TYPE Original Research PUBLISHED 09 January 2023 DOI 10.3389/fpsyt.2022.1015489 Severity in the ICD-11 OPEN ACCESS personality disorder model: EDITED BY Jared Keeley, Virginia Commonwealth University, Evaluation in a Spanish mixed United States REVIEWED BY sample Mark Waugh, Oak Ridge National Laboratory (DOE), United States Fernando Gutiérrez1,2*, Anton Aluja3,4 , Claudia Rodríguez1 , Bo Bach, Miguel Gárriz5 , Josep M. Peri1 , Salvador Gallart6 , Psychiatry Region Zealand, Denmark *CORRESPONDENCE Natalia Calvo7,8,9 , Marc Ferrer7,8,9 , Fernando Gutiérrez Alfonso Gutiérrez-Zotes8,10,11 , Joaquim Soler9,12 and fguti@clinic.cat Juan Carlos Pascual9,12 SPECIALTY SECTION This article was submitted to 1 Institute of Neuroscience, Hospital Clínic of Barcelona, Barcelona, Spain, 2 Institut d’Investigacións Psychopathology, Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain, 3 Lleida Institute for Biomedical a section of the journal Research Dr. Pifarré Foundation, Lleida, Spain, 4 Department of Psychology, University of Lleida, Frontiers in Psychiatry Lleida, Spain, 5 Neuropsychiatry and Drug Addiction Institute, Parc de Salut Mar, Barcelona, Spain, 6 Department of Psychiatry, Mental Health, and Addiction, GSS–Hospital Santa Maria, Lleida, Spain, RECEIVED 09 August 2022 7 Department of Psychiatry, Vall d’Hebron University Hospital, Barcelona, Spain, 8 Network Centre ACCEPTED 16 December 2022 for Biomedical Research in Mental Health (CIBERSAM), Barcelona, Spain, 9 Psychiatry and Legal PUBLISHED 09 January 2023 Medicine Department, Autonomous University of Barcelona, Barcelona, Spain, 10 Pere Virgili Health CITATION Research Institute (IISPV), CERCA, Reus, Spain, 11 Pere Mata Psychiatric University Hospital, Reus, Gutiérrez F, Aluja A, Rodríguez C, Spain, 12 Hospital de la Santa Creu i Sant Pau, Barcelona, Spain Gárriz M, Peri JM, Gallart S, Calvo N, Ferrer M, Gutiérrez-Zotes A, Soler J and Pascual JC (2023) Severity in the ICD-11 personality disorder model: Evaluation in a Spanish mixed Severity is the main component of the ICD-11 personality disorder (PD) sample. Front. Psychiatry 13:1015489. classification, but pertinent instruments have only recently been developed. doi: 10.3389/fpsyt.2022.1015489 We analyzed the psychometric properties of the ICD-11 Personality Disorder COPYRIGHT Severity scale (PDS-ICD-11) in a mixed sample of 726 community and clinical © 2023 Gutiérrez, Aluja, Rodríguez, subjects. We also examined how the different components of the ICD-11 PD Gárriz, Peri, Gallart, Calvo, Ferrer, Gutiérrez-Zotes, Soler and Pascual. system —five trait domains, the borderline pattern specifier, and severity, all This is an open-access article of them measured through self-reports— are interconnected and operate distributed under the terms of the Creative Commons Attribution License together. PDS-ICD-11 properties were adequate and similar to those of (CC BY). The use, distribution or the original instrument. However, regressions and factor analyses showed a reproduction in other forums is permitted, provided the original considerable overlap of severity with the five personality domains and the author(s) and the copyright owner(s) borderline specifier (72.6%). Bifactor modeling resulted in a general factor of are credited and that the original PD (g-PD) that was not equivalent to severity nor improved criterion validity. publication in this journal is cited, in accordance with accepted academic The whole ICD-11 PD system, i.e., five personality domains, borderline, and practice. No use, distribution or severity, explained an average of 43.6% of variance of external measures reproduction is permitted which does not comply with these terms. of well-being, disability, and clinical problems, with severity contributing 4.8%. Suggestions to further improve the ICD-11 PD taxonomy include remodeling the present definition of severity to give more weight to the real-life consequences of traits. KEYWORDS personality disorder, personality pathology, severity, ICD-11, PDS-ICD-11 Frontiers in Psychiatry 01 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 1. Introduction careful consideration should be given to dimensionality. Although severity is usually depicted as a unidimensional Severity is the most important component of personality construct reflecting the dysfunctional features of any PD (18, disorder (PD) diagnosis in the newer International Classification 28–30), it actually encompasses very disparate or even antithetic of Diseases, 11th Revision (ICD-11) (1). The diagnostic process features. For example, the PDS-ICD-11 conceives severity as first involves rating the subject into five levels of disturbance, an aggregate of either too low or too high sense of self- from none to severe PD. The most prominent personality traits worth, insufficient or excessive goal orientation, imperious or can then be optionally described according to five domains — no need for close relationships, too lax or too tight control negative affectivity, detachment, dissociality, disinhibition, and over emotions, and so on. It is improbable that all these aspects anankastia— plus a borderline pattern specifier based on the and their opposites are equally relevant for maladaptation, so a Diagnostic and Statistical Manual of Mental Disorders, 5th more fine-grained analysis is warranted. Furthermore, it would Edition (DSM-5) (2). be also unlikely for all personalities to show the same way Whereas the relevance of PD severity —termed personality of being dysfunctional. For example, fearful, psychopathic, or dysfunction in the DSM-5—, has been fostered for 30 years asocial personalities could be equally severe at the topmost level (3–5), its definition has been changing all the while (6). Some of abstraction, but may be related to quite different "types of definitions have relied upon the consequences of traits, such severity" at lower levels (31). Thus, understanding severity will as impairment in several life areas, subjective distress, risk of require careful examination at the item level. serious self-injury or death, risk to others, or service utilization Another underexplored aspect is the joint functioning (7, 8). Other definitions have revolved around symptomatic of the whole ICD-11 PD system, that is, how its different complexity, including the total number of PD criteria or components —personality domains, borderline specifier, and disorders, the involvement of more than one cluster, or the severity— relate to each other and operate together. Concerning presence of particular diagnoses, mostly borderline (3, 9, 10). In the architecture of the diagnostic system, a twofold model that this case, severity is assumed to capture comorbidity between separates personality traits from severity/functioning has been individual disorders, and is tightly related to the notion of a gaining ground in current classifications (5, 8, 18, 32–35). This general factor that underlies all specific PDs (g-PD) (11–15). Still model, however, requires personality and severity to be two other definitions, rooted in the psychoanalytic literature, have different things in the first place, which is currently far from focused on dysfunction of the self, such as compromised reality clear. This separation could not be proved in the case of DSM- testing, primitive defense mechanisms, and identity diffusion 5 personality functioning, which massively overlaps with traits (5, 16). For the time being, there is insufficient evidence on (23, 36–42), and this might be the case of the ICD-11 as well. how these diverse conceptions of severity relate to each other Indeed, the scant evidence suggests that self-dysfunction is or whether any of them should be preferred over the rest (7, 8). factorially inseparable of negative affectivity and disinhibition, In fact, whereas the initial ICD-11 proposal accentuated major and that interpersonal dysfunction is mixed with negative problems in occupational, social, and/or personal relationships affectivity and detachment (25). Similar findings have been (17), the final version incorporated self-dysfunction in order reported using diverse measures of personality and functioning to bring itself into line with the DSM-5 (18–20), and both (36, 43, 44), so the relationships between the descriptive approaches are now pretty similar (21–23). and valuative components of the ICD-11 classification need Among the instruments developed to measure severity, further examination. the Standardized Assessment of Severity of Personality Disorder Finally, few data exist on the diagnostic utility of severity (SASPD) (24) was a premature attempt, as it did not yet reflect within the ICD-11 system. Previous operationalization of this the last-minute changes in the definition (21). An updated construct have generally shown to be strong predictors of proposal are the still unnamed scales by Clark et al. (25) that, maladjustment, comorbid psychopathology, well-being, and despite acceptable psychometric properties, may need additional treatment outcome (10, 13, 18, 22, 28, 45–47), and this could improvements before clinical use, and are deemed preliminary also be the case of the PDS-ICD-11 (26). The point