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Is it BPD or Narcisism or Anti-social or…?

It seems there is not much difference!

If you look at the “DSM-5” (Diagnostic and Statistical Manual of Mental Disorders) you know that there you will find 10 personality disorders (Paranoid, Schizoid, Schizotypal, Antisocial, Narcissistic, Borderline, Histrionic, Dependent, Obsessive-Compulsive, and Avoidant).


In reality, there has always been a high rate of co-occurring personality disorders. Even families will notice that if they read about the 10 different personality disorders they might see that their loved one probably meets criteria for several…and which ones, and when, can seem to be a moving target!


News Flash: There is no scientific evidence for 10 distinct personality disorders!


Since 2015 researchers have been conducting studies in which they entered all the symptoms of personality disorder into a factor analysis to verify the existence of 10 distinct personality disorders. Studies have failed to demonstrate a “10-factor covariance structure underlying personality disorder symptoms.” Essentially the research conclusion again and again is that there are not ten different personality disorders...there is only one central construct: how adaptive and healthy is the self and interpersonal functioning.


Unknown even to many clinicians, there is an “Alternative Model for Personality Disorder” in the DSM (Section 3). The essence of this alternative model aligns with the new standard for personality disorders in the International Classification of Diseases (IDC). In both cases they eliminate the 10 classifications and replace them with a single new assessment, Level of Personality Function Scale (LPFS).


The Level of Personality Function is a single, clear, general factor of personality pathology.


Carla Sharp, Ph.D., one of the leading researchers in this field wrote:

"This means that we can think of people as lying on a single continuum of personality function similarly to IQ. We can therefore ask what a person’s personality pathology quotient is, instead of needing to fit people into personality types or disorders for which we have little empirical evidence. Interestingly, while our study showed that specific factors (flavors or types) emerged for narcissism, avoidant, obsessive–compulsive, schizotypal, and antisocial flavors, BPD symptoms loaded exclusively onto the general factor of personality pathology. This suggests that BPD, all along, may have been a relatively good proxy for the maladaptive self and interpersonal features shared by all personality disorders."[1]


Level of Personality Function is measured across five levels of severity, from 0 (healthy, adaptive personality function) to 4 (severe impairment in personality function).[2] This means that level 2 or greater would establish the diagnosis of Personality Disorder at a moderate or greater level of impairment. Personality Function is defined in terms of self and interpersonal functioning, both of which have two domains, all four of which include: identity, self-direction, empathy and intimacy. Below is a summary of these 4 areas that, put together, assess the degree to which a person’s personality is healthy or impaired.

Level of Personality Function (LPF)


SELF-FUNCTIONING

IDENTITY: - Experience of oneself as unique, with clear boundaries between self and others - Stability of self-esteem and accuracy of self-appraisal - Capacity for, and ability to regulate, a range of emotional experience

SELF-DIRECTION: - Pursuit of coherent and meaningful short-term and life goals - Utilization of constructive and prosocial internal standards of behavior - Ability to self-reflect productively on internal mental processes



INTERPERSONAL FUNCTIONING

EMPATHY: - Comprehension and appreciation of others’ experiences and motivations - Tolerance of differing perspectives - Understanding of one’s own behavior on others


INTIMACY: - Depth and duration of positive connection with others - Desire and capacity for closeness - Ability to engage in reciprocal relationships and exhibit mutual regard


The LPF scale boils down to a single number from 0-4. If that does not simplify things, consider that research has shown that that assessing the severity of a personality disorder can be done reliably by persons with no clinical training or experience, simply following the instructions for interviewers.[3] (If you are interested in a deeper dive into understanding this assessment, download the attached document below for an example of the Structured Clinical Interview for the Level of Personality Functioning Scale.) [4]

LPFS sample
.pdf
Download PDF • 1.30MB

Notes:

[1] Sharp, Carla; Bevington, Dickon. (2022) Mentalizing in Psychotherapy (Psychoanalysis and Psychological Science) (p. 10). Guilford Publications. [2] Sharp C, Wall K. DSM-5 Level of Personality Functioning: Refocusing Personality Disorder on What It Means to Be Human. Annu Rev Clin Psychol. 2021 May 7;17:313-337. doi: 10.1146/annurev-clinpsy-081219-105402. Epub 2020 Dec 11. PMID: 33306924.


[3] Johannes Zimmermann, Cord Benecke, Donna S. Bender, Andrew E. Skodol, Henning Schauenburg, Manfred Cierpka & Daniel Leising (2014) Assessing DSM–5 Level of Personality Functioning From Videotaped Clinical Interviews: A Pilot Study With Untrained and Clinically Inexperienced Students, Journal of Personality Assessment, 96:4, 397-409, DOI: 10.1080/00223891.2013.852563

[4] Hummelen B, Braeken J, Buer Christensen T, Nysaeter TE, Germans Selvik S, Walther K, Pedersen G, Eikenaes I, Paap MCS. A Psychometric Analysis of the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders Module I (SCID-5-AMPD-I): Level of Personality Functioning Scale. Assessment. 2021 Jul;28(5):1320-1333. doi: 10.1177/1073191120967972. Epub 2020 Nov 6. PMID: 33155489; PMCID: PMC8167914.

[5] Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.): Routledge/Taylor & Francis.

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