Revolutionizing Personality Disorder Diagnosis: Understanding the DSM-5's Alternative Model of Personality Disorders (AMPD) and its Clinical Implications with Dr. Robert Krueger Part 1

Join in on another brilliant episode of Psychotherapy & Applied Psychology. This week, Dan is joined by Dr. Robert Krueger and discuss the ongoing studies of personality disorders.

Dr. Krueger is a clinical psychologist and member of the DSM-5 Personality Disorders Workgroup. Dan and Dr. Krueger discuss the importance of understanding a person's personality in clinical case conceptualization as well as the tension between wanting to make psychiatric classification more scientifically justifiable and clinically beneficial. Dr. Krueger provides an overview of the Alternative Model for Personality Disorders (AMPD) and the criteria for diagnosis, as well as the distinction between criterion A (self-related dysfunction) and criterion B (personality traits).

Stay tuned for Part 2!

Special Guest:
Dr. Rober Krueger
HiTop Website
The Personality Inventory for DSM-5 (PID-5)
Practitioner's Guide to the Alternative Model of Personality Disorders

Keywords: personality disorders, DSM-5, clinical case conceptualization, alternative model, AMPD, diagnostic criteria, self-related dysfunction, personality traits, psychiatric classification

Takeaways

Understanding a person's personality is important in clinical case conceptualization.

The decision-making process behind the alternative model for personality disorders involved considering the scientific evidence and the impact on individuals who have already been diagnosed.

The Alternative Model for Personality Disorders (AMPD) includes criterion A (self-related dysfunction) and criterion B (personality traits).

There is a tension between making psychiatric classification more scientifically justifiable and clinically beneficial while considering the impact on individuals.

Self-report measures for criterion A may have limitations, and additional perspectives, such as expert judgments and collateral data, can provide a more comprehensive understanding of personality pathology.

Sound Bites

"I find it hard to do clinical case conceptualization without thinking about a person's personality."

"The DSM exerts a strong kind of way of influencing the way people think about cases and in our culture more broadly."

"The DSM-5 Personality Disorders Workgroup had a number of psychologists involved, which is somewhat unusual."

