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Abstract

Purpose of the review:

Many original studies have evaluated the validity and utility of the Alternative Model for Personality Disorders (AMPD) in Iran. However, the present review is a unique attempt to summarize the data in a critical framework to cover gaps in the AMPD research and determine future directions. The review aimed to explore the psychometric evidence for the AMPD, including reliability (alpha coefficient) and validity (construct, convergent, criterion, and incremental types) data in Iran. We also reviewed the overlap between the two AMPD criteria and the associations between the constructs and general psychopathology.

Collection and Analysis of Data:

We searched PubMed, PsycNet, Google Scholar, and three national databases for English and Persian records related to the AMPD from January 2013 to 2023. Several keywords and criteria were applied to select studies before summarizing the data. The self-report scales were the first-line measures to assess the AMPD constructs, while interviews were rarely used. The research body provided relative support for both the unidimensional nature of Criterion A measures and the five-factor structure of Criterion B measures. Regarding Criterion B, however, there are still questions about the validity of the disinhibition factor and its clinical utility and generalizability.

Conclusion:

Although a decade of research on the AMPD in Iran has contributed to improving our knowledge, the current review provided a more comprehensive and clear profile of this model’s validity and generalizability to Iranian culture. We discussed the details of validation studies, limitations, and future considerations.

Keywords

AMPD DSM-5 personality disorders review validity

Key Messages:

Question: What does current research say about the validity, reliability, and utility of the AMPD in Iran, and what gaps remain?

Finding: In Iran, current research on the AMPD primarily relies on self-report scales, supporting some structural aspects while questioning the validity and clinical utility of the disinhibition factor.

Meaning: This review summarizes AMPD research in Iran, highlighting validity, generalizability, and research gaps.

Personality disorders (PDs) are among the most common mental health problems in the world,¹ and they are related to many negative personal and social outcomes.² PDs are classified by current classification systems, such as the fifth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Section II based on phenotypic symptoms that represent the categorical model.³ The categorical model faces difficulties in boundaries of mostly overlapping PDs, classifying patients into a few categories, and does not account for the severity of PDs within each category.⁴ However, the DSM-5 Section III introduces a dimensional model that follows the transdiagnostic paradigms in psychopathology.³ Therefore, the Alternative Model for Personality Disorders (AMPD) was provided by the DSM-5 in response to the limitations of the categorical model of PD.

The AMPD is the conceptualization of PD based on two criteria: A (severity) and B (maladaptive traits).⁵ Criterion A comprises self-functioning (identity and self-direction elements) and interpersonal functioning (empathy and intimacy elements).⁶ Criterion A conceptualizes these elements as interpenetrating and thus as a unidimensional factor to assess the severity of PD or overall personality functioning.^6-8 The Level of Personality Functioning Scale is used to operationalize Criterion A, with five levels including “no impairment,” “personality difficulty,” “mild,” “moderate,” and “severe.”^6,9-10 The self-report versions of the Level of Personality Functioning Scale (LPFS-SR), the Level of Personality Functioning Scale-Brief Form (LPFS-BF), and interview forms such as the semi-structured interview for personality functioning DSM-5 (STiP-5.1) are commonly employed to assess the severity of PD.^5,11,12

Criterion B, which was conceptualized to determine the PD manifestation, includes 25 maladaptive traits that collectively load on five higher-order domains of negative affectivity, detachment, antagonism, disinhibition, and psychoticism.^5,13 To meet the criteria for PD, at least one domain must be in the clinical range.^3,10 Criterion B can be assessed by the Personality Inventory for DSM-5 (PID-5)¹³ and its shorter versions, including the 100-item short form¹⁴ and the 25-item brief form.¹⁵ The Modified Personality Inventory for DSM-5 and ICD-11–Brief Form Plus (PID5BF+M) is also a 36-item version designed to harmonize the DSM-5 and ICD-11 models.¹⁶ The original and short versions of the PID-5 are also utilized to operationalize six PD composites proposed by the AMPD, including schizotypal, antisocial, borderline, narcissistic, avoidant, and obsessive-compulsive PDs.³

