The “Lost” Personality Disorders and Their Relationships to the Alternative Model of Personality Disorders Among Older Adults
Abstract
Abstract. Four personality disorders (PD) have become “lost” throughout the various editions of the DSM: Depressive, Passive-Aggressive, Sadistic, and Self-Defeating. The Alternative Model of Personality Disorders (AMPD) is a novel approach to PD classification, containing two diagnostic criteria: personality functioning and pathological personality traits. This study identifies the personality functioning and pathological personality trait features of the Lost PDs among older adults (N = 202; Mage = 67.47 years). Results indicate that the Lost PDs related more strongly with the self-functioning domains (versus the interpersonal domains). Some pathological traits emerged in expected directions, whereas others did not, which is consistent with research on the traditional PDs. The AMPD appears to have mixed validity in capturing the Lost PDs in older adults, though overall it performed comparably well and warrants further examination.
Historically, the diagnostic category of personality disorders (PD) has been rife with revisions, reformulations, and changes to the classification system over the various versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), making classification of PDs an ongoing challenge (Cierpialkowska, 2013; Coolidge & Segal, 1998). An example of a notable revision is exemplified in the four “Lost PDs” that were included in earlier editions of the DSM before being eventually removed in DSM-5 (American Psychiatric Association [APA], 2013): Depressive, Passive-Aggressive, Sadistic, and Self-Defeating PDs. Although they were removed from the DSM, significant historical foundations, clinical lore, and some research exist to suggest these disorders still have validity and clinical utility (Millon et al., 2004). Moreover, negative traits or behaviors among people likely do not disappear simply because they are no longer included in a particular classification system. With the publication of the Alternative Model of Personality Disorders (AMPD) in Section III of DSM-5, in which PDs are examined dimensionally, rather than categorically, the four Lost PDs warrant revisiting and empirical scrutiny.
Research on the Lost Personality Disorders
Depressive PD describes a pervasive pattern of depressive cognitions and behaviors that occur in a variety of contexts. It was introduced in the Appendix to DSM-IV (APA, 1994) but was ultimately removed from consideration in DSM-5. There is concern about the similarity of Depressive PD to Persistent Depressive Disorder (formerly dysthymia), but research suggests that it is psychometrically distinct from mood disorders (McDermut et al., 2003; Phillips et al., 1998) and has a distinct genetic etiology (Ørstavik et al., 2007). Passive-Aggressive PD represents a pattern of negativistic attitudes and passive resistance that was originally introduced in the first edition of the DSM (APA, 1952) and was included in every DSM edition until being moved to the appendix in DSM-IV and removed entirely from DSM-5, because of an apparently limited research base. Rotenstein et al. (2007) found that the Passive-Aggressive PD had a multidimensional nature and lacked internal consistency, whereas Hopwood et al. (2009) found adequate stability over time, and Hopwood and Wright (2012) found that its discriminant validity and diagnostic overlap with other PDs are improved when removing its highly negativistic content. Other studies have indicated that Passive-Aggressive PD has clinical significance among suicidal individuals (Joiner & Rudd, 2002), and that it is related to interpersonal problems in distinct and meaningful ways (Laverdière et al., 2019).
Sadistic PD was introduced in the Appendix to DSM-III-R (APA, 1987) and was defined as a pervasive pattern of being cruel, demeaning, and aggressive toward others. The disorder was removed in DSM-IV. Some criticized the potential overlap of Sadistic PD with Antisocial PD (Berger et al., 1999), but the construct appears to be especially relevant, distinct, and clinically meaningful for inpatient and forensic populations, suggesting that it may merit revisitation (Hill et al., 2006; Myers et al., 2006; Spitzer et al., 1991). Lastly, Self-Defeating PD, which also appeared in the Appendix to DSM-III-R, was described as a long-standing pattern of undermining one’s pleasurable experiences, being drawn to unhealthy and harmful relationships, and avoiding help from others. It was also removed in DSM-IV. The available research on Self-Defeating PD is limited and noted significant overlaps with dependent, borderline, and depressive PDs, but its incremental validity concerning these PDs is mixed, with some studies supporting its distinct predictive qualities (Cruz et al., 2000; Skodol et al., 1994) and others finding a lack of utility (Huprich et al., 2006; Reich, 1987). Overall, the existing but rather limited research on these four Lost PDs suggests that they may show high overlap with the other remaining PDs, but that they still have some validity and clinical utility. However, this issue of comorbidity with other PDs becomes less problematic when assessing PDs dimensionally, as proposed by the AMPD.
