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Contents Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction: Personality Disorders and the Five-Factor Model of Personality . . Paul PART T xi 3 Costa, Jr., and Thomas A Widiger l: CONCEPTUAL BACKGROUND 2 Historical Antecedents of the Five-Factor ModeL . . . . . . . . . . . . . . . . . . . . . . . . . . 17 John M. Digman 3 Toward a Dimensional Model for the Personality Disorders . . . . . . . . . . . . . . . . . 23 Thomas A Widiger and Allen J Frances 4 A Five-Factor Perspective on Personality Disorder Research . . . . . . . . . . . . . . . . . 45 Timothy J Trull and Robert R. McCrae 5 6 Five-Factor Model Personality Disorder Research . . . . . . . . . . . . . . . . . . . . . . . . . . 59 Thomas A. Widiger and Paul T Costa, Jr. A Description of the DSM-IV Personality Disorders With the Five-Factor Model of Personality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Thomas A Widiger, Timothy J Trull, John F. Clarkin, Cynthia Sanderson, and Paul T Costa, Jr. PART II: MODELS OF PERSONALITY DIMENSIONS AND DISORDERS 7 Personality Structure and the Structure of Personality Disorders . . . . . . . . . . . . . 1 03 Jerry S. Wiggins and Aaron L. Pincus 8 Personality Disorder Symptomatology from the Five-Factor Model Perspective. . . 1 2 5 Lee Anna Clark, Lu Vorhies, and Joyce L. McEwen 9 Dimensions of Personality Disorder and the Five-Factor Model of Personality . . . 1 49 Marsha L. Schroeder, Janice A. Wormworth, and W John Livesley 1 0 Two Approaches to Identifying the Dimensions of Personality Disorder: Convergence on the Five-Factor Model . . . . . . . . . . . . . . . . . . . . .. . . . . . . .. . . .. 161 Lee Anna Clark and W John Livesley vii Contents 1 1 Big Five, Alternative Five, and Seven Personality Dimensions: Validity in Substance-Dependent Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ' 1 77 Samuel A. Ball 12 Constellations of Dependency Within the Five-Factor Model of Personality 203 Aaron L. Pincus 1 3 Personality Disorders and the Five-Factor Model of Personality i n Chinese Psychiatric Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1 5 Jian Yang, Xiaoyang Dai, Shuqiao Yao, Taisheng Cai, Beiling Gao, Robert R. McCrae, and Paul T Costa, Jr. 1 4 Tests of General and Specific Models of Personality Disorder Configuration . . . , 223 Brian P. O'Connor and Jamie A. Dyce PART III: PATIENT POPULATIONS AND CLINICAL CASES 1 5 Personality Trait Characteristics o f Opioid Abusers With and Without Comorbid Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , Robert K. Brooner, Chester W Schmidt, Jr., and Jeffrey H. Herbst 249 1 6 The NEO Personality Inventory and the Millon Clinical Multiaxial Inventory in the Forensic Evaluation of Sex Offenders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , Gregory K. Lehne 269 1 7 A Case of Borderline Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 283 Stephen Bruehl 1 8 Narcissism From the Perspective of the Five-Factor Model . . . . . . . . . . . . . . . . . . 293 Elizabeth M. Corbitt 1 9 Personality of the Psychopath . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 299 Timothy]. Harpur, Stephen D. Hart, and Robert D. Hare 20 Psychopathy From the Perspective of the Five-Factor Model of Personality . . . , 325 Donald R. Lynam PART IV: DIAGNOSIS AND TREATMENT USING THE FIVE-FACTOR-MODEL 2 1 22 Further Use of the NEO-PI-R Personality Dimensions in Differential Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , Cynthia Sanderson and John F. Clarkin Using Personality Measurements in Clinical Practice K. 23 . . . 3 5 1 . . . . . . . . . . . . . . . . . . . , 377 Roy MacKenzie Implications of Personality Individual Differences Science for Clinical Work on Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 391 Allan R. Harkness and John L. McNulty 24 Treatment of Personality Disorders From the Perspective of the Five-Factor Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405 . . , Michael H. Stone 2 5 A Proposal for Axis I I : Diagnosing Personality Disorders Using the Five-Factor Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , 43 1 Thomas A. Widiger, Paul viii T Costa, Jr., and Robert R. McCrae ConlenlS APPENDIXES A The DSM-III-R Personality Disorders and the Five-Factor Model . . . . . . . . . . . . . 