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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.
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