BACKGROUND: The Alternative DSM-5 Model for Personality Disorders and the latest eleventh version of the International Classification of Diseases implement the level of impairment in self and interpersonal personality functioning (Level of Personality Functioning Scale - LPFS) as a core feature of personality pathology. However, some studies have indicated that personality functioning is also impaired in other mental disorders, but a more thorough exploration is missing. Thus, this study aims to develop profiles of levels of personality functioning in people with personality disorders and some other psychiatric diagnoses as well as without diagnosis. METHODS: One-hundred-forty-nine people participated in the study. They came from three groups - healthy controls (n = 53), people with personality disorders (n = 58), and people with mood and anxiety disorders (n = 38). The LPFS was assessed by the Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1). An optimal clustering solution using agglomerative hierarchical cluster analysis was generated to represent profiles of personality functioning. RESULTS: The two patient groups showed significantly higher levels of personality functioning impairment than healthy controls. People with personality disorders showed higher levels of impairment than the other groups. In addition, the clustering analysis revealed three distinct profiles of personality functioning. CONCLUSIONS: The impairment of personality functioning seems to be useful in the clinical assessment of other than personality disorders as well. As the resulting clustering profiles suggest, LPFS can be seen as an overall indicator of the severity of mental health difficulties and the presence of mental disorders symptoms. The LPFS provides valuable and detailed information about the individual's mental health and can thus serve as a broad basis for case formulation, treatment and therapy planning, and prognosis.

Faculty of Education Charles University Prague Czech Republic

National Institute of Mental Health Topolová 748 250 67 Klecany Czech Republic

University of New York Prague Prague Czech Republic

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American Psychiatric Association . Diagnostic and statistical manual of mental disorders. 5. Arlington: American Psychiatric Publishing; 2013.

Hopwood CJ. Research and Assessment with the AMPD. In Hopwood CJ, Mulay AL, Waugh MH, editors. The DSM-5 Alternative Model for Personality Disorders: Integrating Multiple Paradigms of Personality Assessment. New York: Routledge; 2019.

Hörz-Sagstetter S, Ohse L, Kampe L. Three Dimensional Approaches to Personality Disorders: a Review on Personality Functioning, Personality Structure, and Personality Organization. Curr Psychiatry Rep. 2021;23:45. doi: 10.1007/s11920-021-01250-y. PubMed DOI PMC

Bender DS, Morey LC, Skodol AE. Toward a Model for Assessing Level of Personality Functioning in DSM–5, Part I: A Review of Theory and Methods. J Pers Assess. 2011;93:332–346. doi: 10.1080/00223891.2011.583808. PubMed DOI

World Health Organization . ICD-11: International statistical classification of diseases and related health problems. Geneva: World Health Organization; 2022.

Hopwood CJ, Bagby RM, Gralnick T, Ro E, Ruggero C, Mullins-Sweatt S, et al. Integrating psychotherapy with the hierarchical taxonomy of psychopathology (HiTOP) J Psychother Integr. 2020;30:477–497. doi: 10.1037/int0000156. DOI

Widiger TA, Trull TJ. Plate tectonics in the classification of personality disorder: Shifting to a dimensional model. Am Psychol. 2007;62:71–83. doi: 10.1037/0003-066X.62.2.71. PubMed DOI

Zimmermann J, Kerber A, Rek K, Hopwood CJ, Krueger RF. A Brief but Comprehensive Review of Research on the Alternative DSM-5 Model for Personality Disorders. Curr Psychiatry Rep. 2019;21:92. doi: 10.1007/s11920-019-1079-z. PubMed DOI

Luyten P, Fonagy P. Integrating and differentiating personality and psychopathology: A psychodynamic perspective. J Pers. 2021. 10.1111/jopy.12656. PubMed

Kernberg OF. What Is Personality? J Personal Disord. 2016;30:145–156. doi: 10.1521/pedi.2106.30.2.145. PubMed DOI

Kotov R, Krueger RF, Watson D, Achenbach TM, Althoff RR, Bagby RM, et al. The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. J Abnorm Psychol. 2017;126:454–477. doi: 10.1037/abn0000258. PubMed DOI

