CHAPTER 3

Articulating a Core
Dimension of Personality
Pathology
Leslie C. Morey, Ph.D.
Donna S. Bender, Ph.D., FIPA

Problems with the categorical approach to personality disorders (PDs) pre-

sented in DSM-III (American Psychiatric Association 1980), DSM-IV (American Psy-
chiatric Association 1994), and the DSM-5 (American Psychiatric Association 2013)
Section II PD classification (which is virtually identical to DSM-IV) have been well doc-
umented. Among the issues of greatest concern is the extensive co-occurrence of PDs,
such that most patients who receive a PD diagnosis meet criteria for more than one
(e.g., Grant et al. 2005; Morey 1988; Oldham et al. 1992; Zimmerman et al. 2005).
Another concern is the relatively poor convergent validity of PD criteria sets, apparent
when considering that patient groups diagnosed by different methods may be only
weakly related to one another (Clark 2007; Hyler et al. 1989; Pilkonis et al. 1995). This
unfortunate situation results in manifestations of putatively different “personality
diagnoses” that are more highly associated than different phenotypic variations within
the same “personality diagnosis” (e.g., Morey and Levine 1988).
Although extensive co-occurrence is perhaps the most consistently replicated result
in the field of PDs, the various editions of DSM, including PDs in DSM-5 Section II (“Di-
agnostic Criteria and Codes”), have yet to offer any representation of PD that accounts
for this phenomenon or provide a compelling explanation as to why it is so reliably
found. At the outset of work on DSM-5, the Personality and Personality Disorders
(P&PD) Work Group was charged with developing a new approach to the “Personal-
ity Disorders” section of DSM-5 that would begin to rectify the comorbidity problem
(Kupfer et al. 2002; Rounsaville et al. 2002). As part of these deliberations, the work
group sought to provide some representation of PD that would delineate the essential

47
48 Textbook of Personality Disorders, Third Edition

similarities, apparently shared by most, if not all, DSM PD categories, that were driv-
ing the remarkable comorbidity among these disorders. The DSM-IV (and DSM-5)
general criteria for a PD indicate that an enduring pattern of inner experience and be-
havior is manifest in two or more of the following areas: cognition, affectivity, inter-
personal functioning, and impulse control. These very broad criteria do not appear to
be very specific for PDs, nor are they always consistent with the specific criteria for
individual PDs in DSM, creating possible confusion about whether individual PDs al-
ways meet the general criteria. Finally, it is important to understand that these general
PD criteria were introduced in DSM-IV without justification or any empirical basis—
there is no mention of them in the PD chapters of the DSM-IV Sourcebook (Gunderson
1996; Widiger et al. 1996) or in articles that described the development of the revised
classification (Frances et al. 1990, 1991; Pincus et al. 1992; Widiger et al. 1991). Conse-
quently, the general criteria for PD in DSM have commonly been ignored in clinical
practice and research, and they fail to provide any insight into the shared elements that
are common to PDs and that differentiate them from other forms of mental disorder.
Many of the significant shortcomings of the DSM PD categories were addressed by
the P&PD Work Group, who developed the Alternative DSM-5 Model for Personality
Disorders (AMPD) found in DSM-5 Section III, “Emerging Measures and Models”
(American Psychiatric Association 2013). The AMPD consists of dimensional assess-
ments of shared core impairments in personality functioning common to all PDs, as
well as dimensional assessments of pathological personality traits that may be found
to varying degrees across different patients. When combined with other DSM-IV-like
inclusion and exclusion criteria, this combination of core impairments and patholog-
ical traits yields diagnoses that bear substantial empirical similarity to DSM-IV PDs
(Morey and Skodol 2013) but have a clear conceptual structure that maps out the ele-
mental “traits” that are present to an unusual degree and also provides an essential
assessment structure of the core features of personality dysfunction.
In this chapter, we provide an overview of the notion of “core dysfunction” in PD, de-
scribing the history of such a concept and the instantiation of the concept in the DSM-
5 Section III model. We also review research that helps articulate the concept and
demonstrates its potential validity and utility, along with clinical illustrations of its
utility.

Historical Background
It is somewhat ironic that there was a significant subgroup of PD experts opposing
the DSM-5 Section III model on the grounds that it is a substantial departure from
precedent, given that the notion of a unitary construct of personality disturbance
greatly predates the DSM-III/DSM-IV representation of discrete PD categories. In fact,
in 1963, Menninger surveyed 2,000 years of the history of classification in psychiatry
and identified “a steady trend toward simplification and reduction of the categories
from thousands to hundreds to dozens to a mere four or five” (Menninger 1963, p. 9).
Menninger thus proposed a revolutionary psychiatric classification that comprised a
single class—a unitary conception of what he called “personality dysorganization,”
in contrast to “disorganization,” in that personality organization has not been lost but
only impaired to various degrees. This “dysorganization” was manifest at five differ-
Articulating a Core Dimension of Personality Pathology 49

ent levels of severity of impairment in adaptive control, impulse management, and

ego failures.
Menninger’s early views and observations by others (e.g., Rushton and Irwing 2011)
have pointed out that the history of the study of personality is replete with such uni-
tary, dimensional severity models. Sir Francis Galton (1887) described a general factor
of personality in his paper “Good and Bad Temper in English Families,” using ratings
from family members across generations to group 15 adjectives indicative of “good
temper” (e.g., self-controlled) and 46 markers of “bad temper” (e.g., proud, uncertain,
vindictive) that could be arrayed along a single dimension. Although there were
about three times as many markers of “bad” personality as “good,” he believed that
the ratio of the number of these markers present was distributed in a bell-shaped fash-
ion, with comparable numbers of individuals at each extreme (identified by Galton as
those manifesting a 2:1 ratio of these adjectives, in either direction). In this description,
Galton was echoing in many ways James Cowles Prichard’s (1835) concept of moral
insanity, which Prichard described as “a morbid perversion of the natural feelings, af-
fections, inclinations, temper, habits, moral dispositions, and natural impulses, without
any remarkable disorder or defect of the intellect or knowing and reasoning faculties,
and particularly without any insane illusion or hallucination” (p. 24). Prichard ac-
knowledged that this single class of mental disorder could take many forms, stating
that “the varieties of moral insanity are perhaps as numerous as the modifications of
feeling or passion in the human mind” (Prichard 1835, p. 24). These different forms
could involve extremes in emotion (despondency or excitement), impulses, hostility,
eccentricity, or “decay of social affection,” but Rushton and Irwing (2011) noted that
the common denominator to moral insanity was self-control (“will-power”), a lack of
which could cause harm to oneself or to others.
In contrast to the taxonomic work of psychiatric writers such as Emil Kraepelin
(1902), who delineated classes of disorder such as manic-depression and dementia
praecox that were presented as qualitatively different phenomena, many personality-
oriented writers continued to emphasize a more unitary approach that identified criti-
cal differences as existing between points along a single continuum. In many accounts,
this continuum was thought to reflect a developmental process, and individuals could
be grouped according to various “stages” in this process. Whereas Freud’s models of
development, including psychosexual stages (Freud 1905/1953) and the evolution of
narcissism to object-love (Freud 1914/1957), were of considerable heuristic influence,
many other theorists described stage models with considerable overlap in the indica-
tors of placement along this continuum. Theorists such as Piaget (1932), Kohlberg
(1963), Erikson (1950), and Loevinger (1976) all denoted developmental sequences
that with maturation resulted in greater self-control and increased prosocial behavior.
Although Menninger (1963) obviously misread the trend that produced the explo-
sion of diagnostic entities in DSM-III that descended from a Kraepelinian rather than
a unitary tradition (Blashfield 1984), Menninger’s overview of the historical evolution
of this model provides a compelling reminder that the significance of a severity gra-
dient in evaluating personality problems has been described for far longer than the
specific personality entities introduced in DSM-III. For example, in the long history of
personality assessment research, the specter of a single, overarching dimension of per-
sonality dysfunction has repeatedly emerged in various empirical approaches to the
study of personality. Early personality inventories such as the Minnesota Multiphasic
50 Textbook of Personality Disorders, Third Edition