Since the AMPD was introduced a decade ago,³ numerous studies have tested its replicability and validity across Western and non-Western cultures such as Iran.^10,17-21 However, some gaps in the AMPD research in Iran need to be addressed. For instance, how much research is there on each criterion, and which ones have been studied the most? Are the constructs of the model mainly measured by self-report questionnaires or clinician-rated interviews? What are the validation methods used? How much does the current research on AMPD support its generalizability to the Iranian culture? Are the samples included in the studies representative of Iran’s population, or are they limited to some gender, age, ethnic, and geographic groups? What is the overlap across the AMPD criteria, and what is their relationship with general psychopathology?

Furthermore, what are the limitations of the current literature and the future directions of research on the AMPD? The answers to these questions could be clearer. The goal of this comprehensive review was to provide richer knowledge by summarizing and organizing the data coherently. Current literature reveals incoherent and heterogeneous knowledge for both validation studies and the relevance of AMPD with other psychopathology constructs in the Iranian populations. A literature review of validation studies on AMPD and associations with general psychopathology is needed to know whether the frameworks originating from one cultural context can be generalized to other cultures (e.g., from the USA to Iran). Since many psychiatrists and almost all clinical psychologists in Iran use the DSM-5 to diagnose mental disorders,²¹ it is important to summarize validation studies.

Additionally, the summary of current evidence can help determine the future research directions for the AMPD in Iran. Therefore, the present review was conducted with several objectives. The first aim was to consolidate the validation data from the measures of both AMPD criteria. Since the published validation data were limited to reliability (alpha coefficient), construct validity (factor analysis of latent constructs), convergent validity (correlations with other adaptive and maladaptive personality constructs), criterion validity (differentiation of the clinical from the non-clinical samples), and incremental validity (predictions of outcomes controlling for other variables), we could not include other validation approaches. The second aim of the review was to examine the relationships between AMPD and psychopathological symptoms (e.g., anxiety and depression). Our third aim was to evaluate associations between criteria A and B. The last objective was to summarize the evidence on six PD composites. Finally, according to the findings related to these objectives, we proposed future directions for research on AMPD in Iran.

Methods

We followed the Narrative Review Checklist framework for the procedure and organization of the present review.²² Three international databases, including PubMed, PsycNet, and Google Scholar, were searched for English records related to the AMPD from January 2013 to 2023. Additionally, three national databases, including Magiran, Scientific Information Database, and Islamic World Science Citation Center, were searched for Persian records. When the national databases were searched, we used the Persian equivalents of the keywords. However, two keywords (i.e., personality functioning and maladaptive traits) had more than one Persian translation, so we included them all to prevent missing any related records. We adapted common translations from the AMPD scientific documents, including Persian books and articles.

We screened the title/abstract to select all studies containing adolescent and adult populations that focused on assessing any psychometric properties of self-report scales or clinician-rated interviews. We only included scientific articles published in official academic journals and excluded duplicate articles, books, theses, abstracts without full text, review studies, studies with completely overlapping samples, and studies that did not report any of the psychometric properties of instruments related to the AMPD (e.g., interventional trials). We did not include any additional filters to exclude some types of reliability (e.g., McDonald’s Omega) and validity (e.g., content validity). Therefore, we reported all available data without biased selection.

The keywords were selected according to international guidelines related to the AMPD, which included the “DSM-5 Alternative Model,” “Personality Functioning,” “Maladaptive Traits,” “Personality Disorders,” “PID-5,” and “LPFS.” We reviewed reliability and different forms of validity, including construct, convergent, criterion, and incremental types for formal measures of both criteria. Since our review was an open-ended exploration of the psychometric properties addressed in research on AMPD, we first intended to synthesize and summarize the data of all types of reliability and validity. However, our pilot search showed that only coefficient alpha was of interest to Iranian researchers, and data obtained from other methods such as inter-rater agreement coefficient, McDonald’s Omega internal consistency, and test-retest are rarely available. Additionally, other types of validity, such as face and content validities, were rarely available. When the search, screening, and data extraction processes were completed, the extracted data were summarized in several tables designed by the research team (See supplementary file).

