Personality Disorders: Theory, Research, and Treatment 2012, Vol. 3, No.

2, 176 184

2011 American Psychological Association 1949-2715/11/$12.00 DOI: 10.1037/a0024030

BRIEF REPORT

The Clinical Utility of the Five Factor Model of Personality Disorder

Natalie G. Glover, Cristina Crego, and Thomas A. Widiger
University of Kentucky Previous research has suggested that clinicians would be unable to recover DSM IVTR personality disorder diagnoses on the basis of information provided by the Five Factor Model (FFM) of personality disorder. However, the prior research did not provide all of the information that would be available to a clinician when determining a personality disorder diagnosis; more specically, the maladaptive personality traits associated with each FFM trait elevation. In the current study, 201 clinicians provided DSMIVTR personality disorder diagnoses on the basis of either the DSMIVTR criterion sets or the respective FFM maladaptive personality traits. Accuracy using the FFM maladaptive traits was much improved over the prior research and comparable to the accuracy obtained with the criterion sets. The clinicians also rated the FFM and the DSMIVTR as comparably useful for obtaining a DSMIVTR personality disorder diagnosis. Keywords: Five Factor Model, clinical utility, personality disorder, personality traits, dimensional

The personality disorders section of the American Psychiatric Associations (APA) Diagnostic and Statistical Manual of Mental Disorders (DSMIVTR; APA, 2000) is currently being revised. One of the fundamental issues being addressed by the DSM-5 Personality and Personality Disorders Work Group (hereafter referred to as the Work Group) is whether to shift from a categorical model of classication to a dimensional model. There is considerable empirical support for such a shift (Clark, 2007; Livesley, 2003; Widiger, Simonsen, Krueger, Livesley, & Verheul, 2005). However, one of the primary arguments against any such revision has been clinical utility (First, 2005). The relative clinical utility of the DSMIVTR diagnostic categories and the Five Factor Model (FFM) of personality disorder is an active line of investigation, with studies directly comparing the

This article was published Online First July 4, 2011. Natalie G. Glover, Cristina Crego, and Thomas A. Widiger, Department of Clinical Psychology, University of Kentucky. Correspondence concerning this article should be addressed to Natalie Glover, University of Kentucky, Department of Psychology, Kastle Hall, 11E Lexington, KY 40506-0044. E-mail: Natalie.glover@uky.edu 176

clinical utility of the FFM with the DSMIVTR by Lowe and Widiger (2009), Mullins-Sweatt and Widiger (in press); Samuel and Widiger (2006); Spitzer, First, Shedler, Westen, and Skodol (2008), and Sprock (2003). A study by Rottman, Ahn, Sanislow, and Kim (2009), however, has been uniquely inuential. Rottman and colleagues provided clinicians with the task of identifying DSMIVTR personality disorder diagnoses, either on the basis of an FFM prole for a prototypic case (obtained from Lynam & Widiger, 2001) or on the basis of the complete set of DSMIVTR diagnostic criteria for the respective personality disorder (participants were instructed not to consult DSMIVTR). Rottman and colleagues reported the accuracy with which the DSM IVTR diagnoses were obtained and the participants ratings of clinical utility for each method of obtaining a DSMIVTR personality disorder diagnosis. They found that it was considerably easier for clinicians to identify the presence (for instance) of antisocial personality disorder on the basis of the DSMIVTR diagnostic criteria for antisocial personality disorder than on the basis of the FFM prole of a prototypic case. Clinicians correctly identied the respective DSMIVTR personality disorder 82% of the time when provided within its respective diagnostic