Personality Inventory (Hathaway and McKinley 1943) were seemingly saturated with
a large single source of variability, with repeated efforts to “eliminate” the contribu-
tions of this large component as an undesirable artifact (e.g., Meehl 1945; Tellegen et
al. 2003) rather than as a personality characteristic of substantive significance. The
“lexical” tradition of factor analysis of personality adjectives, pioneered by Norman
(1963) and Digman (1990) and culminating in the five-factor model (FFM), began with
a set of personality descriptors that purposefully sought to remove “evaluative” (i.e.,
good vs. bad) descriptors of personality as a basis for the resulting dimensional struc-
ture, presumably because of the compelling influence such a dimension had on sub-
sequent factor analyses (Block 1995). Despite those efforts, it appears that a unitary
dimension of dysfunction may underlie even putatively orthogonal factor structures
such as the FFM. For example, research studying the different DSM PDs consistently
finds that the various disorders display quite similar configurations on the FFM (Morey
et al. 2000, 2002; Saulsman and Page 2004; Zweig-Frank and Paris 1995), a configura-
tion particularly characterized by high neuroticism and low conscientiousness and
agreeableness. Several studies have concluded that the five factors themselves are sub-
sumed under higher-order factors, such as the “Big Two” factors, labeled alpha and
beta by Digman (1997) or stability and plasticity by DeYoung et al. (2002). However,
evidence supports the contention that even these two super factors are themselves sub-
sumed by a higher-order dimension. In two meta-analyses of Big Five interscale cor-
relations, Rushton and Irwing (2008) and Van der Linden et al. (2010) concluded that
there was strong evidence of what Rushton and Irwing described as a single “general
factor of personality”; these meta-analyses included the data sets that Digman (1997)
had used to establish the “alpha” and “beta” factors. Additional analyses found very
poor fit of a model specifying that the Big Two were uncorrelated.
In addition to results from factor analysis studies, theoretical accounts support the
contention of a super factor of personality functioning. Block (2010) provided the in-
teresting observation that the Big Two components of stability and plasticity, as two
presumably desirable elements of personality, have important theoretical parallels to
Piaget’s (1932) notions of assimilation and accommodation, fundamental processes in
the development of the child. Piaget identified these as the core principles by which
the child constructs and modifies internal representations of objects and actions, allow-
ing him or her to achieve equilibrium as well as adapt to the world. As Block (2010)
noted, assimilation and accommodation represent manifestations of a single, central
developmental process that continues to influence behavior throughout the life span,
and research on social cognition supports the conclusion that these processes play a
foundational role in shaping interactions with others. For example, Anderson and Cole
(1990) demonstrated that when a new acquaintance is assimilated into a category of
“significant other representations,” perceivers are quick to inappropriately apply pre-
conceived notions that are, in some instances, quite inaccurate. Thus, maturation (or
the failure thereof) of these representational processes has a powerful influence on
one’s view of self and of others.
Kernberg (1967) was one of the first contemporary writers to formulate a classifica-
tion of character pathology that encompasses different forms of personality problems
arrayed along a severity continuum reflecting what he terms different levels of “per-
sonality organization.” Central to this concept was the notion of identity, comprising
the various ways in which individuals experience themselves in relation to others
Articulating a Core Dimension of Personality Pathology 51

(Kernberg 1984). Normal identity involves a self-view that is realistic and integrated,
with a correspondingly realistic and stable experience of others. With increasingly
problematic personality organization, identity becomes more diffuse, inflexible, un-
stable, and poorly integrated. Kernberg and Caligor (2005) offered an ordering of the
different DSM categories of PD, as they could be arrayed along this continuum of per-
sonality organization severity.

Contemporary Status of Global Concept of

Personality Impairment
Efforts to identify core elements of PD are found in numerous measures and scales de-
signed to identify personality problems. In the process of attempting to identify these
core impairments in personality functioning, Bender et al. (2011) reviewed several re-
liable and valid clinician-administered measures for assessing personality function-
ing and psychopathology and demonstrated that content relevant to representations
of self and other permeates such instruments and that these instruments have solid
empirical bases and significant clinical utility. For example, numerous studies using
measures of self and interpersonal functioning have demonstrated their utility for de-
termining the existence, type, and severity of personality pathology. These measures
include clinician-completed rating scales or interviews, as well as patient self-report
measures. Among the clinician instruments reviewed were measures such as the Social
Cognition and Object Relations Scale (M. Hilsenroth, M. Stein, and J. Pinsker, “Social
Cognition and Object Relations Scale: Global Method [SCORS-G],” unpublished man-
uscript, The Derner Institute of Advanced Psychological Studies, Adelphi University,
Garden City, NY, 2004; Westen et al. 1990) and the Structured Interview of Personality
Organization (Stern et al. 2010). The review by Bender et al. (2011) found that all such
measures sampled content pertaining to distorted and maladaptive thinking about
oneself and others. A synthesis of these common elements suggested that the compo-
nents most central to effective personality functioning fall under the rubrics of identity,
self-direction, empathy, and intimacy, with reliability estimates for existing measures of
these constructs typically exceeding 0.75.
Such concepts appeared to merit consideration as common mechanisms that may
underlie all PDs. The existence of such core impairments is suggested by the high rates
of co-occurring PD diagnoses based on DSM criteria (e.g., Morey 1988). The idea that
all PDs may be arrayed along a common dimension reflecting PD severity was also
supported by the finding that efforts to make the DSM diagnostic rules more restric-
tive (by narrowing the diagnostic rules to include only the most “prototypical” cases)
had the seemingly paradoxical effect of increasing rather than decreasing PD comorbid-
ity. An early effort by Morey (2005) examined three different data sets that each in-
cluded information about every DSM-defined PD criterion. In these data sets, a score
was calculated for each patient that reflected the summed count of all PD criteria
present in that patient. In these three data sets, the coefficient alpha values were 0.81,
0.96, and 0.94, suggesting that the problematic behaviors and characteristics listed in
the criteria for the various DSM PDs form an internally consistent dimension that cuts
across virtually all of the disorders. Given the nature of the DSM decision rules, it was
apparent that higher “scores” on this single dimension would account for the widely
52 Textbook of Personality Disorders, Third Edition