is, by the authors. Finally, the ICD-11 Personality Disorder Severity however, whether the same information could be provided more scale (PDS-ICD-11) (26), which is the focus of the present parsimoniously by personality traits, either individually or in the study, reflects in a one-to-one basis the ICD-11 requirements for form of a g-PD factor, making severity superfluous. To date, the severity and has worked well in its original version. However, its contribution of severity seems modest at best, both in predicting properties have been tested on community subjects, except for categorial PDs (31, 38, 39, 41, 48–50) and external dysfunction limited analyses in 87 clinical subjects (26, 27). criteria (51). It is clear from the above that many critical aspects of ICD- It is apparent from the above that further research is needed 11 severity remain to be tested. The psychometric properties of regarding some aspects of the ICD-11 classification of PDs. We the PDS-ICD-11 need to be replicated in clinical samples and still lack a sufficiently established measure of severity, as well as a in different cultures and languages. Among these properties, clear idea of how the ICD-11 diagnostic system works as a whole. Frontiers in Psychiatry 02 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 Our study aims 1) to analyze the psychometric properties of the (25.2%), anxiety or phobic disorder (20.9%), mixed affective and Spanish version of the PDS-ICD-11 in a mixed community and anxious disorder (28.8%), eating disorder (1.8%), substance- clinical sample, with particular emphasis on dimensionality, 2) related disorder (0.7%), and other disorders (22.6%) each with to examine how the different components of the ICD-11 PD a frequency below 2%. No categorical diagnoses of personality system —the five trait domains, the borderline pattern specifier, disorder were made. With α = 0.05 and 1-β = 0.80, the combined and severity— interact with each other, and 3) to test how these sample allowed detecting correlations of 0.11. The study was components operate together as predictors of external measures approved by the ethical committees of the respective centers. of psychosocial impairment. 2.2. Instruments and procedure 2. Materials and methods Questionnaires were delivered to community participants 2.1. Participants by undergraduates taking part in a personality research and practice program. Participants answered anonymously and did The community sample consisted of 436 volunteers, 50.5% not receive any compensation for participating. Clinical subjects women, with mean age 46.3 years (SD = 18.0, range 18- filled the questionnaires in their respective hospitals, as a part of 87). Participants were undergraduates and their relatives and their diagnostic procedure. All questionnaires were completed acquaintances recruited from a university in Spain. This sample individually, in paper-and-pencil format, and in the same order was representative of the general Spanish population in terms they are presented below. of age (43.4 years)1 and level of education: about 17% had The Personality Inventory for ICD-11 (PiCD) (52) is a completed primary and lower secondary education, 37% upper 60-item Likert-type self-report measuring the five personality secondary and post-secondary education, and the remaining domains of the dimensional ICD-11 personality model: 46% tertiary education. The clinical sample consisted of 290 negative affectivity, detachment, dissociality, disinhibition, and outpatients, 67.9% women, with mean age 41.2 years (SD = 14.8, anankastia (1). Each domain has 12 items rated from 1 (strongly range 18–80). They were consecutively referred to the mental disagree) to 5 (strongly agree). With a similar format, the health units of six hospitals in Catalonia, Spain. Patients Borderline Pattern Scale (BPS) (53) includes 12 items and was were clinically diagnosed at their respective centers, with the developed to accommodate the DSM-5 borderline diagnosis (2) main diagnoses including mild to moderate affective disorders into the ICD-11 classification. Both instruments have shown good psychometric properties in their Spanish versions (54, 55). The ICD-11 Personality Disorder Severity Scale (PDS-ICD- 1 www.ine.es 11) (26) is a 14-item measure designed to assess the various TABLE 1 Pearson’s (lower triangle) and disattenuated correlations (upper triangle) between the ICD-11 system components with alphas in the diagonal, and multiple regressions of severity on personality traits. PiCD negative PiCD PiCD PiCD PiCD BPS total PDS-ICD-11 affect detachment disinhibition dissociality anankastia Correlations PiCD negative affect 0.90 0.44 0.63 0.42 0.08 0.91 0.84 PiCD detachment 0.38 0.85 0.41 0.36 0.19 0.53 0.54 PiCD disinhibition 0.55 0.34 0.83 0.66 −0.54 0.72 0.65 PiCD dissociality 0.37 0.31 0.56 0.86 −0.21 0.55 0.50 PiCD anankastia 0.07 0.16 −0.44 −0.17 0.79 −0.14 −0.16 BPS total 0.84 0.47 0.64 0.49 −0.12 0.92 0.92 PDS-ICD-11 0.76 0.47 0.56 0.44 −0.13 0.83 0.89 Standardized betas R2 Regressions Five domains + BPS 0.290 0.147 −0.055 0.029 −0.138 0.527 0.726 Five domains 0.660 0.232 −0.021 0.093 −0.213 − 0.664 PiCD, personality inventory for ICD-11; BPS, borderline pattern scale; PDS-ICD-11, ICD-11 personality disorder severity scale. Correlation coefficients > 0.10 are significant at p < 0.01. r Disattenuated correlations are Pearson’s correlations divided by the square root of the product of the reliabilities of each pair of variables (rc = √ω xy×ω ). Significant regression x y coefficients are in boldtype. Frontiers in Psychiatry 03 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 components of PD severity in the ICD-11: four items are An item response theory (IRT) analysis based on Samejima’s related to self-dysfunction (identity, self-worth, self-perception, graded response model was undertaken using the “ltm” and goals); four to interpersonal dysfunction (interest in package (63) to analyze the information provided by each relationships, perspective-taking, mutuality, and disagreement item (Supplementary Table 2). Items 9 (emotional control) management); five to control over emotions, behavior, and and 2 (self-worth) showed the highest discrimination ability cognition; and one measures global psychosocial impairment. with a > 2.50, whereas item 13 (harm to others) showed the The instrument was translated by four Spanish native speakers lowest (0.95). Items 11 (experience of reality), 12 (harm to who were familiar with the constructs being measured and self), and particularly item 13 (harm to others, b3 = 5.15), worked independently. The translators agreed on a common showed high difficulty in parameter b3 , questioning the utility version, which was blindly back-translated by an English of the most extreme response option (“I often harm others”) native speaker and compared with the original. Discrepancies (Supplementary Figure 1). This item also offered the least were consensually resolved by the translators and the authors information (Supplementary Figure 2). The test information of the instrument. function shows that the highest reliability came about at theta The Level of Personality Functioning Scale–Brief Form 2.0 values between 0 and 2 (Supplementary Figure 3). (LPFS-BF 2.0) (56) is a 12-item self-report measuring the The unidimensionality of the PDS-ICD-11 was tested self-functioning and interpersonal-functioning components of through confirmatory factor analysis (CFA) in R package personality dysfunction described in Section III of the DSM-5. “lavaan” (64), using weighted least squares estimation. Results It has shown good reliability and validity in different samples suggested adequate fit, with χ2 = 193.81, df = 77, p < 0.001, and languages (57). Comparative Fit Index CFI = 0.993, Tucker-Lewis Index Subjective well-being was measured through the World TLI = 0.992, Root Mean Square Error of Approximation Health Organization-5 Well-Being Index (WHO-5), a 5-item RMSEA = 0.046 and Standardized Root Mean Square Residual self-report that has been widely used to measure the impact SRMR = 0.051 (Supplementary Table 2). All loadings were of mental problems on quality of life (58). It measures levels above 0.60 except for items 11 (experience of reality) and of mood, energy, and interest for things in a 0-100 scale, 13 (harm to others). Factor structure was invariant between with higher scores indicating greater well-being. Disability the community and clinical samples, as given by the “sirt” was measured through the 12-item self-reported World Health package (65). Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) (59), which assesses difficulties due to health conditions in six different life areas: understanding and communication, self- 3.2. Structure of the whole ICD-11 care, mobility, interpersonal relationships, work and household system: PiCD, BPS, and PDS-ICD-11 roles, and community and civic roles. Scores range from 0 (no disability) to 48 (total disability). The Work and 3.2.1. Correlation and regression analyses Social Adjustment Scale (WSAS) (60) is a 5-item self-reported Pearson’s and disattenuated intercorrelations between the measure of general impairment assessing the impact of an five personality domains, the borderline specifier, and severity identified problem, mental condition in this case, on five areas: are shown in Table 1. Strong associations were found of severity work, home management, social leisure, private leisure, and with borderline (0.83), negative affectivity (0.76), and PiCD relationships, each rated on a scale of 0 to 8. Higher scores in total score (0.72), which rose to 0.92, 0.84, and 0.80 after a 0-40 range denote more disability. disattenuation for reliability (66). The considerable overlap between severity, negative affectivity, and borderline can be better appreciated through an Euler diagram (Figure 1). 3. Data analysis and results Associations were moderate with the remaining personality domains and negligible with anankastia. Accordingly, multiple 3.1. PDS-ICD-11 psychometric regression analyses showed that 72.6% of the variance of properties severity is explained by the five PiCD domains and the borderline specifier. Borderline was the best predictor of severity All analyses were made using R package ‘psych’ (61) and (beta = 0.527), followed by negative affectivity (Table 1, below). SPSS v. 25 (62) unless stated otherwise. Descriptive statistics Disinhibition and dissociality showed little or no relationship for the ICD-11 components and the remaining instruments are with severity even after the borderline specifier was excluded, shown in Supplementary Table 1. The PDS-ICD-11 showed and anankastia showed an inverse association. good internal consistency, with Cronbach’s alpha of α = 0.89 and McDonald’s omega of ω = 0.93 based on the one-factor solution. 3.2.2. Item-level analysis All corrected item-scale correlations were ri−s > 0.50 except for Additionally, we wanted to clarify whether certain item 13 (ri−s = 0.44). personality traits were associated to specific aspects of Frontiers in Psychiatry 04 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 FIGURE 1 Euler diagram showing the overlap between negative affectivity, borderline, and severity. Circle sizes are proportional to variances. Due to the geometric impossibility to represent the overlap between more than three variables through a proportionally-built Euler diagram, anankastia and detachment —explaining an additional 2% of the PDS-ICD-11 variance— have been omitted. Drawn at http://eulerr.co/. severity. To this end, two different scoring procedures for the to more disagreements and lack of behavioral control (0.28 PDS-ICD-11 were used: Whereas in the standard unipolar and 0.27). However, each aspect of severity is measured scoring the two poles of each item are added together and by a single item in the PDS-ICD-11, and associations were contribute interchangeably to a single dimension of severity generally not strong. (2-1-0-1-2), we adopted an alternative bipolar procedure in which the two poles pointed in opposite directions (0-1-2-3-4). 3.2.3. Factor analysis Under unipolar scoring, Spearman’s correlations showed that The structure of the whole ICD-11 system, operationalized all PDS-ICD-11 items were homogeneously correlated with the by the PiCD, the BPS, and the PDS-ICD-11, was then examined borderline specifier (mean rs = 0.50), negative affectivity (0.47) at the item-level through exploratory factor analysis based on and PiCD total score (0.47), although with some advantage the polychoric matrix (Supplementary Table 4) and unweighted for self-worth and psychosocial impairment (Supplementary least squares estimation. Kaiser-Meyer-Olkin index was 0.874 Table 3). By contrast, associations were more specific under and Bartlett’s sphericity test was 7,569.7 (df = 3,655; p = 0.00001), bipolar scoring (Supplementary Table 3, below): negative indicating suitability of data for factor analysis. Velicer’s MAP affectivity and borderline became more associated to low self- and optimal implementation of parallel test (67) suggested worth and emotional dysregulation, whereas detachment was four and five factors, respectively. One to seven factors were weakly but differentially linked to low interest in relationships successively retained, rotated to Promin, and examined. The (rs = 0.27), anankastia to rigid goals and behavioral overcontrol four-factor solution (Supplementary Table 5) reproduced the (0.25 and 0.41), disinhibition to difficulty following goals and usual structure containing disinhibition-anankastia (r = −0.79 lack of behavioral control (0.34 and 0.41), and dissociality and 0.85 with the original domain scores), dissociality (0.95), Frontiers in Psychiatry 05 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 and detachment (0.94), along with a broader factor gathering TABLE 2 Correlations of the ICD-11 components with external indicators of well-being, disability, and clinical problems, and multiple negative affectivity, borderline, and severity together (0.94, 0.94, regressions of indicators on ICD-11 components. and 0.87). Solutions of five or more factors produced empty or trivial factors, and were unsuccessful in separating this latter WHO-5 WHODAS WSAS Caseness factor into its original components. Correlations Additionally, we adopted a pure exploratory bifactor PiCD negative affect −0.60** 0.56** 0.62** 0.59** approach (68) implemented in FACTOR 12.01.02 (69) to PiCD detachment −0.40** 0.41** 0.33** 0.33** clarify whether a general factor of personality disorder (g-PD) could be extracted from the ICD-11 personality descriptors — PiCD disinhibition −0.36** 0.38** 0.38** 0.33** five domains and the borderline specifier— and whether this PiCD dissociality −0.18** 0.20** 0.23** 0.21** g-PD would be equivalent to severity. KMO was 0.902 and PiCD anankastia 0.07 0.02 −0.03 0.00 Bartlett’s statistic 7,842.2 (df = 2,556; P = 0.00001). MAP and PiCD total −0.51** 0.53** 0.53** 0.50** parallel test suggested retaining four and five specific factors, g-PD −0.49** 0.49** 0.52** 0.47** respectively. Whereas the former solution had one empty and one uninterpretable factor, the five-factor solution showed a BPS total −0.59** 0.54** 0.60** 0.55** clear g-PD with 72% of items loading over 0.30 and five specific PDS-ICD-11 −0.61** 0.58** 0.66** 0.59** factors roughly representing detachment (r = 0.56 with the DSM-5 LPFS-BF −0.60** 0.57** 0.60** 0.53** original domain), negative affectivity-borderline (0.67 and 0.62), Regressions (% exp. variance) dissociality (0.64), anankastia (0.56), and a factor gathering 5 domains + 42.9% 48.3% 50.0% 43.4% disinhibition items but with little relation with the original PDS-ICD-11 items domain (0.29) (Supplementary Table 6). The g-PD was mostly All ICD-11 40.6% 45.8% 47.9% 39.9% associated to negative affectivity and borderline (0.70 and 0.73) components and moderately to the remaining personality domains (0.29 to 5 domains + severity 40.6% 45.7% 47.9% 39.9% 0.62), but could not be regarded as exactly equivalent to severity (0.66) or the LPFS-BF (0.69). 5 domains alone 36.2% 42.2% 40.1% 36.2% Severity alone 33.8% 37.4% 43.8% 33.8% PiCD, personality inventory for ICD-11; g-PD, general factor of personality disorder; 3.3. Concurrent and criterion validity of BPS, borderline pattern scale; PDS-ICD-11, ICD-11 personality disorder severity scale; LPFS-BF, level of personality functioning scale-brief form; WHO-5, World Health the ICD-11 system Organization-5 well-being index; WHODAS 2.0, World Health Organization Disability Assessment Schedule 2.0; WSAS, work and social adjustment scale. Caseness is dichotomous, so point-biserial correlations are shown, but linear regressions were used 3.3.1. Correlation and regression analyses for the sake of comparison (125, 126). Alternative logistic regressions gave Cox & Snell’s We examined the relationships of the ICD-11 components pseudo-R2 coefficients 2% smaller. **p < 0.01. with external indicators of maladaptation: caseness (belonging to the clinical sample, as an indicator of clinically significant were non-significantly or inversely related to maladaptation. problems), as well as three World Health Organization (WHO) The exclusion of the borderline specifier was inconsequential for scales reflecting well-being and disability. Severity showed the prediction. Interactions of personality traits with severity, which strongest correlation with all indicators (mean r = 0.60), albeit reflect the additional contribution of having an extreme trait plus with little advantage over negative affectivity (0.59), borderline high severity, were non-significant too. (0.57), and the DSM-5 LPFS-BF (0.58), with which severity correlated 0.81. PiCD total and the g-PD showed slightly 3.3.2. Item-level analysis lower averages (0.52 and 0.49), whereas anankastia showed However, the best predictions resulted from replacing the no relation to maladaptation (Table 2). Due to the extensive PDS-ICD-11 scale with its items in regression analyses. All overlap among ICD-11 components, the predictive utility of models invariably retained items 2 and 14, suggesting that diverse combinations of these components was then analyzed self-worth and global psychosocial impairment are particularly through multiple regression. The whole ICD-11 system —five relevant aspects of