Running head: CLINICAL UTILITY OF A DIMENSIONAL TRAIT MODEL OF BPD

The Clinical Utility of a Dimensional, Trait-Centered Diagnostic Classification of Borderline Personality Disorder Colleen Coyne University of Minnesota- Twin Cities

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Abstract With the upcoming release of DSM-5, many personality disorder experts have posited the potential success of a dimensional classification system. Borderline Personality Disorder (BPD) is often at the forefront of discussion because it is the most prevalent personality disorder (Skodol et al., 2002) and individuals with BPD have a notoriously low quality of life (Masthoff et al., 2007). While many propositions for specific dimensional models have been introduced, few have examined the clinical utility of such models, which is a continuing concern of many psychologists and psychiatrists. Nonetheless, with consideration for the major aspects of clinical utility: ease of usage, case conceptualization, communication, stigmatization, and treatment planning, a dimensional, trait-system model of BPD would improve clinical utility on all counts as well as improving the validity of diagnoses. Though logic points to a dimensional taxonomy of BPD, these claims still need to be empirically justified.

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The Clinical Utility of a Dimensional, Trait-Centered Diagnostic Classification of Borderline Personality Disorder The history of the diagnostic classification of psychological disorders involves a long string of trial-and-error approaches to categorizing symptom patterns in hopes of a compilation of diagnoses that combines empiricism with clinical utility. This juxtaposition has been the source of much debate and numerous revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) culminating in its fourth and most recent edition, DSM-IV-TR (American Psychiatric Association [APA], 2000). The DSM-IV-TR is one of the most widely used classification systems in mental health around the world (Mezzich, 2002). Historically speaking, the DSM-IV-TR is the most valid and reliable DSM thus far, however, this is not saying much considering the inadequacies of the previous DSM’s (Widiger & Trull, 2007; Sprock 2003; Westen, DeFife, Bradley, & Hilsenroth, 2010; Skodol et al., 2002). Numerous research studies recapitulate the deficiencies of DSM-IV-TR both from clinical and research perspectives. In recognition of such issues and due to the upcoming revision, DSM-5, many psychologists and psychiatrists have steered research efforts toward more valid and empirically based classifications of diagnosis in nearly all accounts of the DSM-IV-TR, most notably with regard to personality disorders. Less prevalent are research projects aimed to assess the clinical utility of such proposals. However, many researchers have underlined the importance of clinical applications of any revision of diagnostic measures (First, Pincus, Levine, Williams, Ustun, & Peele, 2004; Verheul, 2005; First, 2005). They assert that any classification system of psychological disorders is only practical if appropriate for the clinical settings in which patients’ improvement depends largely upon the quality of their assessment (First et al., 2004; Verheul, 2005).

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Due to an apparent lack of empirical evidence supporting the current taxonomy of personality disorders in DSM-IV-TR, they have remained at the forefront of current discussions on revision (Bernstein, 2011). Researchers have questioned whether or not some of the personality disorders exist at all, while others are simply not optimally described by the current categorical model. Borderline Personality Disorder (BPD) is an example of the latter, as well as the most researched and most prevalent personality disorder (Skodol et al., 2002). The BPD construct has caused a lot of disagreement among researchers and clinicians. These disagreements revolve around not only the clinical utility of the classification of the disorder but also conceptual issues regarding its classification (Griffiths, 2011). Many researchers have proposed alternative approaches to the current categorical model of BPD (Westen et al., 2010; Krueger et al., 2011; Spitzer, First, Shedler, Westen, & Skodol, 2008), however few have investigated the clinical utility of such models (Verheul, 2005). Drawing on present research and keeping past classifications in mind, a dimensional, trait-centered model would improve overall clinical utility of the Borderline Personality Disorder diagnosis. While clinical utility has been defined in a variety of ways, it generally refers to the ability of the DSM to aid clinicians in carrying out diverse functions in practice (Verheul, 2005; First et al., 2004). Researchers have enumerated an abundance of factors that influence clinical utility, but four in particular seem to encompass much of the variability. Those factors are (1) ease of usage, (2) case conceptualization, (3) communication (between practitioners and between the client and practitioner), and (4) treatment planning (Widiger & Mullins-Sweatt, 2010; Samuel & Widiger, 2006; Verheul, 2005). With the possible exception of ease of usage, these considerations are undoubtedly predicted by the validity and reliability of the classifications themselves (Verheul, 2005). Additionally, especially with enduring diagnoses, there is growing