observed comorbidity because the presence of additional symptom features would

by definition increase the likelihood of any particular disorder. However, the high in-
ternal consistency values indicated that this was not simply a computational artifact
but rather the operation of a substantive construct. The conclusion from this study
was that failures in empathic relatedness, including the inability to accurately under-
stand the perspective of others in shaping the self-concept, were present in varying
degrees in all PDs. Furthermore, more severe and pervasive empathy problems are
linked to the presence of more and diverse PD features and hence to assignment of mul-
tiple PD diagnoses to such patients.
Our work with the Collaborative Longitudinal Personality Disorders Study (CLPS)
(Gunderson et al. 2000; Skodol et al. 2005) provided an important opportunity to bet-
ter understand the correlates and implications of this putative global personality pa-
thology dimension. The CLPS was a 10-year prospective, repeated-measures study
that included patients with one of four specific DSM-IV-TR (American Psychiatric As-
sociation 2000) PDs (schizotypal, borderline, avoidant, or obsessive-compulsive) or
patients with major depressive disorder in the absence of PD as a comparison group.
Participants in the CLPS were assessed with interview and questionnaire measures of
PD symptoms, traits, and functioning regularly throughout the course of the study. In
a set of CLPS analyses reported by Hopwood et al. (2011), we sought to disentangle
elements of global personality severity from the stylistic expression of these problems,
because these were confounded in the DSM-III and DSM-IV conceptualization of PD.
Thus, that study had four aims: 1) to identify which DSM PD features constitute the best
markers of “severity”; 2) to isolate elements of personality style that are independent of
general severity; 3) to examine whether the severity and stylistic elements of PD should
be assessed in parallel; and 4) to determine whether each element provides incremen-
tal information about impairment, longitudinal course, and outcomes of patients.
As in the various data sets described by Morey (2005), the severity composite rep-
resenting the sum of all DSM-IV PD criteria was highly internally consistent (coeffi-
cient α=0.90). The PD criteria that had the largest item-total correlations with this
severity composite consistently demonstrated problems in self (e.g., avoidant: “feelings
of inadequacy”; borderline: “identity disturbance”) or interpersonal (e.g., avoidant:
“social ineptness” or “preoccupation with being rejected”; schizotypal: “paranoid
ideation”) domains. The analyses of the predictive validity of this composite suggested
that generalized personality pathology severity was the strongest predictor of concur-
rent and prospective dysfunction, although stylistic elements of personality pathology
symptom expression proved incrementally useful for predicting specific kinds of dys-
function. Interestingly, most pathological personality traits and even those normative
(i.e., FFM) traits thought to be most related to PD tended to be strongly related to global
severity rather than to specific styles of dysfunction. Given that the global severity
score accounted for most of the valid variance provided by PD concepts in predicting
patient outcome, Hopwood et al. (2011, p. 317) offered the following recommendation
for DSM-5:

PD severity should be represented in the DSM-5 by a single quantitative dimension that

accommodates a diverse array of elements, including dysfunction in social, emotional,
and identity-related functioning, analogous to the GAF [Global Assessment of Func-
tioning] score for general functioning but specifically linked to personality systems.
Articulating a Core Dimension of Personality Pathology 53

The DSM-5 P&PD Work Group explicitly attempted to follow through on these rec-
ommendations by reviewing relevant literature (Bender et al. 2011) and by analyzing
additional existing data sets to further elaborate this dimension (Morey et al. 2011).
Specifically, Morey et al. (2011) sought to identify items reflective of the core impair-
ments in self and other representation described by the DSM-5 P&PD Work Group
(Bender et al. 2011), with the aim of characterizing the manifestations of this impair-
ment continuum at different levels of severity using item response theory (Lord
1980). The study derived a composite dimension of severity that was significantly as-
sociated with 1) the probability of being assigned any DSM-IV PD diagnosis, 2) the
total number of DSM-IV PD features manifested, and 3) the probability of being as-
signed multiple DSM-IV PD diagnoses. The key markers of this dimension involved
important functions related to self (e.g., identity integration, integrity of self-concept)
and interpersonal (e.g., capacity for empathy and intimacy) relatedness—features that,
as reviewed by Bender et al. (2011), play a prominent role in influential theoretical
conceptualizations of core personality pathology (Kernberg and Caligor 2005; Kohut
1971; Livesley 2003). The patterning of markers along the putative severity contin-
uum demonstrated some interesting features. Self-related features such as identity is-
sues, low self-worth, and impaired self-direction appear to be central characteristics
of milder levels of personality pathology, whereas interpersonal issues (in addition to
self pathology) become discriminating at the more severe levels of personality pathol-
ogy. Such a finding is consistent with the view of Kernberg (e.g., Kernberg 1984) and
others that identity issues play a foundational role in driving the characteristic inter-
personal dysfunction noted in PDs.
Taking findings from these and other studies into account, the DSM-5 P&PD Work
Group sought to synthesize various concepts across self-other models to form a foun-
dation for rating personality functioning on a continuum, with the goal of creating a
severity scale that could be easily applied by clinicians. This rating scale was refined
through a focus on elements that could be assessed reliably in previous research
(Bender et al. 2011) and that also emerged in various studies as discriminating mark-
ers of this dimension. The resulting scale, titled the Level of Personality Functioning
Scale (LPFS; American Psychiatric Association 2013), was thus designed to serve as a
basis for determining global level of impairment in personality functioning in DSM-5.
This rating represents a single-item composite evaluation of impairment in the four
self-other areas described in Table 3–1. The LPFS provides anchor points describing
characteristics of five impairment levels (little or none, some, moderate, severe, and
extreme). (The LPFS is provided in its entirety in the Appendix to this volume. See
also Chapter 4, “The Alternative DSM-5 Model for Personality Disorders,” in this vol-
ume for a more complete discussion of the AMPD.)

Measures of DSM-5 Personality Functioning

In the AMPD, the assessment of PD core impairment is presented as a rating scale,
with a clinician applying the LPFS to provide a rating on a five-point scale of severity
ranging from healthy functioning (level=0) to extreme impairment (level =4). Al-
though the LPFS has been criticized as potentially being too difficult for clinicians to
use without extensive training, which would result in poor reliability (e.g., Pilkonis
54 Textbook of Personality Disorders, Third Edition

TABLE 3–1. Four self-other areas of personality functioning typically impaired in

personality disorder

Self
Identity: Experience of oneself as unique, with clear boundaries between self and others;
stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a
range of emotional experience.
Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of
constructive and prosocial internal standards of behavior; ability to self-reflect productively.
Interpersonal
Empathy: Comprehension and appreciation of others’ experiences and motivations; tolerance
of differing perspectives; understanding of the effects of one’s own behavior on others.
Intimacy: Depth and duration of positive connection with others; desire and capacity for
closeness; mutuality of regard reflected in interpersonal behavior.