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criteria, but only 47% of the time when provided with the FFM prole. It then naturally followed that these clinicians considered the DSMIVTR to be considerably more useful than the FFM for patient description. The ndings of Rottman and colleagues (2009) were considered to be signicant enough to be provided the unique distinction of being accompanied in its publication by an editorial coauthored by the Chair and a member of the DSM-5 Work Group. Skodol and Bender (2009) reiterated in this editorial the nding that clinicians made fewer correct diagnoses of personality disorders and more incorrect diagnoses when giving ratings of patients on a list of the 30 facet traits of the FFM (p. 389). They asked rhetorically, if clinicians are unable to recognize common clinical syndromes using a new trait-based system, how can [the FFM] be more clinically useful? (p. 389). Skodol (2010) subsequently reafrmed the particular importance of the Rottman et al. study on the DSM-5 website, stating that these ndings indicate that personality traits in the absence of clinical context are too ambiguous for clinicians to interpret; although it may be possible to describe personality disorders in terms of the FFM, mentally translating personality traits back into syndromes or disorders is cognitively challenging (p. 389). However, the Rottman et al. (2009) study included a fundamental limitation in testing the ability of the FFM to recover the DSMIVTR personality disorders. Rottman et al. stated that the methods used in our studies are not based on the assumption that the FFM, if adopted, would be used without . . . diagnostic information (p. 432). However, this was precisely the methodology of the study as no FFM diagnostic information was in fact provided, whereas the full set of diagnostic criteria were provided for the DSMIVTR personality disorders. The FFM of personality disorder consists of four steps (Widiger, Costa, & McCrae, 2002; Widiger & Lowe, 2007). The rst step is the obtainment of an FFM prole (which the clinicians in Rottman et al. were provided); the second step is the identication of the problems in living that are associated with each respective scale elevation (which the clinicians in Rottman et al. were not provided). A personality disorder diagnosis would not and cannot be provided in the absence of knowing what maladaptive personality traits are present.

The FFM prole that was provided to the clinicians by Rottman and colleagues was in terms of the Five Factor Model Rating Form (FFMRF; Mullins-Sweatt, Jamerson, Samuel, Olson, & Widiger, 2006). The FFMRF, however, is conned largely to a description of normal personality traits. Each of the 30 facets of the FFM is labeled within the FFMRF in terms of the normal traits (e.g., altruism, trust, straightforwardness, order & dutifulness). Abnormal variants for some (albeit not all) of these traits are at times provided for illustrative purposes but, most importantly, there is no indication on the FFMRF whether a high score is in reference to the normal or abnormal variants (even if the latter is provided). This is in distinct contrast to the Five Factor Form (FFF; Mullins-Sweatt, Glover, Derenko, Miller, & Widiger, 2010) and the Five Factor Model Score Sheet (FFMSS; Few et al., in press), the latter administered in the clinical utility study of Spitzer et al. (2008). On the FFF and the FFMSS, the highest score on each trait is explicitly and distinctly referring only to the maladaptive variant of each respective trait. In sum, the facet trait labels on the FFMRF provided to the clinicians by Rottman and colleagues to describe each personality disorder referred to normal personality traits. One cannot tell from the FFMRF whether a person with a high score has the abnormal variant of these respective traits and, in many cases, what that abnormal trait would even be. It would naturally be very difcult for persons to identify which personality disorder is likely to be present on the basis of just an FFM prole conned largely to the normal variants of each FFM trait (i.e., step 1 of the four-step procedure), lacking sufcient information concerning the maladaptive variants of the FFM trait elevations (i.e., step 2). For example, knowing that someone is trusting (normal variant of FFM trait) doesnt necessarily mean that the person is gullible (abnormal variant). The clinicians in Rottman et al. were told (for instance) that the person (with obsessive compulsive personality disorder) was high in the conscientiousness facets of competence, order, dutifulness, achievement-striving, self-discipline and deliberation, but were not told if this necessarily indicated the presence of the maladaptive variants of perfectionism, workaholism, rigidity, or rumination. The clinicians were told that the person (with dependent personality disorder) was high in the agreeableness facets of trust, compliance, and modesty, but were not told if this nec-

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essarily implied the presence of the maladaptive variants of gullibility, submission, and selfeffacement. Being able to identify which DSM IVTR categorical diagnosis is present would require knowing that the maladaptive variants that are associated with that specic personality disorder are in fact present. If the FFM of personality disorder replaced the DSMIVTR categorical diagnoses these maladaptive variants would clearly be provided within the diagnostic manual, as they are in fact provided within the dimensional model that has been proposed for DSM-5 (Clark & Krueger, 2010). The dimensional model proposed for DSM-5 includes 37 maladaptive traits organized with respect to six broad domains (Clark & Krueger, 2010), one usage of which is to serve as diagnostic criteria for the personality types, such as dependent or borderline (Skodol, 2010). These maladaptive personality traits parallel closely the traits included within step two of the FFM of personality disorder, and would be used in precisely the same manner. In sum, it is these maladaptive traits that are used within the FFM of personality disorder to render personality disorder diagnoses (Mullins-Sweatt & Widiger, 2009; Widiger et al., 2002), not the normal variants that were used by the clinicians in the study by Rottman and colleagues (2009). The purpose of the current study was to replicate and extend the ndings of Rottman and colleagues (2009), this time providing the maladaptive variants of each facet that is elevated within the FFM prole of a prototype case of each respective personality disorder (Lynam & Widiger, 2001). Clinicians were asked to identify which DSMIVTR personality disorder is suggested on the basis of either the respective DSMIVTR diagnostic criteria, or the FFM maladaptive personality traits (listed within the FFF). The clinicians were subsequently asked to indicate how useful they considered the DSM IVTR diagnostic criteria and the FFM descriptors to be for various clinical tasks. Method Participants and Procedure Clinicians were randomly selected from the directory of the American Psychological Associations Division 42, (independent practice). Each clinician was provided with a description