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consideration for the role of stigmatization (Perry, 2011; Rusch et al., 2006; Servais & Saunders, 2007). Though previous research has not factored stigma as an aspect of the clinical utility of diagnoses, recent research has underscored the impact of a permanent label on a patient’s progression (Kendell, 2002; Aviram, Brodsky, & Stanley, 2006; Servais & Saunders, 2007).With these factors in mind, a new diagnostic classification system should be designed to balance empiricism with clinical utility. Borderline Personality Disorder- An Overview In order to understand the classification of Borderline Personality Disorder, it is first important to understand the basic characteristics of the disorder. As it is currently classified in DSM-IV-TR, there are nine symptoms that encompass BPD. They are (1) affective instability, (2) intense anger, (3) impulsivity, (4) unstable relationships, (5) chronic emptiness, (6) stressrelated paranoid ideation, (7) identity disturbance, (8) avoidance of abandonment, and (9) self injury and/or suicide attempts (APA, 2000). In other definitions, BPD is marked by various combinations of traits like high neuroticism, low conscientiousness, low agreeableness, high distress, low emotional stability, impulsivity and antagonism (Eaton et al., 2011; Kendler, Myers, & Reichborn-Kjennerud, 2010; Gunderson et al., 2011). Most data show prevalence rates of BPD to be around 1-2% of the population (Skodol et al., 2002), however, newer research suggests it may be as high as 5-6% (Grant et al., 2008). BPD is the most common personality disorder in clinical settings with rates of around 10% of all psychiatric outpatients and 15-20% of all inpatients (Skodol et al., 2002). The causes of BPD are still unknown but it is believed to be the product of a combination of biological and psychosocial factors including interpersonal pathology and maladaptive personality traits (Livesly, 2008). It

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has also been linked to some factors of instability in early life including child abuse. Sanstone, Songer, and Miller (2005) reported higher rates of traumatic exposure and more types of trauma in childhood among BPD inpatients. The prognosis of BPD is often discouraging from a treatment standpoint. BPD is considered chronic, and many of the key features are relatively stable over time (Adebowale, 2010; Gunderson et al., 2011; McGlashan et al., 2005; Zanarini et al., 2007). Longitudinal studies show preservation of severe disturbance in social functioning over time (Gunderson et al., 2011) including issues with abandonment and dependency as well as stable elevated levels of anger and emptiness or loneliness (Zanarini et al., 2007). In a study examining quality of life, patients with any kind of personality disorder had a lower overall quality of life (Sansone et al., 2005). Furthermore, quality of life is negatively correlated with neuroticism and harm avoidancetwo areas in which people with BPD score highly (Masthoff, Trompenaars, Van Heck, Hodiamont, & De Vries, 2007; Kendler et al., 2010). The longevity and pervasiveness of BPD lead to severe functional impairment and high rates of utilization of particular mental health services related to the disorder (Sansone et al., 2005; Skodol et al., 2002). Most tragically, suicide rates of people with BPD are astoundingly high. Around 10% die by suicide, and an even higher percentage attempt suicide (Skodol et al., 2002). A new taxonomy for BPD with high clinical utility has potential to improve life satisfaction for people with BPD as well as lower the constant necessity of mental health services over time. Higher clinical utility of a diagnostic system means psychologists and psychiatrists can better understand their client’s individual needs and more easily lead the client to congruous treatment in a timely matter (Clark, 1993; Verheul, 2005)- addressing a common criticism of the current model.