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Transcript

Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a Professor of Counseling Psychology at the University of British Columbia. Welcome to episode number 14 of Psychotherapy & Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way in an attempt to bring new ideas to helping professionals, those training to be helping professionals, and the applied psychology curious. I'd love to connect with you.
Send me a text or leave me a voice message. You can find links in the episode show notes, and if you're willing, I'd love to know your name and where you're from. This is part one of my conversation on the alternative model of personality disorders.
In this conversation, we discuss what it was like to be on a DSM-5 task force, the decision to create an alternative model for personality disorders, balancing scientific justification with clinical considerations, the personality inventory for DSM-5, also known as the PID-5, which is the self-report measure that corresponds with the alternative model of personality disorders, and the Hierarchical Taxonomy of Psychopathology, or the HITOP model. HITOP is a movement aimed at moving beyond categorical mental health diagnoses to a dimensional approach. In the show notes, I've included links to the PID-5 and to the HITOP website, which is a treasure trove of resources.
Today, I couldn't be more excited to welcome one of the world's foremost experts in personality disorders, and in particular, the Alternative Model of Personality Disorders. He is the Hathaway Distinguished Professor of Clinical Psychology and Distinguished McKnight University Professor in the Department of Psychology at the University of Minnesota. He is the co-editor-in-chief of the Journal of Personality Disorders, and he was part of the DSM-5 Working Group on Personality Disorders.
We begin our conversation with my guest answering my question about how he got into studying personality disorders. So, without further ado, it is my absolute pleasure to welcome Dr. Robert Krueger.
Well, so I was trained as a clinical psychologist, and in the course of that training, I encountered personality in every clinical presentation pretty much. So, I find it hard to do clinical case conceptualization without thinking about a person's personality. I guess it's the way that I would put that.
So, naturally, the part of the sort of existing psychiatric nomenclature that deals with personality explicitly is the personality disorders. But my interests sort of extend beyond the classical personality disorder syndromes described in things like the DSM-4 and so on to just the general idea that a person's personality is an important thing to understand when you're trying to work with them therapeutically.
So, you were involved with the DSM-5 task force. So, how did you get even approached for that?
Well, so for clarity, the DSM-5 efforts are organized by a task force, which consists of the chairs of the workgroups. So, technically speaking, I wasn't a member of the task force per se, although I did attend some task force meetings. I was a member of the Personality and Personality Disorders Workgroup.
Got it.
So, how did I get involved? I got a phone call from Andy Schodl, who was the chairperson of the workgroup one afternoon in my office, asking if I would be interested in being involved. And I said yes.
So I think that the powers that be, right, like the chairs of these workgroups sort of figure out who they might like to have involved and then approach them and see if they're willing to, well, essentially volunteer their time in that manner, right? So you aren't directly compensated for this kind of effort.
And so, I mean, I was thinking about that, that obviously, you're a researcher and done a lot of influential work in that area, and that who these folks choose to put on these working groups is very consequential.
Yeah, for sure.
And so, I was just thinking about like that process for them and their decision-making in terms of who to reach out to, you know?
Definitely, right? I agree about that being consequential for the way in which these things proceed. I mean, I would note that the DSM-5 Personality Disorders Workgroup had a number of psychologists involved, which is not unprecedented, but somewhat unusual, right?
In the sense that the people involved in the task force and workgroups for the DSM are typically psychiatrists in terms of their training and background. But the Personality Disorders was a bit different because there were a number of us who are psychologists by training.
Why do you think that was different for Personality Disorders?
Well, I think there's always been a substantial interest among psychologists in Personality Disorders in a sort of lively literature, right? That's spurred on by psychologists who are interested in those phenomena and are writing about and studying them. And so I think if you sort of tried to figure out who's active and sort of making contributions, you end up with a list that's maybe more dense with psychologists to a certain extent.
I want to be careful though, of course, because I'm not implying that psychologists aren't contributing to other substantive literatures and psychiatric classification, but I think that's probably part of why that happens. And I think there was an interest, right, in DSM-5 in the psychological perspective on Personality Disorders being represented on the workgroup.
So I'm also, I think this is my experience, never having been a part of that, is that for trainees and practitioners, we get this book that's kind of a, whether one is critical of it or not, it's still like this huge thing in our field, whether you're a psychologist, psychiatrist, social worker, it goes on, right? And fascinated by the behind-the-scenes of that. So, and in particular, when I was, you know, I pulled out my DSM and looked, and you know, so you were the, so I'm curious what your experience of that was like, and you also had the role of text coordinator, which I have some guesses as to what that means, but I'm also curious what that means and how that influenced your experience.
