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WIDIGER AND SIMONSENALTERNATIVE DIMENSIONAL MODELS OF PD

ALTERNATIVE DIMENSIONAL MODELS OFPERSONALITY DISORDER:FINDING A COMMON GROUND

Thomas A. Widiger, PhD, and Erik Simonsen, MD

The recognition of the many limitations of the categorical model of per-sonality disorder classification has led to the development of quite a num-ber of alternative proposals for a dimensional classification. The purposeof this article is to suggest that future research work toward the integra-tion of these alternative proposals within a common hierarchical struc-ture. An illustration of a potential integration is provided using theconstructs assessed within existing dimensional models. Suggestionsfor future research that will help lead toward a common, integrativedimensional model of personality disorder are provided.

The many limitations of the categorical model of personality disorder classi-fication are well recognized (Clark, Livesley, & Morey, 1997; Cloninger,2000; First et al., 2002; Livesley, 2003; Rounsaville et al., 2002; Oldham &Skodol, 2000; Trull & Durrett, in press; Tyrer, 2001; Widiger & Samuel, inpress). One expected response is proposals for dimensional classifications.If the authors of a future edition of the diagnostic manual shift toward a di-mensional model, they will have quite a few alternative proposals to con-sider. The purpose of this presentation is twofold. We will first simplydescribe alternative proposals. More importantly, we suggest that future re-search work toward an integration of these alternative models within acommon hierarchical structure.

EIGHTEEN PROPOSALSTable 1 provides the citations for 18 proposals, along with (in most in-stances) an instrument commonly used for their assessment. Space limita-tions prohibit a thorough summary of each of them. They involve four basicstrategies.

Journal of Personality Disorders, 19(2), 110-130, 2005© 2005 The Guilford Press

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From the Department of Psychology, University of Kentucky (T.A.W.) and the Institute of Per-sonality Theory and Psychopathology, Fjorden, Denmark (E.S.).Address correspondence to Thomas A. Widiger, PhD, Department of Psychology, University ofKentucky, Lexington, KY 40506-0044; E-mail: [email protected].

DIMENSIONAL PROFILE OF EXISTING (OR MODIFIED) DIAGNOSTICCONSTRUCTS

One approach is to simply provide a dimensional profile of the existing (orsomewhat revised) diagnostic categories (Widiger & Sanderson, 1995).Three such proposals have been developed by Oldham and Skodol (2000),Tyrer and Johnson (1996), and Westen and Shedler (2000). An advantage ofthis approach is that it would retain the existing diagnostic constructs (e.g.,antisocial), thereby easing the transition to a dimensional classification. Alimitation of this approach is that there might be more fundamental dimen-sions of maladaptive personality functioning that cut across the existingpersonality disorders, contributing to their diagnostic co–occurrence.

DIMENSIONAL REORGANIZATION OF PERSONALITY DISORDERSYMPTOMS

A second approach is to reorganize the existing (and perhaps expanded) di-agnostic criterion sets into more clinically useful and empirically valid di-mensions of maladaptive personality functioning. Four such proposals have

ALTERNATIVE DIMENSIONAL MODELS OF PD 111

TABLE 1. Eighteen Alternative Proposals for aDimensional Model of Personality Disorder

Citation Assessment Instrument Acronym

Proposals to provide dimensional representation of existing constructs:Oldham & Skodol (2000) Any existing personality disorder instrumentTyrer & Johnson (1996) Personality Assessment Schedule PASWesten & Shedler (2000) Schedler & Westen Assessment Procedure–200 SWAP–200

Proposals to provide dimensional reorganization of diagnostic criteria:APA (2000) Any instrument for existing cluster arrangementLivesley (2003) Dimensional Assessment of Personality

Pathology–Basic QuestionnaireDAPP–BQ

Clark et al. (in press) Schedule for Nonadaptive & Adaptive Personality SNAPHarkness & McNulty (1994) Personality Psychopathology–5 PSY–5Shedler & Westen (2004–b) Schedler & Westen Assessment Procedure–200 SWAP–200

Proposals to integrate Axes II and I with respect to common spectra:Siever & Davis (1991) NoneKrueger (2002) None

Proposals to integrate Axis II with dimensional models of general personality structure:Eysenck (1987) Eysenck Personality Questionnaire EPQ

Eysenck Personality Profiler EPPCloninger (2000) Temperament and Character Inventory TCIZuckerman (2002) Zuckerman Personality Questionnaire ZKPQTyrer (2000) Personality Assessment Schedule PASMillon et al. (1996) Millon Index of Personality Styles MIPS

Millon Clinical Multiaxial Inventory–III MCMI–IIITellegen & Waller (1987) Multidimensional Personality Questionnaire MPQCosta & McCrae (1992) NEO Personality Inventory–Revised NEO PI–RWiggins (2003) Any interpersonal circumplex measure IPC

been developed by Clark (Clark, Simms, Wu, & Casillas, in press), Harknessand McNulty (1994), Livesley (2003) and Shedler and Westen (2004b). Thethree clusters included within the American Psychiatric Association’s (APA)Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; APA, 2000)could be said to represent a fifth version of this proposal, although theDSM–IV clusters do not in fact reorganize the criterion sets into a morecoherent structure.