Lost Personality Disorders and Older Adults
Despite the growing proportion of older adults relative to the population, research on the Lost PDs among older adults is scarce. Segal et al. (2006) argued for their clinical utility and provided theoretically based predictions for how these PDs might manifest and present among older adults, although empirical studies are limited. To our knowledge, only one study examining the Lost PDs among older adults exists. Segal et al. (2015) examined relationships between the four Lost PDs, suicidal ideation, and reasons for living in a later life population. They found that the four Lost PDs (particularly Depressive PD) provided unique contributions to suicidality and warranted assessment for suicidal older adults. More broadly, the available research on PDs and older adults suggests that the diagnostic criteria for several of the PDs are problematic, showing age-bias against older adults and lacking consideration for age-related behavioral and interpersonal changes (Van Alphen et al., 2006). Although there is limited empirical research, the problem of inapplicable criteria for older adults likely extends to the categorically measured Lost PDs (Segal et al., 2006). However, the previously noted problems regarding overlap between the Lost PDs with other Section II PDs, and the problems of age-biased criteria have the potential to be remedied when assessing personality pathology dimensionally, rather than categorically.
The Alternative Model of Personality Disorders
In Section III of DSM-5, the portion of the manual devoted to suggestions for future research, the AMPD is presented as a novel method of diagnosing PDs (APA, 2013). The AMPD was developed because of documented shortcomings of the categorical PD system, including comorbidity, heterogeneity within a diagnostic category, lacking reliability and validity, lacking stability over time, and lacking information for treatment indication (Krueger, 2013). The AMPD proposes PD diagnosis according to two diagnostic criteria. Personality functioning (Criterion A) is meant to be a marker of personality severity and contains four overarching domains: Identity, Self-Direction, Intimacy, and Empathy. Pathological personality traits (Criterion B) are meant to be a marker of pathological personality style and contain five higher-order domains (Negative Affect, Detachment, Antagonism, Disinhibition, and Psychoticism) and 25 trait facets. The AMPD proposes that personality functioning (i.e., severity) and pathological personality traits (i.e., style) should be used in combination to comprehensively understand to what extent and in what pattern personality pathology affects an individual. The model posits that each of the traditional 10 PDs should have distinct personality functioning and pathological personality trait profiles. In fact, specific profiles are presented for 6 of the 10 PDs present in Section II of DSM-5, though the AMPD notes that the remaining four standard PDs may be diagnosed by identifying and specifying a pattern of functioning, domains, and traits (APA, 2013).
Under the AMPD, the four Lost PDs could easily be added as diagnoses if functioning and traits are meant to be able to represent all combinations of personality pathology. However, patterns for the Lost PDs were not included, and further, aging issues were not considered at all in the AMPD. Subsequently, the purpose of this study was to identify prominent personality functioning and pathological personality trait features (as measured by the AMPD) among the four Lost PDs. An older adult sample was selected because of the lack of research surrounding PDs in later life.
Previously, we examined relationships between the 10 Section II PDs and the AMPD among older adults using the same data described here (Stone & Segal, in press) to determine how the AMPD performed for PD diagnoses that currently exist in DSM-5. We found that there was significant overlap between the traditional 10 PDs and the AMPD in unpredicted directions, and substantially different trait patterns emerged in contrast to previous findings among younger adults. To extend this line of research, we are presently examining PDs present in previous editions of the DSM to determine whether they perform comparably. We hypothesized that they would show personality functioning and pathological personality trait patterns that are distinct from any of the previously reported 10 PDs (Stone & Segal, in press), providing further evidence for their uniqueness and validity.
Method
Participants and Procedure
Participants consisted of 202 older adults (M age = 67.47 years; SD = 2.98 years). The gender distribution was 59% men (n = 119) and 41% women (n = 83). Regarding ethnicity, 84% identified as not Hispanic or Latinx, 13% identified as Hispanic or Latinx, and 3% opted not to identify. The racial distribution breaks down as follows: White (70%), Black or African American (16%), East Asian (6%), American Indian or Alaskan Native (3%), Unidentified (2%), Other (1.5%), Native Hawaiian or other Pacific Islanders (1%), Multiracial/Multiethnic (1%), and West Asian (0.5%). The mean level of education was 15.36 years (SD = 2.54).