severity. Other items made smaller personality domains (PiCD), the borderline specifier (BPS), and contributions that fluctuated across models. Mean incremental severity (PDS-ICD-11)— predicted 40.6% of the variance of the variance of items over the five personality domains was 7.4% WHODAS, 45.8% of the WHO-5, 47.9% of the WSAS, and (Table 2). Supplementary Figure 4 shows that most PDS-ICD- 39.9% of caseness (Table 2, below). The five personality domains 11 items are more maladaptive in one of their extremes. Namely, alone were better predictors than severity alone. However, having a weak sense of identity, feeling worthless, perceiving both severity and the personality domains added incremental few strengths in oneself, lacking emotional control, losing touch variance to each other (4.8 and 6.3%, respectively). Among with reality under stress, harming oneself or others, and showing personality domains, disinhibition, dissociality, and anankastia psychosocial impairment in several important areas of life (items Frontiers in Psychiatry 06 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 1 to 3, 9, and 11 to 14), are more detrimental than their little specific variance (55), but it deserves further consideration opposites. By contrast, having too rigid goals and being over- regarding severity. As a second point, we could not confirm controlled are just as bad as lacking any goal at all and being either that severity reflects the maladaptation resulting from impulsive (items 4 and 10). Similarly, in the interpersonal a wide range of dysfunctional personality styles. Instead, domain, being uninterested in relationships, unempathetic, regression analyses reveal that the PDS-ICD-11 provides little or selfish, or adversarial (items 5 to 8) is almost as bad as being no coverage of the possible impairments linked to disinhibition, afraid of loneliness and disagreements, or being too kind or dissociality, and anankastia (Table 1). This has been also the case clingy. with the German PDS-ICD-11 regarding the two latter domains (27). 3.3.3. ROC analysis One possible explanation is that, indeed, certain traits are Finally, the seven components of the ICD-11 PD system harmful whereas others are innocuous. For example, negative were tested as for their ability to predict caseness through emotionality has proven to be definitely impairing with regard to receiver operating characteristics (ROC) analysis. Negative a broad range of clinical outcomes, whereas all other dimensions affectivity and severity obtained virtually identical areas under are associated to only a few detrimental outcomes or are the curve (AUC 0.844 and 0.842, respectively), closely followed clinically inconsequential (71). In fact, anankastic features such by borderline (0.812) (Figure 2). The remaining scales showed as perfectionism, workaholism, rigidity, or even the obsessive- AUCs between 0.501 and 0.684. Although the Youden’s index compulsive PD, have shown to be fairly harmless (29, 72, 73), suggested a cutpoint of 10 (resulting in 69% sensitivity and 85% or even beneficial in certain areas (71, 74), and the same is specificity), a still lower threshold of 8 would be necessary to true of disinhibition and dissociality (71, 75–77). In accordance detect at least 80% of cases whereas still discarding 73% of non- with this, these domains are also unrelated in our study cases. The proposed cutoff of 17.5 (26, 27) would only detect to either caseness or the WHO scales. A second possibility about 22% of cases. is that the ICD-11 and DSM-5 unidimensional constructs of severity/dysfunction are pervaded by the frequency and intensity of aversive emotions, which is the defining feature 4. Discussion of negative affectivity, but they do not reflect the type of impairment characteristic of most other traits. Only when The PDS-ICD-11 shows good psychometric properties in its we take advantage of the bipolar nature of the PDS-ICD- Spanish version, similar to those of the original and the German 11 items (Supplementary Table 3) we can appreciate that versions (26, 27). Specifically, it has high internal consistency anankastia causes subjects to adhere rigidly to unreachable and a well-fitted unidimensional structure, and it is among the goals and impulse control, that detachment results in social best predictors of external indicators of well-being, disability, isolation, that dissociality turns disagreements into major and clinical problems. This makes it a suitable instrument for conflicts, and that disinhibition prevents subjects from attaining measuring the severity dimension of the ICD-11 PD system. their predefined goals. Thus, the unidimensional construct of On the other hand, some unexpected results suggest that severity/dysfunction may overdetect distress-related problems there remains scope for improvement. The ICD-11 diagnostic but be blind to the many other ways of being maladapted. system does not explicitly assume that personality domains A third possibility is that, whatever it is the domain that is and severity are independent constructs. Rather, elevations in severity are expected to be associated to elevations in one causing problems in the first place, most patients may ultimately or several personality domains, which reflect distinct styles of seek help because of distress and demoralization, which would malfunctioning. However, what is unanticipated is the ample thrust both severity and negative affectivity at the same time overlap between personality traits and severity/dysfunction (78). This is consistent with the fact that all domains (except which has been repeatedly found regarding both the ICD-11 anankastia) are significantly associated to severity until negative and DSM-5 systems (25, 36, 38, 70). In our study, almost affectivity is controlled for through regression (Table 1). A final three quarters of the variance of severity is accounted for possibility is that it is the PDS-ICD-11, not the severity construct by personality descriptors, particularly the negative affectivity in itself, which is biased toward negative affect. In this case, domain and the borderline specifier. In fact, these three clinician ratings, interviews, or other self-reports available in components cannot be split and are virtually the same thing the near future could be better able to differentiate severity from a factor-analytic perspective (25, 55). A major consequence from negative affect, or to capture the maladaptive aspects of is that severity plays a smaller role than expected in predicting disinhibition, dissociality, and anankastia. For example, it has maladaptation, and borderline plays no role whatsoever; for this been reported that personality functioning overlaps with traits purpose, negative affectivity alone would work almost as well. to a lesser extent when it is measured longitudinally through This result is rather expected for the borderline specifier, which daily diaries (79). By contrast, the only study using clinician was appended to the system at the eleventh hour and shows ratings of ICD-11 severity shows results which are very similar Frontiers in Psychiatry 07 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 FIGURE 2 ROC curves for the components of the ICD-11 PD system predicting caseness. to those of self-reports (80). All these possible explanations are example, one might wonder what negative emotionality would not mutually exclusive. look like after distress and impairment have been removed, if No consensual solution to these shortcomings has been such a thing exists at all, and what is the point of having a so found so far, and the debate is ongoing (28). Given that severity inert domain in a diagnostic system. is the pivotal component of the system, and that personality Thus, psychometric refinement may not be sufficient domains are only optional ways to identify particular styles of to break this deadlock, mainly caused by the fact that malfunctioning, it has been proposed that it is domains which severity and negative affectivity are largely the same. Another should be amended or replaced with normal-range traits to proposed solution has been the elimination of severity in reduce overlap (6, 42, 81). Normal traits, however, such as those its current form (38, 40). However, severity is upheld not of the Five Factor Model, have shown to be equally related only on empirical but also on theoretical grounds, and so to severity, so the problem is left unsolved (6, 39). A more its conceptual foundations need previous clarification and statistically sophisticated solution is the extraction of a general discussion. Impairments in self- and interpersonal functioning factor of PD (g-PD) that accounts for the common variance have been emphasized in many widely accepted models of PD, across disorders or traits (11, 12, 15). This approach significantly as those of Kernberg, Livesley, Parker, or Cloninger (16, 86– reduces the overlap between domains (82), and the resulting 88). A central assumption underpinning these models and, by g-PD is a good indicator of maladaptation, thus precluding the extension, the ICD-11 and DSM-5 systems, is that the main need for a separate assessment of