INTEGRATE AXES I AND II USING COMMON CLINICAL SPECTRA OFDYSFUNCTION

Clark et al. (in press) include within their factor analyses of personality dis-order symptoms trait–like manifestations of anxiety and mood disorders be-cause the diagnostic co–occurrence of personality with disorders on Axis I ofthe DSM–IV (APA, 2000) could be due to the presence of common, underly-ing dimensions of maladaptive personality functioning. A third approach toa dimensional model of personality disorder is to identify spectra of dysfunc-tion that cut across the existing personality, mood, anxiety, substance use,and other diagnostic classes. Two such proposals have been developed bySiever and Davis (1991) and Krueger (2002).

INTEGRATE AXIS II WITH DIMENSIONAL MODELS OF GENERALPERSONALITY STRUCTURE

Personality disorders may not only be on a continuum with Axis I disorders,they may also be on a continuum with general personality functioning, con-tributing to the absence of a clear boundary between normal and abnormalpersonality functioning and to the presence of a considerable amount of per-sonality disorder symptomatology within the general population (Livesley,2003; Widiger & Sanderson, 1995). A fourth approach is to integrate theclassification of personality disorders with dimensional models of generalpersonality structure. There are quite a few dimensional models of personal-ity (John & Srivastava, 1999; Wiggins, 2003). Eight that have been relatedexplicitly to the DSM–IV personality disorders are those of Cloninger (2000),Costa and McCrae (1990), Eysenck (1987), Miles and Hempel (2004), the in-terpersonal circumplex (Benjamin, 1996; Wiggins, 2003), Millon et al.(1996), Millon, Millon and Davis (1994), Tellegen (Watson, Wiese, Vaidya, &Tellegen, 1999), Tyrer (2000), and Zuckerman (2002).

TOWARD AN INTEGRATION OF ALTERNATIVE MODELSIt is possible that the authors of a future edition of the diagnostic manualwould simply choose one of the 18 proposals. These proposals do vary intheir empirical support as a dimensional model of personality disorder (e.g.,O’Connor & Dyce, 1998), and one of them is likely to have more validity andclinical utility than any one of the other 17. The additional articles within thecurrent and a future special section of the Journal of Personality Disorders

112 WIDIGER AND SIMONSEN

address (in part) research concerning behavioral genetics, neurobiologicalmechanisms, childhood antecedents, cross–cultural application,continuity with Axis I, coverage, and clinical utility.

However, it may also be true that some common ground can be foundamong them. It does appear to be the case, at least to us, that none of themodels lacks any limitations that could not at times be well compensatedthrough an integration with another model. Each model will have someflaws and deficits, and each model will likely have at least some useful fea-tures. The optimal decision for the authors of a future edition of the diagnos-tic manual might not be a zero–sum game, where one model is victoriousand all other models are abandoned. The ideal solution might be to develop acommon, integrative representation that includes the important contribu-tions and potential advantages of each of the models.

COMMON HIGHER–ORDER DOMAINS

Fortunately, most of the alternative models do appear to be readily inte-grated within a common hierarchical structure (Bouchard & Loehlin, 2001;John & Srivastava, 1999; Krueger & Tackett, 2003; Larstone, Jang,Livesley, Vernon, & Wolf, 2002; Livesley, 2003; Markon, Krueger, & Watson,2005; Trull & Durrett, in press; Zuckerman, 2002; Widiger & Mul-lins–Sweatt, in press). This should not be surprising, as most of them are at-tempting to do largely the same thing (i.e., identify the fundamentaldimensions of maladaptive personality functioning that underlie and cutacross the existing diagnostic categories). We suggest more specifically thatall but a few of the personality traits and behaviors contained within the 18proposed models could be organized within a more fully developed, hierar-chical structure. At the highest level could be the two clinical spectra of in-ternalization and externalization identified by Krueger (2002) andAchenbach (1966). Immediately beneath the two dimensions of internaliza-tion and externalization would be three to five broad domains of personalityfunctioning. Immediately beneath these broad domains would be personal-ity trait scales, and at the lowest level would be the more behaviorallyspecific diagnostic criteria.

Table 2 indicates how the broad domains of most of the models might bealigned with one another. Each model is identified with the acronym pro-vided in Table 1. We will discuss in more detail below the fit at this broadlevel of the DAPP–BQ, EPQ, IPC, MCMI–III, MPQ, NEO-PI–R, PAS, PSY–5,SNAP, TCI, ZKPQ, and the Siever and Davis (1991) clinical spectra models.However, we want to acknowledge that a couple of the models are not asreadily fit within this common structure, at least based on the existing re-search. For example, the self–other, pleasure–pain, and active–passive po-larity model of Millon et al. (1996) is not included in Table 2 because itsalignment with the other models is not readily apparent and there has beenonly one study that has empirically related the polarities to any one of theother models included in Table 2 (i.e., Millon, 1994, reports correlations ofthe six MIPS scales with the NEO-PI–R). On the other hand, factor analyses


of the personality disorder scales of various editions of the MCMI–III haveproduced solutions that do converge well with the four- (or five-) factorstructure (e.g., Choca, Retzlaff, Strack, Mouton, & Van Denburg, 1996;Dyce, O’Connor, Parkins, & Janzen, 1997; O’Connor & Dyce, 1998; Retzlaff& Gibertini, 1987; Simonsen, in press). In addition, the SWAP–200 is alsonot included in Table 2 because current research suggests that it does nothave a congruent higher-order factor structure (Shedler & Westen, 2004a).