Approval from the university’s Institutional Review Board was obtained, and informed consent was obtained before participants gained access to the questionnaires. Older adults, recruited via Amazon’s Mechanical Turk (MTurk), completed the following self-report questionnaires in a counterbalanced order: Coolidge Axis II Inventory (CATI), Personality Inventory for DSM-5 (PID-5), and Level of Personality Functioning Scale-Self-Report (LPFS-SR). Participants were paid $2.00 for their participation. Participation was limited to older adults (> 60 years old) who were living in the United States and who reported being proficient in English. They were not screened for any other variables. Four attention/validity checks were included throughout the study in which participants were asked to respond to items that are highly unlikely to be true (e.g., I played quarterback for the Denver Broncos football team). A total of 26 participants were excluded from the sample because they failed one or more attention checks. Data were drawn from a larger project (Stone & Segal, in press), with data regarding the Depressive, Passive-Aggressive, Sadistic, and Self-Defeating PD scales on the CATI being analyzed for the first time in this paper.
Measures
Coolidge Axis II Inventory (CATI)
The CATI (Coolidge, 2020) is a 250-item self-report questionnaire in which response options are on a 4-point Likert-type scale, ranging from 1 (strongly false) to 4 (strongly true). The CATI measures the 10 PDs as outlined in Section II of DSM-5. Relevant to this study, the CATI also contains scales for the four PDs that appeared in previous editions of the DSM but were omitted from DSM-5: Depressive, Passive-Aggressive, Sadistic, and Self-Defeating. For the four Lost PDs, Cronbach’s α values were good to strong in the current sample: Depressive = .71, Passive-Aggressive = .72, Self-Defeating = .78, and Sadistic = .88. See Table 1 for further descriptive statistics.
Personality Inventory for DSM-5 (PID-5)
The PID-5 (Krueger et al., 2012) is a 220-item self-report questionnaire in which response options are on a 4-point Likert-type scale, ranging from 0 (very false or often false) to 3 (very true or often true). The PID-5 measures the conceptualization of pathological personality traits of the AMPD, containing five higher-order domains and its 25 trait facets. The AMPD recommends assessing traits on the facet-level to gain the most amount of detail and specificity possible. In the current sample, Cronbach’s α values for the five domains were all excellent: Negative Affect = .93, Detachment = .93, Antagonism = .94, Disinhibition = .95, and Psychoticism = .97. For the 25 facets, the internal consistency of scale scores was moderate to strong, ranging from .68 (Suspiciousness) to .95 (Depressivity). See Table 1 for further descriptive statistics.
Level of Personality Functioning Scale-Self-Report (LPFS-SR)
The LPFS-SR (Morey, 2017) is an 80-item self-report questionnaire in which response options are on a 4-point Likert-type scale, ranging from 1 (totally false, not at all true) to 4 (very true). The LPFS-SR measures the AMPD’s conceptualization of personality functioning, and the measure includes one total dysfunction score and four domain scores. In the current sample, Cronbach’s α for each scale was strong: Empathy = .84, Identity = .89, Intimacy = .89, Self-Direction = .90, and Total Score = .97. See Table 1 for further descriptive statistics.