severity (13, 14, 30). However, components of severity/dysfunction —self-direction, sense of the g-PD does not work well in our study: It is not equivalent to identity, empathy, intimacy— are of a different nature than either ICD-11 severity or DSM-5 personality functioning, and it personality traits. Concretely, they have been considered to be does not bring significant advantage over preexisting variables in core features, basic psychological capacities, meta-constructs, predicting well-being and disability. An additional drawback of key components of an intrapsychic system needed to fulfill this approach is that it provides the clinician with a broad factor universal life tasks, or even the cornerstone of humanness (5, whose meaning we can barely envisage (83–85), and a number 28, 86, 88–91). These appellations do not clarify, however, what of specific factors with no less ambiguous significance. For exactly makes them different from all remaining traits (92). Frontiers in Psychiatry 08 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 For example, there is no reason to think that these features are clearly different from traits, which reduces conceptual reflect capacities or serve universal life tasks to a greater extent confusion and redundancy. Second, this approach recovers a than any other trait. In fact, all traits reflect the variation of more pragmatic view of PDs as extreme traits causing suffering brain systems that enable and impel us to perform essential life- or functional impairment (112), rather than as pathological sustaining tasks: detecting and managing threats, exploring the entities characterized by poorly known intrapsychic processes. surroundings, striving for incentives, gaining power or status, Third, it puts the accent on functional status, the most difficult becoming attached to others, deterring rivals, and dozens of aspect to attain and maintain in severe PD patients, and then equally —if no more— important pursuits (93–97). We also a primary goal for intervention (113). Fourth, it gives us the lack evidence to assert that identity or empathy are either chance of exploring from scratch what traits change what more universal or consequential, or are more central to PDs, aspects of our lives for the worse (or for the better). As a than all others. And certainly, we do not know which —if final advantage, it excludes the possibility of diagnosing a PD any— is the cornerstone of humanness. In essence, self- and in the absence of negative consequences in the real world interpersonal dysfunctions may simply reflect the fact that (33), and thus the risk of pathologizing normal behavior. In most PDs are underlain by neuroticism and disagreeableness doing so, it offsets the increasing trend toward assuming that (98, 99). A second, closely related assumption of current PDs are defects, illnesses, or dysfunctions sensu Wakefield: the classifications is that the components of severity/dysfunction failure of a mental mechanism to perform its evolved function are inherently maladaptive. For example, whereas negative (34). On the contrary, a life-outcome perspective focuses on affectivity, disinhibition, or dissociality need an additional whether traits are harmful —negative or undesirable by social criterion to be considered pathological in the ICD-11 system, the standards (34, 114–117)— and then fits in better with the fact deleterious nature of low empathy or self-directedness is taken that, at present, no evidence supports a dysfunction model for for granted. In practice, this leads to a tautological diagnostic PDs. Whereas we know what normal lungs and hearts look process in which the severity of some traits is determined on the like and what they are expected to do, this is not the case basis of other —or even the same— traits. On empirical grounds, of “normal” personality (118). On the other hand, what is this is at odds with the well-known fact that negative affectivity normal in nature, from insects to higher primates and humans, is the most maladaptive trait ever found (71, 100, 101). By is the coexistence of different personalities, often maintained contrast, the premise that self-complexity, low self-directedness, by balancing selection (119, 120). For example, certain traits aloofness, or lack of empathy are dysfunctional in themselves may damage important biological goals while promoting others, has no comparable support (71, 75–77, 102–104). Although the or may be globally beneficial or detrimental depending on abovementioned assumptions are difficult to prove or refute environmental circumstances, thus remaining in the population at this time, they certainly warrant in-depth examination and at evolutionary equilibrium. The very existence of a single debate with a view to future revisions of the taxonomy. “normal” personality would then be an evolutionary anomaly A promising alternative may be the replacement —or the (121, 122). complementation— of the current severity construct with an Whereas this approach may lay the foundations for a assessment of the negative consequences of traits (33, 71, 92, 105–108). Negative consequences have been categorized in less conjectural and more pragmatic taxonomy of difficult many ways, but they generally include difficulties or failures in personalities, some caution is needed. On the one hand, it a number of key areas: education/work, e.g., inability to finish is not as objective as it may seem, as we cannot establish studies, hold a paid job, or achieve financial independence; which life outcomes are undesirable and which constitute a interpersonal functioning, e.g., trouble finding or maintaining ‘good life’ without a significant amount of subjectivity and romantic relationships, chronic conflict with family, or lack theorizing (114). On the other, personality functioning and of a support network; social functioning, e.g., difficulties for psychosocial impairment are different constructs. Whereas the life in society, breaking rules of coexistence, or harming former is about what do all PDs have in common (e.g., low self- others; physical health and longevity, e.g., problems for self- directedness, impaired mentalizing, the g-PD), and then about care, harming oneself, or putting oneself at risk of death; and the mechanisms of personality pathology (28, 123), the latter psychological health, e.g., chronic suffering, substance abuse, refers to the impact of traits on the life of individuals. It is psychopathology, requiring specialized care or hospitalization, argued, therefore, that the consequences of disease are essential or being unable to attain acceptable levels of well-being (71, 109– in clinical decision making but are not the disease itself, and 111). This is a redress rather than a turning point, as the PDS- cannot be part of diagnosis (28). In turn, this assumes that ICD-11 already encompasses outcomes such as harm to self, PDs are diseases rather than disliked traits, a point on which harm to others, or psychosocial impairment. However, the focus we are far from a consensus (114–117). Ultimately, even if is moved further from theory-driven intrapsychic constructs both approaches are deemed complementary, life outcomes have towards concrete outcomes in the real world, which may been relatively overlooked in current classifications and deserve bring a number of interwoven advantages. First, life outcomes greater consideration they have received so far. Frontiers in Psychiatry 09 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 Some caveats on the scope of this study are in order. Ethics statement First, the instruments are not the model, so that the shortcomings identified in the ICD-11 diagnostic system could The studies involving human participants were reviewed be circumscribed to specific questionnaires such as the PiCD, and approved by Comité de Ética de Investigación the BPS or the PDS-ICD-11. Moreover, all instruments are con Medicamentos (CEIm, Drug Research Ethics self-reported, which may produce common-method bias and Committee), Hospital Clínic, Barcelona, Spain. The overestimate overlapping (124). Therefore, the generalizability patients/participants provided their written informed consent or our results depends on their eventual confirmation using to participate in this study. different tools, preferably interviews or clinician rating forms, when they are developed. Second, the same is true of criterion variables. Particularly, caseness cannot be considered equivalent to PD diagnosis, but it is a general indicator of clinically Author contributions significant problems. Other criteria suggestive of disordered FG, AA, CR, MG, and JMP contributed to the personality need to be tested in upcoming studies. Third, certain conception and design of the study. FG and CR performed parts or our analysis are performed at the item level. Even if the statistical analyses and wrote the first draft of the severity is a complex construct and its components need to manuscript. CR, SG, NC, MF, AGZ, JS, and JCP made be examined separately, it should be taken into account that amendments to the manuscript and rewrote parts of items are less reliable than scales, and these results