the fundamental problems with the personality disorders ( pd ) diagnostic system in the previous version of dsm , such as all - or - nothing diagnostic categories , considerable heterogeneity within categories , extensive overlap or comorbidity among categories , indistinct boundaries with normal personality , and incomplete coverage of personality psychopathology , led to the revision of the dsm approach ( 1 , 2 ) . since 2000 , after the revision of dsm - iv , pd researchers largely agree that personality pathology should be represented dimensionally rather than categorically ( 3 ) . thus , many alternative dimensional models of personality have been considered ( 4 - 7 ) , and ongoing research has been performed to delineate the conceptual and empirical structure of personality traits in the pathological range ( 6 , 8) . finally , a multidimensional system was proposed for representing and diagnosis of personality disorder features in dsm-5 .
the new approach for the assessment of personality pathology identifies core impairments in levels of personality functioning , pathological personality traits , and prominent personality pathology types ( 9 ) .
however , there is wide consensus that severity assessment is essential for any dimensional system of personality psychopathology ( 10 ) .
moreover , the dsm-5 personality disorders work group has proposed impairments in personality functioning as the central element of pd ( 11 ) .
thus , in the dimensional model of personality disorder any pd ( schizotypal , antisocial , borderline , narcissistic , obsessive - compulsive and avoidant ) is associated with fundamental disturbances of self and interpersonal relations , problems with identity , self - direction , empathy and intimacy .
the review of literature showed that levels of personality functioning or self - other approach for diagnosis are informative in determining both the type and the severity of personality pathology ( 12 - 14 ) .
the severity of impairment in personality functioning has also been shown to be important in planning treatment and predicting its outcome . despite the good advantages and empirical background of levels of personality functioning , practical studies in clinical settings with specific pds and cross - cultural studies in this field
also , researchers need to determine which levels of personality functioning better predict and explain severity than others .
the purpose of the current study was firstly , to examine the relationship between dsm-5 levels of personality functioning on an iranian sample with antisocial and borderline personality disorders , and second , to explore which levels of personality functioning in patients with antisocial and borderline personality disorders can better predict severity .
of the 300 participants , 252 individuals with antisocial ( n = 122 ) and borderline personality disorders ( n = 130 ) were selected from september to november 2013 . with regard to  = 0.05 and
based on partial r = 0.095 , the sample size for antisocial personality disorder ( aspd ) was calculated to be 119 . for borderline personality disorder ( bpd ) ,
 and  were 0.05 and 80% , respectively , and four variables were tested by multiple regression analysis . based on partial r = 0.1 , the adequate sample size for bpd was 113 .
participants were selected from prisoners ( 48.8% ) , outpatients ( 16.5% ) and inpatients ( 7.5% ) .
they were recruited from tehran prisons , and clinical psychology and psychiatry centers of razi psychiatric hospital and taleghani general hospital , tehran , iran .
inclusion criteria were diagnosis of antisocial and borderline personality disorders ( for personality disorders ) , being at least 18 years old , having at least secondary education , and the exclusion criteria were presence of a psychotic disorder , presence of severe mood disorder , presence of mental retardation , and presence of physical condition that impairs the person 's mental state .
participants were 90.5% males and 9.5% females , aged 18 to 60 years ( sd =  1.37 ) , with guidance school degree education level or higher .
disorders of axis i ; 106 patients ( 42.06% ) had no impairment , 78 patients ( 30.97% ) had a history of substance - related disorders , 35 patients ( 13.88% ) had mood disorder , 15 patients ( 5.96% ) had anxiety disorders , 8 patients ( 3.17% ) had had a history of psychotic spectrum disorder and 10 patients ( 3.96% ) had other disorders .
data gathering measurements included psychological reports , scid - ii - pq , scid - ii , and dsm-5 levels of personality functioning checklist .  
the scid and its versions are considered to be the most comprehensive of the structured diagnostic interviews , which are currently available .
in fact , in 1987 they were new and wide range of instruments , by spitzer , gibbon , williams and built in compliance with the criteria of the dsm - iv ( 16 ) .
this instrument has been established as the gold standard for reliable assessment of psychiatric disorders .
