Level of Personality Functioning: An Essential Clinical Consideration

Clinicians who are committed to assisting patients with their mental health have been trained to assess symptoms and syndromes that present adaptive challenges. However, clinical attention often travels very quickly to circumscribed diagnoses to the exclusion of other factors that may be shaping the difficulties for which the person is seeking treatment. Neglecting the assessment of the proper context for particular symptoms could significantly limit the effectiveness of the interventions employed. For example, anxiety stemming from perfectionistic self-expectations is quite different from anxiety based on a lack of trust of others.

Humans are a meaning-making species, creating narratives to understand our experiences. Every individual has a unique personality and characteristic ways of viewing one’s self, shaping how life is navigated, for better or for worse. Consideration of this subjective world as a context for symptomatic presentation is necessary for improving the impact of treatment.

The need to look beyond problems such as anxiety and depression may become more obvious when personality issues are very prominent, but even then, clinicians often are hesitant to address these factors. There are a number of influences that may drive this reticence, such as concern about the stigma of assigning a personality disorder diagnosis or the limitations of the DSM-IV/DSM-5 Section 2 categorical diagnoses, leading clinicians to capturing personality by assigning the vague “Personality Disorder NOS.” There clearly has been an unfilled need for a system that better characterizes personality factors shaping mental well-being and provides easily applied clinical assessment tools.

The Alternative DSM-5 Model for Personality Disorders (AMPD), published in Section III of the manual, provides an improved system for understanding personality and personality psychopathology. As science has progressed, it has been shown that many aspects of physical and mental health are more meaningfully characterized dimensionally rather than categorically. While there is a longstanding history of dimensional conceptualizations of personality, the AMPD is the first comprehensive integration of personality dimensionality into the DSM system.

One of the central components of this model, the Level of Personality Functioning Scale (LPFS), was created for assessing the core of personality and personality psychopathology. Considering that humans are hard-wired to create mental representations of self and self-in-relation-to-others, the LPFS is a tool for capturing essential qualities and capacities of an individual’s characteristic ways of perceiving and interacting with other people and of approaching tasks of living. Four core personality elements using a self and interpersonal framework comprise the LPFS dimension. These domains emerged from empirical work, and are defined as following:

Self

• Identity: Experience of oneself as unique, with clear boundaries between self and others, stability of self-esteem and accuracy of self-appraisal, capacity for and ability to regulate a range of emotional experience.

• Self-direction: Pursuit of coherent and meaningful short-term and life goals, utilization of constructive and prosocial internal standards of behavior, ability to self-reflect productively.

Interpersonal

• Empathy: Comprehension and appreciation of others’ experiences and motivations, tolerance of differing perspectives, understanding of the effects of own behavior on others.

• Intimacy: Depth and duration of positive connections with others, desire and capacity for closeness, mutuality of regard reflected in interpersonal behavior.

The LPFS is arrayed over five levels ranging from 0=little or no impairment to 4=extreme impairment. While the four elements—identity, self-direction, empathy, and intimacy—are defined at each level, the scale yields a single, global, overall rating of functioning. In applying the LPFS to a particular individual, the clinician is instructed to think about the level that best characterizes the person’s presentation, even if some facets of the four elements at that level do not perfectly correspond.

Interest in, and utilization of, the AMPD and the LPFS has grown significantly around the world, leading to many investigative initiatives. To facilitate clinical application and research, the Structured Clinical Interview for the DSM-5 Alternative Model for Personality Disorders (SCID-5-AMPD) has been developed. Module I of the SCID-5-AMPD is designed to assess the components of the LPFS. This interview presents the opportunity to talk with someone in a more in-depth and elaborated way about the beliefs, assumptions, and biases that color the construction of the personal stories used to navigate adaptation.

Knowledge about a patient’s perspectives on self and others can enhance the clinician’s ability to understand and address patient concerns, foster the therapeutic alliance, and facilitate treatment that will be beneficial in the long-term. SCID-5-AMPD personality functioning can be assessed as a stand-alone indicator or in combination with the trait or disorder components of the model. While the LPFS enables the assignment of an overall rating of personality functioning, it also possesses heuristic value in providing a structure for case formulation and the consideration of particular personality capacities. Several studies have demonstrated that the LPFS is a clinically informative, valid, reliable, and easily employed tool. Assessing personality impairment along a generalized severity dimension has also been shown to be the most significant predictor of current and prospective dysfunction.

Clinicians have long wrestled with how to best capture the personality influences they explicitly and intuitively know are factors in patient presentations. The SCID-5-AMPD presents a new opportunity for enhancing understanding of the individuals we serve, improving our relationships with them, and better choosing the interventions we utilize. Considering personality functioning, as operationalized by the LPFS and the SCID-5-AMPD Module I, is central to deepening the effectiveness and the satisfaction of our work. ■