The five-factor model and personality disorder empirical literature: A meta-analytic review☆
Introduction
Recently, efforts have been made to integrate the previously independent areas of personality theory and personality disorder research Clark et al., 1994, Dyce & O'Connor, 1998, Livesley, 2001, Schroeder et al., 1994. The bridging of normal and abnormal personality has largely come from examining how the five-factor model of personality may be used as a method for conceptualizing personality disorders. Derived from numerous factor analyses, the five-factor model arguably represents a general consensus as to the structure of normal personality Costa & McCrae, 1992a, Costa & Widiger, 1994a, Digman, 1990, Digman, 1994, Digman, 1996, McCrae, 1991. The five-factor model provides a dimensional account of the structure of normal personality traits, dividing personality into the five broad dimensions of Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness (Costa & McCrae, 1992b). It is a hierarchical model, where more specific personality traits or facets are classified under each broad trait dimension. For example, the dimension of Neuroticism is composed of the facets of anxiety, angry hostility, depression, self-consciousness, impulsiveness, and vulnerability (Costa & McCrae, 1992b).
Studies examining the relationships between the five personality dimensions and the personality disorder diagnostic categories have mostly been correlational and have used a variety of sample types and dependent measures. The hypothesis underlying this research effort is that personality disorders can be conceptualized as extreme variants of these normal personality dimensions Costa & Widiger, 1994b, Widiger & Costa, 1994, Widiger & Trull, 1992, Wiggins & Pincus, 1989. Thus, many studies have tried to identify the particular combination of five-factor model personality dimensions associated with each personality disorder. Specific relationships between the five trait dimensions and each personality disorder have been hypothesized based on the diagnostic criteria for each disorder (Widiger, Trull, Clarkin, Sanderson, & Costa, 1994). Furthermore, it has been empirically demonstrated that personality disorders are related to these normal personality trait dimensions in meaningful and predictable ways Ball et al., 1997, Blais, 1997, Brieger et al., 2000, Brooner et al., 1994, Cloninger & Svrakic, 1994, Coolidge et al., 1994, Costa & McCrae, 1990, Duijsens & Diekstra, 1996, Dyce & O'Connor, 1998, Hyer et al., 1994, Lehne, 1994, Morey et al., 2000, Schroeder et al., 1992, Shopshire & Craik, 1994, Soldz et al., 1993, Trull, 1992, Trull et al., 1995, Trull et al., 2001, Wiggins & Pincus, 1989, Yeung et al., 1993.
The volume of published data in this area is case enough for conducting a meta-analytic review to summarize the relationships between the five-factor model and personality disorders. However, a quantitative summary of this literature can serve an even more important function. Ultimately, this body of research brings together two classification and research traditions that exist within the personality disorder literature (i.e., the categorical and the dimensional; Widiger, 1991, Widiger, 1992). It is the present authors' contention that the five-factor model and personality disorder literature reviewed here is essentially a synthesis of these two traditions, and as such, this meta-analysis represents a hybrid system of personality disorder classification Benjamin, 1993, Millon, 1994b, Morey et al., 2000. Both categorical and dimensional approaches are worthwhile and have their own strengths; therefore, a merging of these two approaches could potentially provide a superior conceptualization of personality disorders, which preserves the strengths of both systems.
To appreciate the rivalry between categorical and dimensional approaches to personality disorder classification, one must first consider the intrinsic difficulty in classifying personality disorders. Personality disorders continue to present an organizational and conceptual dilemma for mental health professionals. This is in part due to their highly heterogeneous nature, which presents a problem for any diagnostic or classification approach. While the challenge of classifying the complex domain of personality disorders has a long history (Morey, 1997), in contemporary psychology, it has been most explicitly and extensively attempted by each successive Diagnostic and Statistical Manual of Mental Disorders (DSM) Task Force (Millon & Davis, 1995). A categorical system of classification and diagnosis was adopted for all mental disorders in the original DSM, and personality disorders were no exception.
The tradition of categorically classifying personality disorders has continued over the years and is present in the most current diagnostic guidelines (DSM-IV by the American Psychiatric Association, 1994 and International Classification of Diseases (ICD-10) by the World Health Organization, 1992). Under these categorical systems, pathological symptomatology is the main focus, as personality disorders are characterised by the presence of a certain number of behavioural criteria. Furthermore, attempting to elucidate the differences among personality disorder categories is a priority. As such, depending on the content and number of criteria met, a particular class of personality disorder may be deemed present in an individual, provided distress or functional impairment accompanies these criteria. It is presumed that these behavioural criteria reflect manifestations of underlying maladaptive personality traits. In essence, if one has sufficiently maladaptive personality functioning in terms of both number and kind, then one is likely to fit into a specified class of abnormal personality. Strengths that are commonly noted for the categorical classification of personality disorders are (a) conceptual ease, (b) communicability, (c) familiarity, and (d) consistency with clinical decision-making and treatment planning Ball, 2001, Widiger, 1991, Widiger, 1993, Widiger & Frances, 1994.