inter - rater reliability for scid - i was above 70 for mood , anxiety , schizophrenic disorders and alcohol abuse ; it was somewhat lower for a few other disorders ( 17 ) , while for scid - ii it was reported between 0.48 and 0.98 for the categorical diagnoses ( cohen s  ) and 0.90 to 0.98 for the dimensional judgments ( intra - class correlation coefficient ) ( 18 ) .
cronbach s  was found between 0.71 and 0.94 for the scid - ii personality disorder scales ( 18 ) . due to high accuracy of the diagnostic criteria and extraordinary compliance with dsm - iv criteria , translated to and adapted with different languages . in iran scid - ii and scid - ii - pq
the duration of the scid - i is 30 to 90 minutes , the duration of the scid - ii is 30 to 60 minutes .
severity was determined in this study by the scores obtained from scid - ii .  
levels of personality functioning refer to the core capacities of personality - related self and interpersonal functioning and determining the severity of any impairment in these areas ( 12 ) .
the dsm-5 levels of personality functioning include identity , self - direction , empathy and intimacy .
the levels of personality functioning scale use each of these elements to differentiate five levels of impairment on a continuum of severity ranging from no impairment , i.e. healthy functioning ( level = 0 ) , to extreme impairment ( level = 4 ) ( 11 ) .
the more impairment in these areas , the more likely that person has pd . in preliminary analysis of a sample of 424 psychiatric patients , morey et al .
( 14 ) found that a score of greater than three ( out of five ) on a short five - item scale , had a sensitivity of 79% and a specificity of 54% for a semi - structured interview diagnosis of pd .
( 20 ) have translated dsm-5 levels of personality functioning scale to farsi , and developed a semi - structured interview .
inter - rater reliability for semi - structured interview of dsm-5 levels of personality functioning items was above 0.80 .
the dsm-5 levels of personality functioning scale domains correlation with dsm - iv was between 0.30 and 0.69 .
the duration of the semi - structured interview for dsm-5 levels of personality functioning is 15 to 25 minutes . in the implementation process ,
the researchers included three post - graduates of clinical psychology . to avoid probable bias outcome from these people ,
they were not informed of the exact goal of the research in detail and they were told that the research goal was to study personality disorders .
they were entirely uninformed of the concerned disorder types . to control the probable bias , the research associates began to collect data periodically per step while they were blinded to the outcome of the previous or next step .
the colleagues were trained to use these instruments . after training under the supervision of the researcher , some people were actually interviewed , and the interviewers bug was fixed . as mentioned above ,
there were two groups of patients ( patients with personality disorders and normal subjects ) .
prior to the research onset , the participants were fully informed and provided a written consent . to avoid fatigue and to increase motivation in subjects , study for each subject
was conducted during two days . in the days following the completion of the demographic questionnaire
furthermore , cases , which had both symptoms of antisocial and borderline personality disorders , were examined by the structured clinical interview for personality disorders ( scid - ii ) .
after the definitive diagnosis of antisocial personality disorder and borderline , they were invited to attend the next stage of the interview process based on dsm-5 levels of personality functioning .
ethics approval was obtained from the university of social welfare and rehabilitation sciences research ethics committee , and the registered ethical code was 92/801/3110/2/a .
we computed bivariate correlations between the dsm-5 levels of personality functioning and aspd , and bpd symptoms . to examine which levels of personality functioning in patients with antisocial and borderline personality disorders can better predicted severity , stepwise regression analysis was used , in which scid - ii results ( aspd and bpd severity ) were the dependent variables and levels of personality functioning were the predictors .
of the 300 participants , 252 individuals with antisocial ( n = 122 ) and borderline personality disorders ( n = 130 ) were selected from september to november 2013 . with regard to  = 0.05 and
based on partial r = 0.095 , the sample size for antisocial personality disorder ( aspd ) was calculated to be 119 . for borderline personality disorder ( bpd ) ,
 and  were 0.05 and 80% , respectively , and four variables were tested by multiple regression analysis . based on partial r = 0.1 , the adequate sample size for bpd was 113 .
participants were selected from prisoners ( 48.8% ) , outpatients ( 16.5% ) and inpatients ( 7.5% ) .
they were recruited from tehran prisons , and clinical psychology and psychiatry centers of razi psychiatric hospital and taleghani general hospital , tehran , iran .
inclusion criteria were diagnosis of antisocial and borderline personality disorders ( for personality disorders ) , being at least 18 years old , having at least secondary education , and the exclusion criteria were presence of a psychotic disorder , presence of severe mood disorder , presence of mental retardation , and presence of physical condition that impairs the person 's mental state .
