The DSM-III-R Categorical Personality Disorder Diagnoses: A Critique and an Alternative Author(s): Thomas A.

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Inquiry Psychological 1993,Vol. 4, No. 2, 75-90

1993by Copyright Inc. Lawrence Erlbaum Associates,

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TARGET ARTICLE

The DSM-II-R Categorical Personality Disorder Diagnoses: A Critique and an Alternative

ThomasA. Widiger
Universityof Kentucky Thepurposeof thisarticle is to reviewtheDiagnostic andStatisticalManualof Mental Disorders (DSM-III-R;AmericanPsychiatricAssociation, 1987) categorical diagnosis of personalitydisordersand toprovide an alternative.Theresultsfrom a variety of studies indicate that the categorical distinctions provided in DSM-III-R lack empiricalsupportand thata dimensionalmodelof classificationwouldprovide more reliable and valid assessments of personality disorder. The argumentsfavoring the categorical model-familiarity, tradition,simplicity,ease, and consistencywith clinical decisions-are also addressed.An alternativeapproachbased on thefive-factor model of personality is presented. Two concerns regarding this model are the relevance of the openness-to-experience dimensionand the differentiation abnorof malityfrom normality,butneitherconcernis problematicwhenpersonalitydisorders are understoodto be maladaptivevariantsof normalpersonality traits. The thirdand revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American PsychiatricAssociation [APA], 1987) provides categoricaldistinctionsfor the personalitydisorder diagnoses. For example, the clinical decision regardingavoidantpersonalitydisorderis whetherthe disorderis presentor absent, not the extent to which a person is avoidant. It is stated in the introductionto DSM-III-R that"thereis no assumptionthateach mental disorderis a discrete entity with sharpboundaries (discontinuity) ... between it and no mental disorder" (APA, 1987, p. xxii), but this denialis belied by the fact that the diagnoses consist of categorical distinctions with no methodfor assessing a continuumwith normal personality functioning. The DSM-III-R is used by clinicians, researchers,and agencies to make categorical distinctionsregardingthe presenceversus absence of personality disorders (Carson, 1991). Approximately 84 empiricalstudies have been publishedin the Journal of Personality Disorders from 1987 through 1990. The analyses of the data were confined to the DSM-III-R categorical distinctions in about 60% of these studies; only 21% includedquantitative(dimensional) analyses of the extent to which the respective personalitydisorderor disorderswere present (Widiger, 1992). It is the purpose of this article to suggest that categorical diagnoses of personalitydisordershave little to no supportwith respect to empirical data or rational The categoricaldiagnoses representinstead argument. a simplistic and presumptiveunderstanding personof ality disorderpathologythatis a hindranceto empirical research and clinical practice. The article concludes with an alternative approach to the assessment and classificationof personalitydisorderpathology. Empirical Support Categorical distinctions would be appropriateif therewas a clear distinctionbetween the presence and absenceof a personalitydisorder(Grove & Andreasen, 1989; Kendell,1975). However,no empiricalstudyhas ever identifiedany clear distinctionbetween the presence and absenceof a personalitydisorderor any clear distinctionamong near-neighborpersonalitydisorder diagnoses. Fourrecent studies have explicitly considered these questions, and, in each case, the authors concludedthatthe resultsthey obtainedwere inconsistentwith the categoricaldistinctions.Frances,Clarkin, Gilmore,Hurt,and Brown(1984) obtainedpersonality disorderratingson 76 psychiatricoutpatientsand concluded that"theDSM-III criteriafor personalitydisorders do not select out mutuallyexclusive, categorical diagnosticentities. ... [The] frequencyof multiple diagnoses supports the argument for a dimensionalrather than a categorical-system of personality

WIDIGER

diagnosis" (p. 1083). Kass, Skodol, Charles, Spitzer, and J. Williams (1985) obtained personalitydisorder ratings from a consecutive sample of 609 psychiatric outpatientsand concluded that "our data do not lend supportto the usefulness of a categoricalapproach" (p. 628). "Since many more patientshad some [maladaptive] personalitytraitsor almost met DSM-III criteria than actually met the full criteria ... the categorical judgments of DSM-III necessarily resultedin the loss of information"(Kass et al., 1985, p. 630). Nestadt et al. (1990) obtainedratingsof the histrionicpersonality disordersymptomatologyfroma representative sample of a local community(N = 810) and reportedthat"this personalitydiagnosisis rather arbitrarily given individuals who extend beyond a cut-off level, yet others less severe but similar in the natureof their dispositional featuresmight have identical symptoms undercertain life circumstances"(p. 420). Last, Zimmermanand Coryell(1990) obtainedpersonalitydisorderratingson 808 first-degree relatives of psychiatric patients and never-ill control subjects and concluded that the personality disorder"scores are continuously distributed without points of rarityto indicate where to make the distinctionbetween normalityandpathology"(p. 690). In the absence of any clear distinctionbetween the presence and absence of a personality disorder, one might ask on what basis the distinctionswere made in DSM-III and DSM-III-R. In fact, therewas no empirical supportfor the thresholdsfor 9 of the 11 personality disorder diagnoses. They were based simply on the expert consensus of the personalitydisorderadvisory committee (Perry, 1990). Requiringfive of the seven criteria for avoidant personality disorderappearedto the committee to be too restrictive,and requiringthree natureof the appearedto be too inclusive. The arbitrary decisions was evident in Morey's (1988) comparison of the DSM-III and DSM-III-R cutoff points: The revisions resulted in "an 800% increase in the rate of schizoid personality disorderand a 350% increase in narcissisticpersonalitydisorder"(p. 575). The definitionof a personalitydisorderin DSM-IIIR could providea rationalefor the settingof a threshold for a categoricaldistinction(Widiger, 1992). "Itis only when personalitytraitsare inflexible and maladaptive and cause either significant functional impairmentor subjective distressthatthey constitutePersonalityDisorders"(APA, 1987, p. 335). That is, a person would be diagnosedas having a personalitydisorderwhen his or her personalitytraitsare inflexible and maladaptive and/or result in significant impairmentor distress. In the absence of inflexibility, distress,or impairment, the personwould be said to be lacking a personalitydisorder. The thresholdsfor the DSM-III-R categoricaldistinctions bear little resemblanceto this definition. For example, the DSM-III-R diagnosis of obsessive-com76

pulsive personalitydisorderrequiresfive of nine criteria,yet a personwith only four could have inflexible and maladaptivepersonality traits that would likely resultin social and/oroccupationalimpairmentand/or subjective distress-for example, perfectionism that interferes with task completion; overconscientiousand ness, scrupulousness, inflexibilityaboutmattersof morality, ethics, or values; restricted expression of affection; and preoccupationwith details, rules, lists, order,organization,or schedules to the extent that the majorpoint of the activity is lost (APA, 1987). In fact, the possession of just the one traitof being excessively devoted to work and productivityto the exclusion of leisure activities and friendshipsis likely to be of sufficient maladaptivity to cause significant social imas pairmentand/ordistress. A personwho has the single dependentitem of being unable to make everyday decisions without an excessive amountof advice or reassurance, single antisothe cial item of being irritableand aggressive as indicated by repeatedphysical fights or assaults, or the single schizoid item of neither desiring nor enjoying close relationships(includingbeing partof a family) would have a maladaptivepersonalitytraitthat would likely be of clinical significance. Most persons with any one of these three traits would likely find that the trait interfered significantly with social or occupational functioning,would find the traitto be troublesomeand distressing,andwould benefit from some form of psychotherapy.These persons, however, would be substantially below the threshold for a DSM-III-R personalitydisorderdiagnosis. The failureof the DSM-III and DSM-III-R to provide clinically meaningfulthresholdswas evident in a studyby McGlashan(1987). McGlashanwas researching the co-morbidityof borderlinepersonalitydisorder and depression,and he needed a comparisongroup of depressives without borderline personality disorder. Therefore,he obtained a group of depressed persons who did not meet the DSM-III criteriafor borderline personalitydisorder.However, these subjects had on average three of the borderlinecriteria."In short, the 'pure' ... cohortwas not pure.... The resultis thatour comparisongroups, although defined to be categorically exclusive, may not have been all thatdifferent,a fact which, in turn,may accountfor some of the similarities"(p. 472) between the supposedlypure depressives and the borderlines.In other words, the persons who were diagnosedas not havinga borderlinepersonality disorderdid in fact have borderlinepersonality disorderpathology.To characterizethese cases as not having borderlinepersonalitydisorderwas inaccurate andmisleading.McGlashanconcludedthatthe current categoricalsystem "emergesas poorly constructedfor
the study of comorbidity" (p. 473).