Discussion

The findings from 62 of the 197 articles that were identified in the initial search were used for the current review. According to the Narrative Review Checklist,²² we synthesized the results and discussed the reviewed research, including key findings. We first summarized the evidence for the factor structure and reliability, convergent, criterion, and incremental validity of both criteria A and B, as well as their relationship with common mental health constructs in a critical framework. Finally, we summarized the data for six PD composites and discussed the interaction between the two AMPD criteria. Throughout the discussion, we used a critical appraisal approach to address the limitations of the reviewed research and future directions. The literature limitations help to understand the possible bias of the data and the degree of accuracy and generalizability of the data to Iranian culture. In the last section, we provided an overall interpretation of the narrative review in the context of clinical practice for mental health clinicians and researchers.

Criterion A: Personality functioning

Unidimensionality and Reliability

Does research in Iran support the unidimensional structure of the measures of Criterion A? We found that only two studies evaluated the latent structure of different forms of personality functioning in Iranian samples.^11,23 The first study, which was the only formal research to test the latent structure of the LPFS-SR, revealed the unidimensional nature of Criterion A using confirmatory factor analysis.²³ Although the LPFS-BF has been used occasionally by some researchers, we have yet to find any formal attempts to report its factorial structure. However, several studies have reported alpha coefficients for both the measures among almost 3500 non-clinical and clinical cases.^11,23-30 The alpha coefficients for overall functioning measured by the LPFS-SR (from 0.92 to 0.96)^23,27-29 and the LPFS-BF (from 0.84 to 0.93)^11,24,30 were acceptable. Although the reliability findings support the unidimensional nature of the self-report scales of personality functioning, alpha coefficients have been criticized as an index of unidimensionality.³¹ Conversely, McDonald’s Omega is a recommended method for assessing the reliability of latent constructs, which is preferable to alpha coefficients.³² Another point is that all of these studies were cross-sectional, and no test-retest reliability or results from other methods were reported. The stability of measures over time -especially in personality science- is an important indicator of reliability that can be evaluated using the test-retest method in different time intervals.

The second study was conducted to evaluate the psychometric features of the Brief Semi-Structured Interview for DSM-5 Personality Functioning (BSSIDPF).¹¹ This is a 20-question interview that takes about 15 minutes and is adapted from the items of the personality functioning model.^7,8 Interview scoring is continuous in two different ways. In the first form, behaviors related to personality functioning levels are scored in a range from no disorder (score 0) to severe disorder (score 2). In the second form, clinicians score personality functioning levels in a range from no disorder (score 0) to severe impairment (score 4). Although the validity and inter-rater consistency of all interview elements were supported (from .81 to .96),^11,25 still need to determine the reliability of overall functioning. A summary of structural validity findings for AMPD Criterion A can be found in the supplementary file (Table S1).

In sum, the few data support the unidimensional structure and reliability of Criterion A, which is measured by self-report scales and interviews. Although all reviewed data were from a large mixed population, the samples are not from all regions of Iran, and mainly central and Western samples are included. Because Iran is a country with heterogeneous cultures and multiple ethnicities, issues of generalizability to other regions are raised. Most studies also used community and student populations whose data are not representative of the clinical population—especially those with PD. None of the studies compared construct validity between sex, age, education, and patient and non-patient groups, which highlights problems with measurement invariance.

Convergent Validity

What are the associations between Criterion A and other maladaptive and adaptive constructs of personality? Two studies aimed to evaluate the associations between the LPFS-SR and the maladaptive personality, both of which showed moderate correlations with affective temperaments (r between 0.40 and 0.61)²⁷ and psychodynamic constructs of personality (r between 0.40 and 0.64).²⁹ The results of one of these studies also showed that the LPFS-SR constructs are weakly to moderately associated with the dimensions of the Five-Factor Model (FFM; r between –0.58 and 0.01).²⁷ Two other studies evaluated the associations between the BSSIDPF and PD symptoms, both of which showed significant correlations with the symptoms of antisocial and borderline PDs,^11,25 The results of one of these studies also showed that the BSSIDPF constructs are weakly associated with the FFM dimensions (r between –0.19 and 0.21).¹¹

