We are the Association for Child and Adolescent Mental Health or ACAMH for short. And this is ACAMH Learn. Good morning. My name is Dr. Carla Sharp. I am a John and Rebecca Moores Professor of Psychology at the University of Houston and Associate Dean for Faculty and Research. And I am a researcher and clinician working primarily in the area of personality disorder, specifically as it pertains to youth, adolescence, and children to some degree. And my orientation is both cognitive behaviour and also mentalization-based therapy. So dimensional models for personality disorder. The learning objectives for the next 20, 25 minutes is for the audience to be a bit more familiar with new advances in personality disorder research and practise, and particularly as it pertains to dimensional approaches to the diagnosis of personality disorder and its developmental aspects. And then, very briefly, there won't be enough time, but to just touch on briefly what the treatment implications of these advances might be for diagnosis of personality disorder. So I want to start with just what motivated these recent advances towards dimensional models and developmental aspects. So why is there an alternative model for personality disorder? And this alternative model, you will find in the DSM-5 section 3. So DSM-5 section 2 contains our standard approaches to diagnosis. Section 3 contains the alternative model. So I'm asking in this 20 minutes, why is it an alternative model to start with? And I'm also asking why did the WHO, the World Health Organisation, already replaced the old categorical system for diagnosis of personality disorder with a new dimensional system? So in the US, we tend to use the DSM-5 a lot. In the rest of the world, the ICD-11 is used. And many of our systems in many countries have already moved over to the ICD-11. In the US, we have not made that transition yet. So let's just look at the DSM-5 for a minute. This is the contents page of the DSM-5. And you'll see up here section 1 and section 2. And here you find all of your disorders that we are all well familiar with. Here are the personality disorders in section 2. And there are 10 of them. They're generally organised into cluster A, cluster B, and cluster C. But here you will see section 3, emerging measures and models. And here you see the alternative model for personality disorder. Now typically still, when we train students and clinicians, we use our 10 old categories, unless you are someone that have been aware of the alternative model. So for instance, in my lab we do use, and in my clinic, we use the alternative model for personality disorder. So here are the 10 personality disorders. And when we train clinicians or student clinicians in all of these disorders, including personality disorders, we tend to teach them as categories. And that means that we tend to give the most salient signs and symptoms of these disorders. Here are the signs of depression. Here are the PTSD criteria, anxiety disorder, and substance use disorder. What that means is that we actually consider the disorder, first of all to be yes/no, you have the disorder or not. That's what we mean with categorical diagnosis. And secondly, we really take a prototype approach to it. There's a sort of ideal vision of what someone looks like with depression, what someone looks like with substance use disorder. We also do the same for personality disorders. So personality disorder, especially the cluster B-- erratic and dramatic personality disorders, lend themselves to good theatre drama. And so we usually see the extreme end of these portrayed in movies or in TV programmes in terms of narcissism, antisocial personality disorder, or sociopaths, but also borderline personality disorder. Also, when we teach our students and clinicians about assessment, we try to promote the idea that using standardised assessment tools for diagnosing disorder is the best way. It's the evidence-based way to do it. So we teach all of these things to our students and our clinicians, and then they start seeing real life clients. And this is typically then the questions that I have in my supervision groups about seeing real life clients. My clients seems to meet criteria for BPD, avoidant paranoid, antisocial, and OCPD. Could that be possible? My client seems to also have depression, anxiety, substance use, and PTSD. What do I do with that? So typically, we find if you meet criteria for BPD, you meet criteria for two or three other personality disorders. Plus, you meet criteria for a mixture of internalising and externalising psychopathology. My students will say I have two clients with BPD, but they are completely different. I'm not sure what to do with that. Does one of them actually not have BPD? How should I adjust the manual? Or they say my client seems BPD, but she does not meet criteria, so should I still treat her BPD? She just meets four out of the nine criteria, not five. She does not seem severe enough, but she also has depression. What do I really do with this? Getting confused between subthreshold and comorbidity and how to make sense of that. Or my client meets criteria for BPD six months ago, but now she does not meet criteria anymore. I thought it was a stable disorder personality because it is personality, after all, does she still have BPD or how should I conceptualise her case now? Should I adjust her treatment? How? Most of the treatment takes six months or more. Perhaps she never had BPD and I misdiagnosed her. Or my client has BPD, but I don't want to label her with such a diagnosis because it's highly stigmatising. Should I rather not diagnose it? Or can I treat her for it and not diagnose it? Or my client is 16 and she