DSM-III-RCATEGORICAL PERSONALITYDISORDERS

In sum, the DSM-III-R cutoff points do not define the point at which personalitytraitsbecome a personality disorder.This fact providesa considerablehandicap for researchers attemptingto identifyotherclinical correlatesof the respectivedisorders.For example, the DSM-III-R threshold for the dependent personality disorderis unlikely to identify the point at which dependent traits provide a predispositionto depression. Researchthatattemptsto assess the relationof dependency to depressionwould be substantiallyhindered by the DSM-III-R categoricaldistinctionbecause the dependent personality disorder diagnosis is unlikely to distinguish dependency associated with depression fromdependencynot associatedwith depression.Many personsbelow the thresholdfor the diagnosisof dependentpersonalitydisorderwill have dependenttraitsthat areassociatedwith depression(e.g., Overholser,1991). Statistically significant group differences can be obtained with the DSM-III-R categorical distinctions & (Gunderson Zanarini, 1987), butthis is as meaningful as arbitrarily distinguishingtall fromshortpersonsand finding that tall persons can reach higher than short persons.A more powerful and informativeassessment of the correlatesof heightwould clearlybe providedby a more continuousand precise measurement. It is unlikely that the thresholdsfor the DSM-III-R categorical diagnoses will be optimal for any clinical decision or theoreticalprediction,as no empiricalstudy has ever documentedthe validity of the currentthresholds with respect to any externalvalidator.The thresholds for the borderline and schizotypal personality disorder diagnoses were based on empirical data (Spitzer, Endicott,& Gibbon, 1979), but this consisted simply of maximizing agreement with a sample of clinical diagnoses. Setting the thresholdat the level of the agreementwith clinical impressionsregarding presence of the disorderprovidesa standard maximimizof ing interraterreliability, not external validity. Given thatunstructured clinical diagnoses of personalitydisordersarenotoriouslyinconsistentandunreliable(e.g., Mellsop, Varghese, Joshua, & Hicks, 1982), clinical judgmentsas to the presenceor absenceof a personality disorderprovide at best a very questionablecriterion for defining the thresholdfor a disorder. Taxometric Techniques There are a variety of taxometric techniques for identifying whether a dimensional or a categorical model is more consistent with the empiricaldata-including factorandclusteranalyses,admixture analysis, maximum covariation (MAXCOV) analysis, latent class analysis, and discontinuousregression(Grayson, 1987; Grove & Andreasen, 1989). Meehl (in press) provided a sophisticated discussion of these tech-

have limitations,but each niques.All these approaches is informativewith respect to evaluatingthe construct of a personalitydisorder. Compelling support for a categorical distinction would be obtained if one found that reliability and validity improvedwith the use of a dichotomousrather thana dimensionalrating.A dichotomousvariablewill show a decreasedrelationto an externalcorrelate(or at least no change)when it is dimensionalized,whereas a dimensionalvariablewill show a reducedrelationwhen it is dichotomized.The formeroccurs as a resultof the inclusion of irrelevant,invalid information.If a more dimensionalratingsimply providedirrelquantitative, evant, tangential,and/orillusory distinctions,then the additionaldiscrimination requiredby the dimensional rating would result in a decreased correlation with variousexternalvalidators. the Widiger(1992) summarized resultsof 16 persondisorderstudies in which the datawere analyzed ality both categorically (i.e., with DSM-III or DSM-III-R diagnoses) and dimensionally (e.g., using the total numberof criteria).In all but one instance,the reliability and/orvaliditydatawerebetterwith the dimensional analyses. The consistency of this finding is not a statistical artifact. It indicates that reliable and valid information is being lost by converting an ordinal, interval, or ratio scale to a nominal scale (Heumann & Morey, 1990). The implications for futureresearch are clear. Correlates of personality disorder pathology will be more evident when the data are analyzed dimensionally. A factor-analysis relevantto the question application of the validity of the dimensional versus categorical models is the comparison of factor solutions across distinctwith respectto a latentclass groupspurportedly taxon.Measuresthatarehighly discriminating between such groups should not correlatesubstantiallywithin the groups, and the factor solution of the intercorrelation among such measuresshould not replicateacross groups(H. Eysenck,1987).TyrerandAlexander(1979) reportedthat the factor solutions for the correlations among 24 personality variables assessed by a semistructured interviewreplicatedacross 65 patientswith a primaryclinical diagnosis of a personality disorder and 65 patientswith other diagnoses. Livesley (1991) similarfindingsusing a self-reportmeasureof reported 79 dimensions of personalitydisorderpathology, the intercorrelations which were factor-analyzedin a of sample of 274 normal subjects and 158 patients. Livesley concluded that "a dimensional model is ... supportedby empiricalevidence that the structureof traits describing the features of personality disorder and pathology is the same in personality-disordered individuals"(p. 53). non-personality-disordered A variablethat is fundamentallycategoricalshould 77

WIDIGER

obtaina bimodal distribution(Kendell, 1975). Admixture analysis examines the distributionof canonical coefficient scores derivedfroma discriminant-function analysis for evidence of bimodality.This techniquehas suggested the presence of discretebreaksin the distributionof measuresof somatoformandpsychoticdisorders (Cloninger, Martin,Guze, & Clayton, 1985). No publishedstudy has reportedan admixtureanalysis of personalitydisorderdata. However, Cloninger(1989) indicatedthat he used it with personalitydisorderdata and"foundthatunderlying[the]relativelydistinctsubgroups appearedto be multiple dimensionsof personality thatwere normallydistributed" 140). "Thereal (p. take-home message to me is not that we do not have methods to detect relatively discrete groups but that with psychiatric disorders the groups are not totally discrete, and this finding may be consistent with extremesyndromesthatdevelop superimposedon top of underlyingdimensionalvariation"(p. 140). MAXCOV analysis capitalizes on the fact that the covariation between any two signs of a categorical variablewill be minimized in groups of subjects who share the class membershipand will be maximized in mixed groups,whereasno such variationin covariation will be found across levels of a dimensionalvariable (Meehl & Golden, 1982). MAXCOV did suggest the presenceof a latentclass variablefor a "schizoid"taxon in a study by Meehl and Golden (1982), using Minnesota MultiphasicPersonalityInventory(MMPI)indicatorsof schizotypy. However, it shouldbe notedthatthe schizoid taxon in this case did not refer to the schizotypal (or the schizoid) personalitydisorder,but ratherto the full spectrumof schizophrenicpathology (including the schizotypal, schizoid, and otherpersonality disorders,as well as psychotic disorders).Nevertheless, the findings of this study could be said to supportthe hypothesis that schizotypal personalityis not on a continuumwith normalpersonalitytraits. Trull, Widiger, and Guthrie(1990) applied MAXCOV to the DSM-III-R criteriafor the borderlinepersonality disorder. The charts of 409 patients were systematically coded for symptoms of dysthymia (a presumably dimensional variable), biological sex (a categoricalvariable),and borderlinepersonalitydisorder.A clearpeakwas foundforbiological sex, thecurve was flat for dysthymia,andno peak in the middleof the distribution was foundfor borderline personalitydisorder. Trull et al. concluded that "the results are most consistent with the hypothesis that [borderline personality disorder]is optimallyconceptualizedas a dimensional variable" (p. 47). However, it should also be notedthatTrullet al.'s findingswere not unambiguous. The MAXCOV curve for borderline personality disorder did not peak in the center of the distribution, but it did peak at the end of the distribution,which is 78

inconsistentwith both the dimensionaland categorical models. Arguments Favoring a Categorical Model The empiricalresearchfavorsthe hypothesisthatthe DSM-III-R personalitydisordersdo not involve qualitativelydistinctdisorders.Instead,they may represent extreme and/or maladaptive variants of personality traitsthatarepresentacross the entirepopulation.One may then ask why theDSM continuesto use a categorical model. Threeargumentsin favorof the categorical have typicallybeen provided(Frances,1990; approach Gunderson, Links,& Reich, 1991; Millon, 1981,1991): traditionand familiarity,(b) ease in conceptualiza(a) tion andcommunication, (c) consistencywith clinand ical decisions. We discuss each of these argumentsin turn. Familiarity and Tradition The categoricalsystem is more familiarto clinicians et (Gunderson al., 1991; Millon, 1981, 1991). All prior and currentdiagnoses within the the DSM have been categorical.Convertingto a dimensionalmodel would representa major shift in clinical practice (Frances, 1990). However, the dimensional model has been more acceptableandfamiliarfor the classificationof personality (Gangestad& Snyder, 1985; Widiger & Frances, 1985), andno surveyhasever documenteda preference amongpracticingclinicians for the categoricalformat. It is perhapspresumptiveto arguethatclinicians prefer the categorical system or would not accept a dimensionalclassification.Maser,Kaelber,andWeise (1991) in surveyed 146 psychologists/psychiatrists 42 countries.Eighty-ninepercentconsideredtheDSM-III-R to be at least fairly successful in providing diagnostic categories.However, the survey questionthatassessed the diagnostic categories concerned all the disorders, whereas"thepersonalitydisordersled the list of diagnostic categorieswith which respondentswere dissatisfied" (Maser et al., 1991, p. 275). The personality disorderswere consideredproblematicby 56% of the respondents;the second most frequently cited category-the mood disorders-was cited by only 28% of the respondents.In response to an optional, write-in question,"35 of 101 respondents(35%) chose to write in personalitydisorders... 'most in need of revision"' (p. 275). Kasset al. (1985) indicatedthatfeedbackfrom staff and trainees during their study on dimensional ratings for the personalitydisorders suggested that a 4-pointseverityratingwas bothfeasible andacceptable in routine clinical practice. Similar results were re-