457 459 the Five-Factor Model . . . . . . . . . . . . . . . 461 B Personality Disorders Proposed for DSM-IV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C The DSM-IV Personality Disorders and D Description of the Revised NEO Personality Inventory (NEO-PI-R) Facet Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463 E Diagnostic Criteria of DSM-IV-TR Axis I I Personality Disorders . . . . . . . . . . . . . 469 Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475 Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 485 About the Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493 ix Contributors Samuel A. Ball, Department of Psychiatry, Yale University School of Medicine, New Haven, CI Robert K. Brooner, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD Stephen Bruehl, Department of Behavioral Science, University of Kentucky College of Medicine, Lexington Taisheng Cai, Clinical Psychological Research Center, 2nd Affiliated Hospital, Hunan Medical University, Changsha, People's Republic of China Lee Anna Clark, John F. Clarkin, Elizabeth Paul T. M. Department of Psychology, University of Iowa, Iowa City Department of Psychiatry, Cornell University Medical Center, Ithaca, NY Corbitt, Costa, Jr., Wright State University School of Medicine, Dayton, OH National Institute of Aging, National Institutes of Health, Baltimore, MD Xiaoyang Dai, University, John M. Clinical Psychological Research Center, 2nd Affiliated Hospital, Hunan Medical Changsha, People's Republic of China Digman, Jamie A. Dyce, Oregon Research Institute, Eugene, OR Department of Psychology, Concordia University of Alberta, Edmonton, Alberta, Canada Allen J. Frances, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC Beiling Gao, Clinical Psychological Research Center, 2nd Affiliated Hospital, Hunan Medical University, Changsha, People's Republic of China Robert D. Hare, Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada Allan R. Harkness, Timothy J. Harpur, Department of Psychology, University of Iulsa, Iulsa, OK Department of Psychology, University of Illinois at Urbana-Champaign xi C o n t ribu t o rs Stephen D. Hart, Department oj Psychology, University oj British Columbia, Vancouver, British Columbia, Canada Jeffrey H. Herbst, Gerontology Research Center, National Institute on Aging, Baltimore, MD Gregory K. Lehne, Johns Hopkins University School oj Medicine, Baltimore, MD W John Livesley, Department oj Psychiatry, University oj British Columbia, Vancouver, British Columbia, Canada Donald R. Lynam, Department oj Psychology, University oj Kentucky, Lexington K. Roy MacKenzie, Department oj Psychiatry, University oj British Columbia, Vancouver, British Columbia, Canada Robert R. McCrae, Gerontology Research Center, National Institute on Aging, Baltimore, MD Joyce 1. McEwen, Department oj Psychology, Southern Methodist University, Dallas, TX John 1. McNulty, Department oj Psychology, Kent State University, Kent, OH Brian P. O'Connor, Department oj Psychology, Lakehead University, Thunder Bay, Ontario, Canada Aaron 1. Pincus, Department oj Psychology, Pennsylvania State University, University Park Cynthia Sanderson, Department oj Psychiatry, Cornell Medical College, Ithaca, NY Chester W Schmidt, Jr., Department oj Psychiatry and Behavioral Sciences, Johns Hopkins University School oj Medicine, Baltimore, MD Marsha 1. Schroeder, Department oj Psychiatry, University oj British Columbia, Vancouver, British Columbia, Canada Michael H. Stone, Timothy]. Trull, Department oj Psychiatry, Columbia University, New York, NY Department oj Psychology, University oj Missouri-Columbia Lu Vorhies, Department oj Psychology, Southern Methodist University, Dallas, TX Thomas A. Widiger, Department oj Psychology, University oj Kentucky, Lexington Jerry S. Wiggins, Department oj Psychology, University oj British Columbia, Vancouver, British Columbia, Canada Janice A. Wormworth, Department oj Psychiatry, University oj British Columbia, Vancouver, British Columbia, Canada Jian Yang, Gerontology Research Center, National Institute on Aging, Baltimore, MD Shuqiao Yao, Clinical Psychological Research Center, 2nd Affiliated Hospital, Hunan Medical University, Changsha, People's