Identity pathology and mentalization deficits: An attempt to support clinical theory with data.

An extensive theoretical literature links identity pathology with deficits in mentalization, which is the ability to understand the internal mental states of self and others. However, only a few investigations have attempted to bridge theory and data by empirically testing the relation between mentalization and identity pathology, and none have done so with mentalization measured using a laboratory task. The current study investigated the association between mentalization deficits and identity pathology in a large, nonclinical sample. Participants (N = 305) completed a self-report measure assessing identity pathology and a laboratory task assessing mentalization ability. Whereas the existing theoretical literature would argue for a robust association between identity pathology and mentalization impairment, our results revealed essentially no association between identity pathology and mentalization impairment. Moreover, we found essentially no association between identity pathology and any of a number of specific mentalization deficits in our sample. Our findings failed to provide empirical support for the clinical and theoretical literature linking mentalization and identity pathology. Given our adequate statistical power to detect even relatively small associations, we offer these findings to advance theoretical and methodological discussion in this important area. We discuss the implications of these null findings, particularly attuned to the possibility that a link between mentalization impairment and identity pathology may be more complicated than hypothesized. We also consider that these results might be related to methodological features of our study (e.g., self-report and laboratory measures; the range of mentalization impairment in our sample). (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Co-occurrence of borderline and schizotypal personality disorders: a scoping review.

BACKGROUND: The historical concept of borderline conditions refers to the pathology on the border between neurosis and psychosis. In DSM-III the conditions were divided into specific but also somewhat overlapping diagnostic criteria for Borderline Personality Disorder (BPD) and Schizotypal Personality Disorder (SPD). This phenomenological overlap, which results in co-occurrence of the two diagnoses, remains a clinical challenge to this day. METHODS: To address this issue we examined the co-occurrence of SPD and BPD according to the established DSM-IV/-5 diagnostic criteria. A literature search was conducted including studies that employed a structured interview with defined BPD and SPD criteria. RESULTS: Studies from 20 samples were included (i.e. 15 patients, 3 community and 2 forensic samples). For patients diagnosed primarily with BPD, 1-27% also met the criteria for SPD and for patients diagnosed primarily with SPD, 5 - 33% showed co-occurrence with BPD. In the forensic samples, co-occurrence for primary BPD was 10% and 67 - 82% for primary SPD. In the community samples, co-occurrence for primary BPD was 29% and 50% for primary SPD. The pattern of co-occurrence across community samples was particularly heterogeneous. CONCLUSION: The identified co-occurrences for BPD and SPD were considerably sample-dependent, and samples and measurements were generally too heterogeneous for a precise meta-analysis. Forensic and community samples generally showed higher co-occurrences, but these findings were characterized by potential methodological limitations.

An examination of the relationship between positive schizotypy and suicide risk using five distinct samples.

Individuals with schizophrenia are at increased risk for suicide. However, much less is known about suicide risk among individuals with schizotypic features. To address this gap in the literature, the current report examines the relationship between positive schizotypy and suicide risk using five distinct samples. Each of these five studies addresses unique, but complementary, questions regarding the relationship between positive schizotypy and suicide risk. Studies 1 and 2 investigate the cross-sectional relationship between perceptual aberrations and suicidal ideation. Study 3 examines the relationship between suicidal ideation and multiple positive schizotypic features (perceptual aberrations, magical thinking, paranoia, and referential thinking). Study 4 investigates the long-term relationship between perceptual aberrations and suicide risk through a 17-year follow-up. Finally, Study 5 examines the specificity of our findings using a psychiatric control group. Results across all five studies support a relationship between suicide risk and positive schizotypy. Specifically, perceptual aberrations were associated with suicide risk both cross-sectionally and longitudinally. Results also suggest that individuals with positive schizotypic features have rates of suicidal ideation that are comparable to those with high negative affect and are significantly greater than healthy controls. Taken together, these findings establish an empirical connection between positive schizotypy and suicide risk, thus expanding the purview of the suicide risk construct. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Contributions of Multimethod Personality Assessment in Indirect Evaluation.