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BPD diagnoses are also notorious for comorbid diagnoses (Grant et al., 2008; Skodol et al., 2002). This is often a primary argument for revision of the current BPD criteria. For patients with BPD, comorbidity rates for substance abuse (50%), mood disorders (50%), and anxiety disorders (60%) are high- with highest rates of alcohol dependence (18%), bipolar I (23%) and PTSD (32%) (Grant et al., 2008). These rates are not well-explained by the current categorical system that lists all disorders as conceptually distinct. Though comorbidity in its entirety is not completely understood, some theorists argue that comorbid disorders accrue from common factors (Grant et al., 2008). Furthermore, some personality disorder experts assert that cause is best understood through the lens of pathological personality (Eaton et al. 2011; Livesly, 2008). Currently, comorbid diagnoses are separate categorical constructs that create a laundry list of disorders for clinicians to sort through. The most pervasive symptoms are unclear and practitioners must rely on other means to determine a treatment plan or decide to treat one diagnosis as more important than the others (Gunderson, 2010). This calls for further tests, additional time, and for the client, more money. In a clinical setting, this can be a serious infringement upon the treatment of BPD. DSM-IV-TR Current Classification and the Necessity for Revision As has been noted, the current classification system of the DSM-IV-TR is categorically based. This follows precedent of the medical model of diagnosis in which a patient’s symptoms add up to a diagnosis which subsequently leads to a treatment that cures the disorder (First, 2005; Widiger & Mullins-Sweatt, 2010). Though this is applicable to physical ailments, psychological disorders do not lend themselves well to this model due to their eclectic and variable nature (Stone, 1997; Widiger & Trull, 2007). Guided by this model, Borderline Personality Disorder is one of 10 exclusive personality disorder constructs in DSM-IV-TR. A person qualifies for a

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diagnosis of BPD through presentation of any five out of nine criteria (APA, 2000). While there is no empirical support for either of these specific numbers, clinicians systematically use them to arrive at a diagnosis. Practitioners and researchers alike have noted that this description of BPD fails to sufficiently distinguish the pathology in clinical practice (Widiger & Trull, 2007). The DSM-IV-TR fails clinicians in nearly all aspects of clinical utility. Some researchers have proposed to maintain a categorical system but revise the current criteria of BPD (Gunderson et al., 2010). With the five listed facets of clinical utility in mind, a revised categorical model would improve next to nothing in DSM-5. A more radical reconstruction is necessary to address the flaws of the current classification system. Prototype Diagnosis A few researchers have proposed to use prototypes to diagnose Borderline Personality Disorder and other personality disorders (Westen, DeFife, Bradley, & Hilsenroth, 2010; Spitzer, First, Shedler, Westen & Skodol, 2008). From this approach, clinicians would be provided with a paragraph or two describing a person with BPD and decide how similar the patient is to the prototype (Westen et al., 2010). A few studies have shown high interrater reliability of practitioners with this method; however, only with symptom patterns that are prototypic (Westen et al., 2010). The majority of cases are not prototypic (Widiger, 1997), which challenges the inherent validity of the approach and also means that a prototypic diagnosis system would likely lead to extremely low levels of reliability. Recently, Spitzer et al. (2008) compared clinicians’ ratings of prototype models to several other kinds of diagnostic classification. Clinicians rated the prototype models to be most useful in assessing a single case of a patient who the clinician knew well. Most of the dimensions on