Yeah, so there's a couple different parts, I think, to your question, right? There's kind of the gravity, right, of the situation. I've used the phrase, you know, in my writings, epistemic authority, you know, in thinking about the way the DSM impacts, you know, mental health research and practice, right?
And I think that's the way I would conceptualize a lot of that, right? It has a surprising amount of epistemic authority, particularly in the post-DSM-3 era, right? So I think there was less interest in classification as a basis for, you know, clinical case conceptualization and work, and then the DSM-3 exerted a stronger influence, right, on that kind of thing with people's, you know, ideas and things being tethered to the DSM-3 style categories, and that I think continued through.
And so, yeah, I think you're right. The DSM exerts a strong kind of, you know, what do we know and how do we know it, kind of way of influencing the way people think about cases, and in our culture more broadly, right? So plenty of people in the world at large, right, are familiar with some of those rubrics, some of those diagnoses, and attach a lot of meaning to those diagnoses in terms of how they think about themselves and others.
So yeah, it has a tremendous impact on our culture and certainly on mental health practice. And then the second part of your question was about my specific role on the workgroup. I mean, so the text coordinator thing was just, you know, sort of looking over all the text and making sure that it's coherent because there are different writers contributing to the different parts of it.
So that was a specific task that I had to deal with.
So is that sort of like an editor role?
Yeah, basically for the PD parts of the book. That I would say was definitely something I did, but it wasn't the bulk of my effort, right? The bulk of my effort in the context of all of that was the creation of a personality inventory for DSM-5, which I created with a number of colleagues, but kind of led that effort, led the effort to assemble that instrument.
So before we leave, how did that work? So you have this working group, so are you all meeting regularly? Who's setting the agenda?
What does it actually look like?
Yeah, there were, as I recall, pretty regular meetings. Some of them by, I want to say, phone at the time. I think this was kind of a pre-Zoom era, right?
So I want to say those meetings were by phone.
Yeah, it must have been.
And a number of them, particularly at the beginning, involved flying to DC, right, or near DC, right? Because the APA headquarters is in Alexandria, I think, right? Just across the river from DCA, from Reagan.
So I remember flying into that airport and going right across the river and meeting at their headquarters on a number of different occasions, or nearby hotels. So yeah, there was a fair amount of meeting as a group. And yeah, the agenda is set by the chair largely, in terms of what the content and nature of those meetings was.
And then it's sort of, I mean, and in particular with the personalities, the personality disorders, the way it came out, is that there was, right, DSM-4, we have these 10 personality disorders in these three different clusters as they're sort of organized. And then, but DSM-5, there's this, well, so I guess that persisted more or less into DSM-5. But then you and your colleagues, but you were really a big push into creating this alternative model for personality disorders.
So was, and we'll dig way into that in a moment, but was that, like, how, like, obviously, the powers that be didn't have to do that. They could have stuck with the sort of categorical, the 10 categorical diagnoses and not included that alternative model or sort of given space for that, right? Because decisions have to be made, but they chose to.
So how did that, what's your sense of how that came to be?
Well, I think there was a strong interest on the part of some of the task force leaders, like Daryl Regier and David Kupfer, in the personality disorders moving toward a more dimensional kind of approach, because, you know, the empirical literature is overwhelmingly aligned with that kind of conceptualization. There's very little evidentiary basis for the idea that personality disorders can be classified naturally into 10 putatively discrete and separable categories. So that's, I think, well established and was established many years ago, definitely before the DSM-5 kind of got rolling.
So there was an interest in bringing the personality disorders more in line with the empirical literature. And that became a kind of complex endeavor because, well, you have different options for how to revise them. The resulting model ends up to be markedly different in certain respects from the classical model.
And that raises numerous issues in terms of, well, this is going to look very different from what people are accustomed to from DSM-4. So to make a long story short, everything inherent in that kind of situation came into play. Can we deal with something that's this different?
What about training people? What about the substantial literatures that exist on at least some of these classical DSM-4 style personality disorder categories? And so on and so forth.
And that dynamic continues to play out to this day. But you're right in noting that ultimately the way that played out was, here's the new model printed in the DSM-5 and hopefully people will be interested in working with it and studying it and this kind of thing. And I think that has played out as intended.
There's a quite substantial, I would say, literature on the alternative model of personality disorders. So one of the things I do is edit this journal along with them. My colleague John Oldham, we edit a journal called the Journal of Personality Disorders.
A lot of what we receive in that space, and you can see this in other journals as well, is focused around studying the AMPD. So it has had that kind of impact. It resulted in a lot of people being interested in wanting to study it and seeing how it functions, and this kind of thing.