Sharp C, Wall K. DSM-5 Level of Personality Functioning: Refocusing Personality Disorder on What It Means to Be Human. Annu Rev Clin Psychol. 2021;17:313–337. doi: 10.1146/annurev-clinpsy-081219-105402. PubMed DOI

Busmann M, Wrege J, Meyer AH, Ritzler F, Schmidlin M, Lang UE, et al. Alternative Model of Personality Disorders (DSM-5) Predicts Dropout in Inpatient Psychotherapy for Patients With Personality Disorder. Front Psychol. 2019;10:952. doi: 10.3389/fpsyg.2019.00952. PubMed DOI PMC

Kramer U, editor. Case formulation for personality disorders: tailoring psychotherapy to the individual client. London: Elsevier/Academic Press; 2019.

Hutsebaut J, Weekers LC, Tuin N, Apeldoorn JSP, Bulten E. Assessment of ICD-11 Personality Disorder Severity in Forensic Patients Using the Semi-structured Interview for Personality Functioning DSM-5 (STiP-5.1): Preliminary Findings. Front. Psychiatry. 2021;12. 10.3389/fpsyt.2021.617702. PubMed PMC

Bach B, First MB. Application of the ICD-11 classification of personality disorders. BMC Psychiatry. 2018;18. 10.1186/s12888-018-1908-3. PubMed PMC

Nazari A, Huprich SK, Hemmati A, Rezaei F. The Construct Validity of the ICD-11 Severity of Personality Dysfunction Under Scrutiny of Object-Relations Theory. Front Psychiatry. 2021;12:648427. doi: 10.3389/fpsyt.2021.648427. PubMed DOI PMC

Gamache D, Savard C, Leclerc P, Payant M, Berthelot N, Côté A, et al. A Proposed Classification of ICD-11 Severity Degrees of Personality Pathology Using the Self and Interpersonal Functioning Scale. Front. Psychiatry. 2021;12. 10.3389/fpsyt.2021.628057. PubMed PMC

Widiger TA, Samuel DB. Evidence-based assessment of personality disorders. Psychol Assess. 2005;17:278–287. doi: 10.1037/1040-3590.17.3.278. PubMed DOI

Hutsebaut J, Kamphuis JH, Feenstra DJ, Weekers LC, De Saeger H. 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 Theory Res Treat. 2017;8:94–101. doi: 10.1037/per0000197. PubMed DOI

Morey LC, Berghuis H, Bender DS, Verheul R, Krueger RF, Skodol AE. Toward a Model for Assessing Level of Personality Functioning in DSM–5, Part II: Empirical Articulation of a Core Dimension of Personality Pathology. J Pers Assess. 2011;93:347–353. doi: 10.1080/00223891.2011.577853. PubMed DOI

Doering S, Blüml V, Parth K, Feichtinger K, Gruber M, Aigner M, et al. Personality functioning in anxiety disorders. BMC Psychiatry. 2018;18. 10.1186/s12888-018-1870-0. PubMed PMC

Bach B. Treating comorbid depression and personality disorders in DSM-5 and ICD-11. Lancet Psychiatry. 2018;5:874–875. doi: 10.1016/S2215-0366(18)30351-1. PubMed DOI

Di Pierro R, Gargiulo I, Poggi A, Madeddu F, Preti E. The Level of Personality Functioning Scale Applied to Clinical Material From the Structured Interview of Personality Organization (STIPO): Utility in Detecting Personality Pathology. J Personal Disord. 2020;34:1–15. doi: 10.1521/pedi_2020_34_472. PubMed DOI

Gruber M, Doering S, Blüml V. Personality functioning in anxiety disorders. Curr Opin Psychiatry. 2020;33:62–69. doi: 10.1097/YCO.0000000000000556. PubMed DOI

Møller L, Meisner MW, Søgaard U, Elklit A, Simonsen E. Assessment of personality functioning in ICD-11 posttraumatic stress disorder and complex posttraumatic stress disorder. Personal Disord Theory Res Treat. 2021;12:466–474. doi: 10.1037/per0000491. PubMed DOI