participants were 90.5% males and 9.5% females , aged 18 to 60 years ( sd =  1.37 ) , with guidance school degree education level or higher .
disorders of axis i ; 106 patients ( 42.06% ) had no impairment , 78 patients ( 30.97% ) had a history of substance - related disorders , 35 patients ( 13.88% ) had mood disorder , 15 patients ( 5.96% ) had anxiety disorders , 8 patients ( 3.17% ) had had a history of psychotic spectrum disorder and 10 patients ( 3.96% ) had other disorders .
data gathering measurements included psychological reports , scid - ii - pq , scid - ii , and dsm-5 levels of personality functioning checklist .  
the scid and its versions are considered to be the most comprehensive of the structured diagnostic interviews , which are currently available .
in fact , in 1987 they were new and wide range of instruments , by spitzer , gibbon , williams and built in compliance with the criteria of the dsm - iv ( 16 ) .
this instrument has been established as the gold standard for reliable assessment of psychiatric disorders .
inter - rater reliability for scid - i was above 70 for mood , anxiety , schizophrenic disorders and alcohol abuse ; it was somewhat lower for a few other disorders ( 17 ) , while for scid - ii it was reported between 0.48 and 0.98 for the categorical diagnoses ( cohen s  ) and 0.90 to 0.98 for the dimensional judgments ( intra - class correlation coefficient ) ( 18 ) .
cronbach s  was found between 0.71 and 0.94 for the scid - ii personality disorder scales ( 18 ) . due to high accuracy of the diagnostic criteria and extraordinary compliance with dsm - iv criteria , translated to and adapted with different languages . in iran scid - ii and scid - ii - pq
the duration of the scid - i is 30 to 90 minutes , the duration of the scid - ii is 30 to 60 minutes .
severity was determined in this study by the scores obtained from scid - ii .  
levels of personality functioning refer to the core capacities of personality - related self and interpersonal functioning and determining the severity of any impairment in these areas ( 12 ) .
the dsm-5 levels of personality functioning include identity , self - direction , empathy and intimacy .
the levels of personality functioning scale use each of these elements to differentiate five levels of impairment on a continuum of severity ranging from no impairment , i.e. healthy functioning ( level = 0 ) , to extreme impairment ( level = 4 ) ( 11 ) .
the more impairment in these areas , the more likely that person has pd . in preliminary analysis of a sample of 424 psychiatric patients , morey et al .
( 14 ) found that a score of greater than three ( out of five ) on a short five - item scale , had a sensitivity of 79% and a specificity of 54% for a semi - structured interview diagnosis of pd .
( 20 ) have translated dsm-5 levels of personality functioning scale to farsi , and developed a semi - structured interview .
inter - rater reliability for semi - structured interview of dsm-5 levels of personality functioning items was above 0.80 .
the dsm-5 levels of personality functioning scale domains correlation with dsm - iv was between 0.30 and 0.69 .
the duration of the semi - structured interview for dsm-5 levels of personality functioning is 15 to 25 minutes .
  the scid and its versions are considered to be the most comprehensive of the structured diagnostic interviews , which are currently available . in fact , in 1987 they were new and wide range of instruments , by spitzer , gibbon , williams and built in compliance with the criteria of the dsm - iv ( 16 ) .
this instrument has been established as the gold standard for reliable assessment of psychiatric disorders .
inter - rater reliability for scid - i was above 70 for mood , anxiety , schizophrenic disorders and alcohol abuse ; it was somewhat lower for a few other disorders ( 17 ) , while for scid - ii it was reported between 0.48 and 0.98 for the categorical diagnoses ( cohen s  ) and 0.90 to 0.98 for the dimensional judgments ( intra - class correlation coefficient ) ( 18 ) .
cronbach s  was found between 0.71 and 0.94 for the scid - ii personality disorder scales ( 18 ) . due to high accuracy of the diagnostic criteria and extraordinary compliance with dsm - iv criteria , translated to and adapted with different languages . in iran scid - ii and scid - ii - pq
the duration of the scid - i is 30 to 90 minutes , the duration of the scid - ii is 30 to 60 minutes .
  levels of personality functioning refer to the core capacities of personality - related self and interpersonal functioning and determining the severity of any impairment in these areas ( 12 ) .
the dsm-5 levels of personality functioning include identity , self - direction , empathy and intimacy .
the levels of personality functioning scale use each of these elements to differentiate five levels of impairment on a continuum of severity ranging from no impairment , i.e. healthy functioning ( level = 0 ) , to extreme impairment ( level = 4 ) ( 11 ) . the more impairment in these areas ,
the more likely that person has pd . in preliminary analysis of a sample of 424 psychiatric patients , morey et al .