In sum, the little evidence available—and somewhat heterogeneous findings for expected negative correlations—provides only mildly promising knowledge for us about the convergent validity of personality functioning measures. The average sample size was about 440 people, and all of them included only adult populations from the capital (Persian culture) and Western (Kurdish culture) of Iran. These methodological limitations caution us in the generalizability of the data to other age groups and residents of other regions. The correlations reported were mostly weak to moderate, which may indicate translation issues if repeated in future research. We recognize that adaptive and maladaptive personality models are extensive, and the literature should be enriched by examining links between personality functioning and other personality frameworks.

Criterion and Incremental Validity

What is the research evidence for Criterion A to differentiate clinical from non-clinical populations? Two studies examined the criterion validity of the LPFS-SR in Iran, and some overlap data was obtained from Western populations.^23,29 The results of both studies showed that overall functioning had a sensitivity rate of 78%–85% for differentiating patients from university students.^23,29 However, there is no evidence for other measures such as the LPFS-BF and the BSSIDPF.

Second, what is the incremental validity of Criterion A beyond other personality models? Only one of the studies assessed the LPFS-SR total score above and beyond PD symptoms in identifying patients with PD. The results showed that the overall level of personality functioning increases the model’s utility in predicting PD cases, ranging from 19% to 44%.²³ There needs to be evidence for the incremental validity of other measures.

Overall, very few studies have aimed to examine the criterion and incremental validity of personality functioning. Some results reported in these studies also overlapped, which highlights problems with generalizability to other samples. Small sample size, non-random sampling, selection from a geographical region, and neglecting the adolescent and elderly age groups increase the possibility of bias and seriously threaten the validity of the findings.

Criterion A and Common Mental Health Constructs

What are the associations between Criterion A and general psychopathology? The reviewed research indicated that few studies reported relationships between personality functioning and non-PD mental health problems, including traumatic life events, substance abuse, interpersonal problems, and emotional difficulties.^24,26,30 Although the results of these studies support the relationship between Criterion A and general psychopathology, some limitations and sources of bias should be critically addressed. First, all studies used the LPFS-BF to measure personality functioning. Second, the studies only measured self- and interpersonal functioning rather than overall functioning. Third, all samples were from the capital of Iran, which does not represent the population of the entire country. Fourth, the size of the samples was relatively small, and non-random methods mainly selected them. Fifth, adolescent and elderly samples were not included in any of the studies. Finally, no study evaluated the relationship between personality functioning and other constructs of mental health, such as depressive and anxiety symptoms, eating and sexual disorders, quality of life, and self-esteem.

Summary of the Research on Criterion A

Less than 10 cross-sectional studies tried to validate Criterion A measures. Despite the paucity of studies, evidence supports the reliability and validity of the LPFS-SR and BSSIDPF. We could not find any studies supporting the validation properties of the LPFS-BF. The lack of research on personality functioning and its measurement tools stems from the cultural context and interests of Iranian researchers, where the tendency to diagnose the type of PD may continue to be preferable to its severity. However, the reviewed research addressed the relationship between the level of personality functioning and some constructs of general psychopathology. The use of measurement tools for Criterion A should be done with caution until more evidence is available to support the unidimensional nature of Criterion A and its applications in clinical settings.

Criterion B: Maladaptive Traits

Factor Structure and Reliability

Does the literature address the five-factor structure of the measures of Criterion B? The latent structure of different forms of PID-5 was investigated in several studies, all of which confirmed a five-factor structure including negative affectivity, detachment, antagonism, disinhibition, and psychoticism.^21,33-42 However, more than half of the studies reported problems with disinhibition as an independent factor.^36-39,41,42 The personality traits specific to disinhibition, especially distractibility, and impulsivity,¹³ tended to load more strongly on the negative affectivity factor. Heterogeneous congruence coefficients (i.e., weak versus high congruency) for the disinhibition factor also raise questions about the nature of this factor.^21,37,39,42

