The validity of trait, symptom and prototypeapproaches for describing borderline andantisocial personality disorders

MATTHEW M. YALCH, KATHERINE M. THOMAS AND CHRISTOPHER J. HOPWOOD,Michigan State University, East Lansing, MI, 48824-1116, USA

ABSTRACTDetermining the relative validity of trait, symptom and prototype approaches to rating personality disorders(PDs) is a pressing concern given that each of these approaches has been considered for the DSM-5. However,as of yet, there is limited empirical evidence to guide this decision. In this study, we compared the proposedDSM-5 traits, DSM-IV symptoms and diagnostic prototypes that were initially slated for inclusion in theDSM-5 for assessing antisocial and borderline PDs. Trait and symptom count models converged with one anotherwithin diagnoses more than either did with the prototypes but also showed more overlap across diagnoses than theprototypes. The traits generally showed superior criterion validity relative to the symptoms, which were superior tothe prototypes, with the exception that symptoms were more valid than traits for predicting externalizing problems.This pattern suggests that traits are the single most effective method for describing antisocial and borderline PDs butthat combining traits and symptoms, as currently proposed for the DSM-5, may be the best combination of thesethree approaches to assessing personality pathology. Copyright © 2012 John Wiley & Sons, Ltd.

The lack of agreement among personality disorder(PD) researchers and clinicians regarding the mosteffective way to assess personality pathology andthe limited existing empirical evidence uponwhich to base this decision are conspicuous giventhe coming publication of DSM-5. As it stands,a number of apparently viable approaches todescribing personality pathology have been shownto have some validity, but none has emerged as adominant model. That combinations of threeapproaches to PD assessment have been proposedacross two drafts by the DSM-5 Personality Disor-der Work Group is striking evidence of the uncer-tainty surrounding this issue in contemporary PDtaxonomic research.

In this study, the three approaches to PD assess-ment that have been considered by the PD workgroup were compared in terms of their convergent,discriminant and criterion-related validity. Thefirst approach is to rate symptoms. For example,in the DSM-IV (American Psychiatric Associa-tion, 2000), polythetic symptom criteria aresummed and become relevant when they achievea diagnostic threshold. Given evidence thatdimensional assessments are more valid than cate-gorical assessments (Markon, Chmielewski, &Miller, 2011; Morey et al., in press), these datacould also be treated dimensionally in the formof symptom counts. In either case, by focusing onsymptoms such as criminal behaviour in the case

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Personality and Mental Health6: 207–216 (2012)Published online 24 January 2012 in Wiley Online Library(wileyonlinelibrary.com) DOI 10.1002/pmh.1184

of antisocial PD (APD) or self-harming behaviourin the case of borderline PD (BPD), the rateremphasizes the behavioural outcomes associatedwith personality pathology. A potential advantageof the symptom approach is that it provides clinicianswith specific information regarding the behavioursthat are likely to be the focus of interventions (First,2010), which may augment the clinical utility of theDSM-5 as well as the next version of the ICD (First,2005; Reed, 2010). Symptoms were not included inthe initial DSM-5 proposal for PDs. However, inthe current proposal, some symptoms are listed incriterion A, organized by higher-order self andinterpersonal domains but specific to disorders withineach PD (http://www.dsm5.org/ProposedRevisions/Pages/PersonalityandPersonalityDisorders.aspx;American Psychiatric Association, 2011).

An alternative approach is to describe the over-all gestalt of a PD by rating the match between agiven patient and an abstract prototypical descrip-tion of the disorder. The DSM-I and the DSM-IIused this model, and it was the rating formatinitially proposed for the DSM-5 PDs inFebruary of 2010 (American Psychiatric Associa-tion, 2011), although prototypes are not in thecurrent proposal. The main arguments in favourof prototypes involve their efficiency in describingcomplex information with a single number,the suggestion that clinicians tend to think interms of diagnostic exemplars (Rottman, Ahn,Sanislow, & Kim, 2009) and the ease of commu-nication associated with diagnostic variables,particularly among clinicians trained to thinkin terms of diagnoses (Spitzer, First, Shedler,Westen, & Skodol, 2008). The suggestion forusing prototypes in the DSM-5 was based in parton the notion that the diagnostic manual shouldbe modelled on the normative cognitive processesof clinicians (Westen, Shedler, & Bradley, 2006)as some research suggests that clinicians tendto interpret clinical data on the basis of their clin-ical experience and cognitive representations ofprototype diagnostic cases (Flanagan & Blashfield,2007; Herkov & Blashfield, 1995; Murphy &Wright, 1984).

