of personality disorder for a patient. Empirical research examining the validity of Criterion A and LPFS assessment indicates that scores of moderate or higher on the LPFS demonstrated a sensitivity of 84.6% and a specificity of 72.7% in correctly classifying patients who met the criteria for at least one traditional personality disorder diagnosis (Morey, Skodol, & Oldham, 2014). Furthermore, Criterion A provided significant additional predictive validity in relation to functional impairment and prognosis, beyond the combined contribution of the 10 traditional personality disorder categories (Morey et al., 2014).
When it comes to assessing the personality traits encompassed by the AMPD Criterion B, our focus on neuroticism within mental health classifications becomes highly relevant. These traits can be systematically evaluated using the Personality Inventory for DSM-5 (PID-5: Krueger, Derringer, Markon, Watson, & Skodol, 2012). The PID-5 offers various versions for self-report, reports from others, and clinician assessments, including a shortened version.
In general, the traits included in the AMPD have been derived from factor analysis using the PID-5 in large representative population samples. It is not surprising, then, that the factor structure of the AMPD traits has been replicated in other samples, such as undergraduates, community samples, and informant reports (Creswell, Bachrach, Wright, Pinto, & Anse, 2016; Morey, Quilty, Bagby, & Krueger, 2013; Wright et al., 2012). Moreover, the PID-5 has received empirical support for its content validity, indicating that it measures what it intends to measure (Anderson et al., 2013; Hopwood, Wright, Ansell, & Pincus, 2013b). The PID-5 also demonstrates stability over time (Wright et al., 2015). Additionally, in terms of criterion validity, the PID-5 traits have been found to predict future dysfunction, and changes in individual traits over time correspond with changes in functioning (Wright et al., 2015). Unlike the previous approach of assessing personality and mental disorders separately, the PID-5 represents an innovative advancement by capturing these related constructs simultaneously.
Exploring the Functional Assessment in the Unified Protocol for Neuroticism
When it comes to disorders within the neurotic/internalizing spectrum, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) offers a functional assessment that aligns well with hierarchical, dimensional models of personality. In the upcoming chapter, we will delve into the details of the UP, but for now, it's important to note that this assessment provides a practical clinical interview that can be easily administered in busy practice settings. It allows professionals to gather essential information at both the spectrum level, focusing on evidence of frequent and intense negative emotions, as well as at the level of specific symptoms or components. For example, it helps identify behaviors like avoidance of public transportation, checking behaviors, or rumination that are relevant to understanding and addressing the individual's condition.
The functional assessment in the Unified Protocol (UP) does not follow the traditional approach of grouping symptoms into specific DSM diagnoses. Instead, it focuses on understanding how all these behaviors serve the purpose of avoiding uncomfortable emotions. These avoidance behaviors stem from a negative reaction to emotional experiences, which serves as a crucial intermediate mechanism between personality and symptoms. This mechanism is not adequately addressed in proposed dimensional models of classification. By conducting a functional assessment, clinicians can identify a small set of transdiagnostic mechanisms that can be targeted for change during treatment.