An important focus of future research will be to determine whether the 3(or 6) polarities of the MIPS and the 12 scales of the SWAP–200 can be inte-grated with the higher–order structure of the DAPP–BQ, SNAP, MPQ, PSY–5,MCMI–III, IPC, NEO-PI–R, EPQ, ZKPQ, and PAS, or whether the MIPS andSWAP–200 concern instead aspects of maladaptive personality functioningthat are not commensurate with these other dimensional models. We do ex-pect that a common structure is likely to be found, as the intention of thesemodels is common: identify the fundamental dimensions of maladaptivepersonality functioning that underlie and cut across the existing diagnosticcategories. We will also present below how the subscales of the SWAP–200might in fact correspond with the subscales of the DAPP–BQ, EPP, MPQ,NEO-PI–R, PAS, SNAP, and TCI.

Table 2 also does not include the proposals to provide a dimensional pro-file of the existing (or somewhat modified) diagnostic categories, as the mod-


TABLE 2. Alignment of Alternative Dimensional Models: Broad Domains

First Second Third Fourth FifthDAPP–BQ –Inhibition Dissocial Compulsivity Emotional

DysregulationNEO PI–R Extraversion Antagonism Conscien-

tiousnessNeuroticism Openness

SNAP & MPQ PositiveAffectivity

(NegativeAffectivity)

Constraint NegativeAffectivity

PSY–5 PositiveEmotionality

Aggressiveness Constraint NegativeEmotionality

Psychoticism

IPC AgencyCommunion

MCMI–III –Withdrawn Aggressiveness Constraint NeuroticismEPQ & EPP Extraversion Psychoticism NeuroticismZKPQ Sociability Aggression–

Hostility–Impulsive Neuroticism

ActivityPAS –Withdrawn Antisocial

–DependentInhibited

Siever & Davis (–Inhibition)Aggression–Impulsive

AffectiveInstability

CognitivePerceptual

Anxiety/Inhibition

TCI –Cooperativeness Persistence HarmAvoidance

Reward Dependence Self-Directedness Self–Transcendence

–NoveltySeeking

Notes. Selected scales are off–center because they lie in between the domains defined by the adjoining col-umns. Selected scales are italicized because they describe domains that are somewhat narrower in scope.Selected scales are noted parenthetically because they are more strongly related to another domain.

els provided in Table 2 concern dimensions of maladaptive (and at times alsoadaptive) personality functioning that, for the most part, cut across the ex-isting diagnostic categories. Some personality disorders do appear to beconfined largely to one broad domain (e.g., schizoid within the introversiondomain, and obsessive–compulsive within the compulsivity domain), butmost of them are more aptly described in terms of more than one domain(e.g., antisocial personality disorder by antagonism and disinhibition,avoidant by neuroticism and introversion, and dependent by neuroticismand agreeableness). The representation of the DSM–IV personality disorderswill become more evident when the lower–order facets of each domain arearticulated.

Extraversion versus Introversion? It is evident from Table 2 that most, ifnot all, of the models include a domain that concerns extraversion, also de-scribed as sociability, activity, positive emotionality, and (when keyed in theopposite direction) inhibition, introversion, or withdrawal. This domain con-trasts being gregarious, talkative, assertive, and active with being with-drawn, isolated, introverted, and anhedonic. The terms “extraversion” and“positive emotionality” might appear to suggest different domains of person-ality functioning. However, many studies have confirmed that these are infact the same domains (Bouchard & Loehlin, 2001; Harkness, McNulty, &Ben–Porath, 1995; John & Srivastava, 1999; Watson, Clark, & Harkness,1994). The title “positive affectivity” is preferred by some because it is be-lieved that positive affectivity might be providing the motivating force forextraversion, reflecting individual differences in a behavioral activation (orreward sensitivity) system (Depue & Collins, 1999; Pickering & Gray, 1999;Watson & Clark, 1997). The interpersonal term of “extraversion” is preferredby others in part because it is more simply descriptive of much of the behav-iors that are included within the domain and it facilitates the recognition ofthe association with the interpersonal circumplex domains of affiliation(communion) and power (agency) (Wiggins, 2003). An important decision forthe authors of the future edition of the diagnostic manual will be to select theoptimal term(s) to characterize this (or any other) domain.

The ZKPQ domains of sociability and activity and the Siever and Davis do-main of inhibition are italicized in Table 2 because they are relatively morenarrow in their scope and coverage. In addition, neither agency nor commu-nion from the IPC are aligned directly with this domain because they are45–degree rotated versions of extraversion and agreeableness (Wiggins,2003). It is possible that the location of the axes provided by the IPC is pref-erable to those used (for example) by the MPQ, EPQ, and NEO-PI–R (McCrae& Costa, 1989; Wiggins & Pincus, 1989), but we would suggest that themore commonly selected location is through the domain of extraversionrather than dominance or affiliation. Of course, none of the models are infact aligned entirely perfectly. For example, there are meaningful differencesbetween the extraversion domain of Eysenck (1987), the extraversion do-main of Costa and McCrae (1992), and the positive affectivity domain ofClark and Watson (1999). Nevertheless, it is also apparent that the bulk of


their meaningful variance is shared (Clark & Watson, 1999; Costa &McCrae, 1992).