Buer Christensen T, Eikenaes I, Hummelen B, Pedersen G, Nysæter T-E, Bender DS, et al. Level of personality functioning as a predictor of psychosocial functioning—Concurrent validity of criterion A. Personal Disord Theory Res Treat. 2020;11:79–90. doi: 10.1037/per0000352. PubMed DOI

Widiger TA, Bach B, Chmielewski M, Clark LA, DeYoung C, Hopwood CJ, et al. Criterion A of the AMPD in HiTOP. J Pers Assess. 2019;101:345–355. doi: 10.1080/00223891.2018.1465431. PubMed DOI

Bender DS. The P-Factor and What It Means to Be Human: Commentary on Criterion A of the AMPD in HiTOP. J Pers Assess. 2019;101:356–359. doi: 10.1080/00223891.2018.1492928. PubMed DOI

Hengartner MP, De Fruyt F, Rodgers S, Müller M, Rössler W, Ajdacic-Gross V. An integrative examination of general personality dysfunction in a large community sample. Personal Ment Health. 2014;8:276–289. doi: 10.1002/pmh.1263. PubMed DOI

World Health Organization . ICD-10: International statistical classification of diseases and related health problems. Geneva: World Health Organization; 2019.

Dolnicar S, Grün B, Leisch F, Schmidt K. Required Sample Sizes for Data-Driven Market Segmentation Analyses in Tourism. J Travel Res. 2014;53:296–306. doi: 10.1177/0047287513496475. DOI

Beck AT, Steer RA, Brown GK. Manual for the BDI-II. San Antonio: Psychological Corporation; 1996.

Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol. 1988;56:893–897. doi: 10.1037/0022-006X.56.6.893. PubMed DOI

Heissler R, Doubková N, Hutsebaut J, Preiss M. Semi-structured interview for personality functioning DSM-5 (STiP-5.1): Psychometric evaluation of the Czech version. Personal Ment Health. 2021;15:198–207. doi: 10.1002/pmh.1508. PubMed DOI

Zettl M, Taubner S, Hutsebaut J, Volkert J. Psychometrische Evaluation der deutschen Version des Semistrukturierten Interviews zur Erfassung der DSM-5 Persönlichkeitsfunktionen (STiP-5.1). PPmP. Psychother Psychosom Med Psychol. 2019;69:499–504. doi: 10.1055/a-1010-6887. PubMed DOI

Buer Christensen T, Paap MCS, Arnesen M, Koritzinsky K, Nysaeter T-E, Eikenaes I, et al. Interrater Reliability of the Structured Clinical Interview for the DSM–5 Alternative Model of Personality Disorders Module I: Level of Personality Functioning Scale. J Pers Assess. 2018;100:630–641. doi: 10.1080/00223891.2018.1483377. PubMed DOI

Preti E, Di Pierro R, Costantini G, Benzi IMA, De Panfilis C, Madeddu F. Using the Structured Interview of Personality Organization for DSM-5 Level of Personality Functioning Rating Performed by Inexperienced Raters. J Pers Assess. 2018;100:621–629. doi: 10.1080/00223891.2018.1448985. PubMed DOI

Maechler M, Rousseeuw P, Struyf A, Hubert M, Hornik K. cluster: Cluster Analysis Basics and Extensions. R package version 2.1.2. 2021.

Kassambara A. ggpubr: “ggplot2” Based Publication Ready Plots. R package version 0.4.0. 2020.

Warners GR, Bolker B, Lumley T, Johnson RC. gmodels: Various R Programming Tools for Model Fitting. R package version 2.18.1. 2018.

Hennig C. fpc: Flexible Procedures for Clustering. R package version 2.2-9. 2020.

Kassambara A. rstatix: Pipe-Friendly Framework for Basic Statistical Tests. R package version 0.7.0. 2021.

Cohen J. Statistical Power Analysis for the Behavioral Sciences. Routledge; 1988.