So at this point, there's a substantial literature supporting the reliability and validity and clinical utility and so on of the AMPD kind of model. So then I think the question becomes, how does it evolve from this point forward?
Well, I think, so just maybe to put a bow on it, in fact, the work that you and a lot of your colleagues are doing with the high top model, the high top approach, that which maybe we'll get into, like that would, that's sort of expanding, at least how I see it, this more dimensional approach to psychiatric disorders across the board, right? So beyond just personality disorders. And so, but the decision was made, maybe the research wasn't as far along, maybe that's why.
I just think that it's interesting that for the Personality Disorder Group, that the decision was made to put this dimensional approach in DSM-5, but it wasn't made for some of the other, you know, areas. And so I think it's, and the reality is these are just, you know, while a lot of these people are pretty much all experts and really thoughtful about these things, that it's just, it's interesting that that decision was made for the Personality Disorders, but not for the others. So that just sort of, you know, and I'm not necessarily even being critical of the others.
I guess I'm more being, my experience of it is more like, wow, there must have been some really, you know, forward thinking people pushing the personalities disorder, writing in DSM-5.
I mean, that's how I sort of perceived the scholarly landscape around that time and have written things to kind of follow on that kind of theme, right? So the idea that the personality disorder is the vanguard of psychiatric nosology, right, is something that I've written about and believe there's good support for that kind of conceptualization, right? That that literature is further along in terms of tackling issues inherent in attempting to impose categories on a reality that's not, in fact, categorical, right?
So I think that's why you see that kind of thing of personality disorder as being the vanguard in the context of official psychiatric nosologies. But again, for various reasons, some of which are entirely understandable, right? There's a lot of inherency in systems like the DSM because it is indeed disruptive, right, to say, okay, well, we're going to do something completely different, right, at this stage.
It's going to look nothing like the previous DSM because so much is framed around it in terms of training programs, in terms of the rubrics people use in their everyday clinical work, and in terms of very practical functions of a nosology, like reimbursement and so on, right? So this presents a sort of, well, fascinating intellectual situation to me, right, because you've got a scientific literature on the one hand that's running, you know, pretty counter to the idea that there are these kinds of psychiatric categories in nature and a whole sort of infrastructure that's based on these categories in every practical respect. So that to me is fascinating and fun to think about and write about and work on, because the question is, well, how do you bring these things more into alignment over time?
So when I reflect on the need for that alignment, which I think is clear, right, there's a need, right, for classificatory systems to be based on evidence and not just tradition. So then how do you accomplish that? Well, when you look at where the most sort of action is, I think it is sitting with the personality disorders, because there's just been such a strong historical interest in an alternative to those ten categories.
So that's kind of my take on this. And one of the reasons I find it interesting to think about and work on and write about, you know.
One thing you touched on there and something that when I was like reading some of your work, a feeling that I had was this tension of wanting to make, as we move forward, wanting to make it more scientifically justifiable. And to an extent, I would argue, clinically beneficial. I think those two things go hand in hand.
But then there's this other tension or this other pull, which is that we've had this other model. And so where we have these discrete disorders, these discrete personality disorders, and it's not just, oh, well, it would be a big ask to train everybody on this new model. It's also that you have real human beings who have these diagnoses of these disorders and are getting certain supports, services because of that.
And so you don't want to disrupt that because these are real human beings. And that just really jumped out at me in reading your work. And I sort of felt that tension in me and sort of had this empathic experience of you and your colleagues of like, man, it's a rock and a hard place.
Because as the scientist and to an extent as the person who wants to create something more beneficial for clinicians, there's just, let's just, this is my experience, let's just drop this old model and move on to this new one. But then also as a human being who cares about other people, it's like, well, there will be some negative consequences to doing that.
Yeah, I mean, I think you're right to highlight that tension. I think that I've tried to be careful, right, in these kinds of conversations and public presentations and then writing about exactly that tension because many very beneficial and good things have been done surrounding some of the classical PD rubrics. I would call out borderline in particular, right?
I think that there's a substantial group of clinicians, scholars, patients, family members and so on, right, who've coalesced around that construct, right, in a way that I think has largely been beneficial to people who are suffering in that way. And so in sort of reformulating things, no one wants to be careful about how that effort has been beneficial to people. And the sort of destigmatization of the borderline syndrome, right, is an important, I think, accomplishment in that area.