A third approach is to describe personalitypathology in terms of the traits thought to under-lie PDs, such as impulsivity, negative affectivityor attachment insecurity. Unlike with PDs whosestructure is unclear (Edens, Marcus, Lilienfeld, &Poythress, 2006; Rothschild, Cleland, Haslam, &Zimmerman, 2003; Widiger, Freiman, & Bailey,1990), there is considerable evidence for a com-mon structure of traits, especially at the higher-order level (Markon, Krueger, & Watson, 2005;Widiger & Simonsen, 2005), which allows empir-ically based determinations of which traits toinclude in the model and how to organize them.The DSM-5 work group has consistently proposedtrait ratings (American Psychiatric Association,2011). In the most recent proposal, these traitconstellations would be treated as criteria for thediagnosis of PDs. Specifically, symptomatic fea-tures involving self and interpersonal dysfunctionwould serve as ‘Criterion A’ for a given disorder,whereas traits thought to be specific to that disor-der would serve as ‘Criterion B’. In addition, thetraits of a person who does not fit into a disordercategory, or who does not have clinically signifi-cant PD but has some maladaptive traits, couldalso be specified.

Although each of these approaches can be usedto derive estimates of the severity and nature of anindividual’s personality pathology, it would likelybe redundant to use all three, so ultimately anydiagnostic system will inevitably choose fromamong them. Unfortunately, there has been littleresearch directly focused on the validity of thesedistinct approaches to assessing personality pathol-ogy, and research that exists is limited in a numberof respects. For instance, according to factoranalytic research (e.g. Markon et al., 2005), traitmodels are often conceptualized as hierarchicaland offered as competing models to a disorder-basedapproach to representing personality pathology.However, traits are also sometimes conceptualizedas systematically related to certain PDs, as in theDSM-5 proposal (also Samuel & Widiger, 2008).Although research suggests that combining traitsand symptoms leads to optimal clinical predictions

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(Morey, 2007; Morey et al., in press), it is not clearhow to do this. Furthermore, validity studies thatcompare a set of traits to a set of disorders conflatedomains (traits vs. symptoms) with theoretical mod-els (dimensional/variable-centred vs. categorical/person-centred). Constraining each model to focuson common and well-validated constructs is oneway to limit the effects of varying underlying contentcoverage on evaluations of the validity of various PDrepresentations. Therefore, in this study, we focus ontwo such constructs, APD and BPD.We chose thesedisorders because they are similar enough that diag-nostic overlap is a serious concern (Zimmerman,Rothschild, & Chelminski, 2005), they are amongthe best-validated PDs (Skodol, Shea, Yen, White,& Gunderson, 2010) and they are likely to beretained in the DSM-5 (American Psychiatric Asso-ciation, 2011).

A second issue is that various models tend toutilize different assessment methods. Specifically,trait models are commonly assessed by self-reportquestionnaires whereas semi-structured interviewsare often regarded as the standard for assessingPD symptoms (Zimmerman, 1994). Comparing adiagnostic interview for PDs to a trait question-naire conflates assessment method with assessmentdomain. Research into the convergent validitybetween these two methods within the contextof both DSM and ICD diagnoses has yieldedmixed results (Schroeder, Andresen, Naber, &Huber, 2007; Huprich, 2004). Furthermore, givensignificant concerns among many clinicians aboutthe ability of patients to accurately report PDsymptomatology, both questionnaires and inter-views may be limited in that they both rely onpatient reports (Huprich & Bornstein, 2007). Inthis study, we address these issues by using infor-mant reports for traits, symptoms and prototypes.

A third issue is the conflation in previousresearch between the clinical utility of variouspersonality models and clinician familiarity ortraining. In particular, findings that clinicianscan more easily recover PD constructs from PDsymptoms than trait ratings (Rottman et al.,2009) may capitalize on the fact that clinicians

were trained in and are more familiar with PDsthan with traits. Therefore, we sampled naïveraters (students enrolled in an undergraduatepsychology class) who are presumably no more orless familiar with any model than the others toassess the broader question concerning the validityof various representations.