Clatworthy J, Buick D, Hankins M, Weinman J, Horne R. The use and reporting of cluster analysis in health psychology: A review. Br J Health Psychol. 2005;10:329–358. doi: 10.1348/135910705X25697. PubMed DOI

Dereboy C, Güzel HS, Dereboy F, Okyay P, Eskin M. Personality disorders in a community sample in Turkey: Prevalence, associated risk factors, temperament and character dimensions. Int J Soc Psychiatry. 2014;60:139–147. doi: 10.1177/0020764012471596. PubMed DOI

Samuels J, Eaton WW, Bienvenu OJ, Brown CH, Costa PT, Nestadt G. Prevalence and correlates of personality disorders in a community sample. Br J Psychiatry. 2002;180:536–542. doi: 10.1192/bjp.180.6.536. PubMed DOI

Stern BL, Caligor E, Clarkin JF, Critchfield KL, Horz S, MacCornack V, et al. Structured Interview of Personality Organization (STIPO): Preliminary Psychometrics in a Clinical Sample. J Pers Assess. 2010;92:35–44. doi: 10.1080/00223890903379308. PubMed DOI

Kampe L, Zimmermann J, Bender D, Caligor E, Borowski A-L, Ehrenthal JC, et al. Comparison of the Structured DSM-5 Clinical Interview for the Level of Personality Functioning Scale With the Structured Interview of Personality Organization. J Pers Assess. 2018;100:642–649. doi: 10.1080/00223891.2018.1489257. PubMed DOI

Buer Christensen T, Hummelen B, Paap MCS, Eikenaes I, Selvik SG, Kvarstein E, et al. Evaluation of Diagnostic Thresholds for Criterion A in the Alternative DSM-5 Model for Personality Disorders. J Personal Disord. 2019;34:1–22. doi: 10.1521/pedi_2019_33_455. PubMed DOI

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. Personal Ment Health. 2019;13:3–14. doi: 10.1002/pmh.1434. PubMed DOI

Weekers LC, Hutsebaut J, Zimmermann J, Kamphuis JH. Changes in the classification of personality disorders: Comparing the DSM–5 Section II personality disorder model to the alternative model for personality disorders using structured clinical interviews. Personal Disord Theory Res Treat. 2021. 10.1037/per0000512. PubMed

Watts J. Problems with the ICD-11 classification of personality disorder. Lancet Psychiatry. 2019;6:461–463. doi: 10.1016/S2215-0366(19)30127-0. PubMed DOI

Bennik EC, Jeronimus BF, Aan Het Rot, M. The relation between empathy and depressive symptoms in a Dutch population sample. J Affect Disord. 2019;242:48–51. doi: 10.1016/j.jad.2018.08.008. PubMed DOI

Ratner K, Mendle J, Burrow AL, Thoemmes F. Depression and derailment: A cyclical model of mental illness and perceived identity change. Clin Psychol Sci. 2019;7:735–753. doi: 10.1177/2167702619829748. DOI

Yan Z, Zeng X, Su J, Zhang X. The dark side of empathy: Meta-analysis evidence of the relationship between empathy and depression. PsyCh J. 2021;10:794–804. doi: 10.1002/pchj.482. PubMed DOI

Clark CB, Thorne CB, Hardy S, Cropsey KL. Cooperation and depressive symptoms. J Affect Disord. 2013;150:1184–1187. doi: 10.1016/j.jad.2013.05.011. PubMed DOI

Hall JA, Schwartz R. Empathy present and future. J Soc Psychol. 2019;159:225–243. doi: 10.1080/00224545.2018.1477442. PubMed DOI

Bach B, Eikenæs IU-M. Transdiagnostic conceptualization of social avoidance through the lens of personality functioning and traits. J Clin Psychol. 2021;77:1249–1258. doi: 10.1002/jclp.23160. PubMed DOI

Michelini G, Palumbo IM, DeYoung CG, Latzman RD, Kotov R. Linking RDoC and HiTOP: A new interface for advancing psychiatric nosology and neuroscience. Clin Psychol Rev. 2021;86:102025. doi: 10.1016/j.cpr.2021.102025. PubMed DOI PMC