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Supplemental Materials A Hierarchical Causal Taxonomy of Psychopathology Across the Life Span by B. Lahey et al., 2016, Psychological Bulletin http://dx.doi.org/10.1037/bul0000069 Supplement 2 PERSONALITY DISORDERS AND THE CAUSAL TAXONOMY OF PSYCHOPATHOLOGY A comprehensive review of the literature on personality disorders and their placement in the causal taxonomy was not included in the main paper to make the review more tractable, because of space limitations, but also because relatively few directly relevant studies have been conducted to date. Nonetheless, a causal taxonomy of only ‘Axis I’ dimensions is incomplete without the inclusion of the personality disorders. Therefore, it will be essential to include personality disorders in future versions of the taxonomy. In anticipation of doing so, we briefly review evidence on the possible role of personality disorders in the causal taxonomy of psychopathology in this supplement. Categorical Personality Disorders The publication of DSM-5 provided two options for the measurement of personality dysfunction, with both traditional categorical personality disorder diagnoses and maladaptive personality traits now being in DSM-5 (Krueger & Markon, 2014). Therefore, we review literatures using both approaches to measuring personality disorders. An EFA of DSM-IV categorical diagnoses of Axis I and II mental disorders in a large representative sample in Norway found that a 4-factor solution provided the best fit to the phenotypic data. This included the usual internalizing and externalizing factors of Axis I diagnoses and two separate factors of Axis II personality disorders (Roysamb et al., 2011). At the level of categorical diagnoses, then, there was not a complete integration of Axis I and Axis II disorders in a single second-order taxonomic structure. Nonetheless, all four factors were substantially correlated, suggesting that the second-order factors of Axis I and II diagnoses are related, possibly through a general factor of psychopathology that was not specified in these analyses, but could account for some or all of the factor correlations. Using data from the same Norwegian sample of adult twins (Kendler et al., 2011), four correlated factors were identified based on genetic correlations among disorders, which reflect the degree to which each pair of disorders share the same genetic influences. There were different causal influences on Axis I and II disorders, but again, the four genetic factors were correlated, suggesting the operation of highly pleiotropic genetic influences. Of great interest, data on 49 symptoms of the DSM-IV categorical personality disorders from a mental health patient sample were subjected to CFA, with the loadings supporting the assignment of symptoms to diagnoses of borderline, avoidant, obsessive–compulsive, narcissistic, antisocial, and schizotypal disorders (Sharp et al., 2015). Interestingly, an exploratory bifactor model found that the large majority of symptoms loaded significantly on a general factor of personality disorder similar to that found with Axis I diagnoses (Lahey et al., 2012). Importantly, however, Livesley and Jang (2008) proposed a model of the causal structure of personality disorders that antedates the present causal taxonomy, but is very similar to it. They did not suggest the existence of a general factor of axis II psychopathology, per se, but hypothesized that highly pleiotropic genetic influences explain the correlations among personality disorders, with additional genetic influences shared by the members of four clusters and unique genetic influences on each personality disorder (Livesley & Jang, 2008). What is still not clear at this point is whether the same general factor is related to both Axis I and Axis II psychopathology. There is growing evidence on patterns of comorbidity between DSM-IV Axis I and Axis II mental disorder diagnoses. In five large population-based studies of adults, each personality disorder or cluster of disorders has been found to be significantly comorbid (concurrently) with most (NewtonHowes et al., 2010), nearly all (Lenzenweger, Lane, Loranger, & Kessler, 2007; Ullrich & Coid, 2009), or all DSM-IV axis I disorders (Huang et al., 2009; Trull, Verges, Wood, Jahng, & Sher, 2012). The same broad relations between axis I and I disorders is also seen in longitudinal studies (Johnson et al., 1999; Kasen, Cohen, Skodol, Johnson, & Brook, 1999a; Lewinsohn, Rohde, Seeley, & Klein, 1997). The magnitudes of these associations are consistently patterned rather than uniform (Eaton et al., 2011; James & Taylor, 2008; Links & Eynan, 2013; Tyrer, Gunderson, Lyons, & Tohen, 1997), suggesting the existence as yet not fully described causal structure linking axis I and II disorders. Furthermore, there is evidence from longitudinal studies that Axis I diagnoses in adolescence predict Axis II personality disorders in early adulthood and vice-versa (Johnson et al., 1999; Kasen, Cohen, Skodol, Johnson, & Brook, 1999b). Maladaptive Personality Traits Other recent studies relevant to the causal taxonomy of psychopathology have been conducted using the new DSM-5 maladaptive personality traits instead of diagnoses (Krueger, Hopwood, Wright, & Markon, 2014). A study of a large sample of college students identified clear second-order internalizing and externalizing factors of the DSM-5 maladaptive personality traits using EFA, raising the possibility that the dimensions of maladaptive personality and psychopathology might factor together within the same internalizing-externalizing structure as Axis I mental disorders (Wright et al., 2012). Furthermore, a study of 628 adults recruited from mental health clinics conducted an EFA of a very broad item pool consisting of both ratings on the DSM-5 maladaptive personality traits and symptom counts of a broad range of mental disorders, including personality disorders (Wright & Simms, 2015). Based on fit indices and interpretability, the authors selected a five-factor solution, which consisted of an internalizing factor, two externalizing factors (with substance use, antisocial personality disorder, and risk taking loading strongly on one externalizing factor, and with personality traits related to psychopathy loading strongly on the second externalizing factor), a schizoid-withdrawal factor, and a psychoticism factor. These factors were moderately correlated, but a general factor was not tested in a bifactor model in these studies. Personality Disorders in a Hierarchical General Factor Model The integration of personality disorders into the proposed causal taxonomy of psychopathology will require studies that include a general factor of psychopathology using measures of Axis I and Axis II dimensions of psychopathology. To date, only one study has done that. A confirmatory bifactor model was fitted to diagnoses from NESARC (Hoertel et al., 2015). Unlike our earlier analyses of NESARC diagnoses (Lahey et al., 2012), these analyses included personality disorder diagnoses. A confirmatory bifactor model, which was invariant across sex, included two internalizing factors (one on which the distress diagnoses of MDD, dysthymia, and GAD loaded, and a second on which fears diagnoses and histrionic, schizoid, paranoid, obsessive-compulsive, dependent, and avoidant personality disorder diagnoses loaded). An externalizing factor also was specified on which alcohol use disorder, drug use disorder, nicotine dependence, pathological gambling, and antisocial personality disorder loaded). Each of the personality disorders loaded robustly on the general factor and on their assigned second-order factor. Notably, however, the fears diagnoses had lower loadings on the second internalizing factor than the personality disorders, suggesting that it primarily represented a personality disorders factor. Mania was assigned to the second internalizing factor, but it had a zero loading on it and a strong loading on the general factor. The findings of these new analyses of NEARC data suggest that personality disorders can be integrated in a hierarchical model that includes a general factor (Hoertel et al., 2015). Unfortunately only a single model was fitted. Although it fit well according to fit statistics, no evidence was provided that it fit better than alternative models that incorporated personality disorders. REFERENCES Eaton, N. R., Krueger, R. F., Keyes, K. M., Skodol, A. E., Markon, K. E., Grant, B. F., & Hasin, D. S. (2011). Borderline personality disorder co-morbidity: Relationship to the internalizingexternalizing structure of common mental disorders. Psychological Medicine, 41, 1041-1050. Hoertel, N., Franco, S., Wall, M. M., Oquendo, M. A., Kerridge, B. T., Limosin, F., & Blanco, C. (2015). Mental disorders and risk of suicide attempt: a national prospective study. 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