et al. 2011), studies have found that speculation to be unsubstantiated and indicated
that, in fact, it can be used with adequate reliability. For example, Morey (2019) had 123
clinicians rate AMPD constructs on 12 clinical vignettes. The interrater reliability for
the LPFS total score had an intraclass correlation of 0.50 for a single rater and 0.98
when aggregated across the multiple raters, values that were larger than those attained
for any of the DSM-IV categorical PD diagnoses. Other studies have reported that
even lay raters can achieve adequate interrater reliability on the LPFS. For example,
Zimmermann et al. (2014) had undergraduate psychology students view recorded cli-
nician interviews and provide LPFS ratings of personality functioning. The median in-
ternal consistency/coefficient alpha for the aggregated LPFS markers was greater
than 0.75 for both domain and total scores, and the interrater reliability for the LPFS to-
tal score had an intraclass correlation of 0.51 for a single rater and 0.96 when aggregated
across the multiple raters, values that are virtually identical to those obtained by
Morey (2019) in his study of experienced clinicians. In a different study, Morey (2018)
determined that undergraduate students were able to use the LPFS indicators with
very high internal consistency, and the indicators aligned well with their lay concepts
of a disordered personality. As such, it appears that concerns about the difficulty of ap-
plying the LPFS in standard practice are unwarranted.
In addition to the clinical use of the LPFS as a rating scale, a variety of formal assess-
ment techniques for measuring this core impairment dimension have been developed
since the introduction of the AMPD, including both structured clinical interviews and
self-report questionnaires. Structured interviews for this purpose include the Semi-
Structured Interview for Personality Functioning DSM-5 (STiP-5.1; Hutsebaut et al.
2017), Clinical Assessment of the LPFS (CALF; Thylstrup et al. 2016), and Structured
Clinical Interview for the Level of Personality Functioning Scale (SCID-5-AMPD
Module I; Bender et al. 2018). Use of these structured techniques may lead to even
greater interrater reliability for the LPFS than with the unstructured use described
earlier; for example, Hutsebaut et al. (2017) described an intraclass interrater correla-
tion of 0.89 for the STiP total score when applied to a clinical sample, whereas Buer
Christensen et al. (2018) obtained an intraclass reliability with the SCID-5-AMPD
Module I of 0.96 for the total LPFS score. However, Thylstrup et al. (2016) obtained a
somewhat lower interrater reliability value of 0.65 for the total score when they used
Articulating a Core Dimension of Personality Pathology 55

the CALF in their total sample, which they attributed to the relatively higher level of
inference required in using that interview.
A variety of self-report questionnaires to measure the AMPD core impairment
dimension also have been developed, including the LPFS—Self-Report (LPFS-SR;
Morey 2017), the LPFS—Brief Form (LPFS-BF; Hutsebaut et al. 2016), the DSM-5 Lev-
els of Personality Functioning Questionnaire (DLOPFQ; Huprich et al. 2018), the Self
and Interpersonal Functioning Scale (Gamache et al. 2019), and a questionnaire de-
signed for use with adolescents, the Levels of Personality Functioning Questionnaire
(LoPF-Q 12–18; Goth et al. 2018). Each of these self-report questionnaires has certain
advantages and disadvantages. The LPFS-BF is a very brief measure involving three
items targeting each of the four content areas of the LPFS, resulting in a total of 12 items.
It has shown expected associations with indicators of problem severity and well-be-
ing and incremental prediction of problems over and above measures of problematic
personality traits (Bach and Hutsebaut 2018). However, because of its brevity, the
LFPS-BF has a limited ability to sample problems that might manifest across different
levels of personality dysfunction. In contrast, the LPFS-SR includes 80 items written
to capture each specific indicator described in the LPFS table (see Appendix) and is thus
particularly well suited for studying the conceptual organization of these features.
The LPFS-SR has been found to correlate substantially with a wide range of problematic
personality traits, PD constructs, and interpersonal problems, while showing discrimi-
nant validity with other indicators of personality with less relationship to distress and
dysfunction (Hopwood et al. 2018). However, at 80 items, the LPFS-SR is appreciably
longer than the 12-item LPFS-BF. Finally, the DLOPFQ has 132 items that assess levels
of functioning across work or school and close relationships. The DLOPFQ scales have
demonstrated incremental prediction over and above problematic traits on several cri-
terion measures (Huprich et al. 2018), although its correspondence with provider rat-
ings of LPFS constructs is limited (Nelson et al. 2018). With 132 items, the DLOPFQ is
lengthy, and the items have less clear correspondence to the DSM-5 LPFS concepts than
the preceding instruments.
As would be expected in a unidimensional construct representing a core impairment
dimension, the internal consistency of these questionnaires tends to be quite high, in
excess of 0.90 for most instruments. Although test-retest reliability has received less
research attention to date, the LPFS-SR also had test-retest correlations of 0.91 for the
total score over short-term periods (Hopwood et al. 2018). As such, these question-
naires represent efficient and reliable ways to estimate an individual’s level of person-
ality dysfunction.

Research on Level of Personality Functioning

Scale Core Dimensionality and Utility
Researchers have increasingly been exploring whether the LPFS does indeed capture
a unitary construct at the heart of personality functioning across a spectrum and how
useful this approach is in clinical work and in characterizing dysfunction.
To ascertain both the utility and the validity of clinician judgments when using the
LPFS, Morey et al. (2013a) examined clinician-rated LPFS scores as applied to a broad
sample of patients with and without prominent PD features. This study had three im-
56 Textbook of Personality Disorders, Third Edition

portant aspects. First, it was assumed that LPFS ratings should be related to DSM-IV
PD diagnoses, given the assumption that all PDs reflect impairment in this core self-
other dimension and that this rating would differentiate those receiving such diagnoses
from those not diagnosed with PD. Second, the study explored whether LPFS ratings
were significantly related to critical clinical judgments, such as estimates of broad
adaptive functioning, risk for harm to self or others, long-term prognosis, and clinical
appraisals of needed treatment intensity. Finally, the study sought to determine
whether mental health professionals would view the LPFS ratings as clinically useful—
whether conceptualizing their patient in this way would be seen as relevant for patient
description and treatment decision making. These questions were addressed in a na-
tional sample of 337 clinicians providing complete PD diagnostic information about
a patient with whom they were familiar, which involved a full formulation of both
DSM-IV and DSM-5 AMPD diagnostic judgments.
The results of the Morey et al. (2013a) study demonstrated that, consistent with the
assumption that these personality functioning deficits underlie all PDs, the single-item
LPFS showed solid sensitivity (0.846) and specificity (0.727) for identifying the pres-
ence or absence of DSM-IV PDs. Furthermore, the scale was also related to DSM-IV PD
comorbidity, with those individuals receiving multiple DSM-IV diagnoses obtaining
more severe ratings on the LPFS. Furthermore, analyses were conducted to compare
the incremental validity of the DSM-5 LPFS rating with that of DSM-IV PD diagnoses
with respect to their ability to predict clinical judgments of psychosocial functioning,
short-term risk, estimated prognosis, and optimal level of treatment intensity. All pre-
dictive validity correlations for both LPFS ratings and DSM-IV diagnoses were statis-
tically significant. However, for three of the four validity variables, the single-item
DSM-5 LPFS rating yielded adjusted multiple correlations that were larger than those
provided when considering all 10 DSM-IV PD diagnoses. In the areas of functioning,
prognosis, and treatment intensity needs, the DSM-5 LPFS successfully captured an ap-
preciable part of the valid variance contributed by DSM-IV PD diagnoses and signifi-
cantly incremented that information as well. Only in the area of risk assessment did
information about the specific PD diagnoses prove useful as a supplement to the LPFS
rating of impairment in personality functioning.
In addition to the results described earlier, a separate investigation by these research-
ers (Morey et al. 2013b) examined clinicians’ perceptions of the clinical utility of the
LPFS and other PD diagnostic constructs. Following completion of ratings for DSM-IV
criteria and the LPFS rating, clinicians were asked six questions about the perceived
clinical utility of each set of information provided. Compared with the DSM-5 LPFS
rating, DSM-IV was seen as easier to use and more useful for communication with other
professionals. However, in every other respect—for treatment planning, patient de-
scription, and communicating to the patient—the DSM-5 LPFS had higher mean use-
fulness ratings than DSM-IV. Thus, clinicians perceived the single-item DSM-5 LPFS
rating as being generally more useful in several important ways than the entire set of
79 DSM-IV PD criteria. This is in spite of these clinicians’ greater presumed familiar-
ity with DSM-IV over the previous 18 years and their having no experience with the
DSM-5 Section III proposal at the time of the study.
Research on validity, latent structure, and internal consistency of the LPFS has con-
tinued to evolve. For example, high internal consistency, unidimensionality, and con-
current validity were demonstrated in two investigations of the LPFS-SR by Morey
Articulating a Core Dimension of Personality Pathology 57