Antagonism versus Compliance? Most of the dimensional models also in-clude traits referring to aggressive, dissocial, or antagonistic interpersonalrelatedness at this higher-order level. This domain contrasts being suspi-cious, rejecting, exploitative, aggressive, antagonistic, callous, deceptive,and manipulative with being trusting, compliant, agreeable, modest, de-pendent, diffident, and empathic. This domain is represented more nar-rowly by the PSY–5 and the ZKPQ as these versions of this domain areconfined largely to interpersonal aggressiveness, whereas the other modelsinclude such additional components as mistrust, exploitation, suspicious-ness, deception, and arrogance. Psychoticism from Eysenck’s dimensionalmodel is not aligned perfectly with this domain because he included within“psychoticism” both interpersonal antagonism and impulsive disinhibition(Bouchard & Loehlin, 2001; Clark & Watson, 1999; Digman, 1990;Eysenck, 1987; John & Srivastava, 1999), comparable to theconceptualization of this domain by Siever and Davis (1991).

A potential point of confusion in Table 2 that should also be noted is that“psychoticism” scales are included in two different locations. This reflectsthe fact that this single term has been used to refer to quite different con-structs. The psychoticism of Eysenck’s (1987) EPQ is not the same as thepsychoticism of Harkness and McNulty’s (1994) PSY–5. As we just indi-cated, the psychoticism of Eysenck (1987) refers to impulsive and aggres-sive behaviors, whereas the psychoticism of the PSY–5 refers to cognitiveand perceptual aberrations.

The three dimensional models of the MPQ and the SNAP do not includethis domain of personality functioning at this higher-order level. The SNAPdoes include scales for mistrust, manipulativeness, and aggression, butthese are placed within the domain of negative affectivity (Clark et al., inpress), as does the MPQ include an aggression scale within the domain ofnegative emotionality (Tellegen & Waller, 1987). Being mistrustful, aggres-sive, and manipulative does often (if not invariably) include a negative affectof angry hostility. However, joint factor analyses of the DAPP–BQ and SNAPsubscales have yielded consistently a four–factor solution (Clark & Livesley,2002; Clark, Livesley, Schroeder, & Irish, 1996) that corresponds to the firstfour domains of Table 2. As indicated by Watson et al. (1994), “extensivedata indicate that . . . the Big Three and Big Five models define a common‘Big Four’ space” (p. 24), consisting of negative affectivity (neuroticism),positive affectivity (extraversion), antagonism, and constraint.

Constraint versus Impulsivity? All but a couple of the models also includea domain concerned with the control and regulation of behavior, referred toas constraint, compulsivity, or conscientiousness, or, when keyed in the op-posite direction, impulsivity or disinhibition. It contrasts being disciplined,compulsive, dutiful, conscientious, deliberate, workaholic, and achieve-ment–oriented with being irresponsible, lax, impulsive, negligent, and hedo-nistic (constraint, as assessed by the SNAP and MPQ also contains aspects


of antagonism). Dimensional models that do not include this domain of per-sonality functioning are the IPC and the PAS. Tyrer (2000) places the symp-toms of the obsessive–compulsive (anankastic) personality disorder withinhis PAS inhibited domain, which is otherwise defined largely by traits of anx-iousness and dysphoria (i.e., a somewhat different meaning for the term, in-hibition, than is used, for instance, for the DAPP–BQ). The IPC does notinclude constraint versus disinhibition, as it is a two–dimensional modelconfined to domains of interpersonal relatedness.

An additional example of the same term having different meanings is theharm avoidance of the TCI and the MPQ. Harm avoidance in the TCI refers toan anxious behavioral inhibition, whereas harm avoidance in the MPQ is aquite different construct, referring to a low constraint (or behavioraldisinhibition that is potentially fearless). The differences between TCI harmavoidance and MPQ harm avoidance are so striking that they are in factplaced within different broad domains.

Emotional Dysregulation versus Emotional Stability? Finally, it is also ev-ident from Table 2 that all but one of the models include a broad domain ofemotional dysregulation, otherwise described as negative affectivity orneuroticism. It contrasts feeling anxious, depressed, angry, despondent, la-bile, helpless, self–conscious, and vulnerable with feeling emotionally sta-ble, self–assured, invulnerable, calm, glib, shameless, and invincible. Theonly model not to include this domain of personality functioning is again theIPC. This fourth domain is also somewhat more narrowly defined by Sieverand Davis (1991) as they separate anxiousness from affective instability.

In sum, the predominant models of normal and abnormal personalityfunctioning appear to converge onto four broad domains of personalityfunctioning (Bouchard & Loehlin, 2001; John & Srivastava, 1999; Krueger& Tackett, 2003; Larstone et al., 2002; Livesley, 2003; Markon et al., 2005;Trull & Durrett, in press; Watson et al., 1994; Widiger, 1998; Zuckerman,2002) that can be described as extraversion versus introversion, antago-nism versus compliance, constraint versus impulsivity, and emotionaldysregulation versus emotional stability. The authors of these various mod-els would not all agree on the best names for each domain, due in part to thefact that no single name is likely to optimally describe an entire domain;some models place more emphasis on the normal variants (e.g., NEO-PI–R &TCI) whereas other models place more emphasis on the abnormal variants(e.g., DAPP–BQ & SNAP); and, finally, the models vary in how broadly or nar-rowly they define each domain. We have provided tentative names for eachdomain that emphasize (for the most part) the maladaptive variants, asthese would be of most relevance and interest to clinicians. In any case, theconvergence among the alternative models with respect to the existence ofthe four domains is quite evident. Empirical support for the convergence ofthese models has been provided in quite a number of studies (e.g., Austin &Deary, 2000; Clark et al., 1996; Deary, Peter, Austin, & Gibson, 1998; Dyceet al., 1997; Livesley, Jang, & Vernon, 1998; Markon et al., 2005; Mulder &Joyce, 1997; O’Connor & Dyce, 1998), including even some of the earliest,


original efforts to develop dimensional models of personality disorder byPresly and Walton (1973) and Tyrer and Alexander (1979).