CATEGORICAL DSM-III-R PERSONALITYDISORDERS

ported in a much earlier study with medical students (Hine & R. Williams, 1975). Diagnostic categories are consistent with the neoKraepelinianemphasis and clinical traditionof trying to define homogeneous, distinctsyndromes(Robins & Helzer, 1986), but they may also reflect a simplistic cognitive economics that fails to appreciatethe complexity and individuality of personality. Cantor and Genero (1986) developed this hypothesis most eloquently in their applicationof prototypaltheory to the diagnosis of mental disorders. Persons naturallycategorize their externalenvironment. It is an adaptivemechanismin that it facilitates daily functioningby limiting the amountand complexity of the information that we receive, process, and communicate. Failing to simplify this information throughthe use of categoricaldistinctionswould likely be overwhelming.However,this natural categorization is also maladaptive"in that there is a tendency, once having categorized,to exaggeratethe similarityamong nonidenticalstimuliby overlookingwithin-group variandfocusability,discountingdisconfirmingevidence, ing on stereotypicexamplesof the category"(Cantor& Genero, 1986, p. 235). This is most clearly evident in person categories and associated stereotypes(e.g., accountant,cop, Black, andfemale), and it can be equally problematicin the diagnosis of mentaldisorders(Ford & Widiger, 1989; Schacht, 1985). The prototypalmodel of categorizationwas influential in the developmentof DSM-III-R, particularly for the personalitydisorders(Spitzer, 1987). The diagnostic criteriafor some of the DSM-III personalitydisorders (e.g., avoidant)requiredall the defining features to be present. However, the authors of DSM-III-R recognizedthatthe monotheticcriteriasets were overly restrictiveandwere inconsistentwith the heterogeneity of personality disorder symptomatology (Widiger, Frances,Spitzer,& J. Williams, 1988). The monothetic criteriasets describedprototypiccases that rarelyappearedin actualclinical practice(Livesley, 1985). Persons with the respective personalitydisordersusually shareonly a subset of the defining features,resembling the prototypewith varying degrees of a family resemblance (Blashfield, 1984). The DSM-III-R personality disorder criteria are thereforepolythetic (Spitzer, 1987). A set of optional criteriais provided,only a subset of which is necessary for the diagnosis. However, this recognition of the heterogeneityamong persons with similarpersonality disordersdoes not actuallyaddressor resolve the problem of the heterogeneity(Widiger & Kelso, 1983). It simply acknowledges and accepts the problem. The polythetic formatstill makes categorical,black-white distinctions that fail to appreciatethe complexity that actuallyexists. Forexample,thereare93 differentways

to meet the DSM-III-R criteriafor the borderlinepersonality disorder and 149,495,616 different ways to meet the DSM-III-R criteriafor antisocialpersonality disorder(only 848 possible combinationsif one does not count the differentways to meet the subcriteria for the conduct disorder and parental irresponsibility items). Yet, only one diagnostic label is provided to characterizeall these differentcases (i.e., presence of the disorder).Onewould not need to distinguishamong all 149,495,616 different combinations of antisocial criteriato providea useful descriptionof a patient,but it is evidentthatnot all antisocialsarealike with respect to theirantisocialsymptomatologyandthatmanyof the differencescan be of considerableimportanceto clinical practice and research(Harpur,Hare, & Hakstian, 1989). Thereare 162 differentpossible combinationsof the borderlinecriteriain persons who would not be given the diagnosis, but all these cases are simply labeled as not having a borderlinepersonalitydisorder.The inadequacy of diagnosing these patientsas simply lacking therespectivepersonalitydisorder was notedby Skodol in his overview of DSM-III-R. The DSM-III-R (1989) provides the option of indicating the presence of "traits"on Axis II when the patient fails to meet the criteriafor the diagnosis.
In practice,however, this option was seldom utilized: in reviewing 200 multiaxialdiagnostic evaluations, I found that fewer than 5% had personalitytraitslisted on Axis II. Severalof my colleagues andI believed that personalitytraitsplay such a significant role in determining treatmentapproach,especially in psychotherapy, that we instituted a scaled system for rating DSM-III personalitydisordersin the outpatientclinic at the Columbia-Presbyterian Medical Center. ...

to Usingthis system,we foundthat,in addition the

50%of clinic patientswho meet criteria approximately for a personalitydisorder,another35% warrantinformationdescriptiveof theirpersonalitystyles on Axis II. (Skodol, 1989, pp. 385-386)

In sum, categories are more familiarto and may at timesbe preferred clinicians.However,thistradition by may reflect in parta naturalinclinationtowardsimplification that fails to appreciatethe complexity of personality functioning.Diagnostic categories do provide vivid, clear descriptions(Frances,1990; Gundersonet al., 1991), but, to the extent that most patients do not provide prototypic cases, these descriptions will be misleadingand stereotyping(Cantor& Genero, 1986; Schacht,1985). A more quantitative descriptionof the extent to which each personalitydisorder(or a set of fundamentaldimensions) is evident would provide a more precise descriptionthatwould be more informative and less stereotyping. The heterogeneity would
79

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then be retained and would in fact inform clinical decisions. It is somewhat ironic that,for a diagnosis in which reliabilityandvalidity areamongthe most problematic, reliable and valid information is being excluded from the classification. Ease in Conceptuali7-tion and Communication It has also been argued that, even if a dimensional classification of personalityfunctioningis more informative, it would be too difficult and cumbersometo make in clinical practice (Gunderson et al., 1991; Millon, 1981, 1991). Categoriesare helpful in simplifying a complex set of information(Cantor& Genero, 1986). It is easier to consider and discuss the presence of one or two disordersthan a profile of the degree to which all the various disordersare present.One category (e.g., borderline)can communicatea greatdeal of vivid information(Frances,1990). Diagnoses within a categorical model requireonly one decision: whether the patienthas or does not have a particular personality disorder.Diagnoses within a dimensionalmodelwould requiremore specific and detailedassessments.To the extent thata dimensionalmodel retainsmore information, it requiresthe acquisitionand communicationof more information(Widiger, 1991). In practice, however, the personalitydisorderdiagnostic categoriesof DSM-III-R are more complex and cumbersomethan most dimensionalmodels. The currenttaxonomyrequiresthe assessmentof 104 diagnostic criteria.Most semistructured interviewscan require 2 hr to providea systematicandcomprehensiveassessment of the 11 diagnoses (e.g., Loranger,1988; Pfohl, Blum, Zimmerman, & Stangl, 1989). Two hours is substantial,but even this amountof time allows only for an averageof 1 min 9 sec to assess each personality disordercriterion.It is then understandable most that clinicians do not systematicallyfollow the DSM-III-R criteria(Morey & Ochoa, 1989) as it is neitherpractical nor even feasible in routineclinical practice. A dimensionalmodel thateliminatesthe redundancy and overlapamong theDSM-III-R categoricaldistinctions would be much easier to use. For example, the five-factormodel (discussedin moredetaillater)would requirethe assessmentof only five dimensions-a task of considerablyless complexity thanworkingwith the 11 diagnostic categories of DSM-III-R. The DSM-III-R categoricalsystem also resultsin a variety of confusing multiple diagnoses (Cloninger, 1989; Widiger & Rogers, 1989). The average number of personality disorderdiagnoses per patient tends to be around four (e.g., Skodol, Rosnick, Kellman, Oldham, & Hyler, 1991), and yet most clinical charts providejust one personalitydisorderdiagnosis(Morey & Ochoa, 1989). One reason that clinicians fail to 80

provideall the diagnoses thatapply is thatit is confusmeaningfulto indicatethatthe ing and not particularly is sufferingfrom four, five, or even six distinct patient and co-morbidpersonalitydisorders.It would be simplerandmoremeaningfulto statethatthepersonsuffers froma personalitydisordercharacterized excessive by and neuroticism,introversion, antagonismthanto state thatthe patienthas three co-morbidpersonalitydisorders (e.g., borderline,avoidant,and histrionic). Consistency With Clinical Decisions The final apparent advantage of the categorical model is thatclinical decision-makingtends to be catdecisions are not usually in shades egorical.Treatment of grey. Therefore,many clinicians would convert a dimensionalprofile to categories in order to facilitate theirdecisions. The MMPI,for example, provides the potential for detailed assessments along dimensions, but it is often converted to typological code types. There might then be little advantageto increasingthe complexity of diagnosis by requiringratings,along a continuum,thatare ignoredin clinical practice. However,consistencywith clinical decision-making is readily retainedin a dimensional model simply by cutoff points for variousclinprovidingrecommended ical decisions. The reverseoption is not possible. After a categoricaldiagnosisis provided,the abilityto return to a moreprecisedescription(e.g., the degree to which the person approachesa prototypic case) cannot be recovered. Manycliniciansconvertan MMPIdimensionalprofile to a categoricalcode type, but these clinicians are unlikely to preferbeing given only the code type and not being given the additional informationobtained from the profile description. A dimensional profile code types and providestheflexibilityto use alternative scores for differentsituationsandclinical decicutting sions. Forexample,some clinical or researchsituations are likely to requiremore liberal or more restrictive thresholdsthanthoseprovidedby theDSM-III-R diagnoses. Different cutoff points will be optimal for predicting responsivityto different treatmentmodalities, need for hospitalization,future course, likelihood of family history, or predispositionto experience future episodes of depression (Finn, 1982; Kendler, 1990; Widiger & Trull, 1991). A dimensionalprofile of the extent to which each personality disorder is present would allow for this flexibility; the categoricaldiagnoses do not. Alternative Proposals A varietyof options for incorporating moredimena sional approachto the classification of the personality disordersis being consideredforDSM-IV(APA, 1991;

DSM-III-R CATEGORICAL PERSONALITYDISORDERS

Widiger, 1991). These proposals were developed in collaborationwith the DSM-IV PersonalityDisorders Work Group;no proposal, however, has yet received the consensus supportof the work group.One proposal is to retainthe categoricalsystem but to providea table for converting the categories to a dimensional format thatwould provide more quantitativeinformation(see Table 1). Six levels are provided:absent, traits,subthreshold, threshold,moderate,andprototypic.The ratingin each case is compatible with the currentformat. "Absent" means what it implies-an absence of any of the specified symptoms. "Traits"means that there are simply one to three symptoms (DSM-III-R currentlyrecommends that the clinician code personality disorder "traits" Axis II when the patientmeets some of the on criteriabut not enough to be given the diagnosis;APA, means that the person is 1987, p. 17). "Subthreshold" only one symptom short of having the disorder. "Threshold" meansthatthe personjust barelymeets the criteria for the disorder. "Moderate"means that the person has more than enough of the criteria. Last, means that all the diagnostic featuresare "prototypic" present. This coding is compatiblewith the currentcategorical formatandstill providesa uniformterminologyand methodfor describingthe extent to which a patienthas each disorder.The terminologyand criteriawould facilitate uniform discussion among clinicians and researcherswho wish to indicate the extent to which the disorderis presentwithout disruptingthe currentdiagnostic system. The DSM-IV PersonalityDisordersWorkGroupis also consideringa more fundamental revision in which the diagnostic categorieswould be replacedby a set of dimensions that are on a continuumwith normalpersonality functioning. A majordifficulty with this proposal has been the lack of consensus within the work group and among personalitydisorderresearchersreTable 1.