When research on the 220-item PID-5 reliability was reviewed, we found that alpha coefficients for all domain scales ranged from 0.64 to 0.98.^{20,33,34,36,38,40,43-50} The alpha coefficients across studies ranged from 0.70 to 0.94 for negative affectivity, 0.64 to 0.94 for detachment, 0.70 to 0.95 for antagonism, 0.74 to 0.91 for disinhibition, and 0.81 to 0.95 for psychoticism.^{33,43,44,48,49} Some studies also reported alpha coefficients for full items between 0.73 and 0.98.^42,51,52 Only one study reported test-retest reliability, the results of which addressed good coefficients for all domain scales in the range of 0.89 (detachment and antagonism) to 0.96 (psychoticism).⁴⁰

We also reviewed the reliability of 25 maladaptive traits measurable using the PID-5.^{20,21,33,34,36-40,42,43-48} Alpha coefficients for a large mixed sample ranged from 0.28 (intimacy avoidance) to 0.94 (eccentricity, depressivity, and withdrawal).^20,34,37,46 Although the six traits of eccentricity, perceptual dysregulation, depressivity, deceitfulness, callousness, and distractibility consistently showed the alpha coefficients equal to 0.70 and above across studies, the four traits of suspiciousness, submissiveness, restricted affectivity, and intimacy avoidance showed the alpha coefficients less than 0.70 in more than 50% of validation studies. Additionally, the results of two studies showed that the test-retest coefficients for all trait scales were in the range of 0.76 (suspiciousness and restricted affectivity) to 0.99 (eccentricity and unusual beliefs).^40,46 More attention to test-retest reliability could be useful for revealing time-dependent effects on construct stability.

We reviewed the latent structure and reliability of other tools, including the PID-5-SF, PID-5-BF, PID5BF+M, and the DSM-5 Personality Trait Rating Form (DSM-5 PTRF) to measure the domain scales. Only one study reported the five-factor structure of the PID-5-SF among adolescents (α from 0.74 to 0.86), the results of which addressed some problems with the disinhibition factor.³⁴ When data from this adolescent sample were used to assess the latent structure of the PID-5-BF, the five-factor structure was confirmed, with some weak loadings in the detachment factor.³⁴ A study involving an adult population also reported the five-factor structure of the questionnaire.³⁵ Since the synthesized data of these two studies are valuable due to the large sample size, adolescent and adult populations, use of mixed populations, and reporting of measurement invariance, they contribute significantly to the literature. Various studies have reported the reliability of PID-5-BF domain scales,^{23,24,27,34,35,43,53-59} which results showed alpha coefficients between 0.53 and 0.90.^{23,34,35,55,56,58} Alpha coefficients between 0.73 and 0.93 were reported for total scale items.^{23,24,26,27,49,56,58-66} Only one study reported test-retest reliability and split-half reliability of the domain scales in a range of 0.48 to 0.72 and 0.62 to 0.82, respectively.⁶⁰

The latent structure of the PID5BF+M was reported under the expected pattern by one study (α from 0.67 to 0.76)⁶⁷ with data largely overlapping with other reports,^42,47 the results of which addressed a relatively weak congruency for both negative affectivity and disinhibition factors. Finally, one study attempted to test the factor structure of the DSM-5 PTRF, the results of which found a five-factor structure.⁶⁸ However, the results of the study again showed that disinhibition facets tended to load strongly on the negative affectivity factor. According to the results of this study, the inter-rater agreement and alpha coefficients for all domain scales were above 0.78 and 0.92, respectively.⁶⁸ A summary of construct validity findings for the AMPD Criterion B can be found in the supplementary file (Tables S2 & S3).