(2017, 2018). The 2017 study showed an internal consistency alpha estimate of 0.969
for the LPFS-SR total score and alphas ranging from 0.816 to 0.891 for the four sub-
components. A single component representing more than 85% of the variance among
the four subscales was yielded by a principal components process, supporting the no-
tion that the LPFS represents a single dimension in structure. Analysis of relevant
measures in exploring concurrent validity indicated that the LPFS had correlations of-
ten exceeding 0.80 for the overall total score. Morey (2018) replicated the internal con-
sistency finding in a study that also showed that undergraduate students were able
to easily and effectively apply the LPFS.
The structure of the LPFS dimension was assessed in another study that yielded two
highly correlated factors (Zimmermann et al. 2015). In addition, a principal compo-
nents analysis by Cruitt et al. (2019) supported a single underlying LPFS dimension.
Hopwood et al. (2018) used multiple measures to explore the validity of the LPFS-SR
and suggested: “Data further support that identity, self-direction, intimacy, and em-
pathy components of the LPFS–SR can be characterized by a single factor and have sim-
ilar correlations with criterion variables, consistent with the hypothesis that DSM-5
Criterion A is a relatively homogeneous construct” (p. 650).
Other studies have also explored the validity of the LPFS and its utility as a mea-
sure of functional capacities of clinical importance. Several self-report measures have
shown convergence with personality functioning and severity of personality psycho-
pathology assessment instruments (Bach and Anderson 2020; Gamache et al. 2019;
Hopwood et al. 2018; Hutsebaut et al. 2016; Morey 2017; Oltmanns and Widiger 2019;
Sleep et al. 2019; Weekers et al. 2019) such as the Severity Indices of Personality Prob-
lems (Verheul et al. 2008), the Personality Assessment Inventory (Morey 2007), and
the General Assessment of Personality Disorder (Hentschel and Livesley 2013). Pres-
ence of DSM-5 Section II PDs (Cruitt et al. 2019; Dereboy et al. 2018; Hutsebaut et al.
2017; Preti et al. 2018; Zimmermann et al. 2014), number of PD symptoms and prog-
nosis (Few et al. 2013; Hutsebaut et al. 2017; Morey et al. 2013a), maladaptive traits
(Hopwood et al. 2018; Morey 2018; Oltmanns and Widiger 2019), and interpersonal
dysfunction (Dowgwillo et al. 2018; Hopwood et al. 2018; Roche et al. 2018) also have
been found to be significantly related to the core construct measured by the LPFS. In ad-
dition, the dimensions of a self-other functioning scale developed by Gamache et al.
(2019) yielded significant associations with poor self-esteem, identity diffusion, neg-
ative emotions, and interpersonal distress. Overall low levels of well-being also were
shown to be correlated with personality functioning in several studies (Gamache et al.
2019; Huprich et al. 2018; Nelson et al. 2018). Similarly, Cruitt et al. (2019) noted that
the personality functioning ratings were useful in predicting clinical outcome, and
strong clinical utility ratings were reported by Zimmermann et al. (2014).

Level of Personality Functioning Case Illustrations

To demonstrate the enhanced utility of the DSM-5 Section III LPFS over the DSM-IV/
DSM-5 Section II categorical approach to PDs, we offer a case comparison. As men-
tioned earlier, one of the problems with the categorical polythetic criteria approach to
PDs is that there can be significant variations within the same diagnosis, causing im-
portant clinical information to be lost if one does not look beyond the limited infor-
58 Textbook of Personality Disorders, Third Edition

mation conveyed by a categorical diagnostic label. The following two clinical case
examples show the importance of assessing the core LPFS elements of personality
functioning.

Case Example 1
Madison is an intelligent, funny, talkative, attractive, age 20-something woman who
sought psychotherapy because she was determined to build a better life for herself than
her family, particularly her emotionally volatile mother and sister, had managed. She
also has been “too stressed out” at her job. Madison had done very well academically
in college and succeeded in obtaining a good position with a large consulting firm. She
works long hours but is often concerned that she is not doing her projects “perfectly,”
which makes her very anxious at times. Her perfectionism causes her to spend exces-
sive effort trying to be completely thorough, adding unnecessary additional time at the
office. She also refuses to take help from colleagues because she is sure they will make
mistakes or not have high enough standards. In spite of her worries, she has gotten very
positive reviews from her supervisors, but she does not derive much reassurance from
that. She also attends a demanding master’s program during the evenings and weekends,
so most of her time is devoted to work, with little left for socializing.
Madison also impresses one as determined to be an engaged and productive “good
patient.” She talks in excessive detail and in a highly intellectualized manner, but strong
emotions are very difficult for her to tolerate and talk about. She can explain very well
how she thinks about things but has trouble considering how she feels. She described
one occasion when it was apparent that she had a panic attack rather than let herself
know how angry she was at her colleagues. Although she is able to consider others’ per-
spectives, she has little tolerance for those who do not agree with her or live up to her
standards. These attitudes lead to additional stress and frustration for Madison in the
workplace.
Madison has a close group of women friends she has known since the beginning of
college, but she is sometimes critical of some of their life choices. She obviously values
these friends and does what she can to socialize with them, given her overloaded sched-
ule. She also has a boyfriend but is having some difficulty getting close to him and is
inhibited in expressing her affection. She is jealous of other women as well, with likely
unwarranted worries that her boyfriend will be unfaithful, but she does not understand
why he finds it troublesome to be distrusted in that way.
Given her excessive devotion to work, perfectionism, overconscientious approach to
tasks, and refusal to delegate tasks to others, Madison meets criteria for DSM-IV/DSM-5
Section II obsessive-compulsive PD. Looking more closely at her inner life and person-
ality functioning with the LPFS, Madison’s profile fits with level 1, some impairment.
She has a relatively intact sense of self but has some difficulty handling strong emotions
(identity); she is overly intellectualizing, is excessively goal-directed, and has unrealis-
tically high standards (self-direction); she is resistant to appreciating others’ perspec-
tives, although she can, and does not quite understand why her jealousy bothers her
boyfriend (empathy); and she has solid and enduring relationships, but they are some-
what compromised by her inhibitions in emotional expression and excessively high
standards for others (intimacy).