of the study within the cover letter, the methodology of which was approved by the University of Kentucky Institutional Review Board. Clinicians were further informed that participants who provided their name and address on the return envelope (which was kept separate from their completed questionnaires upon receipt of the return envelope) would be entered into a lottery (two of these participants received $250 via the lottery). If they agreed to participate they were asked to complete a demographic form, a DSMIVTR rating form, and a clinical utility form. Each clinician was provided with a self-addressed, stamped envelope in which to return the material. Each clinician was asked to provide the DSMIVTR diagnosis for ve DSMIVTR disorders described in terms of the FFM (presented on either the front or back of the form) and for ve DSMIVTR disorders described in terms of the DSMIVTR diagnostic criteria (presented on either the front of back of the form). For each participant, the ve personality disorders described in terms of the FFM were not the same as the ve described in terms of the DSMIVTR in order to avoid a DSMIVTR criterion set helping to cue recognition of an FFM description (and vice versa). As a result, each clinician, therefore, provided results for all 10 DSMIVTR personality disorders, half described in terms of the FFM, the other half described in terms of the DSMIVTR diagnostic criteria. Approximately half of the clinicians received the DSMIVTR diagnostic criteria for the antisocial, dependent, schizoid, schizotypal, and narcissistic personality disorders (either on the front page or the back page of the form) along with the FFM descriptions for the obsessive compulsive, avoidant, histrionic, paranoid, and borderline personality disorders (either on the front page or the back page of the form). The other half received the DSMIVTR descriptions for the obsessive compulsive, avoidant, histrionic, paranoid, and borderline personality disorders, along with the FFM descriptions for the antisocial, dependent, schizoid, schizotypal, and narcissistic personality disorders. Materials Demographic questionnaire. Each clinician was rst asked to complete a brief (one

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page) questionnaire that gathered basic demographic information as well as information about training, experience, direct clinical contact hours, and theoretical orientation. In addition, the clinicians were each asked to rate their familiarity with the DSMIVTR on a 15 Likert scale where 1 Very Unfamiliar, 2 Moderately Unfamiliar, 3 Neutral, 4 Moderately Familiar, and 5 Very Familiar. Clinicians were similarly asked to rate their familiarity with the Five Factor Model on the same scale. In addition, clinicians were asked to rate their opinion of the DSMIVTR on a 15 Likert scale where 1 Very Unfavorable, 2 Moderately Unfavorable, 3 Neutral, 4 Moderately Favorable, and 5 Very Favorable. Finally, clinicians were asked whether they believe the current DSMIVTR system should be replaced by a dimensional classication of personality disorder, with the available options of 1 Denitely no, 2 Probably no, 3 Unsure, 4 Probably yes, and 5 Denitely yes. DSMIVTR rating form. The primary task of the clinician was to identify which DSMIVTR personality disorder was suggested (by either the DSMIVTR diagnostic criteria or the FFM maladaptive personality traits). On the left side of the page was (if the DSMIVTR criteria were being presented rst) a summary of the DSMIVTR criterion sets for ve personality disorders. For example, in the case of obsessive compulsive personality disorder the diagnostic criteria were presented as, Preoccupied with details, rules, lists, order, organization, or schedules; Perfectionism; Excessive devotion to work and productivity; Overconscientious, scrupulous, and inexible; Unable to discard worn-out or worthless objects; Reluctant to delegate tasks or to work with others; Adopts a miserly spending style; Rigidity and stubbornness (i.e., consistent with Rottman et al., 2009, only the primary feature of each criterion was provided). On the right side of the page were the 10 DSMIVTR personality disorders. They were instructed to circle which of the 10 personality disorders was associated with the respective criterion set. When they completed the task using the ve DSMIVTR diagnostic criterion sets, they were instructed to turn the page over and complete the same task (but now for ve different personality disorders) using the FFM maladaptive