In sum, the evidence supports both the five-factor latent structure and the reliability of the PID-5 for assessing the AMPD Criterion B in Iranian populations. The findings are relatively robust due to the large number of studies, the use of a large mixed sample, the selection of samples from different regions, and the reporting of psychometric properties of both the domain and trait scales. However, non-random sampling methods, focusing on the population of adult students, non-representative samples, neglecting measurement invariance, heterogeneous statistical methods, and ambiguous methodologies in some studies indicate caution in research and clinical applications of the scale. Additionally, the reliability of some traits, including suspiciousness, submissiveness, restricted affectivity, and intimacy avoidance, was consistently weak, which may be due to translation or cultural issues. We found that few studies are available to evaluate other measurement tools of the AMPD Criterion B. Regarding the shorter versions of the PID-5, very few studies reported latent structure, whereas the studies mainly reported alpha coefficients. The reviewed research showed that the studies evaluated the alpha coefficient for the original constructs of these measures rather than the extracted latent constructs. Although the results obtained for all these scales were promising for their applicability in Iranian culture, more findings supported the construct validity and reliability of the 25-item PID-5-BF.

Convergent Validity

What are the associations between Criterion B and other maladaptive and adaptive constructs of personality? Over the last decade, numerous studies have tested the relationships between the maladaptive domains of Criterion B and other personality constructs. These studies found that the maladaptive domains were significantly related to (a) categorical PDs (e.g., borderline and avoidant),^{20,36,45,47,50,53,63,66-71} (b) other maladaptive personality constructs such as the personality scales of the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF), detachment manifestations, grandiose and vulnerable narcissism, perfectionism, and interpersonal problems,^{44,50,54,62,72,73} (c) temperament traits such as novelty seeking, harm avoidance, and hyperbolic temperaments,^{27,39,40,45,56,74} and (d) the dark personality traits.^58,60 The maladaptive domains are also negatively related to normal-range personality constructs (e.g., extraversion, agreeableness, self-directedness, and cooperativeness) in both clinical and community samples.^{27,35,39,40,45,60,75-77}

In sum, the reviewed research supports the convergent validity of Criterion B constructs. However, some weak nonsignificant correlations between the maladaptive domains and other personality constructs (e.g., other-oriented perfectionism and symptoms of obsessive-compulsive PD) were reported across studies. Most studies examined the associations for the original constructs of these measures rather than the extracted latent constructs, and few examined the impact of cultural differences on the results. Although the overall sample size was large, the sample size of some individual studies was small, which may increase the risk of sampling error in the initial reports. The samples of these studies were also from different regions of the country. However, non-random sampling methods and overall focus on adult populations are sources of bias from non-representative samples. Further research would be beneficial in enriching the literature.

Criterion and Incremental Validity

What is the research evidence for Criterion B to differentiate clinical from non-clinical populations? Several studies tested the sensitivity of the PID-5 to clinical diagnoses. Two studies showed that all PID-5 domain scales significantly differentiate psychiatric patients with PD and other psychiatric conditions from non-clinical cases.^{37,42,48,51,74} Conversely, the results of one study showed that none of the PID-5 domains differentiated individuals with a history of childhood sexual abuse from individuals without experienced abuse.²⁰ Three studies that used the PID-5-BF found that the domain scales significantly discriminated psychiatric samples from non-clinical populations.^35,78,79 Finally, one study showed that the PID5BF+M domain scales significantly differentiate both psychiatric outpatients and PD patients from non-clinical individuals.⁶⁷

Second, is the predictive ability of Criterion B beyond other personality models meaningful? Three studies with highly overlapping data tested the ability of PID-5 scores to predict psychiatric symptoms, including PDs, controlling for other personality scales.^38,47,52 The results of one of these studies showed that the PID-5 scores, above and beyond affective temperaments, can significantly predict 7%–19% of the variance in general factors of psychopathology.⁴⁷ The results of other studies showed that the PID-5 scores beyond a conjoint model of temperament can significantly predict somatization.^38,52

In sum, the data from about 10 studies support the criterion validity of different versions of PID-5, especially the 220-item version. However, sampling varied across these studies, and diagnostic comorbidities were often not reported. We found limited research on the incremental validity of the PID-5, whereas other Criterion B measures have yet to be investigated at all. Although initial findings are promising for incremental validity, future research should validate measures that have been less studied in large representative samples.