Republic oj China xii PERSONALITY DISORDERS AND THE FIVE-FACTOR MODEL OF PERSONALITY C H A P T E R 1 INTRODUCTION: PERSONALITY DISORDERS AND THE FIVE-FACTOR MODEL OF PERSONALITY Paul T Costa, jr., and Thomas A. Widiger In the last 20 years, interest in personality disorder research has shown substantial growth. Personality disorders were, no doubt, catapulted into a prominent position by the creation of a special axis, Axis II, in the third edition of the Diagnostic and Statistical Manual oj Mental Disorders (DSM-III; American Psychiatric Association, 1 980), a multiaxial classification of mental disorders system. Research interest in personality disorders can be documented by the more than 750 empirical studies that are abstracted in the American Psychological Association's PsycLIT database, covering the 5-year period from January 1987 to June 1992. Since the first edition of this book (Costa &: Widiger, 1 994), not only has there been a steady flow of empirical research dealing with personality disorders, but there have also been important theoretical and empirical developments, which are pointed out later in this introductory chapter to the second edition of Personality Disorders and the Five-Factor Model oj Personality. This large and growing literature on personality disorders should not obscure the fact that there are serious theoretical and methodological problems with the whole DSM personality disorder diagnostic enterprise. Officially, the diagnostic criteria sets of the fourth edition of the Diagnostic and Statistical Manual oj Mental Disorders (DSM-IV; American Psy­ chiatric Association, 1 994) Axis II are supposed to define or diagnose patients into mutually exclusive, categorical diagnostic entities. But as many reports document, the average number of personality disorder diagnoses is often greater than 4 (Skodol, Rosnick, Kellman, Oldham, &: Hyler, 1 988; Widiger, Trull, Hurt, Clarkin, &: Frances, 1 987). This comorbidity is a serious problem because it suggests redundancy, or a lack of divergent construct validity, for the current set of 1 0 diagnostic categories of DSM-IV-defined personality disorders. Other crucial problems concern the excessive comorbidity of Axis I and Axis II diagnoses (Docherty, Fiester, &: Shea, 1986; McGlashan, 1987; Widiger &: Hyler, 1 987) and the general lack of evidence supporting the con­ struct validity of many of the personality disorder categories. Problems with the official DSM-classification scheme for personality disorders continues to receive the attention of researchers, reviewers, and editors alike. In a Special Feature section of the Spring 2000 issue of the Journal of Personality Disorders, ed­ itor John livesley boldly stated that "problems with the DSM model are all too obvious" (p. 2). These "obvious problems" concern the limited clinical utility of the categories; the diagnostic constructs that clinicians find useful and the conditions they treat are not included in the system. Personality disorder not otherwise speCified is often the most frequent diagnosis, suggesting that the existing diagnostic categories are inadequate in their coverage. Furthermore, livesley (2000) lamented the limited construct validity of the Axis II system, noting that "almost all empirical investigations fail to support DSM diagnostic concepts" (p. 2). The fact that personality disorder has its own axis in the multiaxial DSM system encourages clinicians to consider the presence of a personality disorder for all patients-a unique position among all 3 Costa and Widiger other classes of mental disorders. But this prominent place makes the difficulties and problems identified above more acute. Oldham and Skodol (2000) noted that "there is growing debate about the continued appropriateness of maintaining the personality disorders on a separate axis in future editions of the diagnostic manual" (p. 1 7) . But moving the personality disorders back to Axis I (Lives ley, 1 998) would do more than just reduce their salience. As Millon and Frances ( 1 987) eloquently stated in the initial issue of the Journal of Personality Disorders, more relevant to this partitioning decision was the assertion that personality traits and disorders can serve