Unconventionality versus Closedness to Experience? Only three of themodels include a fifth broad domain, characterized within the NEO-PI–R asopenness to experience, described as unconventionality by Tellegen andWaller (1987), identified within the PSY–5 as psychoticism (i.e., illusions,misperceptions, perceptual aberrations, & magical ideation), and identifiedwithin the clinical spectra of Siever and Davis (1991) as cognitive–percep-tual aberrations. There are also subscales within the SNAP (e.g., eccentricperceptions), the DAPP–BQ (perceptual cognitive distortion), and the MPQ(absorption) that relate empirically to this domain (Bouchard & Loehlin,2001; Clark & Livesley, 2002). A domain of unconventionality (or openness)is obtained in joint factor analytic studies that provide sufficient representa-tion (e.g., Clark & Livesley, 2002). However, it appears to be the case thatwhen this domain is narrowly defined as simply cognitive–perceptual aber-rations, scales to assess it either load on other factors (typically negativeaffectivity) or they define a factor that is so small that it might not appear tobe worth identifying (Austin & Deary, 2000; Clark et al., 1996; Larstone etal., 2002). Openness to experience is itself the fifth and smallest domain ofthe Five-Factor Model (Ashton & Lee, 2001). It is also possible that cogni-tive–perceptual aberrations do not belong within a dimensional model ofnormal and abnormal personality functioning, consistent with the WorldHealth Organization’s (WHO, 1992) inclusion of DSM–IV (APA, 2000)


TABLE 3. Lower–Order Traits within a Domain of Constraint versus Impulsivity

Abnormally High Traits

DAPP–BQ: compulsivity

SNAP: workaholism

TCI: perfectionism, work–hardened

SWAP–200: obsessionality

Normal Traits

NEO PI–R dutifulness, order, achievement–striving, self–discipline, deliberation,competence

PAS: conscientiousness

MPQ: achievement, control, traditionalism, harm avoidance

SNAP: propriety

TCI: resourcefulness, eagerness of effort, responsibility, ambitiousness,purposefulness

Abnormally Low Traits

SNAP: impulsivity

TCI: impulsiveness, disorderliness

PAS: irresponsibility, childishness, impulsiveness

EPP: impulsivity, risk taking, irresponsibility

schizotypal personality disorder as a variant of schizophrenia. We willdiscuss this issue further below.

LOWER–ORDER TRAITS AND SYMPTOMS

We now turn to the constructs and scales that might be included withineach one of these four (or five) broad domains. This is facilitated by the factthat some of the dimensional models include lower–order scales that havebeen related empirically to one another. Consideration of the lower–orderscales also provides a better understanding of the potential integration ofthe SWAP–200 within the hierarchical structure.

Constraint versus Impulsivity. Table 3 provides trait scales within a do-main of constraint versus disinhibition (or impulsivity). Normal and abnor-mal variants of constraint are readily identified, with a number of scalesfrom the TCI, PAS, MPQ, and NEO-PI–R that refer to normal, adaptive levelsof constraint (or conscientiousness), such as dutifulness, conscientious-ness, responsibility, ambitiousness, achievement, resourcefulness, deliber-ation, control, and self–discipline, and maladaptive variants of these traitsemphasized by the DAPP–BQ, SWAP–200, EPP, and SNAP (i.e.,compulsivity, obsessionality, workaholism, and propriety). We placed theTCI scales of perfectionism and work–hardened, and the EPP scales ofimpulsivity, risk taking, and irresponsibility within the abnormal range, butthese could just as well have been placed within the normal range.

We are not suggesting, of course, that a future edition of the diagnosticmanual provide all of the 30 scales included in Table 3. There is clearly sub-stantial redundancy. Only a small subset would in fact be necessary, and animportant issue for future research is which subset would represent the op-timal choice. Considered in this selection might be extent of overlap, ade-quate coverage of the domain, representation of different dimensionalmodels, clinical relevance, familiarity, and ease of usage.

An additional question for future research is the potential bipolarity of thehierarchical structure. The existing hierarchical structure of the DSM–IV(APA, 2000) does not include any such bipolarities. This does represent alevel of complexity that is not evident anywhere within the DSM–IV (e.g.,there is no maladaptive variant of high intelligence or low compulsivity).However, we would suggest that this bipolarity is evident in other areas ofmedicine. For example, there are maladaptive consequences of both highand low blood pressure, with normal blood pressure occupying an interme-diate ground. In addition, a bipolar structure appears to be inherent to anyhierarchical organization of the adaptive and maladaptive personalityscales included within the existing instruments. For example, in thehigher-order structure of the SNAP, the SNAP impulsivity scale loads nega-tively on the constraint domain, whereas the SNAP propriety andworkaholism scales load positively (Clark et al., in press). A comparablefinding occurs for other domains. SNAP exhibitionism loads positively onthe domain of positive affectivity whereas detachment loads negatively


(Clark et al., in press), just as the DAPP–BQ stimulus seeking scale loadspositively on this domain and the DAPP–BQ social avoidance scale loadsnegatively (Livesley et al., 1998). The same finding also occurs whenhigher–order structures are developed with the DSM–IV personality disor-der criterion sets. For example, in one of the initial efforts to integrate empir-ically the dimensional and categorical models of personality and personalitydisorder, Wiggins and Pincus (1989) indicated how the histrionic and nar-cissistic personality disorders loaded positively on an extraversion dimen-sion, whereas schizoid loaded negatively. Dependent personality disorderloaded positively on an agreeableness factor, whereas the antisocial, para-noid, and narcissistic disorders loaded negatively. Comparable findingshave consistently occurred in subsequent higher–order organizations of theDSM–IV personality disorder constructs (Coker, Samuel, & Widiger, 2002;O’Connor & Dyce, 1998).