gardingwhich dimensions to include. Several dimensional models for the personalitydisordershave been proposed(e.g., Clark,1990; Cloninger,1987; Costa & McCrae, 1992; H. Eysenck, 1987; Kass et al., 1985; Kiesler, 1991; Livesley, 1991; Siever & Davis, 1991; Tellegen & Waller, in press). The proposalhaving the least opposition among the work group members-no support-is to develop a comproposalhas substantial consensus model that attempts to represent promise, equally each of the majoralternatives.This is comparable to the procedureused to develop the DSM-III criteriafor borderlinepersonalitydisorder.During the construction of DSM-III, it was evident that there should be a borderlinepersonalitydisorderdiagnosis, but there was substantialdisagreementregardingthe optimal criteria set for this diagnosis. Therefore, Spitzeret al. (1979) developed a compromise,consensus model in consultationwith leading borderlineresearchers (Drs.Gunderson, Kernberg, Rinsley, Sheehy, & Stone). Disagreementsregarding optimalcriteria the still remain (e.g., Zanarini,Gunderson,Frankenburg, Chauncey,& Glutting, 1991), but there is substantial was agreementthata flawed representation betterthan no representation. The dimensionalproposal being considered by the DSM-IV PersonalityDisorders Work Groupwas developed in consultation with Drs. Cloninger, Costa, Eysenck, McCrae,Siever, Tellegen, and Wiggins and consists of seven dimensions:(a) neuroticism(from H. Eysenck, 1987), (b) extraversion (from H. Eysenck, 1987), (c) constraint (from Tellegen & Waller, in press), (d) agreeableness (from Costa & McCrae, 1985), (e) openness (from Costa & McCrae,1985), (f) reward dependence (from Cloninger, 1987), and (g) cognitive disorganization (fromSiever & Davis, 1991). Each dimensionwould be briefly discussed within an appendixto DSM-IV(or within the introductionto the PersonalityDisorderssection) as an alternativemodel for the diagnosis of personality disorder pathology.

Converting the Diagnostic Categories to Dimensional Ratings

Number of Criteria

Personality Disorder Paranoid Schizoid Schizotypal Antisociala Borderline Histrionic Narcissistic Avoidant Dependent Compulsive Passive-Aggressive

Absent 0 0 0 0 0 0 0 0 0 0 0

Traits 1-2 1-2 1-3 1-2 1-3 1-2 1-3 1-2 1-3 1-3 1-3

Subthreshold 3 3 4 3 4 3 4 3 4 4 4

Threshold 4 4 5-6 4-5 5 4-5 5-6 4 5-6 5-6 5-6

Moderate 5-6 5-6 7-8 6-9 6-7 6-7 7-8 5-6 7-8 7-8 7-8

Prototype 7 7 9 10 8 8 9 7 9 9 9

aConfined to items occurring since age 15.

81

WIDIGER

Widiger (1992) providedfurtherdetails regardingthis proposal. However, my opinion is thatthe five-factormodel of personality-consisting of the dimensions of neuroticism, extraversion,openness, agreeableness,and conscientiousness-is largely sufficient for characterizing normaland abnormalpersonalityfunctioning(Widiger & Trull, 1992). The remainder this articlediscusses of this alternativemodel for the classification of personality disorderpathology. Five-Factor Model of Personality Empiricalsupportfor the five-factor(or "Big Five") model is extensive. A comprehensiveoverview of this researchis beyond the scope of this articlebut is readily available elsewhere (e.g., Digman, 1990; John, 1990; McCrae& Costa, 1990;Wiggins & Pincus,1992). Only a brief overview is presentedhere. Initial derivation of this model was based on the compelling rationalethat the most importantand fundamental traits of personality could be identified throughan empirical (lexical) analysis of naturallanguage. "Those individualdifferences thatare the most significant in the daily transactionsof persons with each other will eventually become encoded into their of language"(Goldberg,1982, p. 204). The importance a trait will be indicated by the numberof terms that describe the trait,and the structureof these traitswill be evident by the relation among these terms. Many such lexical analyses have been conducted, and the findings have consistently supported the five-factor model (John, Angleitner, & Ostendorf,1988). On the basis of his review of this research, Digman (1990) concluded that, over a 20-year period, "the domainof personalityattributeshad been successfully analyzed, not just once, but by five competent, independentinvestigators, all of whom came to the same general conclusion: that the domain could be adequatelydescribedby five superordinate constructs" 420). One (p. of the more recenteffortswas by Goldberg(1990), who analyzeda sufficiently comprehensiveset of 1,431 trait adjectives across a variety of factor-analytic techniques. Goldbergsuggested that it nowseemsreasonable conclude analyses to that of of trait anyreasonably sample English adjectives large in eitherself-descriptions peer descriptions or will elicitavariant thefive-factor of and structure, therefore thatvirtually suchterms be represented all can within thismodel.(p. 1223) Good to excellent replications of the five factors have also been found with other languages, including German(Angleitner,Ostendorf,& John, 1990), Dutch (De Raad, Mulder, Kloosterman, & Hofstee, 1988), 82

Japanese(Bond,Nakazato,& Shiraishi,1975), Filipino (Church & Katigbak, 1989), and Chinese (Yang & or Bond, 1990), usingeithernatural-language questionnairemeasures. The five-factor structurehas also been replicated across self, peer, spouse, and other observer ratings (e.g., Borkenau& Ostendorf, 1989; Goldberg, 1990; McCrae & Costa, 1987). The five factors have been replicatedacross age groups, includingchildren(Digman & Inouye, 1986), young adults(Goldberg, 1990), andolderadults(McCrae& Costa, 1985b). Substantial temporalstability has been reportedacross 6-, 7-, and even 30-year periods (Costa & McCrae, 1988, 1992). The five factors have also been very successful in subsumingandaccountingfor the traitsincludedwithin othermodels of personalityandpersonalityassessment (e.g., Borkenau& Ostendorf,1989; Costa & McCrae, 1988; McCrae & Costa, 1985a, 1989). John (1990) concluded the following on the basis of his review of this latterresearch: Forone, theBig Fivedimensions at capture, a broad levelof abstraction, commonalities the mostof among the existingsystemsof personality Secdescription. andevenmoreimportant, other most ond, personality scalescanbe interpreted the contextof thesefive in dimensions. That,I believe,is one of themajor goals
of scientific, "synthetic" description.(p. 33)

The five-factormodel is not without its critics (e.g., Tellegen & Waller, in press; Waller & Ben-Porath, 1987), but muchof the concernis with technicaland/or secondaryissues (e.g., optimal label for a factoror the optimaldelineationof the facets within a factor).There is no alternativemodel that has comparableempirical support.Even the most vocal critics of the five-factor model acknowledge that it does provide the point of for of departure the understanding the personalitydisorders.Grove and Tellegen's (1991) "view is that the Big Five ... providea good startingpointfor describing normaland disorderedpersonality"(p. 36). Five-Five Model and the DSM-III-R Personality Disorders Table 2 presentsan interpretation the DSM-III-R of personalitydisordersfrom the perspectiveof the fivefactor model developed by Widiger, Trull, Clarkin, Sanderson,and Costa (1993) on the basis of a systematic review of each of the respectivediagnosticcriteria and associated features presented in the DSM-III-R (APA, 1987) and provided in the clinical literature.It is evident from Table 2 that there is little difficulty in of providingan adequatecharacterization each of the DSM-III-R personalitydisordersusing the dimensions and facets of the five-factor model. An understanding

PERSONALITYDISORDERS CATEGORICAL DSM-III-R

Table 2.

DSM-III-R Personality Disorders and the Five-Factor Model

DSM-III-R Personality Disorder"

Factor

PAR

SZD

SZT

ATS

BDL

HST

NAR

AVD H

DEP H H h

OBC

PAG

Neuroticism Anxiety Hostility Depression Self-Consciousness Impulsiveness Vulnerability Extraversion Warmth Gregariousness Assertiveness Activity Excitement Seeking PositiveEmotions Openness Fantasy Aesthetics Feelings Actions Ideas Values Agreeableness Trust Straightforwardness Altruism Compliance Modesty Tender-Mindedness Conscientiousness Competence Order Dutifulness Achievement Striving Self-Discipline Deliberation

h
H

h/L

L
1

h
H h

H h
L h

H H H
H

H H

H h/L H

h H H
L/H L L L

h h h

H H

h
H

H
h L L H

1 1

L L

L L

1
h h

h
H

H
h

h h
H

L H

h H h
1

H
L L L

L H h

L L L 1
h

L
L

L L

h 1 L

L L L
L

H
H

L
L

L L

H
h L H H H H L L

L
1

L 1 L L
L h L

h Note: H and L = high and low, basedon DSM-III-R diagnosticcriteria; and 1 = high and low, basedon associatedfeatures
provided in DSM-III-R (APA, 1987); H, L, h, and 1 = high and low based on clinical literature. aPAR = paranoid, SZD = schizoid, SZT = schizotypal, ATS = antisocial, BDL = borderline, HST = histrionic, NAR =

and AVD = avoidant,DEP = dependent,OBC = obsessive-compulsive, PAG = passive-aggressive. narcissistic, bFromWidigeret al. (1993).

of personalitydisorderpathologyfrom the perspective of the five-factor model is in fact helpful in addressing a variety of problematic findings obtained with the DSM-III and DSM-III-R diagnostic categories-as well as in highlighting inconsistencies between the as DSM-III-R and the clinical literature, in the case of the extraversionfacet of warmthfor the avoidantpersonality disorder. For example, borderline personality disorder involves primarilyexcessive elevations on all or most of the facets of neuroticism (particularlyhostility, impulsivity, traitanxiety, traitdepression,andvulnerabilas borderline ity). Conceptualizing personalitydisorder extremeneuroticismis helpful in explainingthe excessive prevalence and co-morbidity of this popularbut controversial diagnosis (Widiger & Frances, 1989).