personality traits. The maladaptive traits were taken, in each instance, from the FFF (MullinsSweatt et al., 2010), which is an abbreviated version of the FFMSS (Few et al., in press), that was administered in the clinical utility study of Spitzer et al. (2008). For example, for obsessive compulsive personality disorder these traits were, Perfectionistic; Preoccupied with organization; Workaholic; Rigidly principled; Critical; Contrary; Dogmatic; Dominant. As noted earlier, some clinicians rst completed the task with the FFM traits, whereas others rst completed the task with the DSMIVTR diagnostic criteria. Clinical utility questionnaire. After attempting to identify the personality disorders based on DSMIVTR diagnostic criteria and the maladaptive FFM personality traits, clinicians were then asked to rate each of the two models on six aspects of clinical utility, including: (a) How easy do you feel it was to apply the system, (b) How useful do you feel the system would be for communicating information about the individual with other mental health professionals, (c) How useful do you feel this system would be for communicating information about the individual to him or herself, (d) How useful is this system for comprehensively describing all the important personality problems the individual has, (e) How useful would this system be for helping you to formulate an effective intervention, and (f) How useful was this system for describing an individuals global personality. These ratings were provided on a 15 Likert scale, where 1 not at all useful, 2 slightly useful, 3 moderately useful, 4 very useful, and 5 extremely useful. Results Of the 942 clinicians surveyed, 228 packets were returned unopened, so approximately 714 persons received the invitation to participate. A total of 203 packets were returned completed, resulting in a 28% response rate, comparing favorably to prior studies. Of the 203 returned packets, two were incomplete and were, therefore, eliminated. The results for the 201 completed questionnaires are provided. Fifty-four percent of the sample was male, 46% female. Ninety-seven percent of the sample identied themselves as Caucasian, the remainder were African American, Asian, Hispanic, or Na-

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tive American (albeit only one person in each case). Eighty-ve percent indicated that that they had a Ph.D., 9% a Psy.D., and 6% an Ed.D. The sample was, on average, relatively older than the typical member of Division 42, with median number of 30 years since receiving the doctoral degree. Seventy-one percent identied themselves as a clinical psychologist, 20% a counseling psychologist, and the rest specialized in such elds as forensic psychology or neuropsychology. Twentynine percent of the participants indicated that 100% of their time is spent in providing clinical service, with more than 80% of the participants spending at least half of their time providing direct clinical service. The single most common theoretical orientation was psychodynamic (11%), albeit participants were allowed to pick more than one theoretical orientation. Eighty-percent of the participants picked more than one theoretical orientation, with the most common combinations being cognitive and behavioral (10%) and psychodynamic, cognitive, and interpersonal (6%). Table 1 provides the percent correct for each of the DSMIVTR personality disorders using either the DSMIVTR diagnostic criterion sets or the FFM maladaptive traits associated with each respective personality disorder. Overall, there was little difference between using the DSMIVTR diagnostic criterion sets versus the FFM maladaptive traits. The clinicians correctly identied 91% of the disorders using the criterion sets, with 100% correct for the paranoid,

Table 1 Percent of Accurate Diagnoses for DSM-IV-TR Criterion Sets and FFM Maladaptive Traits
Personality disorder Paranoid Schizoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-Compulsive Total Percent Correct DSM-IV-TR 100 79.5 74.4 99.1 100 78.8 98.3 84.8 98.3 100 91 FFM 85.6 84.8 87.5 89.9 88.9 82.4 92.5 83.1 96.3 97.5 89 Chi square (df 1) 12.62 .90 5.22 7.33 9.51 .40 2.741 .11 .191 .701 3.30

Note. DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders, 4th edition; FFM Five factor model. 1 Yates correction due to expected values less than 5. p .05. p .01.