should be interpreted cautiously. Finally, our sample included less than it. All authors recruited samples in their respective 300 patients. This is enough to reach our study’s aims but did not centers, assessed outpatients, organized the database, allow deeper examination of different levels of severity, which is contributed to the manuscript revision, and approved the an important feature of the ICD-11 system. submitted version. With these objections in mind, we conclude that the PDS-ICD-11 has proven adequate properties as a measure of severity. However, the ICD-11 system as a whole is conditioned Funding by important limiting factors. Whereas the adoption of a dimensional taxonomy has meant a significant improvement, Open access publication fees were financed by the Hospital the overlap between personality domains —one major reason Clínic de Barcelona (Spain). for the abandonment of traditional categories (35)— remains a problem (81, 82). Furthermore, while the conceptual separation between personality traits and severity/dysfunction is widely Conflict of interest accepted and helpful, the existing operationalizations of severity lack solid theoretical justification and are too close to The authors declare that the research was conducted in the negative affectivity to serve diagnostic purposes. Irrespective of absence of any commercial or financial relationships that could whether this is due to personality traits containing variance of be construed as a potential conflict of interest. impairment (29) or the other way around (38, 39), the result is a redundant and conceptually confusing diagnostic system. In contrast, the types of impairment resulting from disinhibition, dissociality, and anankastia are not well reflected by severity, Publisher’s note or these traits are not significantly harmful, as suggested by previous research (71, 74). We take up previous suggestions All claims expressed in this article are solely those of the that a model with refined, truly independent domains (82), authors and do not necessarily represent those of their affiliated followed by a list of undesired life consequences would be more organizations, or those of the publisher, the editors and the parsimonious, feasible, and theoretically clearer than the current reviewers. Any product that may be evaluated in this article, or approach (33, 106). claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Data availability statement Supplementary material The datasets presented in this study can be found in online repositories. The names of the repository/repositories The Supplementary Material for this article can be and accession number(s) can be found below: https://osf.io/ found online at: https://www.frontiersin.org/articles/10.3389/ mvyug/?view_only=94d52cde2dd540b09665d775a9eea52e. fpsyt.2022.1015489/full#supplementary-material Frontiers in Psychiatry 10 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 References 1. World Health Organization [WHO]. ICD-11 clinical descriptions and 24. Olajide K, Munjiza J, Moran P, O’Connell L, Newton-Howes G, Bassett P, diagnostic guidelines for mental and behavioural disorders. Geneva: World Health et al. Development and psychometric properties of the standardized assessment Organization (2019). of severity of personality disorder (SASPD). J Pers Disord. (2018) 32:44–56. doi: 10.1521/pedi_2017_31_285 2. American Psychiatric Association [APA]. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association (2013). 25. Clark L, Corona-Espinosa A, Khoo S, Kotelnikova Y, Levin-Aspenson H, Serapio-García G, et al. Preliminary scales for ICD-11 personality disorder: self 3. Tyrer P, Johnson T. Establishing the severity of personality disorder. Am J and interpersonal dysfunction plus five personality disorder trait domains. Front Psychiatry. (1996) 153:1593–7. doi: 10.1176/ajp.153.12.1593 Psychol. (2021) 12:668724. doi: 10.3389/fpsyg.2021.668724 4. Tyrer P. The problem of severity in the classification of personality disorder. J 26. Bach B, Brown T, Mulder R, Newton-Howes G, Simonsen E, Sellbom M. Pers Disord. (2005) 19:309–31. doi: 10.1521/pedi.2005.19.3.309 Development and initial evaluation of the ICD-11 personality disorder severity 5. Morey L, Berghuis H, Bender D, Verheul R, Krueger R, Skodol A. Toward a scale: PDS-ICD-11. Personal Ment Health. (2021) 15:223–36. doi: 10.1002/pmh model for assessing level of personality functioning in DSM–5, part II: empirical 27. Zimmermann J, Falk C, Wendt L, Spitzer C, Fischer F, Bach B, et al. Validating articulation of a core dimension of personality pathology. J Pers Assess. (2011) the German version of the personality disorder severity-ICD-11 scale using 93:347–53. doi: 10.1080/00223891.2011.577853 nominal response models. Psychol Assess. (2022). doi: 10.1037/pas0001199 [Epub 6. Hopwood C, Malone J, Ansell E, Sanislow C, Grilo C, McGlashan T, et al. ahead of print]. Personality assessment in DSM-5: empirical support for rating severity, style, and 28. Sharp C, Wall K. DSM-5 level of personality functioning: refocusing traits. J Pers Disord. (2011) 25:305–20. doi: 10.1521/pedi.2011.25.3.305 personality disorder on what it means to be human. Annu Rev Clin Psychol. (2021) 7. Crawford M, Koldobsky N, Mulder R, Tyrer P. Classifying personality disorder 17:313–37. doi: 10.1146/annurev-clinpsy-081219-105402 according to severity. J Pers Disord. (2011) 25:321–30. doi: 10.1521/pedi.2011.25. 29. Morey L. Thoughts on the assessment of the DSM–5 alternative model for 3.321 personality disorders: comment on sleep et al. (2019). Psychol Assess. (2019) 8. Zimmerman M, Morgan T, Stanton K. The severity of psychiatric disorders. 31:1192–9. doi: 10.1037/pas0000710 World Psychiatry. (2018) 17:258–75. doi: 10.1002/wps.20569 30. Hopwood C, Good E, Morey L. Validity of the DSM–5 levels of personality 9. Soeteman D, Verheul R, Busschbach J. The burden of disease in personality functioning scale-self report. J Pers Assess. (2018) 100:650–9. doi: 10.1080/ disorders: diagnosis-specific quality of life. J Pers Disord. (2008) 22:259–68. doi: 00223891.2017.1420660 10.1521/pedi.2008.22.3.259 31. Anderson J, Sellbom M. Evaluating the DSM-5 Section III personality 10. Clark L, Nuzum H, Ro E. Manifestations of personality impairment severity: disorder impairment criteria. Personal Disord. (2018) 9:51–61. doi: 10.1037/ comorbidity, course/prognosis, psychosocial dysfunction, and ’borderline’ per0000217 personality features. Curr Opin Psychol. (2018) 21:117–21. doi: 10.1016/j.copsyc. 32. Pincus A. Some comments on nomology, diagnostic process, and narcissistic 2017.12.004 personality disorder in the DSM-5 proposal for personality and personality 11. Oltmanns J, Smith G, Oltmanns T, Widiger T. General factors of disorders. Personal Disord. (2011) 2:41–53. doi: 10.1037/a0021191 psychopathology, personality, and personality disorder: across domain 33. Leising D, Zimmermann J. An integrative conceptual framework for assessing comparisons. Clin Psychol Sci. (2018) 6:581–9. doi: 10.1177/2167702617750150 personality and personality pathology. Rev Gen Psychol. (2011) 15:317–30. doi: 12. Sharp C, Wright A, Fowler J, Frueh B, Allen J, Oldham J, et al. The structure 10.1037/a0025070 of personality pathology: both general (’g’) and specific (’s’) factors?. J Abnorm 34. Wakefield J. Disorder as harmful dysfunction: a conceptual critique of DSM- Psychol. (2015) 124:387–98. doi: 10.1037/abn0000033 III-R’s definition of mental disorder. Psychol Rev. (1992) 99:232–47. doi: 10.1037/ 13. Conway C, Hammen C, Brennan P. Optimizing prediction of psychosocial 0033-295x.99.2.232 and clinical outcomes with a transdiagnostic model of personality disorder. J Pers 35. Widiger T, Trull T. Plate tectonics in the classification of personality disorder: Disord. (2016) 30:545–66. doi: 10.1521/pedi_2015_29_218 shifting to a dimensional model. Am Psychol. (2007) 62:71–83. doi: 10.1037/0003- 14. Williams T, Scalco M, Simms L. The construct validity of general and specific 066X.62.2.71 dimensions of personality pathology. Psychol Med. (2018) 48:834–48. doi: 10.1017/ 36. Clark L, Ro E. Three-pronged assessment and diagnosis of personality S0033291717002227 disorder and its consequences: personality functioning, pathological traits, and 15. McCabe G, Oltmanns J, Widiger T. The general factors of personality psychosocial disability. Personal Disord. (2014) 5:55–69. doi: 10.1037/per000 disorder, psychopathology, and personality. J Pers Disord. (2022) 36:129–56. doi: 0063 10.1521/pedi_2021_35_530 37. Fossati A, Borroni S, Somma A, Markon K, Krueger R. Testing relationships 16. Kernberg O. Severe personality disorders: psychotherapeutic strategies. New between DSM-5 Section III maladaptive traits and measures of self and Haven: Yale University Press (1984). interpersonal impairment in Italian community dwelling adults. Personal Disord. (2017) 8:275–80. doi: 10.1037/per0000192 17. Tyrer P, Crawford M, Mulder R, Blashfield R, Farnam A, Fossati A, et al. The rationale for the reclassification of personality disorder in the 11th revision of the 38. Sleep C, Lynam D, Widiger T, Crowe M, Miller J. An evaluation of International Classification of Diseases (ICD-11). Personal Ment Health. (2011) DSM-5 section III personality disorder criterion a (impairment) in accounting 5:246–59. doi: 10.1002/pmh.190 for psychopathology. Psychol Assess. (2019) 31:1181–91. doi: 10.1037/pas000 0620 18. Tyrer P, Mulder R, Kim Y, Crawford M. The development of the ICD-11 classification of personality disorders: an amalgam of science, pragmatism, and 39. Sleep C, Weiss B, Lynam D, Miller J. The DSM-5 section III personality politics. Annu Rev Clin Psychol. (2019) 15:481–502. doi: 10.1146/annurev-clinpsy- disorder criterion A in relation to both pathological and general personality traits. 