Over the last decade, the classification of personality disorders has become a more controversial issue Clark & Livesley, 1994, Nelson-Gray & Farmer, 1999, Widiger, 1992. Extensive debate has developed between supporters of a categorical system Benjamin, 1993, Benjamin, 1996, Frances, 1982, Frances, 1993, Millon, 1996, Millon & Davis, 1993 and proponents of a dimensional system Costa & McCrae, 1992a, Costa & Widiger, 1994a, Livesley, 2001, McCrae, 1994b, Widiger, 1991, Widiger, 1992, Widiger, 1993, Wiggins & Pincus, 1989. Those favouring a dimensional conceptualization of personality disorders argue that personality disorders do not reflect dichotomous distinctions as is inherent in a categorical approach, but reflect continua of functioning where distinct boundaries between normal and abnormal personalities are not clear. Within the dimensional approach, the chief focus is on underlying personality dimensions rather than on particular sets of symptoms. In doing so, dimensional accounts can highlight the similarities and differences between the personality disorders. Strengths commonly noted for the dimensional classification of personality disorders are (a) resolution of categorical classification problems of comorbidity and heterogeneity, (b) increased information, and (c) greater diagnostic flexibility Widiger, 1991, Widiger & Frances, 1994.
To read the majority of literature on the issue of personality disorder classification, one might think that categorical and dimensional conceptualizations are mutually exclusive Millon, 1994b, Widiger, 1991, Widiger, 1992, Widiger & Frances, 1994. That is, it could appear as if personality disorders are either traits that are abnormal and qualitatively distinct from normal personality, which fall into natural classes based on descriptive content, or underlying traits that are both variants of and quantitatively distinct from normal personality (Wiggins & Pincus, 1994). However, it is also possible to view the research examining the relationships between the five-factor model and personality disorders as a synthesis of these categorical and dimensional approaches. The research summarized here uses dimensions to describe categories (Benjamin, 1993), maps the five factors onto each personality disorder (Ball, 2001), and in doing so presents a hybrid system for conceptualizing personality disorders.
The blending of these two traditionally opposed classification approaches and the implications that arise from this amalgamation can be better understood by reflecting on the type of data obtained from the literature. Summarizing this research creates a table of effect sizes with 10 rows, each representing the different DSM-IV personality disorder diagnostic categories, and five columns, each representing the five dimensions of the five-factor model of personality. The table can be read in two ways, and the major implications of this research come from these two complementary readings. Firstly, the table can be read within disorder (i.e., from left to right). Analyzing the table horizontally, one can examine the five-factor model personality dimension profiles specific to each personality disorder category. Secondly, the table can be read across disorder (i.e., from top to bottom). Analyzing the table vertically, one can examine the five-factor model personality dimensions consistent and inconsistent across personality disorder categories. Research to date has mostly focused on examining what is different and unique to each personality disorder. Studying how personality disorders are similar has been of secondary importance in the literature. Recently, there have been indications that this trend is being reversed Lynam & Widiger, 2001, Morey et al., 2000, and this meta-analysis seeks to extend this trend. As such, the importance and implications of both types of understanding of personality disorders will be a main focus of Section 4 of this review.
This meta-analytic study has three main aims: (1) to provide a comprehensive, objective, and quantitative summary of five-factor model and personality disorder research, (2) to consider the within-disorder and across-disorder implications of the empirical literature, and (3) to provide a clear picture of the current status of research in this area and use this to identify possible future research directions and clinical implications. Essentially, this meta-analytic review presents a summary of what five-factor personality dimensions are maladaptive both within and across personality disorder categories, showing which dimensions define which disorders and how compelling these definitions are.
Section snippets
Study selection
Electronic literature searches of PsychInfo (1967–2001) and Medline (1985–2001) databases were conducted to obtain relevant studies. The following keywords were used in the literature search: personality disorder, personality disorders, personality dysfunction, personality inventory, five-factor model, big five, NEO-PI-R, NEO, neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. These keywords were entered both individually and in combination by pairing all
Results
Table 4, Table 5 display the main meta-analytic findings for the relationships between personality disorders and five-factor model personality dimensions. Table 4 shows the unweighted mean effect sizes and standard deviations and Table 5 shows the sample size weighted mean effect sizes, for all studies included in the meta-analysis. A comparison of unweighted and weighted means reveal minimal differences (Mdifference=.02, Mindifference=.00, Maxdifference=.15). Therefore, only weighted means are
Discussion
Results of this meta-analysis are consistent with the view that personality disorders can be conceptualized using the five-factor model of normal personality (Costa & Widiger, 1994b). Examining the current meta-analytic data, this finding can be demonstrated on two levels, corresponding to the two complementary readings of the data tables. At a within-disorder level (i.e., a horizontal reading of data tables), each of the personality disorders shows associations with the five-factor model that
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Portions of this article were included in the first author's PhD thesis and in a paper presented at the Australian Association for Cognitive and Behaviour Therapy, WA State Conference, May 2001, Western Australia.