Indirect assessment is a useful tool in forensic evaluation, especially in cases of threat assessment. To this end, we illustrated the ability to conceptualize a complicated case (i.e., Theodore John Kaczynski) using an indirect approach, with a particular emphasis upon dimensional frameworks of personality. Raters who were unrelated to Mr. Kaczynski's case and with expertise in relevant domains were asked to study information available in the public domain about Mr. Kaczynski and provide ratings using several assessment instruments. Our aim was not to provide a professional clinical opinion, but rather engage in scholarly discourse about the utility of instruments. Mr. Kaczynski was rated to demonstrate characteristics associated with lone actor terrorists. He showed an elevation on a measure of psychosis, and raters conceptualized trauma as an important aspect of his functioning. He demonstrated impairments in detachment and psychoticism (Criterion B of the AMPD) and interpersonal functioning (Criterion A of the AMPD). Clinical conceptualizations for Mr. Kaczynski emphasized schizotypal and paranoid personality disorders. This analysis of an infamous case about which considerable data are publicly available demonstrates the ease with which indirect and multimethod assessment can be applied and integrated in forensic assessment, using modern conceptualizations of personality pathology.

Proximal Processes, Temperament, and Pathological Narcissism: An Empirical Exploration from the Longitudinal Study of Personality Disorders.

INTRODUCTION: It is argued that all personality pathology represents the final emergent product of a complex interaction of underlying neurobehavioral systems, which are reflected in personality factors, in conjunction with environmental inputs. Neurobehavioral systems manifest themselves in dispositional temperament and personality processes. Environmental inputs include, obviously, interpersonal relationships (e.g., parenting, social, and mentoring relations) as well as other factors such as abuse, neglect, and/or environmental insults (e.g., economic hardship, deprivation). Narcissistic personality disorder (NPD) is hypothesized to reflect both dispositional and environmental inputs to its pathogenesis. Temperament and personality-based theorizing regarding NPD proposes high dispositional levels of anger and related temperament features that could shape early development and subsequent NPD. Many classic theorists (e.g., Freud, Kernberg, Kohut, Miller) have also proposed that profound parenting failures are implicated in the emergence of NPD, each suggesting some failure in proper engagement and responsivity with the developing child. Such a failure in parenting can be thought of as reflecting diminished proximal process engagement with the developing child. METHOD: Using data from the Longitudinal Study of Personality Disorders, the present study examines both proximal process and temperament factors in relation to clinically significant NPD features from a prospective perspective. RESULTS: Results suggest that both proximal process and temperament (notably anger) factors independently predict the level of NPD features over time. CONCLUSION: Both interpersonal relationships and temperament should be considered in models of etiology of NPD, it is not just one or the other.

Narcissistic Personality Disorder Studied the Long Way: Predicting Change in Narcissistic Pathology During College.

OBJECTIVE: Otto F. Kernberg pioneered the description, understanding, and treatment of pathological narcissism. Narcissism has emerged as a clinical construct of considerable interest in clinical psychology, psychiatry, and psychoanalysis and has often been featured in the literature on personality and social psychology. Considerable discussion in recent years has focused on whether levels of narcissism seen among young adults have been increasing. Nearly all of that discussion has been focused on changes in successive cohorts in normative (normal-range) expressions of narcissism. No direct prospective longitudinal study of the same individuals has assessed for pathological narcissism during college, the period that has been the specific focus of such lively debate. This study aimed to fill that gap in the literature. METHODS: This multiwave, longitudinal study explored pathological narcissism during college by enrolling first-year undergraduate students (N=250) from the Longitudinal Study of Personality Disorders and by using individual growth curve (IGC) analysis. Participants were assigned to either a possible personality disorder or no personality disorder group, according to results from the International Personality Disorder Examination. RESULTS: By the third wave of assessments, 16% of the sample received a probable or definite diagnosis of at least one axis II personality disorder. IGC analysis revealed that pathological narcissism declined across the first 4 years of college. Personality predictors of this pattern of change are also discussed. CONCLUSIONS: This study highlights the need for a fine-grained prospective study of the same participants over time to illuminate patterns of change in narcissism.