Case Example 2
Ryan presented with a similar style to Madison’s. He is a married, well-educated, highly
intelligent, and verbal 28-year-old engineer. Ryan greatly values his career and is proud
of working for a prestigious firm. His presenting complaint was difficulty with com-
pleting work effectively, due to perfectionism that generates excessive anxiety. Ryan
puts in long hours at his job attempting to make progress on his projects but often
Articulating a Core Dimension of Personality Pathology 59

dwells on fairly insignificant points for days on end. He also experiences some friction
at times with his coworkers because of his insistence that his opinions and approach to
tasks are most correct. Ryan also reported that he is very active in his church, at least on
Sundays, the only day he does not work. He seemingly derives satisfaction from that
community, with his and his wife’s social life centering on their relationships there.
However, Ryan has been very upset that his suggestions to the church leadership for
changing procedures have not been accepted unconditionally. He is considering leav-
ing the congregation because of this, but his wife has managed to convince him to stay
thus far.
Like Madison, Ryan’s perfectionism interferes with task completion, and he is exces-
sively devoted to work. He is stubborn and rigid in his collaborations with others and
becomes too preoccupied with the small details of his projects. Given these characteris-
tics, Ryan also meets criteria for obsessive-compulsive PD.
However, if one stopped the clinical interview of Ryan at this point, a great deal of
very important information would be lost, and an inadequate treatment plan may be
formulated. By probing about the LPFS areas of identity, self-direction, empathy, and
intimacy, one discovers important differences between Madison and Ryan. Ryan re-
ported that he often feels terrible about himself and has an ongoing terror of being crit-
icized. He constantly seeks approval from his boss and feels miserable if he is not
praised for his work. He sees himself as particularly gifted and entitled to special rec-
ognition and as much smarter than his colleagues. Similarly, his anger at his church for
not taking his suggestions makes him feel “invisible” and indignant. “I have an Ivy
League degree, and those dullards can’t seem to appreciate what I have to offer.”
Clearly, he has some issues with regulating self-esteem and looks to others for ongoing
approval (identity). It is also apparent that Ryan’s slavish devotion to work is not moti-
vated only by an internal set of high standards but is primarily a means to try to gain
external approval (self-direction).
In the area of empathy, Ryan does not have a very good sense of how his stubborn,
opinionated behavior might affect others, nor does he seem to care very much. He longs
for praise and acceptance at work and at church, but he seems to lack the ability to con-
sider why others might have a different opinion, and he has trouble having dialogues.
When asked about his marriage and friendships, Ryan says his relationships often dis-
appoint him because people do not appreciate him enough (intimacy). Not surprisingly,
he is having some marital problems.

As can be seen in the comparison of these two cases, it is important to clinically ex-
plore the core components of personality functioning to get beyond surface behaviors
and attitudes. Both of these patients meet criteria for obsessive-compulsive PD under
the DSM-5 Section II criteria, but the significant differences in their character struc-
tures are identified by the LPFS assessment. Whereas Madison showed personality
difficulties rated at level 1, indicating some impairment, Ryan had more marked
problems, which would be scored as level 2, for moderate impairment. In addition, as
assessed with the new Section III model, Madison would not meet full criteria for a
PD because an LPFS level of 2 or greater is required for disorder status to be assigned.
As a clinician, one would likely take a different approach with Madison, because her
self-structure is more intact, than with Ryan, who has more vulnerable self-esteem.
Furthermore, with the greater severity of Ryan’s central personality issues, we begin
to see indications of other PD diagnoses (such as attributes of narcissistic PD), which
in DSM-IV/DSM-5 Section II would be portrayed as “comorbidity,” leading to possi-
ble confusion and contradictions when considering the criteria of multiple categories.
However, the LPFS more effectively represents these phenomena simply as increased
impairment in the core components.
60 Textbook of Personality Disorders, Third Edition

Conclusion
In contrast with any “official” representation of PD provided in various editions of
DSM, the DSM-5 AMPD diagnostic system delineates a specific continuum of core
personality functioning that captures features underlying all PDs. This continuum is
represented in the new system with a single-item rating of the LPFS that Morey et al.
(2013a, 2013b) found to bear strong relationships to PD diagnosis and to important
clinical judgments. The lack of a conceptualization of PD severity in the DSM-IV tax-
onomy (a lack that continues to pertain to DSM-5 Section II) represents a significant
failure of an antiquated diagnostic system to adequately capture a primary source of
variance in virtually all markers of clinical validity. Availability of such a PD-specific
severity measure not only may assist in identifying central aspects of personality pa-
thology but also will help guide treatment decisions and help stimulate research on
the fundamental nature of PD. It is hoped that in future revisions, DSM will provide the
field with official recognition of the importance of such an assessment.

References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd
Edition. Washington, DC, American Psychiatric Association, 1980
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition. Washington, DC, American Psychiatric Association, 1994
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th
Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition. Arlington, VA, American Psychiatric Association, 2013
Anderson SM, Cole SW: “Do I know you?” The role of significant others in general social per-
ception. J Pers Soc Psychol 59:384–399, 1990
Bach B, Anderson JL: Patient-reported ICD-11 personality disorder severity and DSM-5 level of
personality functioning. J Pers Disord 34:231–249, 2020
Bach B, Hutsebaut J: Level of Personality Functioning Scale—Brief Form 2.0: utility in captur-
ing personality problems in psychiatric outpatients and incarcerated addicts. J Pers Assess
100:660–670, 2018
Bender DS, Morey LC, Skodol AE: Toward a model for assessing level of personality function-
ing in DSM-5, part I: a review of theory and methods. J Pers Assess 93:332–346, 2011
Bender DS, Skodol AE, First MB, et al: Module I: structured clinical interview for the level of
personality functioning scale, in Structured Clinical Interview for the DSM-5 Alternative
Model for Personality Disorders (SCID-AMPD). Washington, DC, American Psychiatric
Association Publishing, 2018
Blashfield RK: The Classification of Psychopathology: Neo-Kraepelinian and Quantitative Ap-
proaches. New York, Plenum, 1984
Block J: A contrarian view of the five-factor approach to personality description. Psychol Bull
117:187–215, 1995
Block J: The five-factor framing of personality and beyond: some ruminations. Psychological
Inquiry 21:2–25, 2010
Buer Christensen T, Paap MC, Arnesen M, et al: Interrater reliability of the structured clinical
interview for the DSM–5 alternative model of personality disorders module I: Level of Per-
sonality Functioning Scale. J Pers Assess 100:630–641, 2018
Clark LA: Assessment and diagnosis of personality disorder: perennial issues and an emerging
reconceptualization. Annu Rev Psychol 58:227–257, 2007
Articulating a Core Dimension of Personality Pathology 61