Statistical Analyses
All statistical analyses were conducted in IBM SPSS Statistics Version 25. Missing data were handled by using listwise deletion (ranging from two to four participants; see Tables 1–4). First, to examine the relationships between the Lost PDs and personality functioning, we computed Pearson correlations between the CATI PD scales and LPFS-SR. Next, we computed a series of hierarchical regressions, with the LPFS-SR domains predicting each of the CATI Lost PD scales. Because of the unequal gender distribution in the present sample, we selected hierarchical regressions to control for the effects of sex. At step one of each hierarchical regression, we added sex as the sole predictor. At step two, we added the four LPFS-SR domains, thus controlling for the effects of sex. Second, to examine the relationship between the Lost PDs and pathological personality traits, we computed Pearson correlations between the CATI PD scales and the PID-5 domains. Next, we computed a series of hierarchical regressions, with the PID-5 facets predicting each of the CATI Lost PD scales. Again, hierarchical regressions were chosen to control for sex, given the unequal gender distribution in the current sample. At step one of each model, we included sex as the sole predictor. At step two, we added the 25 facets from the PID-5 scales as predictors, thus controlling for the effects of sex. For all hierarchical regressions, the results from step two are reported. Interpretation of values and effect sizes (i.e., Pearson correlation coefficients and standardized beta weights) follow recommendations provided by Cohen (1992): .20 as small, .50 as medium, and .80 as large. We assessed the statistical assumptions of all regression analyses, including normally distributed variables and multicollinearity; all assumptions were satisfied.
Results
Relationships Between the Lost PDs with Personality Functioning (Criterion A)
To examine simple relationships between the AMPD’s conceptualization of personality functioning and the four Lost PDs, we computed Pearson correlations between the LPFS-SR domains and the CATI PD scales (see Table 2). All correlations between the four LPFS-SR domains and the four CATI Lost PD scales were positive and significant (p < .001) with large effect sizes (≥ .67).
Next, to determine which LPFS-SR domain was most prominent for each Lost PD, we computed a series of hierarchical regressions with the LPFS-SR domains predicting each CATI Lost PD scale. Results from the hierarchical regressions are displayed in Table 3. For Depressive PD, the LPFS-SR model accounted for 56% of the variance (F(5, 194) = 57.24, p < .001), and Self-Direction (β = .34) was the sole significant predictor. For Passive-Aggressive PD, the LPFS-SR model significantly accounted for 47% of variance (F(5, 194) = 42.06, p < .001), and Intimacy (β = .30) was the sole significant predictor. For Sadistic PD, the LPFS-SR model accounted for 60% of variance (F(5, 194) = 92.51, p < .001). Sex (β = .11) and Self-Direction (.47) were significant predictors. Lastly, for Self-Defeating PD, the LPFS-SR model accounted for 57% of variance (F(5, 194) = 62.82, p < .001), and Identity (β = .53) and Self-Direction (.26) were its significant predictors.
Relationships Between the Lost PDs with Pathological Personality Traits (Criterion B)
First, we computed Pearson correlations between the CATI Lost PD scales and the PID-5 domains to examine simple relationships (see Table 2). As Table 2 shows, all four Lost PD scales were significantly and positively correlated (p < .001) with all five PID-5 domains with large effect sizes (≥ .62). This indicates a substantial overlap between the Lost PDs and every trait domain of the AMPD.
Next, we computed a series of hierarchical regression models with each of the four Lost PD scales as outcome variables. Results from the hierarchical regressions are displayed in Table 4. For Depressive PD, the PID-5 model significantly accounted for 79% of the variance, F(1, 171) = 25.21, p < .001. The following facets were significant predictors of Depressive PD: Irresponsibility (β = .25), Anxiousness (.21), Emotional Lability (.17), and Anhedonia (.17). For Passive-Aggressive PD, the PID-5 model accounted for 70% of variance, F(1, 171) = 15.50, p < .001. The following facets were significant predictors of Passive-Aggressive PD: Anxiousness (β = .29), Anhedonia (.28), Eccentricity (.26), Callousness (.25), and Grandiosity (−.24). For Sadistic PD, the PID-5 model significantly accounted for 83% of variance (F(1, 171) = 31.78, p < .001), and the sole significant predictor was Callousness (β = .38). Lastly, for Self-Defeating PD, the model PID-5 accounted for 72% of variance (F(1, 171) = 16.83, p < .001), and the significant predictors included Eccentricity (β = .28) and Submissiveness (.21).
Discussion
This study examined the AMPD’s relationship to the four PDs included in previous editions of the DSM but removed from DSM-IV or DSM-5 (Depressive, Passive-Aggressive, Sadistic, and Self-Defeating). Correlational results between the four Lost PDs and the AMPD’s personality functioning and pathological personality traits revealed substantial overlap, with all correlations positive and significant with large effect sizes. This pattern is consistent with our previous work with the 10 Section II PDs in which all PDs were significantly and positively correlated with all PID-5 domains and LPFS-SR domains (Stone & Segal, in press). These similar findings indicate that the four Lost PDs perform similarly and equally well, compared to the traditional 10 PDs among older adults.