borderline, and obsessive compulsive criterion sets (99% and 98% correct for the antisocial and dependent, respectively), but only 74% correct for the schizotypal, 79% correct for the histrionic, and 80% correct for the schizoid. The clinicians correctly identied 89% of the disorders using the FFM maladaptive personality traits, with the best success for obsessive compulsive (98%) and dependent (96%) and the least for histrionic and avoidant (83% in each case). There was no statistically signicant difference in the overall hit rate. The clinicians were more often correct using the DSMIVTR criterion sets for the paranoid, antisocial, and borderline personality disorders, and more often correct using the FFM maladaptive traits for the schizotypal. There was no signicant difference for the other six personality disorders. Table 2 provides the mean utility ratings for the DSMIVTR criterion sets and the FFM maladaptive trait terms. It is apparent from Table 2 that there was little difference between the FFM maladaptive traits and the DSMIVTR criterion sets with respect to their perceived clinical utility. There was no signicant difference with respect to communication with other professionals, description of all problems, formulation of intervention strategy, or description of global personality. The DSMIVTR criterion sets were considered to be easier to use and the FFM was considered to be better for communication with the patient. Table 3 provides the participants average level of familiarity with the DSMIVTR and the FFM, how favorable they were toward the DSMIVTR, and their degree of support for a shift to dimensional model. Also included in Table 3 is the correlation of this information with the sum of their clinical utility ratings across all six utility questions. It is evident from Table 3 that the clinicians were, on average, moderately familiar with the DSMIVTR and moderately unfamiliar with the FFM, a difference that was statistically signicant (t 20.1, df 200, p .001). Familiarity with the DSM IVTR and the FFM however, was only weakly related to the ratings of clinical utility. The participants were, on average neutral with respect to how favorable they felt toward the DSMIVTR and whether they supported a shift to a dimensional model. Favorability toward the DSMIVTR was correlated with their rating of the utility of the DSMIVTR but not the FFM.

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Table 2 Clinical Utility Ratings for DSM-IV-TR Criterion Sets and FFM Maladaptive Traits
Question Ease in application Communication with other professionals Communication with Patient Description of all problems Formulation of intervention strategy Description of global personality DSM-IV-TR 3.89 (.82) 3.69 (.76) 3.10 (.93) 3.26 (.90) 3.11 (.88) 3.27 (.86) FFM 3.62 (.88) 3.59 (.84) 3.40 (.98) 3.32 (.90) 3.23 (.92) 3.37 (.89) t 3.15 1.11 3.10 .65 1.51 1.18 df 189 187 187 187 187 188

Note. Standard deviations appear in parentheses below means. DSM-IV-TR Mental Disorders, 4th edition; FFM Five factor model. p .01.

Diagnostic and Statistical Manual of

Support for a shift to a dimensional model was signicantly but not strongly correlated with their DSMIVTR and FFM utility ratings. Discussion One might question whether clinical utility should play a substantial role in determining the content and structure of DSM-5. Priority should probably be given to validity over clinical utility (Mullins-Sweatt & Widiger, 2009). Nevertheless, the authors of DSM-5 have indicated on the DSM-5 website (Skodol, 2010) and in an editorial published in the American Journal of Psychiatry (Skodol & Bender, 2009) that one of their priorities is clinical utility and have identied in particular the clinical utility study by Rottman and colleagues (2009) as a signicant basis for their rejection of the FFM. Rottman et al. (2009) provided clinicians with previously published FFM proles for each of the DSMIVTR personality disorders (Lynam & Widiger, 2001) and asked them to identify which DSMIVTR personality disorder was suggested by each respective prole. They reported that it was considerably easier for clinicians to identify the DSMIVTR personal-

ity disorder on the basis of the DSMIVTR diagnostic criterion sets than the FFM proles. They concluded that these results suggest that the FFM descriptors are ambiguous to clinicians without additional contextual information, and that the FFM may be less able to convey important clinical details than the DSMIV (Rottman et al., 2009, p. 6). A limitation of the Rottman et al. study, however, is that the contextual information necessary for a personality disorder diagnosis is available but was not provided to the clinicians. An FFM of personality disorder diagnosis would not be based simply on an FFM prole that is conned largely to the presence of the normal personality traits. As indicated by Widiger et al. (2002) the FFM prole is only the rst step toward achieving a personality disorder diagnosis. The second step is to identify whether any maladaptive variants of a respective FFM trait elevation are present (Widiger & Trull, 2007). The results of the current study indicated that when clinicians are provided with this additional information, their ability to recover the DSMIVTR personality disorders is improved considerably. In Rottman et al., clinicians identied the correct personal-