Neuroticism, as a characteristiclevel of personality dysfunction(i.e., vulnerabilityto stress, impulse dyscontrol, and negative emotionality) is almost ubiquitous within clinical populations(H. J. Eysenck & M. W. Eysenck, 1985). Personality dysfunction to the point of needing inpatienthospitalizationusually involves excessive neuroticism.A diagnostic category that consists essentially of excessive neuroticism shouldbe very prevalentandthe most commonpersonality disorderwithin inpatientsettings. To the extent that the other personalitydisorders involve some degree of neuroticism (see Table 2), one would also with boroverlapandco-morbidity expectconsiderable disorder.The excessive prevalence derlinepersonality and co-morbidityof borderlinepersonalitythat are so problematicfor its validity as a distinct personality
83

WIDIGER

disorder (Cloninger, 1989; Gunderson & Zanarini, 1987; Widiger& Frances,1989) arethenreadilyunderstandablefromthe perspectiveof the five-factormodel. Conceptualizingborderlinepersonality disorderas excessive neuroticism is also consistent with Kemberg's (1984) concept of borderlinepersonality organization,therebyprovidinga meansfor integrating the competing formulations developed by Kernberg and theDSM-III-R (APA, 1987). Kernberg interpreted borderlinepersonality organizationas a fundamental level of personality organization that cuts across the DSM-III-R personality disorders. Likewise, neuroticism is a characteristic level of personalitydysfunction that cuts across other importantindividualdifferences (e.g., degree of extraversion and conscientiousness). Kerberg would preferto use a more inferentialmeans for assessing a patient's level of personalityorganization (e.g., assess the degree of identity diffusion, reliance on primitive defenses, and reality testing within object relations),but a substantialcorrelationbetween Big Five neuroticismandlevel of personalityorganization is likely. The nonspecificmanifestations borderof line personality functioning identified by Kernberg (e.g., anxiety tolerance, impulse control, and vulnerability to stress) are very close to the facets of neuroticism identifiedby Costa and McCrae(1985). The five-factor model is also helpful in explaining an anomaly reportedin the the factor-analyticstudies of personalitydisorders.Hyler and Lyons (1988) and Kass et al. (1985) providedfactor-analytic resultsthat, a three- dimensionalmodel they suggested, supported for the personality disordersthat was consistent with the three-clusterarrangement providedin DSM-III-R and (i.e., odd-eccentric,dramatic-emotional, anxiousfearful). However, both studies had in fact obtained four-factorsolutions, with the fourthfactoranchoredin each case by thecompulsivepersonalitydisorder.Hyler and Lyons and Kass et al. both dismissed the fourth factor as a methodological artifact, but it is readily understoodfrom the five-factor perspective as representing a maladaptive variant of conscientiousness. Conscientiousness, as defined by Costa and McCrae (1985), contraststhe tendencyto be organized,reliable, hard-working,self-disciplined, punctual, scrupulous, neat, ambitious, and perseveringwith the tendency to be aimless, unreliable, lazy, careless, lax, negligent, and hedonistic. Maladaptiveconscientiousnesswould clearly suggest an obsessive-compulsive personality disorder-involving such symptomsas perfectionism; preoccupationwith details, rules, order,and organization; excessive devotion to work and productivity; and overconscientiousness (as defined by DSM-III-R; APA, 1987). A factor that contrasts the compulsive personalitydisorderwith the antisocialand the borderline (as in Kass et al., 1985) does appearto represent 84

variantsof high andlow conscientiousness maladaptive respectively. As a final illustration the relationof the five-factor of model to the personality disorders-Widiger et al. (1993) provides a more comprehensive discussionthe five-factor model is also helpful in explaining the confusionanddifferentiation the avoidantandschizof oid personality disorders. This differential diagnosis has been controversial (Livesley, West, & Tanney, 1985). However, both the overlap and the differentiation of the schizoid and avoidantpersonalitydisorders are readily understood from the perspective of the five-factormodel. The avoidantandschizoid personalbothinvolve excessive, maladaptive introity disorders version. However, to the extent that an excessively introvertedperson is also characteristicallyself-conscious, anxious, andvulnerable,he or she would likely be diagnosed with avoidant personality disorder(see Table 2). The avoidantand schizoid personalitydisorders may also be distinguishedin partby the facets of introversion areprimarilyinvolved. A purecase of that schizoid personalitydisorderwould involve primarily the facets of low positive emotions in addition to low warmthand low gregariousness,whereas the avoidant personality disorder involves primarilythe facets of low warmth,low gregariousness, low assertiveness and Table 2). However, it is importantto emphasize (see that the typical case will share some combination of these facets-as well as some degreeof neuroticismand hence may often be difficult to diagnose as either schizoid or avoidant. It is precisely for these typical cases thatthe more individualizedand precise description providedby the five-factormodel would be particularlyuseful. Therehave been only fourpublishedempiricalstudies concernedwith the relationbetween the personality disordersand the five-factormodel (Costa & McCrae, 1990; Trull, in press; Widigeret al., 1991; Wiggins & Pincus, 1989), and one of these did not include an measureof the five factors(Widigeret al., independent Additionalstudies and discussion are provided 1991). in Costa and Widiger(in press). For the most part,the findings have been very supportive. However, questions regardingthe adequacy and application of the five-factormodelto thepersonalitydisordershavebeen raisedby this research.Two majorconcernsaddressed in this targetarticleare (a) the importanceof openness to experience and (b) the distinction of abnormality fromnormality. Openness to Experience The factor-analytic studies of Hyler and Lyons (1988) and Kasset al. (1985) obtainedonly fourfactors

DSM-III-RCATEGORICAL PERSONALITYDISORDERS

(i.e., not five)-none of which suggested openness to experience.Neuroticism,Extraversion, Agreeableness, and Conscientousness have obvious and well-supported relations to the DSM-III-R personality disorders, but Openness to Experience has not obtained consistentempiricalsupportwith respectto the personality disorders.Widigeret al. (1993) suggestedthatthe schizotypal and histrionic personality disorders are characterized partby a maladaptively in extremeopenness (to ideas and fantasy for the schizotypal;to feelings for the histrionic) and the obsessive-compulsive, paranoid,schizoid, and avoidantpersonalitydisorders arecharacterized partby being excessively closed to in but therearebothconceptualandempirical experience, limitationsto these hypotheses.In the interestof space limitations, this discussion is confined to the schizotypalhypothesis. Costa and McCrae (1990) reportedno significant correlations between the Morey, Waugh, and Blashfield (1985) MMPI Schizotypal scale and self, spouse, or peer NEO PersonalityInventory(NEO-PI) Openness ratings(Costa & McCrae, 1985) or between the revised Millon Clinical Multiaxial Inventory Schizotypal scale (MCMI-II; Millon, 1987) and selfreportNEO-PI Openness. In fact, they obtaineda significantnegativecorrelation(r = -.19,p < .01) with the MCMI-II Schizotypal scale. Trull (in press) reported nonsignificant correlations between the NEO-PI Openness scale and the MMPI Schizotypal scale (r = .21,p > .05), the PersonalityDiagnosticQuestionnaireRevised (Hyler & Rieder, 1987; r = .09), and the StructuredInterview for DSM-III-R PersonalityDisorders(Pfohl et al., 1989; r = -.07). The only study to obtain any direct empiricalsupportfor this hypothesis was by Wiggins and Pincus (1989). In their factor analysis of the NEO-PI, the Big Five version of the InterpersonalAdjective Scales (IAS-B5; Trapnell & Wiggins, 1988), the MMPIPersonalityDisorderscales, and the Personality Adjective Check List (Strack, 1987), the only scale to load on the Opennessto Experience factor-defined by both the NEO-PI and IASB5 Openness scales-was the MMPI Schizotypal scale. However, thatno otherpersonalitydisorderscale loaded on this factorwould also suggest thatopenness to experience was not particularlyimportant useful or in assessing personalitydisorderpathology. There are reasons to expect that there may be no maladaptivevariant of excessively high openness to experience. The NEO-PI Openness scale was derived in part from prior researchon self-actualization,selfCoan's realization,andpersonalgrowth-in particular, (1974) work on mental health. From this perspective, extreme openness should correlatewith indicatorsof ideal mental health ratherthan with personalitydisorder pathology. The unusualand aberrant beliefs of the