And the recognition of it as a legitimate major kind of psychiatric problem that deserves, you know, the attention and research dollars and so on of all the classical mood and psychotic disorders, right, which have been the focus of a lot of efforts through the years and where research dollars have pointed. So I think that's all incredibly important.
So you want to be careful about that while still kind of moving toward an understanding of important issues that a more dimensional approach can address. So, for example, what is the psychological quintessence of borderline personality disorder is debatable because the criteria that we described, for instance, in the DSM-4 are highly heterogeneous in terms of what they're getting at, at least in my reading. And so you can end up with people who have emotional dysregulation and sort of a generalized impulsivity.
You can end up with people who are highly emotionally dysregulated with reasonable impulse control. You can end up with different kinds of people who might fall within the same cumulative diagnosis, and that heterogeneity has important clinical consequences that you want to be able to characterize without amalgamating all of that into one diagnostic category. So there are important case conceptualization advantages to thinking about the person's entire personality and not reducing that complexity to one diagnostic label.
So I think it's a matter of kind of explaining stuff like that step by step and moving toward what are hopefully more useful. Empirically based is important, obviously, but clinically useful kinds of ways of thinking about the psychopathology that we see in the people who come to us because they're suffering. And yeah, I think that needs to be done very carefully.
I want to mention, I think it was, at least I learned this from Steve Hyman, who was a previous director of NIMH, this idea of we're trying to fix a plane while it's in flight, right? But that's really what we're trying to do, right? We can't land the plane and say, all right, look, we're not going to provide services for a year while we get our acts together, right?
Because we are trying to help people every day as a profession. So, you know, how to then balance those considerations and move forward, there aren't many tensions in that space. But yeah, my mind naturally goes to kind of more multidimensional case conceptualization, because I just have a really hard time thinking of people in terms of what is presumably somewhat indelible categories, right?
Even in things that are very, I guess, commonly encountered in the clinic, like someone who's quite depressed. Some of those people are very antagonistic, because that's another domain of personality that's separate from neurotic domain. Some of those people are very agreeable and pleasant, right?
Those differences have a big impact on how you end up working with somebody, even if the putative presenting complaint and associated, you know, primary diagnosis is something like recurrent major depressive disorder. I just, it's hard for me to think about people without thinking about, well, who is this person? Like, what are their personality style and how does it intersect with whatever they're going through that's kind of like the acute or what DSM might call the more florid aspects of the clinic presentation.
So here we are in 2024. How at this point do you understand optimally, right? So not just being married to DSM-5, but how do you, how have you come to understand if you're to say, you know, this is, this is the my best understanding of truth of what personality disorders are, right?
Sort of the Platonic ideal. I don't know. What is that?
Where are you with that today?
That's a deep one. I think, well, one way to answer that question is to think about kind of where the field seems to be headed. It's because we could say like the consensus of many people who are working on this might represent something that hopefully like is, you know, slouching toward reality or some phrase like this, right?
And so in that respect, I might mention that, you know, the ICD, right, the International Classification of Disorders, you know, approach to personality disorders that's now codified in the 11th edition looks a lot like the AMPD model from DSM-5. So the international kind of perspective looks more like this kind of dimensional approach that's epitomized by things like the AMPD and less like the classical DSM-4 style categories. So there's a sense in which, you know, one could argue that things are moving this direction.
And if that's in any way indicative of kind of like the modal opinion in the field or some construct like that, because there's still obviously a diversity of approaches and opinions and so on. And I think it's hard in a field that's this challenging scientifically to say that there exists one approach, right? That in some way trumps the other approaches based on such a substantial evidentiary basis that it would almost be like malpractice, not to think that way.
I think that's not really the situation we're in, right? Because these constructs are so challenging to think about scientifically. But yeah, if you look at the preponderance of the sort of thinking and evidence and kind of like where the field is, I think it moves towards something that looks more like the AMPD and less like the classical categories.
And, you know, science continues to progress. We may learn other things, right? The challenge, things about that conceptualization.
But at least in a snapshot way, like at this moment in the history of these disciplines, I think that's close to what I think would be, you know, a typical kind of opinion.
So I think this is probably, so I'm going to, I think I'm going to come back to this and sort of like push you a little more on like your personal opinion about it. But, you know, whatever, this isn't a this isn't this isn't a peer reviewed journal article. But, but, but we're kind of here, I think, in terms of why don't we get into the alternative model of personality disorders.