In summary, in this study, we comparedsymptom, prototype and trait approaches to ratingPD features by having naïve informants ratepeople they selected as having difficult personali-ties in terms of APD, BPD and common conse-quences of personality disturbance. We evaluatedthe convergent, discriminant, criterion-relatedand incremental validity of each approach usinga design that controls for assessment method,theoretical content and rater familiarity.

Method

In this study, 283 students provided data inexchange for course credit. Of these participants,44 were omitted from the study because of over-endorsement (i.e. scores> 75T) of items fromthe infrequency scale of the Personality AssessmentInventory (Morey, 2007), which has been vali-dated for detecting random responding. Partici-pants were asked to imagine an individual theyknow well who has interpersonal problems thatseemed to be related to his or her personality,on the basis of global disturbances in self (e.g.identity diffusion) and interpersonal (e.g. empathyproblems) functioning—the defining features ofgeneral personality pathology according to thecurrent DSM-5 proposal. Participants were askedhow well they know this person on a 5-point scaleranging from ‘I don’t really know the person’ (1)to ‘Extremely well’ (5). Those participants whodid not endorse a 3 (‘Fairly well’) or higher on thisscale (n= 4) were not included in the analyses.Of the remaining 235 raters, 234 (99%) were18–25 years old, 160 (68%) were women and193 (82%) were white. Participants tended toselect targets who were demographically similarto themselves: 225 (95%) targets were between

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18 and 25 years old, 144 (62%) were women and200 (86%) were white.

Participants described antisocial and borderlinefeatures of the target individual in three ways.First, they rated the person using the DSM-5 pro-totypes initially proposed by the DSM-5 workgroup for APD and BPD (rated on a 5-point Likertscale ranging from ‘no match’ (1) to ‘very goodmatch’ (5)). These prototypes consisted of a two-paragraph to three-paragraph description of thebehaviours and emotions of a prototypical individ-ual with each PD. The average scores on thesevariables were 2.4 (standard deviation (SD) = 1.2)for BPD and 2.5 (SD=1.2) for APD. Second,raters listed the DSM-IV criteria using the Person-ality Diagnostic Questionnaire 4+ (Hyler et al.,1988; rated true or false) items formatted for infor-mant reporting. Cronbach’s alpha coefficientswere .70 for the eight DSM-IV symptoms ofAPD and .57 for the nine DSM-IV symptoms ofBPD. On average, targets were rated as having2.8 (SD=2.1) APD and 3.5 (SD= 1.9) BPDsymptoms. From DSM-IV cut-offs, 115 targets(51%) met the full criteria for APD and 69 targets(30%) met the full criteria for BPD; however, datawere treated continuously. Third, participantsrated 16 traits initially proposed as descriptive ofthese disorders by the DSM-5 work group (ratedon a 4-point scale ranging from ‘very little or notat all’ (1) to ‘extremely descriptive’ (4)). Thesetrait scales consisted of 10 traits for BPD (e.g. emo-tional liability, tendency to self-harm) and ninetraits for APD (e.g. callousness, irresponsibility)with three traits (aggression, hostility and impul-sivity) overlapping between the two disorders(American Psychiatric Association, 2011).1 Alphasfor these scales were .78 (BPD) and .79 (APD).Mean levels of each trait ranged from 1.61 to 2.15(SD= .87 to 1.04) for APD and 1.36 to 2.26(SD= .66 to 1.04) for BPD, suggesting that, on

average, the traits were at least mildly descriptivefor the individuals rated. Overall, the means anddiagnostic rates across all three approaches suggestthat participants tended to identify targets withsignificant borderline and antisocial personalitypathology. Additionally, of those individuals rated,54 (20%) were reported to have spent time inprison and 113 (41%) had received some form oftreatment from a mental health service provider.