meets criteria for BPD, but BPD does not exist in adolescence. So what should I do? So what clinicians face with real life clients is comorbidity between PDs, high comorbidity with other syndromes, heterogeneity within the disorder. People don't look the same. BPD and PD is just not a yes/no no thing. People move in and out of clinical threshold. It's not stable. There's huge fear of stigmatisation. And then finally, the category makes understanding the developmental course quite difficult. So we can meet a 16-year-old that clearly meets seven or eight or nine criteria for BPD, but we don't want to diagnose him because we think that it's not developmentally applicable. And then one of the biggest questions I tend to get is which treatment manual should I now use? Because we have all of these categories that the client meets criteria for. The end result is problems in clinical utility. So in the end, no diagnosis is made for personality disorder. And these individuals fall through the cracks. Misdiagnosis is made. They give a diagnosis of ADHD, depression, anxiety, substance use in a young person. They get the treatment for those things. The treatment doesn't work. So again, these young people fall through the cracks. Often also get diagnosed as bipolar II. And recently, and they've been put on a mood stabiliser. And recently, I've also seen quite a bit of autism spectrum misdiagnosis instead of a personality disorder diagnosis. Some clinicians put PDD-NOS in not otherwise specified in the chart. They feel convinced that it is personality disorder, but it doesn't fit any of the boxes of personality disorder. Clinicians start with haphazard use of manualized treatment protocols, or they delay the diagnosis for young people. Finally, the young person as a young adult makes it into a clinic where personality disorder is assessed and they finally get the appropriate treatment. For clients, this, needless to say, leads to confusion and hopelessness, and a perpetuation of the stigma. By saying that I'm not going to diagnose personality disorder because I don't want to stigmatise my patient or my client, one is actually perpetuating the stigma and making personality disorder something special. Putting it on a sort of pedestal and saying we can diagnose schizophrenia, depression, and anxiety and substance use, but we cannot diagnose personality disorder. And that really comes from a misunderstanding of what personality means. So I hope to debunk some of these myths as we go along. So is there a more parsimonious way of conceptualising personality disorder that accounts for comorbidity, heterogeneity, severity, developmental considerations, that allows for change moving in and out of threshold as we know patients do, and that is less stigmatising? In other words, is there a way of conceptualising personality disorder that more closely match real life patients so that we can increase clinical utility? And I should also say that match our data better because when we factor analyse the signs and symptoms of personality pathology, we do not get 10 categories that explain the covariance structure of symptoms. So when the DSM-5 work group in 2013 submitted their proposal for personality disorder, they actually did recommend an overall of the 10 categories. And they recommended a single unidimensional severity criterion that articulates what all personality disorders have in common. So instead of diagnosing those 10 categories, just one single unidimensional severity criterion that articulates what the PDS have in common. And what is that severity continuum? It is maladaptive self and interpersonal functioning. So that is what they did. They identified maladaptive self and interpersonal functioning as what is shared by BPD, narcissism, antisocial, schizoid, schizotypal, OCPD. And they put it on a 5 point scale to make it a dimension from healthy personality functioning at 0 to unhealthy personality functioning at 4. And somewhere in between, most of us lie. Most of us are between 0 and 1. We have some bad days where we are not very good at managing ourselves in interpersonal functioning and then we'll be at 2. But if we are consistently at a 2 or a 3 or a 4, then we warrant a diagnosis of personality disorder. So this is what it looks like. The alternative model in section 3. There is criterion A, our first criterion that the clinician considers. It's called level of personality functioning on that 5-point scale. It asks about self-functioning which is identity and self-direction, and interpersonal personal functioning, which is empathy and intimacy. The clinician then has the option to also assess maladaptive trait domains. That's criterion B across five maladaptive traits-- negative affectivity, detachment, antagonism, disinhibition, and psychoticism. And these are maladaptive endpoints of the big five. So that's what I have in brackets there. Neuroticism, extraversion, disagreeableness as an opposite of agreeableness, conscientiousness, and openness. In the alternative model, there was then a third step where you can look at criterion A and criterion B features. And you can then say, does this fit a borderline pattern, a narcissism pattern, an antisocial pattern? The data has shown that this third step is redundant, because all of the individual variation that we are looking for to be able to capture what's going on with someone with personality disorder is already captured in criterion A and criterion B. ICD-11 followed suit when it was published in 2022. It had maladaptive staff and interpersonal functioning as criterion A, maladaptive trait domains as criterion B, and then the borderline pattern as an option for matching. Now all of the other 