Does Self-Silencing Behavior Mediate the Relation Between Rejection Sensitivity and Sexual Violence Victimization?

Previous research reveals that rejection sensitivity is associated with both sexual violence victimization and self-silencing behavior, yet the association among these variables has not been examined. As the foundation for this study, we propose a theoretical model that integrates these constructs. Using mediational analyses with bootstrapping, the results from a sample of 241 heterosexual college women revealed that consistent with the proposed model, self-silencing mediated the link between rejection sensitivity and reports of unwanted sexual contact and rape. The implications of the findings for the prevention of victimization/revictimization and interventions with victimized women are discussed.

Identity and Personality Pathology: A Convergence Across the DSM-5 Personality Disorder Model and the Alternative Model for Personality Disorders.

Long-standing theory regarding personality pathology as well as the recently proposed DSM-5 Alternative Model for Personality Disorders (AMPD) posit that self/identity problems are a hallmark feature cutting across forms of personality pathology. With emergence of the AMPD, researchers have started to focus empirical investigations on identity pathology as a transdiagnostic factor across personality pathology. The current study investigated identity pathology across indicators of personality pathology from both the current categorical perspective (DSM-5 PD) and the dimensional perspective in the AMPD. Identity diffusion and low self-concept clarity were correlated with all PD feature scales and all maladaptive personality dimension scales. Regression analyses revealed most indicators of personality pathology were significant correlates of identity diffusion and low self-concept clarity. Borderline and Avoidant PD feature scales and Negative Affectivity and Detachment maladaptive personality dimension scales emerged as the strongest correlates of identity pathology. The role that identity pathology plays in personality pathology is highlighted.

Resilience and psychosocial functioning in schizotypy.

Understanding resilience has expanded our knowledge of certain risk and protective factors regarding the development of different forms of psychopathology. Particularly, a focus on resilience can be used to implement interventions and to target specific behaviors in hopes of mitigating the onset of a disorder or to alleviate symptoms. Less research on resilience has been done with individuals with psychosis, particularly schizophrenia spectrum disorders. Only 1 previous study has targeted individuals assessed for schizotypy. The current study examined associations between resilience and schizotypy features, assessed using self-report measures. Specifically, we compared 3 different resilience measures, social and occupational functioning, and 3 schizotypy measures in 3 different samples: undergraduate students (n = 878), adult community members (n = 120), and an Amazon Mechanical Turk adult community members (n = 329). Data analyses consisted of correlation and regression analyses, including tests for statistical moderation. Specifically, this study found negative associations between schizotypy and both psychosocial functioning and resilience. Although we predicted resilience would moderate the relations between schizotypy and psychosocial functioning, our analyses did not provide support for a moderating role for resilience. We discuss our findings in terms of understanding the relations among schizotypy, resilience, and psychosocial outcome constructs. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Reconceptualization of borderline conditions through the lens of the alternative model of personality disorders.

Borderline (BPD) and schizotypal personality disorder (SPD) were introduced in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III). However, the clinical differentiation of the 2 diagnoses (e.g., psychotic-like features) was challenging for diagnostic classification and clinical management. With the introduction of the alternative model for personality disorders (AMPD) in DSM-5 Section III, a dimensional approach was proposed, which potentially holds promise for better future differentiation between BPD and SPD. The present study sought to examine the psychopathology using the AMPD model. A total of 105 patients were interviewed, 25 were excluded according to exclusion criteria, and the final sample comprised 80 patients who fulfilled the DSM-5 criteria for BPD (n = 35), SPD (n = 25), and comorbid BPD + SPD (n = 20), respectively. All patients were administered The Structured Clinical Interview for DSM-5 alternative model for personality disorders Modules I and II. One-way analysis of variance tests with planned contrasts were used. Results showed that for AMPD Criterion A, the BPD + SPD group had the most severe impairment of personality functioning, except for Identity, where the SPD group showed the most severe impairment. For AMPD Criterion B, the domain of Detachment and the facet of Eccentricity from the Psychoticism domain were most prominent for the SPD group relative to the 2 other groups. The differentiating between BPD and SPD manifestations of cognitive/perceptual disturbances does not seem resolved by the Psychoticism domain, which covers broader aspects of psychopathology. Future research should further investigate the construct of Psychoticism, especially to differentiate nonpsychotic symptoms (e.g., dissociation) and address thought disorder. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Schizotypy 17 years on: Psychotic symptoms in midlife.