Five criterion variables were used to evaluatethe validity of these models. We focused ondifficulties that are commonly associated withpersonality pathology: interpersonal dysfunction,treatment utilization and externalizing behaviour.Interpersonal problems were measured using theInventory of Interpersonal Problems Short Circumplex(Soldz, Budman, Demby, & Merry, 1995), a32-item instrument with items about behavioursan individual does too much (e.g. ‘This person istoo passive’2) or not enough (e.g. ‘This persondoes not show enough affection’) rated on a5-point Likert scale ranging from ‘not at all’ to‘extremely’. The Inventory of Interpersonal ProblemsShort Circumplex had an alpha of .89. Interpersonalimpacts were measured using the InterpersonalSensitivity Circumplex (Hopwood et al., 2011a), a64-item questionnaire with items about whatinterpersonal behaviours enacted by the personbeing rated bother the person doing the rating(e.g. ‘It bothers me when the person is bossy’).These behaviours are rated on an 8-point Likertscale ranging from ‘not at all, never bothers me’to ‘extremely, always bothers me’ (a= .96). Lastly,participants answered 14 questions about how theperson they rated functioned interpersonally (e.g.‘how close is he/she with his/her family?’, ‘has he/she ever been to jail or prison?’). Factor analysisof these questions indicated four problem areas:attachment problems involve questions about theintimacy and stability of relationships (e.g. ‘He/she has difficulty getting and keeping closerelationships’). Family problem items gauge how

1This proposal has changed since the completion of this study(http://www.dsm5.org/; American Psychiatric Association,2011). 2All items are paraphrased.

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unstable and combative the rated person’s rela-tionships were within his or her own family (e.g.‘How often does he/she have conflicts or argu-ments with family?’). The final two sets of itemsmeasured problems in externalizing behaviours(e.g. ‘Does he/she fight with others?’) and historyof psychiatric treatment (e.g. ‘Has he/she everbeen hospitalized for psychiatric reasons?’). Inter-nal consistency coefficients for the scales createdusing these items ranged from .68 to .73.

We evaluated the validity of various represen-tations of APD and BPD in four ways. First, weassessed the overlap of these disorders within eachsystem, as overlap has been a common criticism ofthe DSM-IV. Second, we evaluated the conver-gence across methods for each construct to evalu-ate the degree to which different approaches wereassessing the same content. Third, we compared thevalidity of each assessment approach for predictingfunctional indicators and normative personalitytraits. Finally, we tested the ability of each approachto increment the others to predict functionalindicators. Given the number of statistical tests inthis study, we selected a conservative type I error rateof p< .01 for statistical significance and focusedprimarily on effect sizes.

Results

Table 1 shows the correlations between symptom,trait and prototype indicators of APD and BPD.The within-method, cross-trait correlation was.18 for prototypes, .38 for symptoms and .57 for

traits (this correlation was .32 when correctingfor trait overlap). All models showed cross-method convergence, with correlations for thesame disorder across methods ranging from .36 to.68 for BPD and .41 to .63 for APD. Convergentcorrelations were consistently greater than diver-gent (cross-method, cross-construct) correlations,although in many cases divergent correlationswere substantial (range = .17–.57). Overall, these-data suggest that although each model convergedwith the others reasonably well, there was stron-ger convergent but weaker discriminant validityfor the trait and symptom approaches andweaker convergent but stronger discriminantvalidity for the prototypes. This pattern suggestseither that the prototypes reflect more distinctconstructs or that they are simply less valid, anissue that can be informed by evaluating crite-rion validity.

Table 2 shows correlations from regressionmodels in which BPD and APD ratings predictedfunctioning variables independently and together.Overall, the traits tended to correlate morestrongly with functioning than did the symptomcounts, which correlated more strongly than theprototypes. The only exception to this was thatsymptoms, and particularly APD symptoms, weremore effective for predicting externalizing difficul-ties than traits. To further clarify the relativevalidity of these approaches to PD assessment,we constructed hierarchical regression models inwhich ratings for both disorders were entered asseparate steps (e.g. we entered both trait ratings

Table 1: Correlations between trait, symptom count and prototype ratings of BPD and APD

APD traits BPD traits APD symptoms BPD symptoms APD prototype

BPD traits .57* (.32*)APD symptoms .63* .39*BPD symptoms .40* .68* .38*APD prototype .59* .27* .41* .14BPD prototype .17 .43* .15 .36* .18*

Note:*p< .01. Parentheses indicate the correlation between APD and BPD trait profiles with overlapping traits removed.APD, antisocial personality disorder; BPD, borderline personality disorder.