Cruitt PJ, Boudreaux MJ, King HR, et al: Examining Criterion A: DSM–5 level of personality
functioning as assessed through life story interviews. Personal Disord 10:224–234, 2019
Dereboy F, Dereboy Ç, Eskin M: Validation of the DSM-5 alternative model personality disor-
der diagnoses in Turkey, part 1: LEAD validity and reliability of the personality function-
ing ratings. J Pers Assess 100:603–611, 2018
DeYoung CG, Peterson JB, Higgins DM: Higher order factors of the Big Five predict confor-
mity: are there neuroses of health? Pers Individ Dif 33:533–552, 2002
Digman JM: Personality structure: emergence of the five-factor model. Annu Rev Psychol
50:116–123, 1990
Digman JM: Higher-order factors of the Big Five. J Pers Soc Psychol 73:1246–1256, 1997
Dowgwillo EA, Roche MJ, Pincus AL: Examining the interpersonal nature of Criterion A of the
DSM-5 Section III alternative model for personality disorders using bootstrapped confi-
dence intervals for the interpersonal circumplex. J Pers Assess 100:581–592, 2018
Erikson EH: Childhood and Society. New York, WW Norton, 1950
Few LR, Miller JD, Rothbaum AO, et al: Examination of the Section III DSM-5 diagnostic sys-
tem for personality disorders in an outpatient clinical sample. J Abnorm Psychol 122:1057–
1069, 2013
Frances A, Pincus HA, Widiger TA, et al: DSM-IV: work in progress. Am J Psychiatry 147:1439–
1448, 1990
Frances AJ, First MB, Widiger TA, et al: An A to Z guide to DSM-IV conundrums. J Abnorm
Psychol 100:407–412, 1991
Freud S: Three essays on the theory of sexuality (1905), in The Standard Edition of the Complete
Psychological Works of Sigmund Freud, Vol 12. Translated by Strachey J. London, Hogarth
Press, 1953, pp 135–243
Freud S: On narcissism: an introduction (1914), in The Standard Edition of the Complete Psy-
chological Works of Sigmund Freud, Vol 14. Translated by Strachey J. London, Hogarth
Press, 1957, pp 73–102
Galton F: Good and bad temper in English families. Fortnightly Review 42:21–30, 1887
Gamache D, Savard C, Leclerc P, et al: Introducing a short self-report for the assessment of
DSM-5 level of personality functioning for personality disorders: the Self and Interper-
sonal Functioning Scale. Personal Disord 10:438–447, 2019
Goth K, Birkhölzer M, Schmeck K: Assessment of personality functioning in adolescents with
the LoPF-Q 12-18 self-report questionnaire. J Pers Assess 100:680–690, 2018
Grant BF, Stinson FS, Dawson DA, et al: Co-occurrence of DSM-IV personality disorders in the
United States: results from the National Epidemiologic Survey on Alcohol and Related
Conditions. Compr Psychiatry 46:1–5, 2005
Gunderson JG: Introduction to Section IV: personality disorders, in DSM-IV Sourcebook, Vol 2.
Edited by Widiger TA, Frances AJ, Pincus HA, et al. Washington, DC, American Psychiat-
ric Association, 1996, pp 647–664
Gunderson JG, Shea T, Skodol AE, et al: The Collaborative Longitudinal Personality Disorders
Study: development, aims, design, and sample characteristics. J Pers Disord 14:300–315, 2000
Hathaway SR, McKinley JC: Manual for the Minnesota Multiphasic Personality Inventory.
New York, Psychological Corporation, 1943
Hentschel AG, Livesley WJ: The General Assessment of Personality Disorder (GAPD): factor
structure, incremental validity of self-pathology, and relations to DSM-IV personality dis-
orders. J Pers Assess 95:479–485, 2013
Hopwood CJ, Malone JC, Ansell EB, et al: Personality assessment in DSM-V: empirical support
for rating severity, style, and traits. J Pers Disord 25:305–320, 2011
Hopwood CJ, Good EW, Morey LC: Validity of the DSM-5 Levels of Personality Functioning
Scale—Self Report. J Pers Assess 100:650–659, 2018
Huprich SK, Nelson SM, Meehan KB, et al: Introduction of the DSM-5 Levels of Personality
Functioning Questionnaire. Personal Disord 9:553–563, 2018
Hutsebaut J, Feenstra DJ, Kamphuis JH: Development and preliminary psychometric evalua-
tion of a brief self-report questionnaire for the assessment of the DSM-5 Level of Personal-
ity Functioning Scale: the LPFS Brief Form (LPFS-BF). Personal Disord 7:192–197, 2016
62 Textbook of Personality Disorders, Third Edition

Hutsebaut J, Kamphuis JH, Feenstra DJ, et al: Assessing DSM-5-oriented level of personality
functioning: development and psychometric evaluation of the Semi-Structured Interview
for Personality Functioning DSM-5 (STiP-5.1). Personal Disord 8:94–101, 2017
Hyler SE, Rieder RO, Williams JB, et al: A comparison of clinical and self-report diagnoses of
DSM-III personality disorders in 552 patients. Compr Psychiatry 30:170–178, 1989
Kernberg OF: Borderline personality organization. J Am Psychoanal Assoc 15:641–685, 1967
Kernberg OF: Severe Personality Disorders: Psychotherapeutic Strategies. New Haven, CT,
Yale University Press, 1984
Kernberg OF, Caligor E: A psychoanalytic theory of personality disorders, in Major Theories of
Personality Disorder. Edited by Clarkin JF, Lenzenweger MF. New York, Guilford, 2005,
pp 114–156
Kohlberg L: The development of children’s orientations towards a moral order, I: sequence in
the development of moral thought. Vita Hum Int Z Lebensalterforsch 6:11–33, 1963
Kohut H: The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of
Narcissistic Personality Disorders. New York, International Universities Press, 1971
Kraepelin E: Clinical Psychiatry: A Textbook for Students and Physicians, 6th Edition. Trans-
lated by Diefendorf AR. London, Macmillan, 1902
Kupfer DJ, First MB, Regier DA: A Research Agenda for DSM-V. Washington, DC, American
Psychiatric Association, 2002
Livesley WJ: Diagnostic dilemmas in classifying personality disorder, in Advancing DSM:
Dilemmas in Psychiatric Diagnosis. Edited by Phillips KA, First MB, Pincus HA. Washing-
ton, DC, American Psychiatric Publishing, 2003, pp 153–189
Loevinger J: Ego Development. San Francisco, CA, Jossey-Bass, 1976
Lord FM: Applications of Item Response Theory to Practical Testing Problems. Hillsdale, NJ,
Erlbaum, 1980
Meehl PE: An investigation of a general normality or control factor in personality testing. Psy-
chological Monographs 59:i–62, 1945
Menninger K: The Vital Balance. New York, Viking Press, 1963
Morey LC: Personality disorders under DSM-III and DSM-III-R: an examination of conver-
gence, coverage, and internal consistency. Am J Psychiatry 145:573–577, 1988
Morey LC: Personality pathology as pathological narcissism, in Personality Disorders. WPA
Series: Evidence and Experience in Psychiatry, Vol 8. Edited by Maj M, Akiskal HS,
Mezzich JE, Okasha A. Chichester, West Sussex, England, Wiley, 2005, pp 328–331
Morey LC: Personality Assessment Inventory Professional Manual, 2nd Edition. Odessa, FL,
Psychological Assessment Resources, 2007
Morey LC: Development and initial evaluation of a self-report form of the DSM-5 Level of Per-
sonality Functioning Scale. Psychol Assess 29:1302–1308, 2017
Morey LC: Application of the DSM-5 Level of Personality Functioning Scale by lay raters. Per-
sonal Disord 32:709–720, 2018
Morey LC: Interdiagnostician reliability of the DSM-5 Section II and Section III Alternative
Model criteria for Borderline Personality Disorder. J Pers Disord 33:721–735, 2019
Morey LC, Levine DJ: A multitrait multimethod examination of Minnesota Multiphasic Per-
sonality Inventory (MMPI) and Millon Clinical Multiaxial Inventory (MCMI). J Psycho-
pathol Behav Assess 10:333–344, 1988
Morey LC, Skodol AE: Convergence between DSM-IV-TR and DSM-5 diagnostic models for
personality disorder: evaluation of strategies for establishing diagnostic thresholds. J Psy-
chiatr Pract 19:179–193, 2013
Morey LC, Gunderson JG, Quigley BA, et al: Dimensions and categories: the “Big Five” factors
and the DSM personality disorders. Assessment 7:203–216, 2000
Morey LC, Gunderson JG, Quigley BD, et al: The representation of borderline, avoidant, obses-
sive-compulsive and schizotypal personality disorders by the five-factor model. J Pers Dis-
ord 16:215–234, 2002
Morey LC, Berghuis H, Bender DS, et al: Toward a model for assessing level of personality func-
tioning in DSM-5, part II: empirical articulation of a core dimension of personality pathol-
ogy. J Pers Assess 93:347–353, 2011
Articulating a Core Dimension of Personality Pathology 63