Determining the long-term psychosis-related outcomes of late-teen individuals characterized initially by a nonpsychotic, schizotypic feature (elevated perceptual aberrations) can further our understanding of the developmental pathways leading to schizophrenia, nonaffective psychotic conditions, and psychotic symptoms later in adulthood. Using the well-known laboratory/psychometric high-risk approach, the present study investigated the associations between nonpsychotic perceptual aberrations measured at age 18, in individuals with no prior history of psychosis, and clinical psychotic symptom outcomes 17 years later in midlife (middle 30s). Clinical assessments for hallucinations and delusions were completed for 191 adults (95% of the original sample) in the follow-up study. Elevated perceptual aberrations at age 18 predicted increased levels of hallucinations, delusions, and total psychotic symptoms in midlife as well as psychotic illness. The associations between baseline perceptual aberrations and later psychotic symptoms were not accounted for by general nonspecific psychopathology factors such as anxiety or depression present at age 18. Early detection of subtle, nonpsychotic forms of perceptual disturbance may aid in identifying individuals at increased risk for nonaffective psychosis outcomes in adulthood. Perceptual aberrations may constitute a useful endophenotype for genetic, neurobiological, and cognitive neuroscience investigations of schizophrenia liability. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Exploring Identity Disturbance and Psychotic Spectrum Symptoms as Predictors of Borderline and Schizotypal Personality Disorders.

INTRODUCTION: Borderline personality disorder (BPD) and schizotypal personality disorder (SPD) were introduced in DSM-III and retained in DSM-5 Section II. They often co-occur and some aspects of the clinical differentiation between the 2 diagnoses remain unclear (e.g., psychotic-like features and identity disturbance). METHODS: The present study explored if self-reported identity disturbance and psychosis proneness could discriminate between the BPD and SPD DSM-5 diagnoses. All patients were interviewed with the Schedules for Clinical Assessment in Neuropsychiatry and the Structured Clinical Interview for DSM-5 Personality Disorders, and administered the Inventory of Personality Organization, Self-Concept and Identity Measure, Schizotypal Personality Questionnaire, Perceptual Aberration Scale, and the Magical Ideation Scale. RESULTS: A total of 105 patients were initially assessed, 26 were excluded, and the final sample (N = 79) was composed of 34 BPD patients, 25 SPD patients, and 20 patients with co-occurring SPD and BPD. The BPD group (n = 34) was first compared with the pure SPD group (n = 25), and secondly with the total group of patients diagnosed with SPD (n = 25 + 20). Logistic regression analyses indicated that primitive defenses and disorganization best differentiated the BPD and the pure SPD group, while primitive defenses and interpersonal factor along with perceptual aberrations best differentiated the BPD and the total SPD group. CONCLUSION: Identity disturbance did not predict the diagnostic groups, but BPD patients were characterized by primitive defenses, which are closely related to identity disturbance. Pure SPD was characterized by oddness/eccentricity, while the lack of specificity for cognitive-perceptual symptoms suggests that the positive symptoms do not differentiate BPD from SPD.

Cognitive and Affective Theory of Mind in Positive Schizotypy: Relationship to Schizotypal Traits and Psychosocial Functioning.