schizotype may be endorsed by a creative and openminded individual (McCrae, 1987), but the endorsementof these same beliefs by a schizotypicpersonmay be due to rigidityof thinking.Schizotypic personsmay not really be open to new ideas but may instead be and impelledto believe in a varietyof aberrant unusual ideas to which a truly open person would at times be receptive. It may then be that a highly elevated openness to experience is not indicative of personality disorder pathologybutmaybe indicativeinsteadof the potential for self-actualization or self-realization. This is not problematicto a five-factormodel for personalitydisorderpathology, as there is no requirementthat each pole of each of the five dimensions have equivalent implicationsfor maladaptivity.Equivalentdegrees of will not be suggested by equivalentlevmaladaptivity els on extraversion,introversion,agreeableness,or antagonism.Elevationson antagonismare more likely to be suggestive of maladaptivedysfunctionthanequivalent elevations on agreeableness,and maladaptivityis moreclosely associatedwith excessively high neuroticism thanwith excessively low neuroticism.Likewise, the dogmatism,rigidity,andclosed-mindednessof low openness may be more suggestive of maladaptivity thanhigh openness. On the other hand, Tellegen and Waller (in press) suggested that the five-factor model is limited in its ability to characterizeabnormalpersonalityby the exclusion of evaluative traitterms (e.g., bad, awful, and vicious) from the originallexical analyses of Goldberg (1982) and others.Goldbergsaid thatthese termsprovide little substantiveinformationwith respect to the content of personality traits. However, they may be particularlyimportantwhen describing the extreme, and variantsof normalpersonalaberrant, maladaptive ity traits.When these termswere includedin analyses, than Tellegen andWallerobtaineda seven-factorrather a five-factor solution. The two additionaldimensions were titledpositive and negative valence. Particularly to of important thisdiscussionis theirreformulation the factor. They indicatedthat the inclusion of Openness the evaluativetermsresultedin a dimensionof conventionality ratherthan openness. Persons who are extremely unconventional are characterized by terms such as odd, strange, unusual, peculiar, and weird, which are clearly more indicative of schizotypic persons thanan excessive openness to experience. However, Widiger and Trull (1992) suggested that the positive- and negative-valence dimensions of Tellegen andWaller(in press)may representmaladaptive variantsof the existing five factors. Negative valence is definedby termssuch as cruel, mean, vicious, nasty,evil, depraved,treacherous,anddeceitful,which could suggest extremeantagonism.Positive valence is 85

WIDIGER

defined by terms such as excellent, outstanding,superior, impressive,remarkable,andflawless, which may suggest excessively low neuroticism. In any case, it may be thatthe NEO-PI assessmentof the five factors is hinderedby the failureto includeitems thatrepresent the most extreme variants of each factor (Clark, Vorheis, & McEwen, in press). The NEO-PI was constructedto assess the five factorswithin normalpopulations and may not provideadequaterepresentation of the most extreme elevations on each factor. Beyond a degree of openness to experiencemay be an odd,peculiar, and weird unconventionalitythat would be descriptive of the schizotypal personalitydisorder. Normality Versus Abnormality The DSM-III-R is a manual for the diagnosis of mental disorders. Replacing the personality disorder diagnosticcategorieswith the five-factormodel would extend the classificationbeyond the scope of providing mental disorderdiagnoses. A criticism of DSM-III is the extent to which it appearsto subsume most problems in living as (medical, psychiatric)mental disorders (Schacht, 1985). Replacingthe Axis II personality disorders with the five-factor model would add substantialfuel to this controversy. However, the inclusion of normal with abnormal personalitytraitsis consistentwith the spiritof a multiaxial diagnostic system (J. Williams, 1985). Their inclusion would enable the clinician to provide a comprehensive description of a patient's personality, including adaptive as well as maladaptivemanifestations. Any descriptionof a person's personalitythatis confined to the features that are maladaptivewould clearly be incomplete and potentially distorting.The patientwould be describedsimply with respect to aberrant,abnormal,and dysfunctionaltraits,ignoringthe ways in which the person is functional and adaptive. For example, knowing the extent to which an avoidant patienttends to be conscientious, agreeable,or open to new ideas or experiences would likely be of considerable use in developing a treatmentplan and in understanding the patient's social and occupational functioning. Likewise, individualpersonalitydisorderdiagnoses are also confined to the more florid or immediatepersonality dysfunction, ignoring additional domains of dysfunction that may be equally importantin understanding the patient's personal, social, and occupational functioning. For example, the diagnosis of borderlinepersonality disorderprovides only limited informationwith respect to a person's characteristic mannerof functioning-being confined largely to the domainof neuroticism.Knowing the extent to which a borderlinetends to be low in conscientiousness,antag86

onistic, or closed to new ideas or experienceswould be and explaining of considerablehelp in understanding at work or within social, personalrelationdifficulties of ships. A complete understanding a person's social and occupationalfunctioningrequiresa consideration of not only a person's level of neuroticismbut also of the person's level of extraversion-introversion, agreeconscientiousness, and openableness-antagonism, ness-closedness. The same limitationwill occur with every personality disorder diagnosis. For example, knowing thata personhas a schizoid personalitydisorderdoes indicatethatthe personis maladaptivelyintroverted-excessively low in warmth,positive emotions, and gregariousness-but a schizoid person could also be characteristically agreeableor antagonisticor characteristicallyhigh or low in conscientiousness.A personality description confined to the domain of would providea very narrow,limited, and introversion distorteddescription. One final concern with replacing the DSM-III-R diagnosticcategorieswith the five factorsof personalon ity is how one would diagnoseabnormality the basis of a profilealong the five factors.The five-factormodel does not provide explicit thresholdsfor when a score along thecontinuumindicatesthepresenceof clinically significant personalitydysfunction.To the extent that extremevariantsof norpersonalitydisordersrepresent mal personality traits, maladaptivitywould be suggested by the extent to which a person is excessively antagonistic, agreeable, introverted, or extraverted (Kiesler, 1991; Widiger& Kelso, 1983; Wiggins, Phillips, & Trapnell, 1989), but diagnosing personality dysfunctionis not simply a matterof identifyinga point along the continuumat which the traitbecomes excessive or extreme.In fact, it would be inconsistentwith a dimensionalmodelof personalitydisorderpathologyto the providea single cutoff pointto demarcate presenceabsence of clinically significant personality dysfunction. Maladaptivity of personality functioning is suggested when the personality trait "causes either significant impairmentin social or occupationalfunctioningor subjectivedistress"(APA, 1987, p. 335), but it should be assessed relative to a person's personal, social, cultural, and occupational environments.The level of antagonismthat would be maladaptivefor a pastoralcounselor might not be maladaptivefor a police officer; the level of antagonism that would be adaptivefor a soldier at war might not be adaptivefor the solder duringpeace time; and the level of antagonism that would be adaptive for the police officer employed to arrestdrug dealers might not be adaptive for this same officer within his or her maritalrelationcontext ship. The failureto considerthe environmental hasbeen one of themajorcriticismsof thecontroversial proposalto includea masochisticor self-defeatingper-

CATEGORICAL DSM-III-R PERSONALITYDISORDERS

sonality disorder diagnosis in DSM-III-R (Caplan, 1987; Walker, 1987). Many of the self-defeating traits-for example, engages in excessive self-sacrifice, fails to accomplishtaskscrucialto personalobjectives, and incites angryor rejectingresponsesin others (APA, 1987)-could representsituationalresponsesto an abusive marital relationshipthat may be adaptive within the context of this disturbed,dysfunctionalrelationship. The DSM-III-R does not currently provide the meansfor assessing distressor social-occupational dysfunction independentlyof the personalitydisorderdiagnosis. However, several instrumentsfor such an assessment are available. For example, Dohrenwend, Shrout, Egri, and Mendelsohn (1980) developed the PsychiatricEpidemiology Research Interview(PERI) to assess importantdimensions of psychopathology independent of any particularmental disorder. The instrumentconsists of 38 scales, including Anxiety, Demoralization, Drinking Problems, Insomnia, Suicidality, Sexual Problems, Somatic Problems, HouseworkNeglect, School Dissatisfaction,Relationship Instability,and RelationshipDissatisfaction.The PERI(or any comparableinstrument) used in conjunctionwith anassessmentof the five factorsof personality would thenprovidea comprehensivedescriptionof the personality along with an independentassessment of the maladaptivity personalityfunctioningwithin the of person's currentsocial andoccupationalenvironments. Conclusions The empirical researchfavors a dimensionalmodel for the classification and conceptualizationof personality disorderpathology. The empirical researchalso favors the five-factor model for the classification of normalpersonalityfunctioning.It is then only natural and reasonableto proposethatpersonalitydisordersbe classified and understoodfrom the perspectiveof the five-factormodel. Perhapsthe only substantiallimitationwith a fivefactor alternativeto the DSM-III-R personalitydisorders is the absence of familiar treatmentand clinical implications for the various dimensions and their facets. Therehave been manychapters,books, andarticles on the treatmentof the compulsive, histrionic,antisocial, schizoid, and borderlinepersonalitydisordersbut of very little on the treatment excessive conscientiousness, extraversion,antagonism,introversion,and neuroticism. Table 2 is useful in providing a translation from the more familiarconcepts of DSM-III-R to the five-factor model, but clinicians would likely have some difficulty, at least initially, in developing treatment planswith the less familiarfive-factortraitterms. Nevertheless, it is anticipatedthat,with additionalexperience and training (Costa & Widiger, in press),