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which the clinicians preferred prototype diagnosis were related to the ease of usage. While this is a factor of clinical utility, it is not intended to be established at the loss of other factors (communication, case conceptualization, stigmatization and treatment planning). Additionally, these clinicians rated a patient whose case was already well conceptualized through other means; this is not representative of the usefulness of a prototypic model in the early stages of diagnosis, which are often most important (Spitzer et al., 2008). Prototype matching has been regarded by some as invalid, unreliable, and convenient (Widiger & Mullins-Sweatt, 2010). In terms of comorbidity, these models suggest that clinicians focus on BPD primarily (Gunderson, 2010). This is not a solution to the co-occurrence of disorders, but rather gives some symptoms priority over others and ignores the holistic symptom constellation of the individual (Gunderson, 2010). Furthermore, prototype matching calls for clinicians to diagnose patients based on their likeness to a paragraph description. Patients are categorized with labels such as, “some match,” versus, “moderate match,” to the prototype (Westen, DeFife, Bradley & Hilsenroth, 2010). These distinctions are ambiguous and call for subjectivity on behalf of the practitioner. The vagueness of classification and specificity of each individual prototype would likely lead to more problems in the clinical utility of BPD. Dimensional Diagnosis With the evident weaknesses of the categorical classification of Borderline Personality Disorder in the DSM-IV-TR, some researchers over the past couple of decades have taken a different approach to classification. A dimensional taxonomy of a disorder generally consists of a profile of a diagnosis in terms of a few relevant and empirically validated traits. This eliminates any sort of cutoff point between “diagnosis” and “no diagnosis” and instead each person is given

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a score on each of the dimensions. Rather than tallying behaviorally based symptoms, traits are intended to give the clinician information on the personality that may underlie such behaviors (Gunderson, 2010). Longitudinal studies show that the enduring aspects of BPD are often traitlike and reflect aspects of personality (Zanarini et al. 2007; McGlashan et al., 2005; Gunderson et al., 2011), while specific behaviors such as self-harm have been shown to be less enduring over time (Zanarini et al. 2007). Dimensional models are intended to reflect these stable features of BPD. This theory hinges on the idea that disorder itself is not a categorical construct but rather a unique and theoretically meaningful constellation of traits (Verheul, 2005). Some have claimed that the rigid cut off point of categorical classification is a quintessential aspect of clinical utility. However, many others note that very few decisions are made based upon a simple diagnosis of “yes” or “no” (Verheul, 2005; Clark, 1993). Rothschild, Cleland, Haslam and Zimmerman (2003) argue that examination of severity, harm, and need for treatment can guide clinical decision making better than placing a person on either side of a mythical fence. A dimensional model absent of any fictitious line drawn in the diagnostic sand is unlikely to hinder clinical decision making but rather provide practitioners with more detailed information with which to make judgments. Clark (1993) asserts that, Whereas it is indisputable that certain clinical decisions are categorical (e.g., whether or not to hospitalize, whether or not to prescribe medication), such dichotomous decisions in the treatment of personality disorders may be the exception rather than the rule. Rather, treatment decisions typically involve consideration of the appropriate degree of various therapist behaviors: where and how firmly to set limits, how much to permit dependence versus encourage independence, how and when to confront versus support in the face of anxieties,

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how a behavioral contract might be formulated, and so forth. For such decisions, diagnostic labels are of far less use than richer personality descriptions. (p. 101) Instead of diagnostic labels, practitioners utilize trait-based personality descriptions that give a more individualized, deeper conceptualization of the patient on several poles (Samuel & Widiger, 2006). Within the scheme of dimensional models, there are a plethora of specific proposals for BPD. By far the most popular and well-researched is the Five Factor Model (FFM; McCrae & Costa, 1990). This is distinct from other trait-based conceptualizations of BPD because it is proposed as a holistic view of personality disorders as abnormal protractions of normal traits (Clark, 2007). The FFM is composed of five polarized traits: openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism (McCrae & Costa, 1990). BPD is hypothesized to be represented by low conscientiousness, low agreeableness, and high neuroticism (Kendler et al., 2010). Though there is little doubt that the FFM describes related aspects of personality, some researchers argue that measures of normal personality cannot fully engulf personality disorders like BPD (Krueger et al., 2011). From this perspective, the FFM may reveal valid constructs related to BPD, but its five poles are of limited clinical use (Clark, 1993). Most other dimensional models are more specific to BPD and do not derive their roots from normal personality. With regard to clinical utility, it is important to differentiate whether or not scales of normal personality, as in the FFM, better assist practitioners in decision making; however, this comparison is not yet well documented. The end goal of many researchers is to eliminate constructs such as “Borderline Personality Disorder” all together and diagnose everyone on a series of poles relevant to all of personality