( 14 ) found that a score of greater than three ( out of five ) on a short five - item scale , had a sensitivity of 79% and a specificity of 54% for a semi - structured interview diagnosis of pd .
( 20 ) have translated dsm-5 levels of personality functioning scale to farsi , and developed a semi - structured interview .
inter - rater reliability for semi - structured interview of dsm-5 levels of personality functioning items was above 0.80 .
the dsm-5 levels of personality functioning scale domains correlation with dsm - iv was between 0.30 and 0.69 .
the duration of the semi - structured interview for dsm-5 levels of personality functioning is 15 to 25 minutes .
in the implementation process , the researchers included three post - graduates of clinical psychology . to avoid probable bias outcome from these people ,
they were not informed of the exact goal of the research in detail and they were told that the research goal was to study personality disorders .
they were entirely uninformed of the concerned disorder types . to control the probable bias , the research associates began to collect data periodically per step while they were blinded to the outcome of the previous or next step .
the colleagues were trained to use these instruments . after training under the supervision of the researcher , some people were actually interviewed , and the interviewers bug was fixed . as mentioned above ,
there were two groups of patients ( patients with personality disorders and normal subjects ) .
prior to the research onset , the participants were fully informed and provided a written consent . to avoid fatigue and to increase motivation in subjects , study for each subject
was conducted during two days . in the days following the completion of the demographic questionnaire
furthermore , cases , which had both symptoms of antisocial and borderline personality disorders , were examined by the structured clinical interview for personality disorders ( scid - ii ) .
after the definitive diagnosis of antisocial personality disorder and borderline , they were invited to attend the next stage of the interview process based on dsm-5 levels of personality functioning .
ethics approval was obtained from the university of social welfare and rehabilitation sciences research ethics committee , and the registered ethical code was 92/801/3110/2/a .
we computed bivariate correlations between the dsm-5 levels of personality functioning and aspd , and bpd symptoms . to examine which levels of personality functioning in patients with antisocial and borderline personality disorders can better predicted severity , stepwise regression analysis was used , in which scid - ii results ( aspd and bpd severity ) were the dependent variables and levels of personality functioning were the predictors .
data are presented as mean  standard deviation ( sd ) or no ( % ) .
the mean and standard deviation scores of the levels of personality functioning in antisocial and borderline personality disorder groups are showed in table 2 .  
bivariate correlation between dsm-5 levels of personality functioning ( identity , self - directedness , intimacy , empathy ) and antisocial and borderline personality symptoms are presented in table 3 .  
as seen in table 3 , positive and significant correlations were found between antisocial personality symptoms and dsm-5 levels of personality functioning .
the total levels are highly correlated with aspd symptoms ( p value < 0.001 ) . in borderline personality disorder , except identity and empathy , other variables had significant correlations with bpd symptoms ( p value < 0.001 and < 0.05 ) . to examine the relationship between dsm-5 levels of personality functioning and aspd and bpd severity ,
a stepwise regression analysis was conducted , where aspd and bpd severity were the dependent variables and levels of personality functioning ( identity , self - directedness , intimacy , empathy ) were the independent variables .
the results of regression analysis for levels of personality functioning and aspd severity are presented in table 4 .  
these results indicate that approximately 21.7% , 31.4% , and 33% of the variance of the aspd severity could be accounted by identity , intimacy and self - directedness , respectively .
the data showed that identity , intimacy , and self - directedness significantly predicted antisocial personality disorder severity .
the results of regression analysis for levels of personality functioning and bpd severity are displayed in table 5 .  
the results showed that intimacy and empathy were good predictors of borderline personality disorder severity .
this means that approximately 16.5% and 25.1% of the variance of the bpd severity could be accounted for by these variables .
the first aim of this study was to examine the dsm-5 levels of personality functioning on an iranian sample with antisocial and borderline personality disorders .
