Criterion A: Level of personality functioning in the alternative DSM–5 model for personality disorders.

Abstract

Criterion A, as represented by Level of Personality Functioning (LPF), offers a means by which to conceptualize the core impairment in self and interpersonal functioning that distinguishes personality disorder (PD) from other forms of psychopathology. One of the most widely cited criticisms of the current Section II in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition categorical diagnostic system is the high level of comorbidity among the categorical PD diagnoses. The Section III alternative Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition model for PDs (AMPD) addresses this problem by assessing the commonalities of the PDs using a single severity continuum, represented in the AMPD by the Level of Personality Functioning Scale (LPFS), which comprises both self and interpersonal pathology. Since its initial introduction, the LPFS has generated an expansive literature base and has also seen significant advancements in its measurement, including both semistructured and self-report methods. Such studies have generally demonstrated that the LPFS can be rated reliably, across both experienced and inexperienced raters, and demonstrates strong validity as evidenced by associations with relevant criterion variables and demonstrations of predictive and clinical utility. This review offers a brief history of the conceptualization and development of Criterion A and the LPFS, describes the major advancements in its measurement, and provides a summary of the status of the empirical literature regarding Criterion A's structure, reliability, and validity.

The problems with Criterion A: A comment on Morey et al. (2022).

“…As noted by Morey and colleagues (2022), overlap between Criterion A and Criterion B has been consistently documented. What they do not mention is that the overlap is quite high and problematic for Criterion A, as assessed using the LPFS.…”

“…We believe the DSM-5 AMPD Section I to be confusing as to the dimensionality of Criterion A. Morey al. (2022) indicate that it was the intent of the Personality Disorders Work group to describe Criterion A as a unidimensional construct.…”

“…This problematic overlap with personality likely explains the generally low incremental validity provided by Criterion A, as assessed with the LPFS. Morey et al (2022) conclude that Criteria A provides “modest” statistically significant incremental variance over Criterion B. We would amend the sentence to read “very modest.” Three studies have examined incremental validity provided by the LPFS and PID-5 in relation to PDs (Few et al., 2013; Sleep et al., 2019b, 2020).…”

“…Although this model represents some forward momentum regarding PD classification, substantial concern remains regarding the operationalization, measurement, and clinical utility of Criterion A. In their review, Morey et al (2022) provide an in-depth look at the impetus for, conceptualization of, and the current state of our understanding of Criterion A. In our view, Morey and colleagues generally paint a selective and overly optimistic view of the current support for Criterion A, overlooking or relegating to the online supplemental materials studies that are critical of Criterion A.…”

“…Despite this advancement, nearly 10 years after its introduction, considerable debate remains regarding the conceptualization, operationalization, and ultimately the utility of personality impairment (i.e., Criterion A). Morey et al (2022) review the impetus for, conceptualization of, the current state of our understanding of Criterion A, and conclude that Criterion A is a valid and clinically useful component of the alternative model of personality disorder. In our commentary, we present a more pessimistic view and review literature critical of Criterion A not included in the main text of their review.…”