10 categories have been thrown away. It's only borderline as a pattern that has been retained. This is just to show you, I said earlier, when we factor analyse, we don't find the 10 categories. Here are the nine criteria for BPD, for avoidant, OCPD, and so forth. And what we see when we factor analyse a cross load. They also all load onto a general factor. This general psychiatric general severity continuum that explains all of the associations between these 10 categories. Whether we want to use the 10 categories to express the flavour, how the general factor manifests itself, or whether we want to do the five trait domains doesn't really matter, except that the five trait domains match our data slightly better than the 10 categories. So this means that personality disorder functions very much like IQ. We have a general factor that we all lie on and that can express itself in terms of particular flavour. So we can say you're of average intelligence, but you're good with verbal stuff, not so good with perceptual stuff. In the same way we can say that a person lies on a 2 for general personality functioning, and they express themselves a little bit more antagonistic and with more negative affectivity than another person who may also lie on a 2, but express themselves as more detached. So we've looked at the data for this, the support for this, the empirical validation of this in a 10-year retrospective in 2022, in personality disorders theory, research, and treatment. We've also done a good review, an annual review of clinical psychology. There are also multiple other reviews of the existing data in support of the alternative model. And by and large, we now know that LPF is unidimensional. It's got strong inter-rater reliability, strong internal consistency, strong convergent validity, strong predictive validity. It's not as sensitive to gender bias as the categories. It's learnable by laypersons. It's acceptable among clinicians. And it also increments traits in the prediction of outcomes. Now, when you want to get a new system into section 2 of the DSM-5, you actually need to also show evidence of superiority of the new system over the old system. And so we've looked at the data in support of that in 2024. Again in PDTRT, we published these head-to-head comparisons for whether section 3, the alternative model outperforms section 2. And this is just the headlines for suicidal behaviours, for psychosocial functioning, for clinician decision-making, for predicting suicide and problematic substance use. Section 3 tends to outperform section 2. This is the cross-sectional findings. And here are the prospective findings again for prospectively predicting clinical symptoms, psychosocial functioning, and quality of life, for pre-post treatment changes, for interpersonal functioning, for ambulatory ratings of affect and stress, and for general psychiatric severity, again prospectively measured, section 3 tends to outperform section 2. More recently, we were asked by the American Psychiatric Association to do a systematic review again of the AMPD and its readiness to be included in section 2. And we did, in fact, find, just as we've been saying, that it tends to outperform categorical PD diagnosis and that it's ready for inclusion in the main section of the DSM-5. So from a clinical standpoint then, instead of asking 118 screening questions, we can just ask the 12 LPF questions, the level of personality functioning questions. This is a more parsimonious way. Instead of diagnosing 3 plus PDs, we can diagnose the core of the problem, which is maladaptive self and interpersonal functioning. Instead of trying to incorporate three treatment manuals 3 plus, we can just consolidate our treatment for personality disorders through the lens of self and interpersonal functioning. And I always say you can continue to do your CBT, but you'll do it through the lens of self and interpersonal functioning. Instead of making a yes/no diagnosis, we can use the five-level severity spectrum to support someone lower down on the severity spectrum, including young people. So this is a gateway for us for early intervention and prevention. Instead of using more stable traits, like nine borderline criteria, we can now conceptualise personality disorder as a malleable treatment target. The psychological apparatus of making sense of self and others. And this is less stigmatising. We're not talking about who you are as a person, what the personality is, we are talking about what the personality does. So this is a malleable treatment target. It's also very useful for young people. When I talk to parents and young people about this, I say you came at exactly the right time at age 15. You're busy making sense of yourself. You're busy putting your toe in the water of intimacy and romantic relationships. You're renegotiating your friendship relationships in the context of being more independent from your parents. This is self and interpersonal functioning. And you've come at the right time for getting that help. So instead of 10 categories to capture or delineate the flavour of manifestation, we can use the five trait domains. And importantly, instead of postponing the diagnosis of treatment for young people, we can use this five-level severity spectrum to diagnose at earlier stages of the disorder progression. So just very briefly, if we then think about dimensional approaches as developmentally sensitive, this is Absalom's caspase 2014 nice visual depiction of the development of psychopathology. And what they didn't include was where BPD or personality disorder fit in the spectrum of the P factor, but also the meta structure of psychopathology with internalising and externalising