Table 3 Relationship of Familiarity and Opinions With Utility Ratings

Question Familiarity with DSM-IV-TR Opinion of DSM-IV-TR Familiarity with FFM Support for Shifting to Dimensional Model Mean 4.18 (.96) 3.18 (.96) 2.16 (1.20) 3.47 (.89) DSM-IV-TR .19 .51 .10 .37 FFM .13 .03 .24 .28

Note. Standard deviations appear in parentheses below means. DSM-IV-TR edition; FFM Five factor model. p .01.

Diagnostic and Statistical Manual, 4th

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ity disorder diagnosis using the FFM only 47% of the time. In the current study, when provided with the maladaptive variants of each respective FFM trait elevation, their accuracy improved to 89%. Contrary to the conclusions of Rottman et al., clinicians are able to recover the DSMIVTR diagnoses using the FFM of personality disorder. The clinicians in the current study were still more successful in identifying the DSMIVTR personality disorders on the basis of the DSM IVTR diagnostic criterion sets, relative to the FFM maladaptive traits, for the paranoid, antisocial, and borderline personality disorders. However, it should be easier at least to some extent to identify the DSMIVTR personality disorders on the basis of the DSMIVTR diagnostic criterion sets versus any other alternative model. Frankly, it is perhaps surprising that the clinicians failed to identify the correct DSM IVTR diagnosis when provided with its respective criterion set 18% of the time in Rottman et al. (2009), 9% of the time in the current study. In the current study the clinicians actually found it relatively easier to diagnose schizotypal personality disorder using the FFM maladaptive traits than the DSMIVTR diagnostic criteria, for which they provided the incorrect diagnosis 26% of the time. The clinicians in Rottman et al. rated the DSMIVTR diagnostic categories as more useful than the FFM with respect to making a prognosis, devising treatment plans, communicating with mental health professionals, describing all the important personality problems, and even describing the individuals global personality. No signicant difference was obtained between the DSMIVTR and FFM with respect to communicating with patients. However, given the difculty the clinicians had in recovering the DSMIVTR diagnoses on the basis of the presence of a prole of normal personality traits, its understandable that they considered the FFM prole to be less useful. In the current study, when provided with the maladaptive variants of these traits, there was no difference between the DSM IVTR and FFM with respect to communication with other professionals, description of all problems, formulation of intervention strategy, or description of global personality. It is perhaps somewhat surprising that the FFM was not considered to have more utility

with respect to global description, as that would appear to be its unique strength given that it includes both normal and abnormal personality traits (Samuel & Widiger, 2006). It is possible that no appreciable difference was found in the current study because these normal traits were not included. In Lowe and Widiger (2009) and Mullins-Sweatt and Widiger (in press) the clinical vignettes and actual patients had complex mixtures of normal and abnormal personality traits, which the FFM would be able to accommodate whereas the DSMIVTR would not. In the current study, the traits within the FFM and the DSMIVTR were conned to the abnormal, maladaptive characteristics. In the current study, the DSMIVTR was considered to be easier to use than the FFM, but this is to be expected given the task was to recover the DSMIVTR diagnostic categories. As noted earlier, one would hope, given prior training and experience, that it would be fairly easy for clinicians to recognize which DSM IVTR diagnosis was suggested by its respective criterion set. On the other hand, the FFM maladaptive traits were considered to be better for communicating with patients. This is perhaps because the FFM traits consist of trait terms within the existing language versus the relatively more cumbersome and complex diagnostic criterion sets (e.g., see example for obsessive compulsive personality disorder within method section). The statistically signicant differences that were obtained for ease of usage and communication with patients though were not substantial. The primary nding of the current study is that, unlike the results of Rottman et al. (2009), clinicians were able to identify which DSM IVTR personality disorder was present on the basis of FFM maladaptive personality traits just as easily as they could using the DSMIVTR diagnostic criteria, and they found these traits to be as useful as the DSMIVTR diagnostic criteria for most clinical decisions. The FFM maladaptive variants included within the current study in fact parallel closely the maladaptive trait scales included within the dimensional model that has been proposed for DSM-5, which consist of six broad domains of general personality structure and 37 traits (Clark & Krueger, 2010). A distinction between the FFM of personality disorder and the DSM-5 proposal is that the latter does not include the rst step of the