 

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pathology (Krueger et al., 2011). For DSM-5 there are a variety of reasons that this is impractical and unlikely. The foremost reason is that this too radical of a change to implement in one step. Both researchers and clinicians have become accustomed to conceptualizing disorders according to the current categorical model of the DSM-IV-TR. To eliminate all such categories is too drastic and unfamiliar to be implemented in the upcoming revision, despite its clinical and research potential. Additionally, the collection of traits that aims to encompass all aspects of pathological personality is still in the early stages of research. Though some have been identified and validated, it is possible that there are other relevant personality traits that have yet to be discovered. Rather than suggesting this complete overhaul of personality disorders in DSM-5, advocates of dimensional models propose utilizing the current DSM-IV-TR constructs such as BPD but replacing their current criteria with trait dimensions. This is viewed as an intermediate step to an ultimate objective of a completely dimensional classification of disorders (Verheul, 2005). Ease of Usage In terms of clinical utility, ease of usage is often cited as an advantage of the current categorical system of DSM-IV-TR (First et al., 2004; Spitzer et al., 2008). It should be noted that a classification system that is easy to use should never be pursued at the cost of validity or patient treatment, but remains a priority. Currently, the taxonomy is conceptually simple, but at the expense of scientific value (Verheul, 2005). Additionally, the DSM-IV-TR model is often rated easier to use as a result of clinicians’ familiarity with these criteria. Sprock (2003) found that clinicians had high ratings of confidence and usefulness of DSM-IV-TR diagnostic criteria of personality disorders even when interrater reliability was low. This suggests that clinicians prefer the familiar even when they are not performing well. Furthermore, clinicians had lower

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interrater reliability using DSM-IV-TR criteria for non-prototypic cases than prototypic cases. Because most cases are not prototypic (Verheul, 2005; Sprock, 2003), lower interrater reliability in diagnosing personality disorders is likely to be the norm. Without reliability there is no validity (Stanovich, 2010). Moreover, Westen (1997) demonstrated that practitioners often choose not to use the structured DSM-IV-TR methods to assess Axis II disorders because they judge them to be insufficient to arrive at a diagnosis. If the current system were in fact userfriendly, clinicians would be likely to follow the guidelines. Clinicians’ ratings of trait-system models is not a well-researched field, however, some have investigated the utility of the FFM. These studies have resulted in mixed clinician ratings of dimensional models like the FFM (Sprock, 2003; First, 2005; Samuel & Widiger, 2006). In terms of ease of usage, any dimensional trait model would function similarly to the FFM but with different dimensions, and therefore similar clinician ratings would be expected. Several studies have found that clinicians prefer the facility of the DSM-IV-TR (Rottman, Kim, Ahn, & Sanislow, 2011; Samuel & Widiger, 2006), but in all examinations, the heavy influence of clinicians’ familiarity with DSM-IV-TR criteria is all but impossible to eliminate because these practitioners are trained with and accustomed to the categorical model. Additionally, many studies comparing the clinical utility of dimensional models to DSMIV-TR criteria examine clinicians’ ability to use the dimensional information to identify DSMIV-TR constructs (Rottman et al., 2011). With use of a trait-centered model, clinicians’ objective will not be to discriminate the invalid BPD description of DSM-IV-TR, but to comprehend BPD in a new way. Even considering clinicians’ comfort with categorical criteria, Samuel and Widiger (2006) investigated clinicians’ ratings of clinical utility using a dimensional model (the FFM) to diagnose three case studies of personality disorder, one of whom demonstrated