down here in thought disorder up here. Based on the evidence at the time in 1718, we placed BPD in here. If we want to now map that onto the AMPD and the ICD-11, we can start this mapping on by looking at traits. We know that children come into the world with dispositional traits. Some kids are more emotional, reactive, impulsive. It interacts with the environment, this is what becomes our personality traits. That interacts with the environment and this becomes our personality trait profile over time. We know that these early temperament and personality traits are basically traits that tell us whether a person tends to approach new situations or withdraw from them. It's called the BIS/BAS system, the Behavioural Inhibition System or the Behavioural Activation System. And this is what our criterion B traits are in our-- remember I said criterion B is the maladaptive trait domain-- the maladaptive end points of our basic traits. When we factor analyse it, we get these two dimensions-- internalising, withdrawing, externalising, approaching, the same with our criterion B traits. And it turns out that these traits remains stable across development. These are the rank order stability coefficients at 0.5 or 0.7. This means, and this is why we've had to move away from a trait-based approach in personality disorder. Traits are descriptive, but they do not explain much about who we are as people. For that, we have to ask the question, what happens in adolescence that did not happen before we become a person, we develop an integrated sense of self? And that means that we are in the territory of criterion A or LPF. Now Dan McAdams is a developmental social psychologist, personality development researcher, and he's not a clinician. He has taught us how personality develop beyond traits. Yes, our traits form the first layer of our personality development. But around age 5 or 7, we begin to develop goals and values. And then around adolescence, we begin to have the metacognitive capacity to integrate our dispositional traits, our goals, and our values, and our life stories to form who we are as a person. And that, then, is what personality functioning is. It develops through our early caregiving relationships. So we move from this dispositional trait-based self that acts upon the world through feedback from our caregivers and feedback from school, peers, and society. And we begin to build a psychological self, the story of who we are as people. So the parent's capacity to do what we call market mirroring or mentalizing really builds and helps the child move from this being that just acts upon the world with dispositional traits to something that is a bit more reflective, making sense of who I am, and then negotiating that in my interpersonal world. So I've just added mentalizing here as the core capacity that binds our personality as we move through these layers. And so I've written a lot of papers that say self-development is therefore the core if we think about personality functioning that drives our interpersonal functioning. All right, so summary. Humans contribute to an active and continuous process of reflection and interpretation of themselves and others. The capacity for this reflective process onsets in adult form in adolescence and facilitate consolidation of identity and adult role function, love, and work, in Freud's terms. If disrupted, personality pathology ensues. Criterion A can account for the onset of personality disorder, but criterion B provides a useful descriptive account of the continuous aspects. Criterion B is descriptive, but criterion A is conditional. Mentalizing is a key mechanism by which the binding of personality is supported. And if the binding of personality did not occur or is unstable, mentalizing is a malleable treatment target that can begin to build a coherent sense of self. So just going back to that triangle, instead of putting BPD there, we can put criterion A level of personality functioning in that model. So from an assessment standpoint, we must assess for personality functioning over and above internalising and externalising pathology. And in young people, we have to ask, is the binding of personality occurring into this unidimensional severity continuum or is it a bit rocky for this young person? Assessment of criterion A is conditional, criterion B is optional and provides nuance. Cell function is essential. I think we've forgotten about cell function a little bit in the last 20 years, and we'll need to bring it back online in order to adequately support young people who are struggling with personality development. Interventions that scaffold self and interpersonal functioning. DBT, if it's mindful of criterion A, I do often see DBT falling into overfocus on emotion dysregulation and skills building for that only without the focus. Marsha Linehan's original focus on self and interpersonal functioning. Mentalization-based therapy for adolescents is tailor-made for criterion A. It's all about the serve and return between us and other people. And then generalist approaches that also take seriously the interpersonal lens. Hypersensitivity, interpersonal hypersensitivity. So like GPM developed by John Gunderson and adapted for adolescents with [INAUDIBLE] and myself. So coming back to which manualized evidence-based treatment. Of course, as someone that understands or promotes the idea of mentalizing as a common factor that binds our personality, I would be promoting thinking about how to incorporate mentalizing into any psychotherapy approach, including CBT/DBT, with a particular focus on supporting personality development in the young person. So thank you. That's all there is from me. [MUSIC PLAYING]