A future diagnostic manual can avoid the conceptual complexity of this bi-polarity, however, by simply excluding it from the visual presentation of thescales, consistent with how the personality disorders are currently pre-sented. Table 4 provides a much simplified version of Table 3. Only a smallsubset of the constructs is provided and the bipolarity is removed from thevisual presentation. Note, however, that the scales included in Table 4 donot represent our suggestion of which scales from Table 3 should be in-cluded or excluded. Its intention is only to indicate visually that the presen-tation of the scales need not be as complex or burdensome as might beimplied by Table 3.

Extraversion versus Introversion. Table 5 provides possible scales for adomain of extraversion versus introversion. At one pole could bemaladaptive scales from the DAPP–BQ (stimulus seeking), SNAP (exhibi-tionism), TCI (extravagence), and SWAP–200 (histrionic sexualization); atthe opposite pole could be the maladaptive scales from the DAPP–BQ (inti-macy problems, social avoidance), SNAP (detachment), PAS (aloofness), andSWAP–200 (schizoid orientation). In between could be the normal variantsof these constructs, as represented by the NEO-PI–R scales concerning gre-


TABLE 4. A Simplified Version of a Domain of Constraint

AbnormalCompulsivityWorkaholismObsessionalityImpulsivityIrresponsibility

NormalDutifulnessAchievement–strivingResourcefulness

gariousness, assertiveness, activity, excitement seeking, and positive emo-tionality; the MPQ scales of social potency and social closeness; the TCIscales of exploratory excitability and sociability; and the EPP scales ofsociability, assertiveness, and activity.

It is also important to note that much of the existing personality disorderdiagnostic criteria would be easily included within this hierarchical struc-ture. Each of the abnormal trait scales would include items for their assess-ment, and in most instances these items would resemble closely the existingpersonality disorder diagnostic criteria. In fact, the existing personality dis-order diagnostic criteria are already included within the DAPP–BQ, SNAP,and SWAP–200 scales. In sum, clinicians familiar with the existing diagnos-tic criterion sets would readily identify much (if not all) of the existing per-sonality disorder symptoms within the dimensional hierarchical structure.The dimensional model will have simply reorganized the criterion sets into amore coherent and empirically supported structure. In addition, the diag-nostic manual could go further by providing guidelines for a profile match-ing with which clinicians could recover the DSM–IV diagnostic constructs(e.g., antisocial or borderline). For example, what was identified in theDSM–IV as a schizoid personality disorder could be diagnosed by elevationson the detachment and aloofness scales. Research has indicated that theseprofile matching algorithms reproduce well the findings that are currently


TABLE 5. Lower–Order Traits, Facets, and Diagnostic Criteria within the Domain ofExtraversion versus Introversion

Abnormal High Traits

DAPP–BQ: stimulus seeking

SNAP: exhibitionism, (entitlement)

TCI: extravagence

SWAP–200: (histrionic sexualization)

Normal Traits

NEO PI–R: gregariousness, assertiveness, activity, excitement seeking, positive emotion-ality, (warmth)

MPQ: social potency, social closeness, well–being

TCI: exploratory excitability, sociability, (attachment)

EPP: sociability, assertiveness, activity

PAS: (optimism)

Abnormal Low Traits

DAPP–BQ: intimacy problems, social avoidance, restricted expression

SNAP: detachment

PAS: aloofness, (shyness)

TCI: (shyness)

SWAP–200: schizoid orientation

Note. Some scales are noted parenthetically because they include aspects of personality function from an-other domain.

obtained with the existing diagnostic constructs (e.g., Miller & Lynam, 2003;Trull, Widiger, Lynam, & Costa, 2003).

Antagonism versus Compliance. Table 6 provides a description of how therespective lower–order personality trait scales from the PAS, DAPP–BQ,SNAP, TCI, NEO-PI–R, MPQ, and SWAP–200 might be aligned with one an-other within a domain of antagonism versus compliance. Scales from theNEO-PI–R and TCI refer largely to normal variants (i.e., being trusting, com-pliant, straightforward, altruistic, modest, helpful, compassionate, senti-mental, and empathic), whereas the scales from the DAPP–BQ, SWAP–200,PAS, and SNAP refer largely to abnormal, maladaptive variants of thesesame traits (i.e., being dependent, diffident, gullible, sacrificial, meek, doc-ile, submissive, or self–denigrating). Table 6 is useful in illustrating the closerelationship of the normal and abnormal variants of these traits, as somescales are difficult to even classify (e.g., MPQ scale for aggression), consis-tent with the considerable amount of research indicating a continuum be-tween normal and abnormal personality functioning (Cloninger, 2000;Livesley, 2001; Reynolds & Clark, 2001; Saulsman & Page, 2004; Trull &Durrett, in press; Tyrer, 2001; Widiger & Costa, 2002).