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characteristics of BPD. In addition to four other areas of superiority, clinicians believed the dimensional model to be easier to use than the DSM-IV-TR. This shows promise for the ease of usage of a dimensional, trait-based model. The adoption of such a model for BPD would call for clinicians to become familiar with a novel set of criteria; however, this is not a sufficient reason to uphold invalid criteria that do not serve the patient as well. Once accustomed to a dimensional trait model of BPD, it is likely that clinicians would find it as easy to use as the DSM-IV-TR, but with added benefits in other areas of diagnosis. Case Conceptualization Case conceptualization refers to the ability of practitioners to comprehend the pathology of the client. With regard to the DSM-IV-TR criteria for BPD, a patient with five out of nine symptoms leads to one of 151 possible diagnosis combinations (Krueger & Eaton, 2010). This leads to a great amount of heterogeneity within the diagnosis (Widiger & Trull, 2007; Aggen et al., 2009). “Borderline Personality Disorder,” while addressed as a unified concept can therefore homogenize a diverse group of people. Patients classified as either “BPD present” or “BPD not present” leaves clinicians with limited information about the patient, especially considering the diversity of presentations of the diagnosis. Moreover, the current classification focuses on observable behavior (Rottman et al., 2011). This approach further limits the impression of a disorder through lack of consideration for other aspects (Skodol et al., 2002) such as stable underlying traits. Some studies have shown that the persistent aspects of BPD are trait-like while the observable behaviors are often periodic (McGlashan et al., 2005; Zanarini et al., 2007). With this in mind, the current DSM-IV-TR criteria for BPD are likely to give clinicians an oversimplified, incomplete conceptualization of the disorder with lack of awareness of the individuality of the client.

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Dimensional trait-system models excel in the amount of imperative information supplied to clinicians (Clark, 1993; Widiger & Mullins-Sweatt, 2010). With a trait-system for BPD, a clinician can appreciate a patient’s relative levels of relevant traits. This provides information regarding the areas that need the most attention as well as areas that are affected, but possibly at a lower threshold. Therefore clinicians approach BPD through a phenomenological lens (Mackenzie, 1987). Additionally, dimensional trait models supply practitioners with a richer, more specific description of the patient’s pathology (Stone, 1997). Rather than a simple diagnostic label, clinicians can contemplate the germane areas that need improvement as well as stronger aspects of the person being treated. Communication A clinician’s ability to accurately conceptualize BPD undoubtedly guides the quality of communication between practitioners and between the client and the practitioner. While the DSM-IV-TR criteria allow the clinician to readily report a client’s status as “BPD” or “not BPD,” this distinction does not relay much information to the patient nor to other clinicians. Often is the case that clients do not fit neatly into either category. In a study examining clinician adherence to DSM-IV-TR diagnostic criteria, Westen (1997) reported a significant number of patients who did not meet criteria for either an Axis I or an Axis II disorder who nonetheless displayed enduring pathological personality patterns. Communicating the case of one of these patients with the current categorical criteria would be all but impossible. Clinicians are in desperate need of an effective manner of communicating diagnoses that retain meaning about the patient.

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The descriptive, individual nature of dimensional, trait-based diagnoses allows for the client to feel more understood which may facilitate a deeper therapeutic alliance (Stone, 1997). BPD patients often have interpersonal issues that can be amplified in the therapeutic relationship (Andrews, Hunt, Pollock, & Thompson, 1991). A trait-centered dimensional approach is phenomenological (Stone, 1997), which can therefore capacitate more empathy on the part of the clinician. In a study comparing dimensional criteria to DSM-IV-TR criteria of personality disorders, clinicians rated the dimensional model to be superior in communication with patients despite overall preference for the categorical model (Samuel & Widiger, 2006). This shows that even among clinicians who prefer the familiar DSM-IV-TR criteria, they could not overlook the advantages a dimensional model offers in communication with patients. Furthermore, the detailed client profile of a trait-centered model improves communication between clinicians through more meaningful descriptions. Rather than a polarized diagnosis of “BPD” or “no BPD” to relay to other practitioners, clinicians can offer more specific, vivid information about the patient. Stigmatization Disappointingly, a permanent label may be the only influential information a DSM-IVTR BPD diagnosis communicates. From the client’s perspective, the diagnosis of a “personality disorder” in general is often received as a fundamental error of the client’s structure. This opposes the notion that it can be changed (Adebowale, 2010; Kendell, 2002). For BPD patients particularly, a pervasive brand can perpetuate a hopeless outlook and the internalization of such a label can interfere with therapeutic progress (Servais & Saunders, 2007). According to Castillo (2003), individuals with BPD describe the disorder with extreme negativity with words such as “stigmatizing” as well as “pejorative,” “marginalizing,” and “objectifying,” (as cited in Griffiths,