Criterion A and the Lost PDs
We computed regression analyses to determine which personality functioning and pathological personality trait domains most influenced each of the Lost PDs, when controlled for their interrelated nature. For personality functioning (Criterion A of the AMPD), these analyses indicated that one to two domains drive the Lost PDs: Self-Direction for Depressive PD, Intimacy for Passive-Aggressive PD, Self-Direction for Sadistic PD, and Identity and Self-Direction for Self-Defeating PD. Overall, these findings indicate that the four Lost PDs relate more strongly to problems of self-functioning (i.e., Self-Direction and Identity) rather than problems of interpersonal functioning (i.e., Intimacy and Empathy) – which is surprising. It makes logical sense that some PDs (e.g., Depressive, Self-Defeating) are highly related to dysfunction in the self-domain, as they are PDs that are highly related to internal distress. However, Passive-Aggressive and especially Sadistic PDs should theoretically be related to high levels of interpersonal dysfunction, and, surprisingly, regression analyses do not indicate a more significant relationship to the AMPD’s interpersonal functioning domains of Empathy and Intimacy. Segal et al. (2006) speculated that Sadistic and Passive-Aggressive PDs may manifest differently in older adulthood, such as decreased physical domination among those with Sadistic PD features and reduced opportunities to display passive-aggressive behaviors (e.g., criticizing or scorning authority in the workplace or passively resisting fulfilling occupational tasks) for those with Passive-Aggressive features. However, these PD types still should be related to interpersonal dysfunction, although it does not appear that the personality functioning conceptualization of AMPD adequately captures these age-specific manifestations of personality pathology. Alternatively, the AMPD does appear to be capturing the self-functioning aspects of the Lost PDs, providing evidence for some validity.
Criterion B and the Lost PDs
For pathological personality traits (Criterion B of the AMPD), regression analyses indicated that clear trait patterns emerge for the four Lost PDs. For Depressive PD, the PID-5 facets of Anxiousness, Emotional Lability, Anhedonia, and Irresponsibility are most salient. All four traits make theoretical sense for Depressive PD, as high levels of anxiety, feelings of unpredictable emotions, experiencing a lack of pleasure, and neglecting responsibilities are associated with chronically depressive personalities. However, it is surprising that the PID-5 facet of Depressivity was not a significant predictor of the Depressive PD scale. Depression, and potentially depressive personality disorder, manifest differently in older adulthood (e.g., decreased cognitive symptoms and increased somatic symptoms; Segal et al., 2018), and the AMPD traits may not adequately capture this different presentation. For Passive-Aggressive PD, the PID-5 facets of Anxiousness, Anhedonia, Callousness, Grandiosity (in the negative direction), and Eccentricity were significant predictors. Some of these traits (e.g., trait anxiety, lack of pleasure, the opposite of grandiose behavior) make logical sense, whereas others (e.g., Callousness and Eccentricity) make less theoretical sense. Highly passive-aggressive individuals are unlikely to show the overtly aggressive and unsympathetic behavior that highly callous individuals show. They are also unlikely to show the odd behavior or beliefs that highly eccentric individuals display. Subsequently, the pathological personality trait conceptualization of the AMPD may be accurately measuring some aspects of Passive-Aggressive PD while inadequately measuring others, indicating mixed evidence for validity.
For Sadistic PD, the PID-5 facet of Callousness was the sole significant predictor. This makes strong theoretical sense, as individuals with a sadistic personality are likely to show the overtly aggressive behavior and uncaring attitudes associated with trait callousness. However, it is surprising that Sadistic PD was not significantly related to other facets of the PID-5 that measure other aspects of similar thoughts and behaviors, such as Hostility, Manipulativeness, Impulsivity, or Deceitfulness. For Self-Defeating PD, the PID-5 traits of Submissiveness and Eccentricity were significant predictors – both of which are unsurprising in their relation to Self-Defeating PD, as they are likely to be highly submissive to others and their behaviors or attitudes may be viewed as odd or eccentric by others. However, like the other Lost PDs, it is surprising that Self-Defeating PD did not relate to other theoretically similar PID-5 traits, such as Withdrawal or Anhedonia. Overall, distinct trait patterns emerged for the four Lost PDs in this sample of older adults that are different from the 10 Section II PD trait patterns. Some traits emerged in predicted directions, whereas other traits that should be theoretically related were not significant.