A decision for the authors of a future edition of the diagnostic manual willbe whether to include normal variants of each of the domains of personalityfunctioning. There are arguments against doing so (e.g., the argument thatthe diagnostic manual is not for the purpose of describing normal psycho-logical functioning). However, there are also compelling arguments for in-


TABLE 6. Lower–Order Facets and Diagnostic Criteria within the Domain ofAntagonism versus Compliance


DAPP–BQ: narcissism, suspiciousness, interpersonal disesteem, conduct problems, pas-sive oppositionality, rejection

SNAP: mistrust, manipulativeness, aggression, entitlement

MPQ: aggression, (alienation)

PAS: suspiciousness, aggression, callousness

SWAP–200: narcissism, psychopathy

Normal Traits

NEO PI–R: trust, straightforwardness, altruism, compliance, modesty, tender–minded-ness, agreeableness

TCI: helpfulness, compassion, pure–hearted, sentimentality, empathy, social ac-ceptance, attachment

MPQ: (social closeness)

Abnormal Low Traits

DAPP–BQ: diffidence, insecure attachment

SNAP: (dependency)

PAS: dependence, submissiveness

TCI: dependence

Note. Some scales are noted parenthetically because they include aspects of personality function from an-other domain.

cluding normal personality scales. Their inclusion will allow for theprovision of a more comprehensive description of a patient’s entire person-ality functioning, their inclusion will facilitate an integration of the diagnos-tic manual with basic science research on general personality functioning,and their inclusion can be helpful clinically by identifying adaptivepersonality traits that contribute to treatment responsivity.

As we discuss further below, future research might indicate that some ofour scale placements are inaccurate or at least not optimal. For example, anumber of studies have placed dependency scales within a domain ofneuroticism or emotional instability (e.g., Clark et al., 1996; De Clercq & DeFruyt, 2003; Clark & Livesley, 2002; Trull, 1992). However, quite a few stud-ies have placed dependency scales within a domain of agreeableness (e.g.,Blais, 1997; Coker et al., 2002; Costa & McCrae, 1990; Dyce & O’Connor,1998; Haigler & Widiger, 2001; Hyer et al., 1994; Lynam & Widiger, 2001;Pincus & Gurtman, 1995; Sprock, 2002; Wiggins & Pincus, 1989; Zuroff,1994). The IPC dimensional models consistently place dependency scaleswithin an agreeableness (or compliance) domain (Pincus & Gurtman, 1995;Widiger & Hagemoser, 1997), as the IPC dimensional models do not includea neuroticism (or negative affectivity) domain. The inconsistency in place-ment is perhaps due largely to the complexity of the dependent personalitydisorder construct (i.e., involving traits of both neuroticism andagreeableness).

Emotional Dysregulation versus Emotional Stability. Finally, Table 7 pro-vides scales for a domain of emotional dysregulation versus emotional sta-bility. The lack of a clear boundary between the normal and abnormalvariants is even more apparent within this domain. The NEO-PI–R includesa scale for anxiousness for persons within the general population who wouldnot typically be diagnosed as having a personality disorder, whereas theanxiousness scale from the DAPP–BQ was derived from studies ofmaladaptive personality functioning. We placed the PAS anxiousness scaleas a normal variant, but it should perhaps have been placed within the ab-normal variant. One could readily include all of the normal personalityNEO-PI–R scales of anxiousness, vulnerability, self–consciousness, angryhostility, and depressiveness within the maladaptive variants. In fact, weplaced the MPQ scales of stress reaction and alienation within the abnormalrange even though they were constructed to assess general personalityfunctioning.

Table 7 places the NEO-PI–R scale of impulsivity within this emotionaldysregulation domain, consistent with its placement within the NEO-PI–Rdomain of neuroticism. However, this is perhaps another instance where thesame terms are being used to refer to somewhat different constructs.NEO-PI–R impulsivity is not equivalent to the impulsivity scales of theSNAP, TCI, MPQ, or PAS (Costa & McCrae, 1992). Impulsivity is itself a con-struct that has quite a few different meanings and interpretations (Depue &Collins, 1999; Whiteside & Lynam, 2001) and it will be important for the au-thors of a unified, integrated dimensional model of personality disorder to


clarify and articulate the particular meaning of the constructs that areincluded.

We also want to note that we did not include all of the scales from the PAS,DAPP–BQ, SNAP, TCI, NEO-PI–R, MPQ, and SWAP–200 within the four do-mains. For example, missing from the respective four tables were SNAP ec-centric perceptions, DAPP–BQ cognitive distortion, PAS eccentricity, PASrigidity, SWAP–200 thought disorder, TCI transpersonal identification, TCIspiritual acceptance, MPQ absorption, SWAP–200 dissociation, and all ofthe openness to experience scales from the NEO-PI–R. The exclusion ofthese scales is perhaps due to our failure to recognize that they could orshould be included in one of the four domains (e.g., emotionaldysregulation). It may also reflect the belief that these constructs should notbe included within a personality disorder classification, belonging insteadwithin the classification of schizophrenic or other psychotic disorders (asschizotypal disorder is currently diagnosed by the WHO). However, it mayalso be a result of the decision to include just four domains of personalityfunctioning, excluding from the model a fifth domain of unconventionalityor openness to experience, where many of these additional scales could beincluded (Costa & McCrae, 1992; Tellegen & Waller, 1987).