050718-095736 Personal Disord. (2020) 11:202–12. doi: 10.1037/per0000383 19. Mulder RT. ICD-11 personality disorders: utility and implications of the new 40. Sleep C, Lynam D. The problems with criterion A: a comment on Morey et al. model. Front Psychiatry. (2021) 12:655548. doi: 10.3389/fpsyt.2021.655548 (2022). Personal Disord. (2022) 3:325–7. doi: 10.1037/per0000585 20. Bach B, Anderson J. Patient-reported ICD-11 Personality disorder severity 41. Widiger T, Bach B, Chmielewski M, Clark L, DeYoung C, Hopwood C, and DSM-5 level of personality functioning. J Pers Disord. (2020) 34:231–49. et al. Criterion a of the AMPD in HiTOP. J Pers Assess. (2019) 101:345–55. doi: 10.1521/pedi_2018_32_393 doi: 10.1080/00223891.2018.1465431 21. Zimmermann J, Müller S, Bach B, Hutsebaut J, Hummelen B, Fischer 42. Morey L, McCredie M, Bender D, Skodol A. Criterion A: level of personality F. A common metric for self-reported severity of personality disorder. functioning in the alternative DSM-5 model for personality disorders. Personal Psychopathology. (2020) 53:168–78. doi: 10.1159/000507377 Disord. (2022) 13:305–15. doi: 10.1037/per0000551 22. Bach B, Simonsen S. How does level of personality functioning inform 43. Farmer R, Goldberg L. Brain modules, personality layers, planes of clinical management and treatment? Implications for ICD-11 classification of being, spiral structures, and the equally implausible distinction between TCI-R personality disorder severity. Curr Opin Psychiatry. (2021) 34:54–63. doi: 10.1097/ "temperament" and "character" scales: a reply to Cloninger (2008). Psychol Assess. YCO.0000000000000658 (2008) 20:300–4. doi: 10.1037/a0012932 23. McCabe G, Widiger TA. A comprehensive comparison of the ICD-11 and 44. Farmer R, Goldberg LR. A psychometric evaluation of the revised DSM-5 section III personality disorder models. Psychol Assess. (2020) 32:72–84. temperament and character inventory (TCI-R) and the TCI-140. Psychol Assess. doi: 10.1037/pas0000772 (2008) 20:281–91. doi: 10.1037/a0012934 Frontiers in Psychiatry 11 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 45. Sharp C. Fulfilling the promise of the LPF: comment on Morey et al. (2022). 68. Lorenzo-Seva U, Ferrando PJ. A general approach for fitting pure exploratory Personal Disord. (2022) 13:316–20. doi: 10.1037/per0000567 bifactor models. Multivar Behav Res. (2019) 54:15–30. doi: 10.1080/00273171. 2018.1484339 46. Buer Christensen T, Eikenaes I, Hummelen B, Pedersen G, Nysćter T, Bender D, et al. Level of personality functioning as a predictor of psychosocial 69. Ferrando P, Lorenzo-Seva U. Program FACTOR at 10: origins, functioning-concurrent validity of criterion A. Personal Disord. (2020) 11:79–90. development and future directions. Psicothema. (2017) 29:236–40. doi: 10.1037/per0000352 doi: 10.7334/psicothema2016.304 47. Veenstra M, van Dijk S, Bouman R, van Alphen S, van Asselt A, van den 70. Sleep C, Lynam D, Widiger T, Crowe M, Miller J. Difficulties with the Brink R, et al. Impact of personality functioning and pathological traits on mental conceptualization and assessment of criterion A in the DSM-5 alternative model wellbeing of older patients with personality disorders. BMC Psychiatry. (2022) of personality disorder: a reply to Morey (2019). Psychol Assess. (2019) 31:1200–5. 22:214. doi: 10.1186/s12888-022-03857-8 doi: 10.1037/pas0000758 48. Few L, Miller J, Rothbaum A, Meller S, Maples J, Terry D, et al. Examination of 71. Vall G, Gutiérrez F, Peri J, Gárriz M, Ferraz L, Baillés E, et al. Seven basic the section III DSM-5 diagnostic system for personality disorders in an outpatient dimensions of personality pathology and their clinical consequences: are all clinical sample. J Abnorm Psychol. (2013) 122:1057–69. doi: 10.1037/a003 personalities equally harmful? Br J Clin Psychol. (2015) 54:450–68. doi: 10.1111/ 4878 bjc.12091 49. Zimmermann J, Kerber A, Rek K, Hopwood C, Krueger RF. A brief 72. Cruitt P, Boudreaux M, King H, Oltmanns J, Oltmanns T. Examining but comprehensive review of research on the alternative DSM-5 model for criterion A: DSM-5 level of personality functioning as assessed through life story personality disorders. Curr Psychiatry Rep. (2019) 21:92. doi: 10.1007/s11920-019- interviews. Personal Disord. (2019) 10:224–34. doi: 10.1037/per0000321 1079-z 73. Peri J, Muñoz-Champel A, Torrubia R, Gutiérrez F. The general criteria for 50. Nysaeter T, Hummelen B, Christensen T, Eikenaes I, Selvik S, Pedersen G, personality disorders assessed by interview: do they still have a role to play?. J Pers et al. The incremental utility of criteria A and B of the DSM-5 alternative model Disord. (2019) 33:515–32. doi: 10.1521/pedi_2018_32_356 for personality disorders for predicting DSM-IV/DSM-5 section II personality 74. Ullrich S, Farrington D, Coid J. Dimensions of DSM-IV personality disorders disorders. J Pers Assess. (2022) 14:1–10. doi: 10.1080/00223891.2022.2039166 and life-success. J Pers Disord. (2007) 21:657–63. doi: 10.1521/pedi.2007.21. 51. Roche M, Jaweed S. Comparing measures of criterion A to better understand 6.657 incremental validity in the alternative model of personality disorders. Assessment. 75. Vall G, Gutiérrez F, Peri J, Gárriz M, Baillés E, Garrido M, et al. Seven (2021). doi: 10.1177/10731911211059763 [Epub ahead of print]. dimensions of personality pathology are under sexual selection in modern 52. Oltmanns J, Widiger TA. A self-report measure for the ICD-11 dimensional Spain. Evol Hum Behav. (2016) 37:169–78. doi: 10.1016/j.evolhumbehav.2015. trait model proposal: the personality inventory for ICD-11. Psychol Assess. (2018) 10.004 30:154–69. doi: 10.1037/pas0000459 76. Gutiérrez F, Peri J, Baillès E, Sureda B, Gárriz M, Vall G, et al. A double-track 53. Oltmanns J, Widiger T. Evaluating the assessment of the ICD-11 personality pathway to fast strategy in humans and its personality correlates. Front Psychol. disorder diagnostic system. Psychol Assess. (2019) 31:674–84. doi: 10.1037/ (2022) 13:889730. doi: 10.3389/fpsyg.2022.889730 pas0000693 77. Meąedović J, Petrović B, Želeskov-Ðorić J, Savić M. Interpersonal and 54. Gutiérrez F, Aluja A, Ruiz J, García L, Gárriz M, Gutiérrez-Zotes A, et al. affective psychopathy traits can enhance human fitness. Evol Psychol Sci. (2017) Personality disorders in the ICD-11: Spanish validation of the PiCD and the 3:306–15. doi: 10.1007/s40806-017-0097-5 SASPD in a mixed community and clinical sample. Assessment. (2021) 28:759–72. 78. Noordhof A, Kamphuis J, Sellbom M, Eigenhuis A, Bagby R. Change in doi: 10.1177/1073191120936357 self-reported personality during major depressive disorder treatment: a reanalysis 55. Gutiérrez F, Aluja A, Ruiz Rodríguez J, Peri J, Gárriz M, Garcia L, et al. of treatment studies from a demoralization perspective. Pers Disord. (2018) Borderline, where are you? a psychometric approach to the personality domains 9:93–100. doi: 10.1037/per0000238 in the International Classification of Diseases, 11th Revision (ICD-11). Personal 79. Roche M. Examining the alternative model for personality disorder in daily Disord. (2022). doi: 10.1037/per0000592 [Epub ahead of print]. life: evidence for incremental validity. Pers Disord. (2018) 9:574–83. doi: 10.1037/ 56. Weekers L, Hutsebaut J, Kamphuis J. The level of personality functioning per0000295 scale-brief form 2.0: update of a brief instrument for assessing level of personality 80. Brown T, Sellbom M. Examining the reliability and validity of the ICD- functioning. Personal Ment Health. (2019) 13:3–14. doi: 10.1002/pmh.1434 11 personality disorder severity diagnosis. Aust N Z J Psychiatry. (2022). doi: 57. Birkhölzer M, Schmeck K, Goth K. Assessment of criterion A. Curr Opin 10.1177/00048674221136457 [Epub ahead of print]. Psychol. (2021) 37:98–103. doi: 10.1016/j.copsyc.2020.09.009 81. Morey L. On parsimony in personality disorder classification: rejoinder to 58. Topp C, Østergaard S, Søndergaard S, Bech P. The WHO-5 well-being index: Sleep et al. (2019). Psychol Assess. (2019) 31:1206–7. doi: 10.1037/pas0000774 a systematic review of the literature. Psychother Psychosom. (2015) 84:167–76. 82. Gutiérrez F, Peri J, Gárriz M, Vall G, Arqué E, Ruiz L, et al. Integration doi: 10.1159/000376585 of the ICD-11 and DSM-5 dimensional systems for personality disorders into a 59. Rehm J, Üstün T, Saxena S, Nelson C, Chatterji S, Ivis F. On the development unified taxonomy with non-overlapping traits. Front Psychiatry. (2021) 12:591934. and psychometric testing of the WHO screening instrument to assess disablement doi: 10.3389/fpsyt.2021.591934 in the general population. Int J Methods Psychiatr Res. (1999) 8:110–22. doi: 83. Hengartner M, van der Linden D, Dunkel C. Establishing the substantive 10.1002/mpr.61 interpretation of the GFP by considering evidence from research on personality 60. Mundt J, Marks I, Shear M, Greist J. The Work and social adjustment scale: a disorders and animal personality. Front Psychol. (2017) 8:1771. doi: 10.3389/fpsyg. simple measure of impairment in functioning. Br J Psychiatry. (2002) 180:461–4. 