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as step 1 followed by both symptom ratings asstep 2 to test the incremental validity of the symp-tom approach; Table 3). The traits incrementedthe other models in most specific cases and onaverage to a greater degree than the other modelsincremented the traits, although the symptomapproach incremented the traits in predictingexternalizing behaviour and the prototypes mod-estly incremented the traits in predicting attach-ment problems. In general, the prototypes wereinferior to trait and symptom approaches to asses-sing PD in terms of criterion validity.

Discussion

This empirical comparison of trait, symptom andprototype approaches to rating APD and BPDyielded two major findings. First, traits convergedthe most with other approaches within diagnosisbut also overlapped the most across diagnoses.Second, traits were the most effective for predictingfunctioning variables (also Lowe &Widiger, 2009),although symptoms meaningfully incrementedtraits for indicating externalizing dysfunction.These results suggest that prototype approaches are

Table 2: Correlations between trait, symptom count and prototype borderline and antisocial personality disorder ratings andfunctioning

Model Interpersonalproblems

Interpersonalimpacts

Attachmentproblems

Familyproblems

Treatmenthistory

Externalizing

PrototypesBPD .31* .17 .40* .24* .28* .11APD .26* .23* .21* .20* .02 .22*Combined .38* .26* .43* .28* .28* .27*

TraitsBPD .64* .31* .54* .45* .43* .31*APD .50* .38* .31* .38* .08 .45*Combined .67* .40* .55* .48* .47* .47*

SymptomsBPD .47* .32* .45* .29* .41* .36*APD .30* .20* .21* .21* .14 .55*Combined .49* .33* .46* .31* .41* .61*

Note:*p< .01. Rows in which BPD and APD predicted criteria together reflect multiple correlations.APD, antisocial personality disorder; BPD, borderline personality disorder.

Table 3: Incremental multiple correlations between trait, symptom count and prototype borderline and antisocial personalitydisorder ratings and interpersonal functioning

Step 1 Prototypes Traits Symptoms

Step 2 Traits Symptoms Prototypes Symptoms Prototypes Traits

Interpersonal problems .31* .13* .01 .01 .06* .18*Interpersonal impacts .09* .07* .00 .04 .03 .08*Attachment problems .15* .12* .04* .02 .08* .10*Family problems .15* .05* .01 .00 .03 .13*Treatment history .15* .11* .01 .04* .03 .09*Externalizing .15* .29* .00 .17* .01 .01

*p< .01.

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less valid than trait or symptom approaches overalland support a model that combines traits andsymptoms, such as the one currently proposed forthe DSM-5. Specifically, these results suggest thatoptimal clinical prediction of personality-relatedfunctioning requires consideration of individualdifferences in personality structure as well as spe-cific, contextual and dynamic problems in living(Morey, 2007).

However, the manner in which these ratingapproaches fit into an overarching theoreticalmodel and framework for rating psychopathologyneeds to be considered thoughtfully. From a traitperspective, it would be more valid to structuretraits according to their empirical inter-relations,such as in the form of a hierarchical trait model,than to organize traits according to multidimen-sional disorder categories. In such a model, therewould not be overlapping traits to indicate differ-ent phenomena, as occurs when traits are used tospecify PD. However, if traits are to be indicatorsof PD categories, common traits need to be repre-sented across PDs in order to maintain the contentvalidity of PDs because these PDs, in fact, shareunderlying traits. This creates a tension in theDSM-5 hybrid model in that either overlappingtraits must be used for diagnosing separatedisorders, leading to problems with discriminantvalidity as observed in this study, or the contentdefinition of PDs must change to avoid overlap-ping criteria (Hopwood et al., 2011b; Hopwood,Thomas, Markon, Wright, & Krueger, in press).One way to resolve this tension would be to ratetraits and disorders separately (Hopwood, 2011).