clinicians will find that it is more helpful to conceptualize treatmentas involving an effort to decrease the extent to which a person is impulsive, self-conscious, unassertive,overly compliant,or closed to mistrusting, emotions within particularsituations in which such tendencies are maladaptive,than to cure an avoidant, or borderline, histrionicpersonalitydisorder. Notes I thank Paul Costa and Jeff McCrae for the many to helpfuldiscussionsthatcontributed the development of thisarticleandBeth Corbitt herhelpfulcomments for on an earlierversion of the article. ThomasA. Widiger,Department Psychology, 115 of Kastle Hall, Lexington,KY 40506-0044. References
AmericanPsychiatric Association.(1987). Diagnostic and statistical manual of mental disorders (3rd ed., rev.). Washington,DC: Author. American PsychiatricAssociation. (1991). DSM-JV options book: Workinprogress. Washington,DC: Author. Angleitner, A., Ostendorf, F., & John, O. P. (1990). Towards a taxonomyof personalitydescriptorsin German:A psycho-lexical study.EuropeanJournal of Personality, 4, 89-118. Blashfield, R. (1984). The classification of psychopathology. New York:Plenum. Bond, M. H., Nakazato,H., & Shiraishi,D. (1975). Universalityand distinctiveness in dimensions of Japaneseperson perception. Journal of Cross-Cultural Psychology, 6, 346-357. Borkenau,P., & Ostendorf,F. (1989). Descriptive consistency and social desirabilityin self- andpeerreports.EuropeanJournal of Personality,3, 31-45. Cantor,N., & Genero,N. (1986). Psychiatricdiagnosis and natural categorization:A close analogy. In T. Millon & G. Klerman directionsinpsychopathology(pp. 233(Eds.), Contemporary 256). New York:Guilford. Caplan,P. J. (1987). The psychiatricassociation's failureto meet its own standards: dangersof self-defeatingpersonalitydisorThe deras a category.JournalofPersonalityDisorders, 1,178-182. Carson, R. C. (1991). Discussion: Dilemmas in the pathway of DSM-IV. Journal ofAbnormalPsychology, 100, 302-307. Church,T. A., & Katigbak,M. S. (1989). Internal,external, and of structure personalityin a non-Westernculture:An self-report and investigationof cross-language cross-cultural generalizability.JournalofPersonality andSocial Psychology,57,857-872. Clark,L. A. (1990). Towarda consensualset of symptomclustersfor assessmentof personalitydisorder.In J. Butcher& C. Spielberger (Eds.), Advances in personality assessment (Vol. 8, pp. 243-266). Hillsdale,NJ: LawrenceErlbaumAssociates, Inc. Clark, L. A., Vorheis, L., & McEwen, J. L. (in press). Personality disordersymptomatologyfromthe five-factorperspective.In P. Costa & T. Widiger (Eds.), Personality disordersand thefivefactor model of personality. Washington,DC: American PsychologicalAssociation. Cloninger,C. R. (1987). A systematicmethodfor clinical description and classification of personalityvariants.Archives of General Psychiatry,44, 573-588. Cloninger, C. R. (1989). Establishmentof diagnostic validity in psychiatricillness: Robins and Guze's method revisited. In L. Robins& J. Barrett(Eds.), Thevalidityofpsychiatric diagnosis (pp. 9-18). New York:Raven. Cloninger,C. R., Martin,R., Guze, S., & Clayton, P. (1985). Diag-

87

WIDIGER Archives of GeneralPsynosis and prognosis in schizophrenia. chiatry,42, 15-25. Coan, R. W. (1974). Theoptimalpersonality.New York:Columbia UniversityPress. Costa, P. T., & McCrae, R. R. (1985). The NEO-PI Personality Inventorymanual. Odessa, FL: Psychological Assessment Resources. Costa, P. T., & McCrae, R. R. (1988). Personalityin adulthood:A six-year longitudinalstudyof self-reportsandspouse ratingson the NEO Personality Inventory.Journal of Personality and Social Psychology, 54, 853-863. Costa, P. T., & McCrae,R. R. (1990). Personalitydisordersand the five-factor model of personality.Journal of PersonalityDisorders, 4, 362-371. Costa, P. T., & McCrae, R. R. (1992). The five-factor model of personalityandits relevanceto personalitydisorders.Journal of Personality Disorders, 6, 343-359. Costa, P. T., & Widiger, T. (Eds.). (in press). Personalitydisorders and the five-factor model of personality. Washington, DC: AmericanPsychological Association. De Raad,B., Mulder,E., Kloosterman,K., & Hofstee, W. K. (1988). verbs.EuropeanJournalofPersonality, Personality-descriptive 2, 81-96. Digman, J. M. (1990). Personalitystructure: Emergenceof the fivefactormodel.AnnualReview ofPsychology, 41, 417-440. Digman, J. M., & Inouye, J. (1986). Further specificationof the five robustfactorsof personality.Journal of Personality and Social Psychology, 50, 116-123. Dohrenwend, B., Shrout, P., Egri, G., & Mendelsohn, F. (1980). Nonspecific psychological distress and other dimensions of psychopathology.Archives of General Psychiatry, 37, 12291236. Eysenck, H. (1987). The definition of personalitydisordersand the criteriaappropriate theirdescription.Journal of Personality for Disorders, 1, 211-219. Eysenck,H. J., & Eysenck, M. W. ( 1985).Personalityand individual differences:A naturalscience approach. New York:Plenum. Finn, S. E. (1982). Base rates,utilities, and DSM-III: Shortcomings of fixed-rule systems of psychodiagnosis.Journal ofAbnormal Psychology, 91, 294-302. Ford,M., & Widiger,T. (1989). Sex bias in the diagnosisof histrionic and antisocial personalitydisorders.Journal of Consultingand Clinical Psychology, 57, 301-305. Frances,A. (1990, May). Conceptualproblems ofpsychiatricclassification. Paperpresentedat the meeting of the AmericanPsychiatricAssociation, New York. Frances, A., Clarkin,J., Gilmore, M., Hurt,S., & Brown, S. (1984). Reliability of criteria for borderline personality disorder: A comparison of DSM-III and the Diagnostic Interview for Borderline Patients. American Journal of Psychiatry, 42, 591-596. Gangestad,S., & Snyder,M. (1985). "To carve natureat its joints": On the existence of discreteclasses in personality.Psychological Review, 92, 317-349. Goldberg, L. R. (1982). From ace to zombia: Some explorationsin the language of personality. In C. Spielberger & J. Butcher (Eds.), Advances in personality assessment (Vol. 1, pp. 203234). Hillsdale, NJ: LawrenceErlbaum Associates, Inc. of Goldberg,L. R. (1990). An alternative"description personality": The Big-Five factorstructure. Journal ofPersonality andSocial Psychology, 59, 1216-1229. Grayson,J. (1987). Can categorical and dimensionalviews of psychiatricillness be distinguished?BritishJournal of Psychiatry, 151, 355-361. and Grove, W. M., & Andreasen,N. (1989). Quantitative qualitative distinctions between psychiatric disorders.In L. Robins & J. Barett (Eds.), The validity of psychiatric diagnosis (pp. 127141). New York:Raven. Grove, W. M., & Tellegen, A. (1991). Problemsin the classification of personalitydisorders.Journal of Personality Disorders, 5, 31-41. Gunderson,J. G., Links, P. S., & Reich, J. H. (1991). Competing models of personalitydisorders. Journal of Personality Disorders, 5, 60-68. Gunderson,J. G., & Zanarini,M. (1987). Currentoverview of the borderline diagnosis.JournalofClinicalPsychiatry,48(Suppl.), 5-11. Harpur,T. J., Hare, R. D., & Hakstian,A. R. (1989). Two-factor conceptualizationof psychopathy:Constructvalidity and assessment implications.PsychologicalAssessment:A Journal of Consultingand Clinical Psychology, 1, 6-17. Heumann,K., & Morey, L. (1990). Reliability and categorical and dimensional AmericanJourjudgmentsof personalitydisorder. nal ofPsychiatry, 147, 498-500. Hine, F., & Williams, R. (1975). Dimensional diagnosis and the medical student's grasp of psychiatry. Archives of General Psychiatry,32, 525-528. Hyler, S. E., & Lyons, M. (1988). Factor analysis of the DSM-III personality disorder clusters: A replication. Comprehensive Psychiatry,29, 304-308. Hyler, S. E., & Rieder,R. 0. (1987). PersonalityDiagnostic Questionnaire-Revised(PDQ-R). New York:Authors. John,O. P. (1990). The "Big Five" factortaxonomy:Dimensions of personalityin the naturallanguageand in questionnaires.In L. A. Pervin(Ed.),Handbookofpersonality: Theoryand research (pp. 66-100). New York:Guilford. John, O. P., Angleitner, A., & Ostendorf, F. (1988). The lexical approachto personality:A historicalreview of traittaxonomic research.EuropeanJournal ofPersonality, 2, 171-203. Kass, F., Skodol, A., Charles,E., Spitzer,R., & Williams, J. (1985). Scaled ratings of DSM-III personality disorders.American Journal of Psychiatry,142, 627-630. Kendell, R. (1975). The role of diagnosis in psychiatry. Oxford, England:Blackwell. Kendler, K. S. (1990). Toward a scientific psychiatric nosology: Strengthsand limitations.Archives of General Psychiatry, 47, 969-973. 0. Kernberg, (1984). Severepersonalitydisorders.New Haven, CT: Yale UniversityPress. methodsof assessmentand diagKiesler,D. J. (1991). Interpersonal nosis. In C. R. Snyder & D. R. Forsyth (Eds.), Handbook of social and clinical psychology: The health perspective (pp. 438-468). Elmsford,NY: Pergamon. Livesley, W. J. (1985). The classification of personalitydisorder:I. The choice of categoryconcept. CanadianJournal of Psychiatry,30, 353-358. Idealtypes, Livesley, W. J. (1991). Classifyingpersonalitydisorders: prototypes,or dimensions?JournalofPersonality Disorders, 5, 52-59. Livesley, W. J., West, M., & Tanney,A. (1985). Historicalcomment on the DSM-III schizoid and avoidant personality disorders. AmericanJournal ofPsychiatry, 142, 1344-1347. A. Loranger, (1988). PersonalityDisorderExamination(PDE) manual. Yonkers,NY: DV Communications. use Maser,J. D., Kaelber,C., & Weise, R. E. (1991). International and attitudestowardDSM-III and DSM-III-R: Growingconsensus in psychiatricclassification.Journal of AbnormalPsychology, 100, 271-279. McCrae,R. R. (1987). Creativity,divergentthinking,and openness to experience.Journal of Personality and Social Psychology, 52, 1258-1265. McCrae, R. R., & Costa, P. T. (1985a). Comparison of EPI and Psychoticismscales with measuresof the five-factormodel of PersonalityandlndividualDifferences,6,587-597. personality. McCrae,R. R., & Costa,P. T. (1985b). UpdatingNorman's"adequate taxonomy":Intelligenceand personalitydimensions in natural language and in questionnaires.Journal of Personality and SocialPsychology, 49, 710-721.