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2011). Though it is not definitive that these descriptions are derived from the label rather than the disorder itself, the negative words are attributed to the label of BPD. Beyond the patient, stigma of severe psychological diagnoses can arouse a negative reaction in the outside world as well as in the patient’s social network (Perry, 2011). Because BPD patients are often hypersensitive to rejection in interpersonal relationships (McGlashan et al., 2005; Gunderson, 2010), this stigma could have a detrimental effect. Even practitioners fall victim to the stigmatization of BPD patients. Clinically, BPD has become synonymous with “untreatable” (Kendell, 2002). This can lead practitioners to consciously or subconsciously put less effort into alleviating the symptoms of BPD patients in treatment. Servais and Saunders (2007) showed that compared to patients with other disorders, clinical psychologists rated borderline patients to be the least desirable and most dangerous. Clinicians may be more guarded and less invested in BPD patients as a result of the negative stigma. Because trait-systems lack a diagnostic label, patients are no longer pushed to accept a diagnosis as a deficiency of their being. They are instead told that they score at a certain point on a trait dimension- one on which all people have a score. Rusch et al. (2006) showed that women with BPD had elevated levels of self-stigma which correlate negatively to self-esteem and quality of life. The presence of a BPD diagnosis is received by the individual as the distinction between healthy and mentally ill. A trait-based taxonomy avoids the self-stigma of a BPD diagnosis that is rendered extreme and abnormal. Additionally, the use of trait language encourages clinicians to take a more neutral perspective of the client (Mackenzie, 1987) which has potential to lessen practitioners’ negative predispositions when working with the client.

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Treatment Planning Finally, treatment planning utilizing the DSM-IV-TR criteria for BPD is often criticized. A taxonomy of disorders is not clinically useful if it does not direct practitioners to a proper course of treatment for each patient (Sprock, 2003; First et al., 2004; Verheul, 2005). Some argue that the DSM-IV-TR does not guide treatment planning at all due to its lack of specificity (Verheul, 2005). Treatments for BPD are not monolithically effective or ineffective (Barnicot, Katsakou, Marougka, & Priebe, 2011). Patients may vary in their primary symptoms; therefore the focus of their treatment should not be the same (Stone, 1997). Additionally, with the high occurrence of comorbidity (Widiger & Trull, 2007; Skodol et al., 2002), practitioners often are unable to distinguish which symptoms are most pervasive. Therefore, clinicians must use means other than the DSM-IV-TR such as additional tests and interviews to create a treatment proposal. While this is one way to arrive at a treatment plan, it utilizes more time on behalf of both the client and the clinician which can be more costly. Also, because diagnoses that lead to appropriate treatments is one of the outlined goals of DSM-5 (Kendler, Kupfer, Narrow, Phillips & Fawcett, 2009), a revised system should aim to make additional tests supplementary in treatment planning rather than a primary source of information. A dimensional trait model of BPD provides the clinician with salient information to help predict a client’s progress in therapy (Mackenzie, 1987). Treatment plans are made according to specific symptoms rather than a whole diagnostic construct. Treatments that are most successful for people with a similar level of a trait can be made available to the clinician who can therefore customize treatments to the client. The clinician can be aware of issues that may arise such as treatment responsivity (Widiger, 1997), as well as choose techniques in accordance with the client’s strengths and weaknesses. Research reflecting the effectiveness of different kinds of