2017.01771 doi: 10.1192/bjp.180.5.461 84. Van der Linden D, Dunkel C, Wu P. The applied relevance of the general 61. Revelle W. Psych: procedures for psychological, psychometric, and personality factor of personality: advancements in the occupational and clinical context. Jpn J research. R package version 2.2.5. Evanston, IL: Northwestern University (2022). Pers. (2022) 30:199–211. doi: 10.2132/personality.30.3.13 62. IBM Corp. IBM SPSS statistics for windows, version 25.0. Armonk, NY: IBM 85. Smith G, Atkinson E, Davis H, Riley E, Oltmanns J. The general factor of Corp (2017). psychopathology. Annu Rev Clin Psychol. (2020) 16:75–98. doi: 10.1146/annurev- clinpsy-071119-115848 63. Rizopoulos D. Ltm: an R package for latent variable modelling and item response theory analyses. J Stat Softw. (2006) 17:1–25. doi: 10.18637/jss.v017.i05 86. Livesley W, Jang K. Differentiating normal, abnormal, and disordered personality. Eur J Pers. (2005) 19:257–68. doi: 10.1002/per.559 64. Rosseel Y. Lavaan: an R package for structural equation modeling. J Stat Softw. (2012) 48:1–36. doi: 10.18637/jss.v048.i02 87. Parker G, Hadzi-Pavlovic D, Both L, Kumar S, Wilhelm K, Olley A. Measuring disordered personality functioning: to love and to work reprised. Acta Psychiatr 65. Robitzsch A. Sirt: supplementary item response theory models. R package Scand. (2004) 110:230–9. doi: 10.1111/j.1600-0447.2004.00312.x version 3.12-66. (2022). Available online at: https://CRAN.R-project.org/package= sirt (accesed December 15, 2022). 88. Cloninger CR. A practical way to diagnosis personality disorder: a proposal. J Pers Disord. (2000) 14:99–108. doi: 10.1521/pedi.2000.14.2.99 66. Osborne J. Effect sizes and the disattenuation of correlation and regression coefficients: lessons from educational psychology. Pract Assess Res Eval. (2003) 89. Bender D, Morey L, Skodol A. Toward a model for assessing level of 8:1–7. doi: 10.7275/0k9h-tq64 personality functioning in DSM-5, part I: a review of theory and methods. J Pers Assess. (2011) 93:332–46. doi: 10.1080/00223891.2011.583808 67. Timmerman M, Lorenzo-Seva U. Dimensionality assessment of ordered polytomous items with parallel analysis. Psychol Methods. (2011) 16:209–20. doi: 90. Livesley W, Jang K. Toward an empirically based classification of personality 10.1037/a0023353 disorder. J Pers Disord. (2000) 14:137–51. doi: 10.1521/pedi.2000.14.2.137 Frontiers in Psychiatry 12 frontiersin.org Gutiérrez et al. 10.3389/fpsyt.2022.1015489 91. Fonagy P, Luyten P, Allison E. Epistemic petrification and the restoration of 109. Wessels N, Zimmermann J, Leising D. Toward a shared understanding epistemic trust: a new conceptualization of borderline personality disorder and its of important consequences of personality. Rev Gen Psychol. (2016) 20:426–36. psychosocial treatment. J Pers Disord. (2015) 29:575–609. doi: 10.1521/pedi.2015. doi: 10.1037/gpr0000088 29.5.575 110. Ozer D, Benet-Martínez V. Personality and the prediction of consequential 92. Zimmermann J. Beyond defending or abolishing criterion A: comment on outcomes. Annu Rev Psychol. (2006) 57:401–21. doi: 10.1146/annurev.psych.57. Morey et al. (2022). Personal Disord. (2022) 13:321–4. doi: 10.1037/per0000561 102904.190127 93. Bowlby J. Attachment and loss: vol. 1. Attachment. 2nd ed. New York, NY: 111. Roberts B, Kuncel N, Shiner R, Caspi A, Goldberg L. The power of Basic Books (1982). personality: the comparative validity of personality traits, socioeconomic status, and cognitive ability for predicting important life outcomes. Perspect Psychol Sci. 94. MacDonald K. Evolution, the five-factor model, and levels of personality. J (2007) 2:313–45. doi: 10.1111/j.1745-6916.2007.00047.x Pers. (1995) 63:525–67. doi: 10.1111/j.1467-6494.1995.tb00505.x 112. Schneider K. Psychopathic personalities. New York, NY: Grune & Stratton 95. Davis K, Panksepp J. The emotional foundations of personality: a (1958). neurobiological and evolutionary approach. London: W. W. Norton & Company (2018). 113. Biskin R. The lifetime course of borderline personality disorder. Can J Psychiatry. (2015) 60:303–8. doi: 10.1177/070674371506000702 96. DeYoung C. Cybernetic big five theory. J Res Pers. (2015) 56:33–58. doi: 10.1016/j.jrp.2014.07.004 114. Leising D, Rogers K, Ostner J. The undisordered personality: normative assumptions underlying personality disorder diagnoses. Rev Gen Psychol. (2009) 97. Harkness A, Reynolds S, Lilienfeld SO. A review of systems for psychology 13:230–41. doi: 10.1037/a0017139 and psychiatry: adaptive systems, personality psychopathology five (PSY-5), and the DSM-5. J Pers Assess. (2014) 96:121–39. doi: 10.1080/00223891.2013.82 115. Leising D, Scherbaum S, Packmohr P, Zimmermann J. Substance and 3438 evaluation in personality disorder diagnoses. J Pers Disord. (2018) 32:766–83. doi: 10.1521/pedi_2017_31_324 98. Saulsman L, Page A. The five-factor model and personality disorder empirical literature: a meta-analytic review. Clin Psychol Rev. (2004) 23:1055–85. doi: 10. 116. Hertler S. The biologically-based bias of personality disorder diagnosis. 1016/j.cpr.2002.09.001 Front Psychol. (2016) 7:1293. doi: 10.3389/fpsyg.2016.01293 99. Samuel D, Widiger TA. A meta-analytic review of the relationships between 117. Zachar P, Kendler K. Psychiatric disorders: a conceptual taxonomy. Am J the five-factor model and DSM-IV-TR personality disorders: a facet level analysis. Psychiatry. (2007) 164:557–65. doi: 10.1176/ajp.2007.164.4.557 Clin Psychol Rev. (2008) 28:1326–42. doi: 10.1016/j.cpr.2008.07.002 118. Wakefield J. The perils of dimensionalization: challenges in distinguishing 100. Lahey B. Public health significance of neuroticism. Am Psychol. (2009) negative traits from personality disorders. Psychiatr Clin North Am. (2008) 64:241–56. doi: 10.1037/a0015309 31:379–93. doi: 10.1016/j.psc.2008.03.009 101. Widiger T, Oltmanns J. Neuroticism is a fundamental domain of personality 119. Penke L, Denissen J, Miller G. The evolutionary genetics of personality. Eur with enormous public health implications. World Psychiatry. (2017) 16:144–5. J Pers. (2007) 21:549–87. doi: 10.1002/per.629 doi: 10.1002/wps.20411 120. Dingemanse N, Réale D. What is the evidence for natural selection 102. Linville P. Self-complexity as a cognitive buffer against stress-related illness maintaining animal personality variation? In: Carere C, Maestripieri D editors. and depression. J Pers Soc Psychol. (1987) 52:663–76. doi: 10.1037//0022-3514.52. Animal personalities: behavior, physiology, and evolution. Chicago, IL: University 4.663 of Chicago Press (2013). p. 201–20. 103. Gutiérrez F, Gárriz M, Peri J, Ferraz L, Sol D, Navarro J, et al. Fitness 121. Del Giudice M. Evolutionary psychopathology: a unified approach. costs and benefits of personality disorder traits. Evol Hum Behav. (2013) 34:41–8. New York, NY: Oxford University Press (2018). doi: 10.1016/j.evolhumbehav.2012.09.001 122. Wolf M, Weissing F. Animal personalities: consequences for ecology and 104. Reynolds J, McCrea S. Environmental constraints on the functionality of evolution. Trends Ecol Evol. (2012) 27:452–61. doi: 10.1016/j.tree.2012.05.001 inhibitory self-control: sometimes you should eat the donut. Self Identity. (2019) 123. Wright A, Hopwood C, Skodol A, Morey L. Longitudinal validation of 18:60–86. doi: 10.1080/15298868.2017.1354066 general and specific structural features of personality pathology. J Abnorm Psychol. 105. McCrae R, Löckenhoff C, Costa PT. A step toward DSM-V: cataloguing (2016) 125:1120–34. doi: 10.1037/abn0000165 personality-related problems in living. Eur J Pers. (2005) 19:269–86. doi: 10.1002/ 124. Podsakoff P, MacKenzie S, Podsakoff N. Sources of method bias per.564 in social science research and recommendations on how to control it. 106. Mullins-Sweatt S, Widiger T. Personality-related problems in living: an Ann Rev Psychol. (2012) 63:539–69. doi: 10.1146/annurev-psych-120710- empirical approach. Personal Disord. (2010) 1:230–8. doi: 10.1037/a0018228 100452 107. Gutiérrez F, Gárriz M, Peri J, Vall G, Torrubia R. How temperament and 125. Mittlböck M, Schemper M. Explained variation for logistic regression. character affect our career, relationships, and mental health. Compr Psychiatry. Stat Med. (1996) 15:1987–97. doi: 10.1002/(SICI)1097-0258(19961015)15:193. (2016) 70:181–9. doi: 10.1016/j.comppsych.2016.07.014 0.CO;2-9 108. Sleep C, Lynam D, Miller J. Personality impairment in the DSM-5 and 126. Hellevik O. Linear versus logistic regression when the dependent variable ICD-11: current standing and limitations. Curr Opin Psychiatry. (2021) 34:39–43. is a dichotomy. Qual Quant. (2009) 43:59–74. doi: 10.1007/s11135-007-9 doi: 10.1097/YCO.0000000000000657 077-3 Frontiers in Psychiatry 13 frontiersin.org