88

DSM-III-RCATEGORICAL PERSONALITYDISORDERS McCrae, R. R., & Costa, P. T. (1987). Validationof the five-factor model of personalityacross instruments observers.Journal and of Personality and Social Psychology, 52, 81-90. of McCrae,R. R., & Costa, P. T. (1989). The structure interpersonal traits:Wiggins's circumplexandthe five-factormodel.Journal of Personality and Social Psychology, 56, 586-595. McCrae,R. R., & Costa,P. T. (1990). Personalityin adulthood New York:Guilford. McGlashan,T. (1987). Borderlinepersonalitydisorderand unipolar affective disorder.Long-termeffects of comorbidity. Journalof Nervous and MentalDisease, 175, 467-473. Meehl, P. (in press). Factorsand taxa, traitsand types, differencesof degree and differences in kind.Journal of Personality. Meehl, P., & Golden, R. (1982). Taxometricmethods.In P. Kendall & J. Butcher(Eds.), Handbookof research methodsin clinical psychology (pp. 127-181). New York:Wiley. Mellsop, G., Varghese, F., Joshua, S., & Hicks, A. (1982). The reliabilityof Axis II of DSM-III. AmericanJournal of Psychiatry, 139, 1360-1361. Millon, T. (1981). Disorders of personality: DSM-III.Axis II. New York:Wiley. Millon, T. (1987). Manualfor the MCMI-II(2nd ed.). Minneapolis: NationalComputerSystems. Millon, T. (1991). Classification in psychopathology: Rationale, alternatives,and standards.Journal of AbnormalPsychology, 100, 245-261. Morey, L. C. (1988). Personalitydisordersin DSM-III and DSMIII-R: Convergence,coverage, and internalconsistency.American Journal of Psychiatry, 145, 573-577. Morey, L. C., & Ochoa, E. (1989). An investigation of adherence to diagnostic criteria: Clinical diagnosis of the DSM-III personality disorders.Journal of Personality Disorders, 3, 180192. Morey, L., Waugh, M. H., & Blashfield, R. K. (1985). MMPI scores for the DSM-III personalitydisorders:Theirderivation and correlates. Journal of Personality Assessment, 49, 245251. Nestadt, G., Romanoski,A., Chahal,R., Merchant,A., Folstein, M., E., Gruenberg, & McHugh,P. (1990). An epidemiologicalstudy of histrionicpersonalitydisorder.Psychological Medicine,20, 413-422. Overholser,J. C. (1991). Categoricalassessment of the dependent personalitydisorder.Journal of PersonalityDisorders, 5, 243255. Perry, J. C. (1990). Challenges in validating personalitydisorders: Beyond description.Journal of PersonalityDisorders, 4, 273289. Pfohl, B., Blum,N., Zimmerman, & Stangi,D. (1989). Structured M., Interviewfor DSM-III-R Personality (SIDP-R). Iowa City: Universityof Iowa, Departmentof Psychiatry. Robins, L., & Helzer, J. (1986). Diagnosis and clinical assessment: The currentstate of psychiatric diagnosis. Annual Review of Psychology, 37, 409-432. Schacht, T. (1985). DSM-III and the politics of truth.American Psychologist, 40, 513-521. Siever, L., & Davis, K. (1991). A psychobiologic perspectiveon the personality disorders. American Journal of Psychiatry, 148, 1647-1658. Skodol, A. E. (1989). Problems in differential diagnosis: From DSM-III to DSM-III-R in clinical practice. Washington,DC: AmericanPsychiatricPress. Skodol, A. E., Rosnick, L., Kellman,H. D., Oldham,J. M., & Hyler, S. E. (1991). Development of a procedurefor validatingstructured assessments of Axis II. In J. Oldham (Ed.), Personality disorders:New perspectiveson diagnostic validity(pp. 41-70). Washington,DC: AmericanPsychiatricPress. R. (1987). Nosology. In A. Skodol & R. Spitzer Spitzer, (Eds.), An annotated bibliography of DSM-III (pp. 3-11). Washington, DC: AmericanPsychiatricPress. Spitzer, R., Endicott,J., & Gibbon,M. (1979). Crossing the border into borderlinepersonality and borderlineschizophrenia.Archives of GeneralPsychiatry,36, 17-24. Strack,S. (1987). Developmentandvalidationof an adjectivechecklist to assess the Millon personalitytypesin a normalpopulation. Journal of Personality Assessment, 51, 572-587. Tellegen, A., & Waller, N. G. (in press). Exploring personality through test construction:Development of the MultidimenIn sional PersonalityQuestionnaire. S. R. Briggs & J. M. Cheek (Eds.), Personality measures: Development and evaluation. Greenwich,CT: JAI. Trapnell,P., & Wiggins, J. S. (1988). Extensionof the Interpersonal AdjectiveScales to include the Big Five dimensionsof personality. Unpublished manuscript, Universityof BritishColumbia, Vancouver. Trull, T. (in press). DSM-III-R personalitydisordersand the fivefactormodel of personality:An empiricalcomparison.Journal of AbnormalPsychology. Trull,T., Widiger,T., & Guthrie,P. (1990). The categoricalversus dimensionalstatusof borderline Journalof personalitydisorder. AbnormalPsychology, 99, 40-48. Tyrer,P., & Alexander,J. (1979). Classificationof personalitydisorder. BritishJournal of Psychiatry,135, 163-167. of Walker,L. E. A. (1987). Inadequacies the masochisticpersonality disorderdiagnosis for women. Journal of Personality Disorders, 1, 183-189. Waller, N. G., & Ben-Porath,Y. S. (1987). Is it time for clinical psychology to embrace the five-factor model of personality? AmericanPsychologist, 42, 887-889. Widiger, T. (1991). Personalitydisorderdimensional models proposed for DSM-IV. Journal of Personality Disorders, 5, 386398. Widiger, T. (1992). Categoricalversus dimensional classification: Implicationsfromand for research.Journal of PersonalityDisorders,6, 287-300. Widiger,T., & Frances,A. (1985). The DSM-III personalitydisorders:Perspectivesfrom psychology. Archives of General Psychiatry,42, 615-623. Widiger, T., & Frances, A. (1989). Epidemiology, diagnosis, and comorbidityof borderlinepersonalitydisorder.In A. Tasman, R. Hales, & A. Frances(Eds.), Reviewof psychiatry(Vol. 8, pp. 8-24). Washington,DC: AmericanPsychiatricPress. Widiger, T., Frances, A., Harris,M., Jacobsberg,L., Fyer, M., & Manning,D. (1991). Comorbidityamong Axis II disorders.In J. Oldham (Ed.), Personality disorders: New perspectives on diagnostic validity(pp. 163-194). Washington,DC: American PsychiatricPress. Widiger, T., Frances, A., Spitzer, R., & Williams, J. (1988). The DSM-III-R personality disorders: An overview. American Journal of Psychiatry,145, 786-795. Widiger,T., & Kelso, K. (1983). Psychodiagnosisof Axis II. Clinical PsychologyReview,3, 491-510. Widiger, T., & Rogers, J. (1989). Prevalence and comorbidity of personalitydisorders.PsychiatricAnnals, 19, 132-136. Widiger,T., & Trull, T. (1991). Diagnosis and clinical assessment. AnnualReview of Psychology, 42, 109-133. Widiger, T., & Trull, T. (1992). Personality and psychopathology: An application of the five-factor model. Journal of Personality, 60, 363-393. Widiger,T., Trull,T., Clarkin,J., Sanderson,C., & Costa,P. (1993). Describing the DSM-III-R and DSM-IVpersonality disorders from the perspective of the five-factor model. Unpublished manuscript, Universityof Kentucky,Lexington. Wiggins,J. S., Phillips,N., & Trapnell,P. (1989). Circular reasoning about interpersonalbehavior: Evidence concerning some untestedassumptions underlyingdiagnosticclassification.Journal of Personalityand Social Psychology, 56, 296-305. Wiggins, J. S., & Pincus, A. L. (1989). Conceptionsof personality disordersanddimensionsof personality.PsychologicalAssess-

89

WIDIGER ment: A Journal of Consulting and Clinical Psychology, 1, 305-316. Wiggins, J. S., & Pincus, A. L. (1992). Personality:Structureand assessment.Annual Review of Psychology, 43, 473-504. Williams,J. B. W. (1985). The multiaxialsystem of DSM-III: Where did it come from and where should it go? I. Its origins and critiques.Archives of General Psychiatry,42, 175-180. Yang, K., & Bond, M. H. (1990). Exploring implicit personality theories with indigenous or importedconstructs:The Chinese case. Journal of Personality and Social Psychology, 58, 1087-1095. F. Zanarini,M. C., Gunderson,J. G., Frankenburg, R., Chauncey, D. L., & Glutting, J. H. (1991). The face validity of the DSM-III and DSM-III-R criteria sets for borderline personality disorder. American Journal of Psychiatry, 148, 870-874. Zimmerman, M., & Coryell, W. (1990). Diagnosing personality disordersin the community. A comparison of self-report and interview measures.Archives of General Psychiatry, 47, 527531.

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