as a dynamic substrate from which clinicians can better grasp the significance and meaning of their patients transient and florid disorders. In the DSM-III then, personality not only attained a nosological status of prominence in its own right but was assigned a contextual role that made it fundamental to the understanding and interpretation of other pathologies. (p. ii) How can the difficulties be constructively addressed and solved without seeming to abandon the i mportance of personality traits and disorders by collapsing the distinction between Axis I and m Many of the problems of DSM-IV might be re­ solved by using continuous dimensions instead of discrete categories. Dimensional alternatives have been frequently proposed, but until recently, there was no consensus on which personality dimensional model should be used. The five-factor model (FFM; Digman, 1 990; McCrae, 1 992) is a taxonomy of personality traits in terms of five broad dimensions (the "Big Five"): Neuroticism (N), Extraversion (E), Openness to Experience (0), Agreeableness (A), and Conscientiousness (C). An emergent and stillgrowing consensus on the FFM suggests that this is a comprehensive classification of personality dimensions that may be a conceptually useful framework for understanding personality disorders. By the early 1 990s, there had been considerable research confirming the FFM and demonstrating the value of studying individual differences in personal­ ity (e.g., Digman, 1990; McCrae, 1992; W iggins &. 4 Pincus, 1 989). But one important question was whether studies using the models and methods of normal personality research could shed light on psychopathological and psychiatric problems, particularly personality disorders. "Normal" and "abnormal" psychology have traditionally been considered separate fields, but this rigid dichotomy has never made sense to trait psychologists. Trait psychologists know that individual differences in most characteristics are continuously distributed. It therefore seems reasonable to hypothesize that different forms of psychopathology might be related to normal variations in basic personality dispositions. Considerable evidence in support of this hypoth­ esis is provided by results of analyses relating measures of personality to measures of psychopathology in normal and clinical samples. Several studies (e.g. , Costa &. McCrae, 1 990; Morey, 1986; Trull, 1 992) show general parallels between psychopathological and normal personality dimensions. In many of the chapters in this book, authors explore ways in which normal personality dimensions can illuminate clinical constructs. We hoped that the first edition of the book would help promote further research and facilitate integration of research on personality disorders with decades of research on normal personality structure and measurement. As many of the new chapters attest (e.g. , chapters 5 , 1 1 - 14, 20), there has indeed been a substantial amount of new and productive FFM personality disorder research. From the time this book was first contemplated, interest in and efforts to apply the FFM to a variety of disorders and populations has moved at a rapid pace. We originally limited our focus to diagnostic issues, but the scope has now been enlarged to include treatment implications. A major addition to the second edition is a specific 4-step process for making diagnoses using the FFM (see Widiger, Costa, &. McCrae, chapter 2 5 , this volume). We hope that readers will want to sample directly the fruits of the field, as it were. One aim of this book is to promote greater interest and research between the FFM and personality disorders. The book is intended to give its readers a glimpse of the application of the FFM for the diagnosis and treat­ ment of personality disorders. Introduction BACKGROUND OF THE FIVE-FACTOR MODEL The FFM is a hierarchical model of the structure of personality traits. Personality traits are often defined as endu ring "di mensions of individual differences in tendencies to show consistent patterns of thoughts, feelings, and actions" (McCrae & Costa, 1 990, p . 