Conclusions
The present results are consistent with the limited previous research that examined how the two diagnostic criteria of the AMPD relate to the traditional, categorical approach to PD classification among older adults (Stone & Segal, in press). Both this study and Stone and Segal (in press) found substantial correlational overlap between the DSM’s traditional conceptualizations of PDs and the AMPD. However, for both studies, regression analyses revealed clearer patterns: One to two personality functioning domains and between one and five pathological personality traits emerged as significant predictors of CATI PD scales. Essentially, the PDs that were not retained in the DSM-5 (i.e., Lost PDs) performed comparably to the 10 PDs that were retained. Because they performed comparably, continuing research investigating how the Lost PDs fit into the AMPD is warranted. In the present study and in Stone and Segal (in press), both theoretically expected and theoretically unexpected functioning and trait patterns emerged, providing mixed evidence of the validity of the AMPD for older adults. More research is needed to clarify whether this mixed evidence extends into other older adult samples. Additionally, more research is needed to clarify whether the present results on the Lost PDs represent geriatric variants or whether they represent more generalized patterns that apply across the lifespan, as the Lost PDs have yet to be examined among younger samples.
In general, PDs among older adults are poorly understood, and it is an ongoing topic of debate whether the areas covered by the AMPD (personality functioning and pathological personality traits) actually capture the essence of PDs for older adults. The present results suggest that the AMPD does capture some personality pathology for older adults, but more research is needed to understand the extent to which the AMPD improves upon the traditional, categorical model of PDs for older adults. The present results also level some criticism toward the current categorical model of PDs in DSM-5. The current model does not include the Lost PDs, but our results suggest that these four excluded PDs do have some validity, as trait patterns unique from the remaining 10 PDs were found. This indicates that the current, categorical model of PDs does not have a complete representation of personality pathology, limiting its comprehensiveness.
Limitations and Future Directions
Although this study used a fairly large sample of older adults, it was also limited in a few ways. The sample contained substantially more men (59%) and consisted mostly of non-Hispanic or Latinx, White individuals (70%), limiting the generalizability of the study to more racially and ethnically diverse populations. McGilloway et al. (2010) indicated prevalence rates of PDs vary by race and ethnicity, potentially suggesting that they present differently. Future studies should seek to include more racially and ethnically diverse older adult populations. The sample also consisted of older adults from a MTurk sample, and we did not assess or control for other mental health symptoms, mental disorders, or nonpersonality functioning levels. Subsequently, the current results have an unknown generalization to clinical or treatment-seeking populations, and future studies should use clinical samples to determine whether results extend to individuals formally diagnosed with PDs. Additionally, samples of older adults recruited through MTurk have some differences compared to nationally representative samples of older adults, including higher cognitive functioning, self-rated health, and depressive symptoms (Ogletree & Katz, in press). Subsequently, one must exercise caution in generalizing results to broader older adult populations. Lastly, the cross-sectional and correlational nature of the study limits the detection of causal relationships over time, and some research indicates that meaningful relationships with the AMPD can be detected longitudinally (Roche, 2018). Given the research that suggests PDs present differently over the life course (Cooper et al., 2014), longitudinal studies of the AMPD that include older adults are sorely needed. Because the present sample contained only older adults, future research should investigate the Lost PDs among younger samples to determine whether results extend to other age groups.
The Lost PDs were removed from previous editions of the DSM because of a reported lack of research supporting them (Bradley et al., 2006). However, since their removal, research on each of the four Lost PDs has significantly declined because they are no longer in the DSM. This resulting lack of research maintains a cycle of justifying their removal, even though the limited research that does exist points to their validity, such as the unique trait patterns that emerged in the present study in largely theoretically consistent ways. One of the main implications of this study is that the four Lost PDs provide valuable clinical information and show distinct patterns of personality pathology according to the AMPD classification system. We hope that this study sparks renewed interest in the PDs that have been lost over time, especially to understand their particular nuances as they present among older adults.
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