And so maybe it would make sense to sort of take these part one, part two, sort of criterion A, criterion B. Yeah, so do you so I could, but it probably would make more sense for you to give sort of the 30 second, 60 second, whatever, overview of the criterion A, and then we can dig into that a little bit.
Yeah, sure. So in the AMPD, as you alluded to, right, the essential criteria, right, although there's other exclusionary criteria, like it shouldn't be a head injury, this kind of thing. But, right, the key criteria are A and B, and A refers to difficulties with self conceptualization, like having a stable sense of who you are and what you're doing in life and interpersonal difficulties that are, you know, closely associated with that.
Right. So lots of conflicts and difficulty dealing with other people successfully and effectively. Right.
That's that's criterion A. It's the conjunction of the self and interpersonal kinds of pathology. And in the AMPD, that's meant to be kind of what separates personality pathology from other kinds of disorders.
At least that's what's positive there. So that's kind of what is PD. It's criterion A.
And then criterion B is meant to give kind of the flavor of the personality disorder by describing the patient's personality in terms of these five broad domains of personality that have been identified empirically time and time again. So one has to do with negative emotionality. Right.
So negative affect and a tendency to experience frequent distressing and unpleasant negative emotions. The second one has to do with detachment. Right.
So sort of being removed from others and interpersonally detached and disinterested. The third is antagonism. Right.
So at its extreme, right, that's hurting other people on purpose and enjoying it or certainly disrespecting the rights of other people. Fourth one is disinhibition. Right.
So acting on impulse without really thinking through the consequences of what might, you know, occur down the line. And the fifth one is labeled psychoticism. Right.
It kind of tries to capture the essence of the things that have classically been called schizotypal kinds of presentations. So unusual beliefs and experiences, perceptual oddities, things of this sort. Right.
So in the AMP PD, the basic idea is you kind of figure out criterion A, right? Is there a personality of sort of present and how severe is it with regard to the person's clarity of self conceptualization and basic interpersonal functioning? And then criterion B allows you to kind of specify the variety.
Right. So what are the most prominent kind of features here in terms of what, how the PD is manifest? So does that kind of address like what is the AMP PD?
So if we were to just hold on, I think in a way criterion B is more interesting to me than I want to get into. But I do think criterion A, okay, so criterion A, the way that I have come to understand it is this is really the distress slash dysfunction criterion. And that's sort of organized in self-related dysfunction, which is as you already said, identity and self-direction, and other related dysfunction, which is empathy and intimacy are sort of the different categories.
So there's sort of these four subcategories, if you will, under this dysfunction slash distress criterion.
And so some of what I've read is some people have argued that this seems more like a single factor, if you will, that's hanging out here. Others have argued, obviously originally, that there are these, whether it's two, self and other, or then the four being what I said earlier. Where are you on that?
So where am I on the kind of structure of criterion A variation?
Yeah, like where do you think, again, 2024, do you think that it does seem like it's four categories, two categories, one category? How do you think about it?
Yeah, well, these things are surely not independent of each other or, to use psychometric jargon orthogonal, right? So they're empirically aligned, right? And so the question is, is there, I suppose, any any utility or evidentiary basis for separating them in that way?
And I think, you know, the challenge is how do you assess and measure this stuff? So based on kind of self-report measures of criterion A features, right, there's plenty of evidence that there's a close correlation between difficulties with self-directedness and things that are more self-focused and the associated interpersonal features that you mentioned, like empathy and intimacy, right? So those things tend to go together, right, such that people who have a lack of self-directedness also have difficulty with perceiving other people empathically.
They're not totally fungible psychologically, though, right? I think that's that seems clear to me, sort of just in terms of clinical thinking, right? Like they're not the same thing psychologically, right?
That a person who is lacking in empathy necessarily lacks self-direction, although one often encounters these things as kind of a mixture of qualities and patience. So I think what's happening there that's useful, right, is fleshing out the broader construct by giving these specific examples versus that someone's positing of a four-dimensional model or something like this, of like Criterion A features. It's more like if you look at everything that's described in Criterion A, you're getting a bigger and clinically richer picture, right, of all the different ways in which the essence of personality disorder can present in the interpersonal and self-domains.
So that's why I think those separate features, which are psychologically separable in my mind, are described in that kind of detail there.
I find that actually really helpful. So that there is a distinction between this sort of self-related dysfunction and other related dysfunction. So there is a distinction there, but they frequently co-occur.
It's not necessary. Right. But it would make sense that if I, so with other related, if I struggle with empathy, that there will be, that if I struggle with empathy, that will also have an impact on my sense of who I am or where I want to go.