If a general factor of personality problemswas implemented as currently proposed by theDSM-5 work group and supported by recentresearch (Hopwood et al., 2011b; Jahng et al.,2011), it would be important for PD constructsto add clinically useful information to one anotherand to that general dimension while also demon-strating discriminant validity. Because a generaldimension would be expected to carry much ofthe weight in predicting functioning (Skodolet al., 2010), the focus of the PD representations

in such a system might shift to describing individ-ual differences in patient style—the specificexpression, manifestation, influences on and con-sequences of the pathology independent of overallseverity. The results of this study are only some-what informative regarding the ability of variousformats to serve this purpose. Future researchfocusing on broad issues such as the underlyingstructure and theoretical assumptions of variousapproaches, as well as specific issues such as theimpact of a general severity composite, is neededto better understand the strengths and weaknessesof different rating formats.

Despite the inferior performance of prototypesin this study, it is important to consider theseresults with regard to the relative burden associ-ated with each of these approaches from a cost–benefit perspective. There are 16 symptomsbetween both disorders in the DSM-IV, and therewere 16 traits between them in the initial DSM-5proposal. Some clinicians and PD researchers mayconsider the validity attenuation observed hereas a fair trade for the diminished clinician burdenassociated with rating single-item prototypes(Rottman et al., 2009; Spitzer et al., 2008).

The design of this study was chosen for itsability to address a number of specific confoundsin the literature, and it enabled us to comparedifferent rating schemes using a common methodrated by common and unbiased raters whofocused upon common constructs. Given itsspecific focus, this study produced results thatcannot speak to a number of important contem-porary questions about PD assessment. First, thiswas not a study of alternative (e.g. dimensionalvs. categorical) models of personality pathology;rather, it focused on BPD and APD. In thissense, the underlying theoretical model isassumed to be categorical, but the underlyingmeasurement model is continuous. Future re-search should continue to compare these modelswhile also carefully considering the impacts oftheir different underlying theoretical modelson issues related to measurement and clinicalimplementation.

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Second, we used naïve raters so that prefer-ences, training background and other potentialfactors related to being a mental health profes-sional that may affect one’s ability to use variousrating systems were controlled. However, thismay limit the generalizability of these results toclinical practice. Future research could build uponthese findings by employing different kinds ofraters, to test empirically the impact of familiarityor preferences and to better evaluate the utilityof various systems among practicing clinicians.Future researchers should also specify in greater de-tail how and in what capacity the rater was familiarwith the rated individual (e.g. through clinicalpractice or through social or professional ties),given the possibility that different relationshipspermit exposure to different kinds of informationthat may be used to inform diagnostic decisions.

Third, we utilized particular ways of represent-ing traits, symptoms and prototypes. Perhaps amore comprehensive or valid set of symptoms thanthe current DSM-IV definition or a more accurateprototype description than the version drafted bythe DSM-5 work group would have led to differentresults. Fourth, we relied exclusively on informantreports. Future research should continue to studythe self-report and interview methods that aremost common in contemporary clinical practiceand also take advantage of a number of noveland innovative approaches to measuring personal-ity and its dynamics, including psychophysiologi-cal, ecological and experimental methods.

Fifth, this study was limited in that we focusedupon two specific PDs. It is possible that aninteraction exists between assessment model andcontent, such as if it were more useful to assessborderline and antisocial criteria with traits butthe features of other PDs with symptom countsor prototypes. It is also possible that rating formatsinteract with construct definition, such that unlikethe symptom counts and prototypes the traitratings were at a disadvantage because the traitswere adapted to describe symptoms. The traitsmay have been further disadvantaged by our useof a single-item rating format, whereas typically

traits are assessed using multi-item questionnaires.Finally, our focus on a limited array of PDs andcriteria limited our ability to fully test the incre-mental value of traits and symptoms, and thus,our conclusion that these results broadly supportthe hybrid model proposed by the DSM-5 mustbe tentative.

In summary, these results suggest that trait andsymptom approaches, which allow raters to articu-late the specific reasons for producing a summaryindication of PD, are more effective than proto-type approaches, which attempt to capture PDusing a single global score. Results also suggest thatalthough traits are more valid than symptomapproaches in general, symptoms may incrementtraits for certain clinical predictions. These resultsbroadly support the DSM-5 proposal, which incor-porates traits and symptoms in PD assessment.Given the limitations of any single study on thisissue and the general lack of agreement in the fieldregarding optimal models and methods for diag-nosing PD, the validity of various approaches torating PD should continue to be a major focus offuture research.

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