23). Traits reflect relatively enduring dispositions and are distinguished from states or moods, which are more transient. The FFM had i ts ori gins i n anal­ yses of trait-descriptive terms in the natural language. J ohn, Angleitner, and Ostendorf (1 988) gave an excellent account of this important line of research, and the contributions of Tupes and Christal ( 1 96 1 ) , Norman ( 1963) , Goldberg ( 1 982), and Borkenau and Ostendorf ( 1990) are deservedly recog­ nized by the field of FFM researchers. But most research and practice of personality assessment has been based on questionnaires. As Wiggins ( 1 968) wrote, the "Big Two" dimensions of N and E have been long associated with Hans Eysenck. Another two-dimensional model that deserves spe­ cial attention is the interpersonal circle model (i.e., the i nterpersonal circumplex) associated with Kiesler ( 1 983) , Leary ( 1957), and Wiggins ( 1982) . W ith the addition of Psychoticism (P), Eysenck's (Eysenck & Eysenck, 1975) P, E, N model is one of several com peting three-factor models. Tellegen ( 1 985) advanced an alternative three-factor model that substitutes Constraint for P It should be noted that in Tellegen's model both N and E are construed as the dimensions Negative Affectivity (NA) and Positive Affectivity, respectively. Watson, Clark, and Harkness ( 1 994) proffered a four-factor model based on th e literature relating personality disorders to the FF M, where the current conceptualizations of the 1 0 personality disorder categories largely ignore O. Many of the personality disorder di agnostic criteria fail to adequately represent O-related features, such as restricted emotional expression or intolerance of differing views. But even if the personality disorders were completely unrelated to 0, which is probably not the case, one would not "downsize" the person­ ality taxonomy to four dimensions because of its currently inadequate representation in the DSM. Un­ like Eysenck's or Tellegen's models, the Watson, Clark, and Harkness model i s not an alternative to the FFM; it is simply the FFM without the dimension of O. However, Cloninger ( 1 987) , a psychia­ trist, advanced a neuroadaptive-based personality model with originally three dimensions that is both similar to and different from Eysenck s and Tellegen's three-factor models. In Cloninger's model, N (or NA) is called Harm Avoidance; Novelty Seeking is largely low C; and the third dimension, Reward Dependence, has no simple and direct correspondence to any of the five established dimensions of the FFM because it loads on three or four of the five dimen­ sions (Costa & McCrae, 1 993; Herbst, Zonderman, McCrae, & Costa, 2000). Cloninger's original instru­ ment, the Tridimensional Personality Questionnaire, has been revised substantially by splitting off the 8item subscale, RD2, into a persistence temperament dimension to yield four temperaments and three socalled character dimensions have also been added, leading to a seven-dimensional model (Cloninger, Svrakric, & Przybeck, 1 993). An important chapter (14, this volume) by O'Connor and Dyce compares Cloninger's seven-dimensional model with alternative models to identify the optimal structural representa­ tion of personality disorders. Other dimensional models that contain more fac­ tors than the familiar five are seen in the 1 0 factors of Guilford, Zimmerman, and Guilford's (1 976) Guilford-Zimmerman Temperament Survey. Of course, Cattell's (Cattell, Eber, & Tatsuoka, 1 970) Sixteen Personality Factor Questionnaire represents Cattell's model of 16 primary personality traits. All of these systems are interesting, and many are valuable i n und erstanding personality disorders, es­ peCially the interpersonal circumplex. But mounting evidence suggests that all or nearly all of these mod­ els can be either subsumed by the F FM or interpreted in terms of it. Postulated dimensions beyond the Big Five, such as the Guilford-Zimmerman and Cattell models, for example, are generally regarded as tapping trait dimensions at a lower level in the hierarchy. The consensus currently is that at the secondorder level, the fi ve broad dimensions of N, E, 0, A, and C are the basic dimensions of personality. For the sake of this text, we adopt the position articulated by McCrae and J ohn ( 1 992) that it is fruitful 5

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