Criterion B and Common Mental Health Constructs

What are the associations between Criterion B and general psychopathology? We found that several studies evaluated the associations between the maladaptive domains and non-PD general psychopathology.^{24,26,34,38,42,47,52,57,59,61,64,70,74,80,81} Associations were found between the Criterion B constructs and some psychiatric conditions, including anxiety, depression, stress, impulsivity, emotion regulation difficulties, alexithymia, psychotic experiences, insecure attachment style, a tendency to drug addiction or substance abuse, fetishism, traumatic life events such as childhood abuse, major depressive disorder, bipolar spectrum disorder, binge eating disorder, somatization, COVID-19-related anxiety symptoms, and a general factor of non-PD symptoms.^{24,26,34,38,42,47,52,57,59,61,64,70,74,80-82} Finally, the results of an intervention study also showed that higher scores on maladaptive traits significantly reduce the effect of cognitive-behavioral therapy on insomnia symptoms.⁸³

In sum, research supported the relationship between the AMPD Criterion B and non-PD psychopathology. However, some sources of bias may threaten the validity of the findings. For instance, most studies measured the maladaptive domains using self-reports, whereas clinician-rated interviews were rarely used. Additionally, the effect of cultural differences may have been underestimated because most studies assessed the associations for the original constructs of these measures rather than the extracted latent constructs. Other sources of possible bias include convenience sampling methods and the exclusion of non-adult populations.

AMPD Composites

Some studies assessed the reliability and validity of six PD composites (i.e., estimates of categorical diagnosis based on combinations of Criterion A and B features). Studies that focused on the reliability of PD composites reported alpha coefficients between 0.50 and 0.96.^48,49,84 One study showed that the domain scales of the MMPI-2-RF significantly predicted all PD composites.⁴⁹ The results of two studies also showed that antisocial and borderline symptoms are positively related to the composite antisocial and borderline PDs. At the same time, the correlations with some of the FFM factors (e.g., agreeableness and conscientiousness) were negative.^75,76 Finally, the results of a study showed that all PD composites can differentiate clinical from non-clinical cases.⁴⁸ However, more research is needed on the criterion validity of PD composites for establishing diagnosis. In general, research on PD composites in Iran is still limited, and more data is needed to determine the reliability and validity of different forms of composites.

Summary of the Research on Criterion B

More than 50 mostly cross-sectional studies have evaluated the AMPD Criterion B in Iran. The validation studies mainly used the PID-5 and the PID-5-BF. Existing research generally supports the reliability and validity of the measures, especially the 220-item original version. However, this research has also raised questions about the interpretation of the disinhibition factor in Iranian culture. We found that research on the short and modified forms of the PID-5 is limited. Clinician-rated interviews have also been neglected in the literature, which is likely due to the applicability of self-report scales in screening large populations and the relatively lower cost and time required of self-reports. The reviewed research also showed that more data on the six PD composites needs to be collected. Although the present review provides initial evidence for the validity and applicability of Criterion B in Iran, there are some sources of bias, such as heterogeneity of data, non-representative samples, invalid statistical analysis methods, and high-overlap data that need to be improved in future research.

The Interplay Between Criteria A and B

Few studies aimed to report associations between the maladaptive constructs of Criteria A and B in Iranian samples.^24,26,27 These studies used PID-5-BF to measure the maladaptive domains, all of which addressed associations between personality functioning and five maladaptive domains. The correlations between the two criteria were reported, ranging from 0.59 to 0.70 in two studies.^24,26 Another study found that the maladaptive domains predict about 43% of the variance in personality functioning components.²⁷ Although these findings support the relationship between Criteria A and B, none of the studies reported associations between overall personality functioning—following the unidimensional structure—and maladaptive domains. Also, there is still no evidence to support strong relationships between these criteria using other forms of PID-5. Therefore, we conclude that research on the overlap of the two criteria is limited, and future research can further improve the current knowledge.