Or that those things, I don't know, maybe I'm probably, I'm sort of thinking on the fly here.
Yeah. I mean, I think that's right. I think if a person, I mean, is limited in the psychological machinery necessary to navigate their self-concept, right, it will make it hard to have stable interpersonal experiences and vice versa.
So those things are kind of often flowing together in the course of people's lives, I think. And when I think about people who have these kinds of challenges, like the Criterion A-style features, right, that's what it would, that's what it's like, right, trying to go through adult life. That way is challenging because you can't quite figure out what you're trying to do in a stable way, and that affects how other people perceive you.
And so you can't quite figure out other people's motives because you're not, you know, stable in a certain way psychologically. They can't figure you out, right? And so it ends up being a kind of vicious cycle, right, of self-pathology and interpersonal pathology so that it's difficult in the course of people's lives to tease them apart.
But psychologically, I think you can see that they're kind of different features of a person's psychological makeup and different ways in which, you know, personality pathology can be manifest. Right, so it's like describing the construct in greater detail by giving it more nuance and more features to think about psychologically is the reason, right, that you'd want to describe self and interpersonal features somewhat separately and describe specific instantiations of those kinds of problems.
My understanding of when you and your colleagues were working on this alternative model of personality disorders, one of the goals was to tease apart the dysfunction and the personality traits piece, because historically those have been sort of... you'll see them both in the same criteria or whatever, so is this idea trying to tease those things apart in these two different... which is an extremely challenging aim?
Yeah, yeah. I think that's the intent of separating them for clarity, again, in terms of case conceptualization and the empirical challenge that's arisen, particularly when all this stuff is addressed through self-report, because I want to emphasize that that's an important feature of the literature. But if you're limited to kind of like patient reports, let's call it, on criterion A and criterion B features, they're pretty correlated.
So it's kind of hard to tease them apart, because even in the way you've described it, right, you're talking about criterion A as being, well, distressing, right? And feeling distressed is, of course, the quintessential aspect of negative affect, which is supposed to be a criterion B domain. So if you write these items, write these self-report items, about being distressed in various ways, you're going to get these things to kind of be, you know, lumpy, right?
And so that's part of the challenge. And the other thing maybe to mention in this kind of conversation is that the features kind of come from different literatures, right? Criterion B features kind of arise from this psychometric literature on self-reports of personality and kind of how those data are structured.
The criterion A stuff is kind of coming from a different literature about clinical observations, right, of people who have personality pathology, kind of like what does it mean to be an adult human, right, in terms of the psychological machinery you need to navigate, you know, life, essentially. So in some ways, there's a kind of creative scholarly synthesis sitting there too, that I would allude to, right, that they're coming from different traditions. And so something I wonder about a lot is what are you getting with self-reports of criterion A, right?
I feel sometimes like you kind of need an, this might be the most provocative thing I say all day, but you kind of need an expert clinician in some ways, right, to look at a patient's functioning and presentation in the consulting room and history and the way that they describe other people in their lives and the way they describe important figures historically, kind of the attachment tradition. Like, if you look at that whole picture, you get a clinical sense of criterion A, and that I think is kind of what criterion A is getting at, right? It's recognizing that kind of clinical perspective.
Whereas criterion B is again coming from kind of more the self-report literature. So sometimes I wonder if, you know, in terms of really kind of instantiating the model in everyday practice, criterion A is more about observing the patient over some period of time, and criterion B can be assessed more readily just using something like the PID-5, right, a self-report instrument. Certainly that's the scholarly background of the two criteria.
That I think is clear, because that's kind of how they got in there, right, or where they come from, right, a literature on clinical observation for criterion A, and a literature on kind of like the structure of patient self-reports for criterion B. But it's hard to study clinical perceptions, right? There's much less literature on, you know, expert clinicians judging patients to get assessment data on criterion A.
So it's much easier to do studies where you have self-reports of both. And then in that literature, they're all very correlated with each other because they're all kind of about, you know, dysfunction in some important sense.
So what do you think that the... What's the flaw in self-report for criterion A?
Okay, let me be clear. I don't think it's a flaw. It's more like a limited perspective, right?
In fact, I think it's often remarkable how much validity there is in people's self-reports of their personalities. Because what you're getting is the person's perception of themselves. All I'm trying to allude to is that the person's perception of themselves is only one angle on a person's personality.