Theory of mind (ToM) impairments are well documented in schizophrenia, although it remains unclear whether these deficits exist among individuals with schizotypy. The current study sought to shed light on mixed findings in schizotypy by differentiating between various aspects of ToM, (cognitive/affective ToM and overmentalization/undermentalization). A three-group design (positive schizotypy, negative affect, and healthy control) was used to assess ToM performance on the Movie for Assessment of Social Cognition. Results indicated that the positive schizotypy group made greater intent overmentalization errors than both control groups. The schizotypy and negative affect groups made greater emotion overmentalization errors relative to healthy controls. In addition, the authors explored the relationship between ToM, schizotypal traits, and psychosocial functioning. Results demonstrated a significant positive relationship between cognitive-perceptual schizotypal traits and intent overmentalization as well as a significant positive relationship between interpersonal traits and emotion overmentalization. Finally, intent and emotion overmentalization were both related to poorer psychosocial functioning.

The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia.

(Reprinted with permission from The American Journal of Psychiatry 2020; 177:868-872).

Personality Disturbances as Emergent Phenomena Reflective of Underlying Neurobehavioral Systems: Beyond Dimensional Measurement, Phenotypic Trait Descriptors, and Factor Analysis.

BACKGROUND AND OVERVIEW: The conceptualization of personality pathology, or personality disturbance, is now at a substantive crossroads. Some researchers (and clinicians) prefer a focus on the domains of personality pathology that are well-described and captured in traditional categorical diagnostic approaches that, in some instances, abut normal personality constructs. Other workers argue to move the study of personality disorder (PD) closer to personality science seeking continuous connections between PD and established dimensions of healthy-range, normal personality. Most of the latter efforts revolve around correlational and factor analytic study of phenotypic expressions of PD features and normal personality dimensions. It is notable, however, that both visions of the PD/personality interface are essentially unlinked to an understanding of shared neurobiological underpinnings (i.e., neurotransmitter-influenced neurobehavioral systems) of both personality disturbance and normal personality1. Here, we present a nontechnical, conceptual overview of our approach to this problem, advancing a neurobehavioral approach that seeks to anchor both normal personality and personality disturbance within a matrix of brain-based neurobiological systems, incorporating genetic, epigenetic, and environmental inputs. In this brief paper, we seek only to provide a necessarily cursory introduction to how we conceptualize this area and illustrate, in broad outline, our effort to characterize both personality and personality disturbance anchored in neurobehavioral systems. Our approach, which we began developing in the middle 1990s, can be juxtaposed with the more recently proposed DSM-5 Alternative Model of Personality Disorders as well as the well-established five-factor approach to PD.

Armand W. Loranger (1930-2019).

Memorializes Armand W. Loranger (1930-2019). A preeminent authority on personality pathology, Loranger was known internationally as a scholar who transformed the diagnosis of personality disorders through the development of a systematic structured interview approach, moving the field away from decades of less reliable methods. Loranger's research reflected his broad range of clinical interests and included numerous publications on diagnosis and classification, psychopharmacology, genetics, and epidemiology, involving schizophrenia, dementia, mood disorders, and the personality disorders. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Self-referential hypermentalization in schizotypy.

There is substantial evidence that patients with schizophrenia have deficits in their ability to make inferences about others' mental states. However, the findings in schizotypy are mixed. In an effort to elucidate these mixed findings, the current study evaluated self-referential theory of mind (ToM) in positive schizotypy, or the ability to make inferences about others' mental states as they apply to the self. In addition, we differentiated between 2 ToM error types: hypermentalization (excessive mental state attribution) and undermentalization (overly simplistic or lack of mental state attribution). We used a 3-group design (positive schizotypy, negative affect psychiatric control group, and healthy control group) to assess ToM performance on the hinting task (Corcoran, Mercer, & Frith, 1995) and a newly developed self-referential version of the hinting task that differentiates between ToM error types. Results demonstrated that the schizotypy group made significantly greater self-referential hypermentalization errors than both control groups. Self-referential hypermentalization was significantly related to referential thinking, aberrant salience, interpersonal schizotypic traits, and functional outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).