the study findings revealed that all levels of personality functioning had significant positive correlations with aspd .
this means that dsm-5 levels of personality functioning had a good relationship with antisocial personality disorder symptoms of an iranian sample .
also , the findings indicate that except identity and intimacy , other variables ( self - directedness and empathy ) had a significant correlation with borderline personality symptoms .
it seems that the study population could be one of the reasons for these findings .
previous studies indicated that severity is the most important single predictor of concurrent and prospective dysfunction in assessing personality psychopathology ( 11 , 21 , 22 ) .
therefore , the second aim of this study was to explore which levels of personality functioning in patients with antisocial and borderline personality disorders can better predict severity .
the stepwise regression analysis results showed that identity , intimacy , and self - directedness are positively and significantly correlated with antisocial personality disorder severity , indicating that those with higher scores on these variables tend to have higher symptoms of aspd .
the analysis showed that intimacy and empathy had a significant association with borderline personality disorder severity .
it means that interpersonal level of personality functioning ( intimacy and empathy ) could explain the severity on patients with bpd in this study .
in addition , the results showed that the dsm-5 levels of personality functioning are an essential part of antisocial and borderline personality disorders .
also , the results revealed that levels of personality functioning were the same in other cultures and the iranian sample .
the present study is one of the first in which researchers examined the dsm-5 levels of personality functioning relationship with severity , and is the first study on iranian patients with personality disorders based on the dsm-5 approach .
overall , our findings showed that the levels of personality functioning are a significant predictor of antisocial and borderline personality disorders severity .
nevertheless , there are a number of important limitations in this work and future research is required to overcome such limitations .
firstly , the results are based on a relatively small number of cases and so caution should be taken in interpreting the data .
secondly , data was gathered by a semi - structured interview designed to assess a dimensional model of personality disorders , and future work should focus on other relevant instruments .
the third limitation of the current study was the nature of the sample , which was drawn from antisocial and borderline personality disorders .
thus , future research should examine the role of axis i disorders in personality disorders severity .
fifth , most participants in this study were males . therefore , other research is needed to investigate dsm-5 levels of personality functioning and severity in females .
seventh and finally , our work focused on the assessment of dsm-5 levels of personality functioning and severity in adults .
 background : fundamental problems with personality disorders ( pd ) diagnostic system in the previous version of dsm , led to the revision of dsm . therefore , a multidimensional system has been proposed for diagnosis of personality disorder features in dsm-5 . in the dimensional approach of dsm-5 , personality disorders diagnosis 
 is based on levels of personality functioning ( criteria a ) and personality trait domains ( criteria b).objectives : the purpose of this study was firstly , to examine the dsm-5 levels of personality functioning in antisocial and borderline personality disorders , and second , to explore which levels of personality functioning in patients with antisocial and borderline personality disorders can better predicted severity than others.patients and methods : this study had a cross sectional design . 
 the participants consisted of 252 individuals with antisocial ( n = 122 ) and borderline personality disorders ( n = 130 ) . 
 they were recruited from tehran prisoners , and clinical psychology and psychiatry centers of razi and taleghani hospitals , tehran , iran . 
 the sample was selected based on judgmental sampling . 
 the scid - ii - pq , scid - ii and dsm-5 levels of personality functioning were used to diagnose and assess personality disorders . 
 the data were analyzed by correlation and multiple regression analysis . 
 all statistical analyses were performed using the spss 16 software.results:firstly , it was found that dsm-5 levels of personality functioning have a strong correlation with antisocial and borderline personality symptoms , specially intimacy and self - directedness ( p < 0.001 ) . 
 secondly , the findings showed that identity , intimacy and self - directedness significantly predicted antisocial personality disorder severity ( p < 0.0001 ) . 
 the results showed that intimacy and empathy were good predictors of borderline personality disorder severity , as well ( p < 0.0001).conclusions : overall , our findings showed that levels of personality functioning are a significant predictor of personality disorders severity . 
 the results partially confirm existing studies . 
1. Background
2. Objectives
3. Patients and Methods
3.1. Study Population and Sampling
3.2. Materials
3.2.1. SCID
3.2.2. The DSM-5 levels of personality functioning scale
3.3. Procedure
3.4. Statistical Analysis
4. Results
5. Discussion