And there may be additional validity in having an expert, someone who's familiar with personality pathology, work with the patient over a number of sessions and interview the patient and take a detailed history in terms of getting a more nuanced conceptualization of the person's kind of criterion A status. That's what I'm trying to say. Not that the criterion A self-reports are invalid.
They don't think there's evidence for that. They have validity in an important sense. But just that the patient's self-report is only one angle on this stuff.
There may be a place for expert judgements, because that's the literature that criterion A is coming from. And frankly, for collateral data too, which we tend not to get very routinely for various reasons. If you really want to do a thorough assessment, you kind of want to ask people who know the person, significant others, that kind of perspective, because you're going to get a different angle.
And it's the convergence among those angles, or divergence among those perspectives, that I think has a lot of potential clinical utility. The person says this about themselves, but their wife or whatever is saying something different, what's going on there? Why is there a difference in perception?
And my sense of this, I've seen this kind of thing clinically, is that that's indicative sometimes of personality pathology, that the person's way of thinking about themselves or describing themselves or that kind of thing is different from how they're perceived by others. And it's those disjunctions that are revealing.
So with Criterion B, this is more of the personality, the five personality traits. And so you were the first author on the Personality Inventory for DSM-5, the PID-5, which is a self-report measure. And by the way, I took, in preparation for this, I took the PID-5 and got my own score.
So I was like, you know, that was useful. So and you sort of earlier went through those five different factors, or how do you think about this? How is this different from like the big five, which is the five-factor model of personality, not problematic personality, just sort of a model of human personality in general?
How do you think about personality disorders in relation to personality?
Yeah, no, sure. Let me start just by mentioning, not to be like too self-promoting, but just for clarity, right? The PID-5, there's a manual now, right?
That's been published by the American Psychiatric Association, as well as associated scoring software and stuff. So very recently, like within the last few months, some of the stuff that one might want to have that thing be useful clinically, like a manual that has norms and a way that people can complete it online and the clinician gets a profile, like that stuff is now in place. So just for your audience, right?
If they're interested in it, they might want to look that up.
Yeah, and so that's what... So I took the... I assume that it was correctly normed and everything like that.
But I took one online where I got my report. And it was, you know, it has colors and everything. I mean, it's very nice.
And it was, you know, a nice explanation of the different... of the five and then the... Is it 24 or 25 that fall underneath of those sort of different categories?
So, yeah, no, I think that, you know, for what it's worth, I'm not above... I'm not elevated above the clinical line in any of the categories. But it was still like, you know, it's still nice.
It's like, oh, yeah, that's something I struggle with. So I think it is something that is very, you know, for the clinician can be useful. And it's, you know, the way it sort of pops out, you know, it can be very useful, I think, to also talk with clients about to say, you know, for them to say, oh, yeah, that is where I struggle.
But anyway, yeah, I'm right there with you.
Yeah, that would be my perspective on that kind of thing clinically, right? I'm a proponent of therapeutic assessment, right? The idea that you have to have a relationship with the person, I think, first, right?
Like some working relationship. But once you've established some of that, I think people often find this kind of thing insightful and helpful to understand kind of like where the rough edges might be, if you will, right? Something like the PID-5 is describing.
But then to return to your question about normative personality, right, and the big five, five factor model tradition and the PID-5, I mean, there's plenty of evidence, a whole cottage industry showing that these things are highly overlapping, right? So it's not too accidental, right? I would emphasize that the way the PID-5 came about is take personality disorder qualities that are described in DSM-4, but kind of reformulate them empirically, right?
So instead of, in an a priori sense, kind of forcing them into these 10 categories, right? Get data on them from people's reports, right? And then do psychometric kinds of things to figure out how they go together naturally.
And lo and behold, you end up with a structure that's very similar to the structure of normative personality, right? Which does suggest, and people have studied this, right? There's a literature on this, right?
That normative and maladaptive personality are on the same continuum largely, right? That there's not a categorical distinction there. So that the PID-5 is describing maladaptive variance of the normative five-factor model, is I guess how I would put that.
And I think there's plenty of literature that supports that perspective.
So is this a reasonable interpretation that disordered, if we want to use that word, let's just use that word and you can edit it if you'd like, if you have a better word, but sort of disordered personality is regular personality, but turned up to a volume that becomes problematic.
Yeah, or expressed in ways that are not typical.
That's a wrap on part one of my conversation with Dr. Robert Krueger. Please be sure to check out part two, which drops next week. And please also reach out by sending a text or leaving a voice message using the links in the show notes.
Until next time!