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FFM approach. The DSM-5 proposal does not include any normal personality traits. Consideration was given to including normal personality traits in DSM-5 (Skodol, 2009), but in the current proposal they are not included (Clark & Krueger, 2010). However, the 37 traits included within the DSM-5 model do overlap substantially with the FFM maladaptive traits included in the current study and one way in which the 37 traits will be used in DSM-5 will be as diagnostic criteria for the categorical diagnoses (Skodol, 2010), particularly in those instances in which the respective personality disorder has lost its ofcial recognition (i.e., the narcissistic, dependent, schizoid, paranoid, and histrionic personality disorders). For example, as suggested on the DSM-5 website, the maladaptive traits that are recommended for the diagnosis of schizoid personality disorder are social withdrawal, social detachment, intimacy avoidance, restricted affectivity, and anhedonia. These parallel closely the maladaptive traits included within the FFF used in the current study (i.e., socially withdrawn, isolated, anhedonic, cold, distant, constricted, and blunted feelings). The results of the current study, therefore, suggest that the DSM-5 maladaptive personality traits might be perceived by clinicians to have as much clinical utility as the existing criterion sets for a variety of clinical decisions. In some instances though there are notable differences between the traits included within the FFF and DSM-5. For example, for avoidant personality disorder the FFF traits were anxious, selfconscious, socially withdrawn, passive, discouraged, vulnerable, and cautious, whereas the traits proposed for DSM-5 are anxiousness, separation insecurity, pessimism, low self-esteem, guilt/ shame, intimacy avoidance, social withdrawal, restricted affectivity, anhedonia, social detachment, and risk aversion. It might be useful for future research to compare these two alternative dimensional model descriptions of personality types with respect to their ability to recover the respective diagnostic categories. Limitations One potential limitation of the current study was that the sample was conned to clinical psychologists. Researchers who have sampled both psychiatrists and psychologists in clinical utility studies (e.g., Mullins-Sweatt, Smit, Verheul, Old-

ham, & Widiger, 2009; Rottman et al., 2009; Spitzer et al., 2008) have not typically found appreciable differences between these two professions, but it is possible that psychiatrists would in some cases prefer a model with which they are more familiar. In the current study, familiarity with the DSMIVTR or the FFM did not correlate appreciably with the overall utility rating. Participants attitude toward DSMIVTR did correlate with their opinion as to the clinical utility of the DSMIVTR criterion sets, but not with respect to their opinions concerning the utility of the FFM. Support for a shift toward a dimensional model did correlate signicantly, albeit marginally, with the participants ratings of the utility of the DSMIVTR and the FFM. These correlations could suggest a degree of a priori bias among some of the participants, but it could also be understood as indicating that their opinions concerning the utility of the DSMIVTR criterion sets and the FFM were generally consistent with their a priori views concerning the DSMIVTR and a dimensional model. The sample of participants was, overall, neutral with respect to their attitude toward DSMIVTR and whether the DSMIVTR should shift to a dimensional model. Conclusions Rottman et al. (2009) provided clinicians with previously published FFM proles for each of the DSMIVTR personality disorders (Lynam & Widiger, 2001) and asked clinicians to identify which DSMIVTR personality disorder was suggested by each respective prole. They reported that clinicians found it considerably easier to identify the DSMIVTR personality disorder on the basis of its respective diagnostic criterion set than on the basis of the FFM prole. The ndings of Rottman et al. (2009) have been cited as indicating that clinicians would not be able to use the FFM to obtain personality disorder diagnoses. However, a limitation of this study was that clinicians would not be expected to obtain personality disorder diagnoses simply on the basis of an FFM prole that is conned largely to normal personality traits. The FFM of personality disorder indicates that what is also needed is knowledge of the maladaptive traits that are associated with each FFM trait elevation. When these maladaptive traits were provided to clinicians they could identify the respective personality disorders at a rate that was comparable to the success they achieved

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with the DSMIVTR diagnostic criterion sets. Their judgments of the respective utility of the two approaches to diagnosis were also comparable, albeit the clinicians did nd the DSMIVTR somewhat easier to use than the FFM for obtaining a DSMIVTR diagnosis and the FFM somewhat more useful in communicating with patients. References
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