Morey LC, Bender DS, Skodol AE: Validating the proposed DSM-5 severity indicator for per-
sonality disorder. J Nerv Ment Dis 201:729–735, 2013a
Morey LC, Skodol AE, Oldham JM: Clinician judgments of clinical utility: a comparison of
DSM-IV-TR personality disorders and the alternative model for DSM-5 personality disor-
ders. J Abnorm Psychol 123:398–405, 2013b
Nelson SM, Huprich SK, Meehan KB, et al: Convergent and discriminant validity and utility of
the DSM-5 Levels of Personality Functioning Questionnaire (DLOPFQ): associations with
medical health care provider ratings and measures of physical health. J Pers Assess
100:671–679, 2018
Norman WT: Toward an adequate taxonomy of personality attributes: replicated factor struc-
ture in peer nomination personality ratings. J Abnorm Soc Psychol 66:574–583, 1963
Oldham JM, Skodol AE, Kellman HD, et al: Diagnosis of DSM-III-R personality disorders by
two structured interviews: patterns of comorbidity. Am J Psychiatry 149:213–220, 1992
Oltmanns JR, Widiger TA: Evaluating the assessment of the ICD-11 personality disorder diag-
nostic system. Psychol Assess 31:674–684, 2019
Piaget J: The Moral Judgment of the Child. New York, Free Press, 1932
Pilkonis PA, Heape CL, Proietti JM, et al: The reliability and validity of two structured diagnos-
tic interviews for personality disorders. Arch Gen Psychiatry 52:1025–1033, 1995
Pilkonis PA, Hallquist MN, Morse JQ, et al: Striking the (im)proper balance between scientific
advances and clinical utility: commentary on the DSM-5 proposal for personality disor-
ders. Personal Disord 2:68–82, 2011
Pincus HA, Frances A, Davis WW, et al: DSM-IV and new diagnostic categories: holding the
line on proliferation. Am J Psychiatry 149:112–117, 1992
Preti E, Di Pierro R, Costantini G, et al: Using the Structured Interview of Personality Organi-
zation for DSM-5 Level of Personality Functioning rating performed by inexperienced rat-
ers. J Pers Assess 100:621–629, 2018
Prichard JC: A treatise on insanity and other disorders affecting the mind. London, Sherwood,
Gilbert & Piper, 1835
Roche MJ, Jacobson NC, Phillips JJ: Expanding the validity of the Level of Personality Function-
ing Scale observer report and self-report versions across psychodynamic and interper-
sonal paradigms. J Pers Assess 100:571–580, 2018
Rounsaville BJ, Alarcon RD, Andrews G, et al: Basic nomenclature issues for DSM-V, in A Re-
search Agenda for DSM-V. Edited by Kupfer DJ, First MB, Regier DA. Washington, DC,
American Psychiatric Association, 2002, pp 1–29
Rushton JP, Irwing P: A general factor of personality (GFP) from two meta-analyses of the Big
Five: Digman (1997) and Mount, Barrick, Scullen, and Rounds (2005). Pers Individ Dif
45:679–683, 2008
Rushton JP, Irwing P: The general factor of personality, in The Wiley-Blackwell Handbook of
Individual Differences. Edited by Chamorro-Premuzic T, von Stumm S, Furnham A. Ox-
ford, UK, Wiley-Blackwell, 2011, pp 132–161
Saulsman LM, Page AC: The five-factor model and personality disorder empirical literature: a
meta-analytic review. Clin Psychol Rev 23:1055–1085, 2004
Skodol AE, Gunderson JG, Shea MT, et al: The Collaborative Longitudinal Personality Disor-
ders Study (CLPS): overview and implications. J Pers Disord 19:487–504, 2005
Sleep CE, Lynam DR, Widiger TA, et al: An evaluation of DSM-5 Section III personality disor-
der Criterion A (impairment) in accounting for psychopathology. Psychol Assess 31:1181–
1191, 2019
Stern BL, Caligor E, Clarkin JF, et al: Structured Interview of Personality Organization (STIPO):
preliminary psychometrics in a clinical sample. J Pers Assess 92:35–44, 2010
Tellegen A, Ben-Porath YS, McNulty JL, et al: MMPI-2 Restructured Clinical (RC) Scales: De-
velopment, Validation, and Interpretation. Minneapolis, University of Minnesota Press,
2003
Thylstrup B, Simonsen S, Nemery C, et al: Assessment of personality-related levels of function-
ing: a pilot study of clinical assessment of the DSM-5 level of personality functioning based
on a semi-structured interview. BMC Psychiatry 16:298, 2016
64 Textbook of Personality Disorders, Third Edition

Van der Linden D, te Nijenhuis J, Bakker AB: The general factor of personality: a meta-analysis
of Big Five intercorrelations and a criterion-related validity study. J Res Pers 44:315–327,
2010
Verheul R, Andrea H, Berghout C, et al: Severity Indices of Personality Problems (SIPP–118):
development, factor structure, reliability, and validity. Psychol Assess 20:23–34, 2008
Weekers LC, Hutsebaut J, Kamphuis JH: The Level of Personality Functioning Scale—Brief
Form 2.0: update of a brief instrument for assessing level of personality functioning. Per-
sonal Ment Health 13:3–14, 2019
Westen D, Lohr N, Silk K, et al: Object relations and social cognition in borderlines, major de-
pressives, and normals: a Thematic Apperception Test analysis. Psychol Assess 2:355–364,
1990
Widiger TA, Frances AJ, Pincus HA, et al: Toward an empirical classification for the DSM-IV.
J Abnorm Psychol 100:280–288, 1991
Widiger TA, Frances AJ, Pincus HA, et al (eds): DSM-IV Sourcebook, Vol 2. Washington, DC,
American Psychiatric Association, 1996
Zimmermann J, Benecke C, Bender DS, et al: Assessing DSM-5 level of personality functioning
from videotaped clinical interviews: a pilot study with untrained and clinically inexperi-
enced students. J Pers Assess 96:397–409, 2014
Zimmermann J, Böhnke JR, Eschstruth R, et al: The latent structure of personality functioning:
investigating Criterion A from the alternative model for personality disorders in DSM-5.
J Abnorm Psychol 124:532–534, 2015
Zimmerman M, Rothchild L, Chelminski I: The prevalence of DSM-IV personality disorders in
psychiatric outpatients. Am J Psychiatry 162:1911–1918, 2005
Zweig-Frank H, Paris J: The five-factor model of personality in borderline and nonborderline
personality disorders. Can J Psychiatry 40:523–526, 1995