CONCLUSIONS AND RECOMMENDATIONSIn sum, we suggest that an important goal of future research will be theidentification of a common ground among the alternative dimensional mod-


TABLE 7. Lower–Order Traits, Facets, and Diagnostic Criteria within the Domain ofEmotional Dysregulation versus Emotional Stability


DAPP–BQ: affective lability, self–harm, anxiousness, identity problems, (insecure attach-ment), (intimacy problems), (social avoidance), (diffidence)

SNAP: self–harm, dependency

PAS: lability, pessimism, worthlessness, (shyness), vulnerability, irritability,hypochondriasis, sensitivity

MPQ alienation, stress reaction

TCI: anticipatory worry, fear of uncertainty, (shyness)

SWAP–200: emotional dysregulation, dysphoria, hostility

EPP: anxiety, inferiority, unhappiness

Normal Traits

NEO PI–R self–consciousness, anxiousness, depressiveness, vulnerability, angry hostil-ity, impulsivity

PAS: introspection, anxiousness, (optimism)

MPQ: (well–being)

TCI: self–acceptance

Abnormal Low Traits

DAPP–BQ: (restricted expression)

Note. Some scales from are noted parenthetically because they include aspects of personality function fromanother domain.

els of personality disorder. We recognize that future research will continueto focus on the particular strengths, nuances, and advantages of alternativemodels. The respective validity and clinical utility of each alternative modelwould be informative to the authors of a future edition of the diagnosticmanual in making decisions regarding which specific components of eachmodel to include within an integrative structure. However, we would alsoencourage researchers to themselves consider the possibility of working to-ward a more unified, integrative model. Given that these models are all at-tempting to do largely the same thing, it would seem likely that they sharecommon ground. It is possible that the authors of a future edition of a diag-nostic manual will come to the decision that one particular model is prefera-ble to all of the others. However, it is our opinion that it is unlikely that anyone particular model will lack any redeeming or useful features or, con-versely, that any one particular model will be without any meaningful faultsor limitations. We would therefore suggest that research that leads to anintegrative structure will be particularly informative to the authors of thisfuture diagnostic manual.

It is also possible that a common, integrative structure will not resembleclosely the illustrative model we provided. Our integrative model is guidedby a considerable amount of supportive research (e.g., Austin & Deary,2000; Clark et al., 1996; Clark, McEwen, Collard, & Hickok, 1993; Costa &McCrae, 1990; Deary et al., 1998; De Clercq & De Fruyt, 2003; De Fruyt, vanDe Wiele, & van Heeringen, 2000; Duijsens & Diekstra, 1996; Dyce et al.,1997; Livesley et al., 1998; Markon et al., 2005; Mulder & Joyce, 1997;O’Connor & Dyce, 1998; Reynolds & Clark, 2001; Schroeder, Wormworth, &Livesley, 1992; Trull, 1992; Trull, Useda, Costa, & McCrae, 1995;Zuckerman, 2002) but, admittedly, there are some studies that suggest thatsome of the existing dimensional models might not be well integrated withinthis structure (e.g., Shedler & Westen, 2004a) and the placement of somemodels (e.g., PAS) is based on only a limited amount of research. Our place-ments of some of the PAS, DAPP–BQ, SNAP, TCI, NEO-PI–R, MPQ, andSWAP–200 scales might also be disputed. Perhaps we have misunderstoodthe constructs assessed by these scales or the research that has been con-ducted to date. Some of the placements (e.g., those placed paranthetically)were difficult because the constructs appear to contain aspects from morethan one domain. Future research could help to determine how these alter-native dimensional models of personality disorder could be best integratedinto a common, unified, hierarchical structure.

The authors of prior editions of the diagnostic manual faced a comparableissue when attempting to develop the optimal criterion sets for each person-ality disorder. For example, it was recognized by the authors of the DSM–III(APA, 1980) that the diagnostic manual should include a diagnosis of bor-derline personality disorder but there were quite a number of alternative cri-terion sets for this diagnosis (Frances, 1980). In the absence of sufficientresearch to indicate that one particular criterion set was without any limita-tions or faults, and the absence of sufficient research to indicate that none ofthe other alternative criterion sets lacked any redeeming benefits, the deci-


sion was made to attempt to find a reasonable integration that would facili-tate a common recognition and acceptance of this new diagnostic construct(Spitzer, Endicott, & Gibbon, 1979).

The devil, of course, could be in the details. It is apparent that the illustra-tive model includes considerable redundancy (a direct effect of the alterna-tive efforts to describe a common ground) and uncertain labeling. If theauthors of a future diagnostic manual prefer to use an integrative, hierar-chical structure, they will need to decide which scales and constructs will beoptimal for inclusion, and how best to represent them. Considered in thisselection could be the extent of overlap, adequate representation of differentmodels, adequate coverage of the domain, clinical relevance, familiarity,and ease of usage. Last, but not least, is whether the diagnostic manualshould include normal, adaptive traits. We again argue for the importance oftheir inclusion. The inclusion of normative, adaptive traits will facilitate theprovision of a more comprehensive (and accurate) description of each pa-tient’s general personality structure; it will facilitate an integration of the di-agnostic manual with basic science research on general personalitystructure; and it will facilitate treatment decisions through the recognitionof traits that contribute to an understanding of treatment responsivity. Evenif the diagnostic manual does not explicitly include normal personalitytraits, it should be closely coordinated with them so that the APA diagnosticmanual of personality disorders is itself well integrated and coordinatedwith basic science research on general personality structure.


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