Limitations

Although the current review is a pioneering study to summarize and synthesize data on the AMPD in Iran, it faces some limitations. First, we used the Persian equivalents of the keywords to search for studies in the local databases, which may lead to missing some records due to the variety of translations. The present study design (i.e., narrative review) limited us in calculating pooled estimates, which are the target of meta-analytic reviews. The study design also prevented us from calculating the heterogeneity of the included studies and the degree of publication bias. Future studies will be able to provide more promising results by overcoming the limitations of the present review.

Future Directions

We comprehensively reviewed research on the AMPD in Iran from 2013 to 2023. Based on this work, we propose considerations for future studies: (a) Almost all validation studies were cross-sectional. More longitudinal research would have value for testing predictive validity, test-retest reliability, stability, and longitudinal associations. (b) The target population of almost all studies was adults from the center and west of Iran, which do not represent the entire population of the country. Future research should be more diverse in terms of geography, gender, age, and clinical status. (c) More research is needed using alternative, brief, and multimethod measures of both Criterion A and B. (d) Reliability estimates beyond coefficient alpha, including McDonald’s Omega, test-retest, and inter-rater, would be beneficial. (e) The measurement invariance of AMPD measures is both in Iranian subgroups and between Iranian samples and samples drawn from other cultural settings. (f) Cut-off scores of the measurement scales of both criteria are useful in the initial screening of high-risk individuals for PD, but there has been little effort to report them.^48,67 (g) Several studies used the same samples. Studies with fully independent samples would afford more generalizable results.^{23,29,38,47,52} And (h) ultimately, when more research evidence is available, quantitative and meta-analytic summaries will be useful for quantifying the psychometric properties of AMPD measures in Iran. In sum, the current research on AMPD in Iran faces some limitations that future studies should consider in order to enrich the literature.

Abbreviations

AMPD: Alternative Model for Personality Disorders; BSSIDPF: Brief semi-structured interview for DSM-5 personality functioning; DSM-5: Fifth revision of the Diagnostic and Statistical Manual of Mental Disorders; DSM-5 PTRF: DSM-5 Personality Trait Rating Form; FFM: Five-Factor Model; ICD-11: Eleventh revision of the International Classification of Diseases; LPFS-BF: Level of Personality Functioning Scale-Brief Form; LPFS-SR: Level of Personality Functioning Scale-Self-Reported; MMPI-2-RF: Minnesota Multiphasic Personality Inventory-2 Restructured Form; PID-5: Personality Inventory for DSM-5; PID-5-BF: Personality Inventory for DSM-5-Brief Form; PID5BF+M: Modified Personality Inventory for DSM-5 and ICD-11 – Brief Form Plus; PID-5-SF: Personality Inventory for DSM-5-Short Form; PDs: Personality disorders; STiP-5.1: Semi-structured interview for personality functioning DSM-5.

Supplemental Material

Supplemental material for this article available online.

Footnotes

Acknowledgements

We are grateful to Dr. Gerald J. Haeffel (Department of Psychology, University of Notre Dame) for comments and edits to improve the content of the review.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Declaration Regarding the Use of Generative AI

No artificial intelligence tools were used for data collection and analysis. The language and grammar of the text were checked using the free version of the software Grammarly. Full responsibility for the content of all parts of the manuscript rests with the authors.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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Supplementary Material

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Research on the Alternative Model for Personality Disorders (AMPD) in Iran: A Narrative Literature Review

Abstract

Purpose of the review:

Collection and Analysis of Data:

Conclusion:

Keywords

Key Messages:

Methods

Discussion

Criterion A: Personality functioning

Unidimensionality and Reliability

Convergent Validity

Criterion and Incremental Validity

Criterion A and Common Mental Health Constructs

Summary of the Research on Criterion A

Criterion B: Maladaptive Traits

Factor Structure and Reliability

Convergent Validity

Criterion and Incremental Validity

Criterion B and Common Mental Health Constructs

AMPD Composites

Summary of the Research on Criterion B

The Interplay Between Criteria A and B

Limitations

Future Directions

Abbreviations

Supplemental Material

Footnotes

Acknowledgements

Declaration of Conflicting Interests

Declaration Regarding the Use of Generative AI

Funding

References

Supplementary Material