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therapy for people with BPD has emphasized the importance of customizing treatment plans to the specific symptom pattern of the individual (Goldman & Gregory, 2010; Soloff, 1998). From psychotherapy to psychopharmacological interventions, clinicians agree that BPD patients cannot be treated uniformly (Widiger, 1997; Soloff, 1998). A dimensional trait system would present practitioners with the appropriate information to proceed with a unique treatment plan for each client. Discussion The primary goal of the DSM-IV-TR is to aid clinical practice (APA, 2000). Unfortunately, categorical classification of Borderline Personality Disorder is not the most effective taxonomy to accomplish this task. For DSM-5, a dimensional, trait-centered model of BPD is likely to improve clinical utility in nearly all aspects including ease of usage, case conceptualization, communication, stigmatization, and treatment planning. Most importantly, it has the potential to improve the prognosis of the BPD. Nonetheless, the transition to a dimensional model alarms many psychologists and psychiatrists. One of the main concerns is the somewhat radical shift from the current system to a new one (First, 2005). However, this apprehension applies to any major change to the diagnostic system and is not specific to a dimensional classification. While it should not be overlooked that a new taxonomy would require training and accommodation on the part of practitioners and researchers, preference for the familiar should never be pursued at the expense of progress. Also, the transitional factors would undoubtedly be temporary. Furthermore, a shift to a dimensional model brings up questions about insurance because insurance companies usually base coverage on the presence of a diagnosis (Kersting, 2004).

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However, personality disorders like BPD are viewed by insurance companies as untreatable and are often not covered under the current system (Kersting, 2004). Many companies claim that evidence of effective treatments for personality disorders has not yet been convincing. This is a common frustration of practitioners who advocate the treatment of personality disorders. Rather than interfere with possible insurance coverage, it is possible that the lack of dichotomous diagnoses will force insurance companies to base coverage on other considerations. One limitation of the current body of research on the clinical utility of categorical versus dimensional models is clinicians’ familiarity with DSM-IV-TR. Their expertise on the utility of a diagnostic taxonomy cannot be severed from their bias for the customary. Additionally, many of the DSM-IV-TR symptoms of BPD are purposefully behavior-based to eliminate some level of subjectivity on behalf of the clinician (Rottman et al, 2011). Because personality traits are much more difficult to observe, it is possible that intense focus on traits could generate some issues with subjectivity. Nonetheless, standardization of diagnostic tests and procedures could prevent much of this. Moving forward, the main consideration for the adoption of a dimensional model of BPD should be scientific evidence. Much of the present research points to a dimensionally based classification of BPD, however, amongst the experts who champion a dimensional model of BPD, there is not much consensus regarding which particular model is best. Krueger et al. (2011) enumerated a few of the more popular dimensional models of personality pathology (see Figure 1), and their common facets. Though many of these models have seemingly similar traits to describe BPD, it is not entirely clear whether the deviations are simply matters of semantics or if the models are describing slightly different traits. There is not yet enough empirical evidence comparing the validity of various dimensional models of BPD, nor is there much research that

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contrasts the clinical utility of such models. Furthermore, with regard to existing research, the focus is often the clinical utility of dimensional models of personality disorders as a whole without much distinction for specific disorders such as BPD. Though it is not the hypothesis of most personality disorder experts, it is possible that BPD varies from other personality disorders in terms of clinical utility. Finally, due to the novelty of dimensional classifications of BPD, outcome research is virtually nonexistent. Although the proposed changes have potential to improve the prognosis of BPD, research has yet to validate this claim. With more investigation into these considerations, it is likely that a dimensional, trait-centered model of BPD in DSM-5 would improve clinical utility.

 

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Figure 1. From Krueger et al. (2011). This table depicts conceptualizations of pathological personality via popular trait models. Many of the models have similar facets, and as labeled, a few are in need of additional research.