Brief Scale Reliably Measures Personality Functioning in Women With ADHD

A psychometric study published in Borderline Personality Disorder and Emotion Dysregulation has confirmed that the Level of Personality Functioning Scale-Brief Form 2.0 reliably assesses personality pathology in adult women diagnosed with attention-deficit/hyperactivity disorder. Conducted by researchers Dara E. Babinski and Daniel A. Waschbusch, the investigation evaluated self-reported clinical data from 171 women aged 29 to 55 across the United States. Confirmatory factor analysis demonstrated that the twelve-item screening questionnaire possesses a robust two-factor structure, dividing into six items reflecting self functioning impairment and six items reflecting interpersonal functioning impairment. Both subscales exhibited strong reliability and accounted for substantial variance across the cohort. Crucially, multiple regression analyses established that these personality dimensions explained unique variance in functional impairment beyond the simultaneous contributions of attention-deficit/hyperactivity disorder severity, depression, and generalized anxiety. The findings provide the first empirical validation of this brief dimensional measure in women with attention-deficit/hyperactivity disorder, offering clinicians a reliable tool to identify individuals needing adjunctive interventions alongside standard care.

The clinical necessity for validating personality assessment tools in this population arises from high rates of co-occurring personality disorders among women with attention-deficit/hyperactivity disorder. Clinical estimates indicate that between 10 percent and 75 percent of adults diagnosed with attention-deficit/hyperactivity disorder also meet criteria for a personality disorder, with borderline and antisocial personality disorders appearing most commonly, alongside frequent paranoid and histrionic diagnoses. Approximately 60 percent of women with borderline personality disorder retrospectively report childhood attention-deficit/hyperactivity disorder, while borderline pathology shows comorbidity rates as high as 80 percent with other personality disorders. This diagnostic co-occurrence carries profound personal and societal burdens, including elevated frequencies of aggression, self-harm, suicidal ideation, and substance use compared to either condition alone. Moreover, emerging evidence suggests that personality pathology compromises adherence to standard attention-deficit/hyperactivity disorder treatments. While stimulant medications represent the primary evidence-based pharmacological treatment for adult attention-deficit/hyperactivity disorder, they lack efficacy for personality pathology, which lacks FDA-approved pharmacotherapies and typically requires psychotherapeutic approaches such as dialectical behavior therapy.

Accurate clinical identification has long been hindered by the limitations of traditional categorical diagnostic systems. In traditional diagnostic manuals, personality disorders are treated as categorical entities defined by polythetic behavioral symptoms, an approach that produces excessive comorbidity and complicates intervention. To address these issues, psychiatric research has shifted toward dimensional assessment models, notably the Alternative Model of Personality Disorders in Section III of the DSM-5. Under this model, Criterion A defines the core of personality pathology through the level of personality functioning, evaluated on a continuum from zero, indicating little or no impairment, to four, representing extreme impairment. This framework assesses functioning across four specific domains: identity and self-direction, which constitute self functioning, and empathy and intimacy, which define interpersonal functioning. Meeting Criterion A requires moderate impairment across at least two domains. This dimensional perspective also underpins the ICD-11 classification, which defines personality pathology through overall personality functioning rather than categorical groupings.

The Level of Personality Functioning Scale-Brief Form 2.0 was created as an efficient twelve-item self-report questionnaire measuring these Criterion A dimensions. Items are rated on a four-point Likert scale ranging from one, meaning completely untrue, to four, meaning completely true. Six items assess self functioning disturbances, such as lacking a clear sense of identity or having difficulty understanding internal thoughts and feelings. The remaining six items evaluate interpersonal functioning problems, including difficulty cooperating with others or empathizing with their perspectives. Total scores span from 12 to 48 under unidimensional scoring, while separate subscales for self and interpersonal domains range from 6 to 24, with higher scores reflecting greater impairment. While personality functioning has sometimes been conceptualized as a unitary construct, empirical investigations in general and clinical cohorts largely support a two-factor correlated structure. Furthermore, bifactor models testing a general factor alongside specific subscales have shown poor utility, frequently yielding anomalous negative factor loadings.

To examine the psychometric properties of this scale in attention-deficit/hyperactivity disorder, the researchers recruited 171 adult women through social media advertisements directed at individuals diagnosed in adulthood. Participants were required to be in middle adulthood, specifically aged 29 to 55 years, reside in the United States, provide informed consent electronically, and possess English language proficiency. To reduce clinical heterogeneity, the study excluded individuals with self-reported diagnoses of bipolar disorder, autism spectrum disorder, schizophrenia, or other psychotic disorders. Data integrity was safeguarded by screening completion speeds against an established threshold that flags protocols completed more than twice as fast as the median duration. No participant met this exclusion criterion, permitting all 171 records to be retained for statistical analysis. Study procedures were reviewed and approved by the university Institutional Review Board and adhered to the 1964 Declaration of Helsinki, ensuring rigorous ethical oversight throughout the recruitment and testing processes.

The web-based survey administered a comprehensive battery of validated measures assessing psychiatric symptomatology and impairment. Adult attention-deficit/hyperactivity disorder symptoms were measured using the 18-item Adult Self-Report Scale, which displayed good internal consistency with a Cronbach’s alpha of 0.874. Depressive symptoms were evaluated via the 20-item Center for Epidemiologic Studies Scale for Depression, yielding scores from 0 to 60 and demonstrating excellent internal consistency with a Cronbach’s alpha of 0.917. Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 screening questionnaire, which scores seven symptoms over the preceding two weeks from 0 to 21, achieving good reliability with an alpha of 0.882. Real-world functional impairment was documented using the Impairment Rating Scale for Adults across eleven specific life domains and one global impairment item, rated from zero to six. Because participants could skip non-applicable items, response rates varied across domains, such as peer and family relationships (N = 169), sibling relationships (N = 151), relationships with parents (N = 158), work progress (N = 140), coworker relationships (N = 133), supervisor relationships (N = 132), romantic relationships (N = 133), and self-esteem and overall impairment (N = 171). Two academic items were omitted from regression analyses due to markedly reduced responses.

Confirmatory factor analysis was conducted in Mplus 8.2 using robust maximum likelihood estimation, which accounts for potential distributional non-normality. Model fit was evaluated using standard fit indices: RMSEA at or below 0.07, CFI at or above 0.95, TLI at or above 0.95, and SRMR at or below 0.05. A unidimensional model demonstrated modest fit: chi-square(54) = 131.720, p < .001, RMSEA = 0.092, CFI = 0.936, TLI = 0.922, and SRMR = 0.064. Modification indices highlighted significant residual covariance between item 5 (difficulty understanding one’s own thoughts and feelings) and item 7 (difficulty understanding the thoughts and feelings of others). Allowing these items to correlate improved unidimensional fit: chi-square(53) = 118.354, p < .001, RMSEA = 0.085, CFI = 0.945, TLI = 0.933, and SRMR = 0.061. However, the hypothesized two-factor correlated model displayed superior fit: chi-square(53) = 88.441, p = .016, RMSEA = 0.063, CFI = 0.971, TLI = 0.964, and SRMR = 0.050. Allowing items 5 and 7 to correlate further enhanced fit: chi-square(52) = 66.443, p = .086, RMSEA = 0.040, CFI = 0.988, TLI = 0.985, and SRMR = 0.044. A direct chi-square difference test confirmed that this two-factor solution fit the data significantly better than the single-factor model (delta chi-square = 51.911, delta df = 1, p < .001).

In the finalized two-factor model, all item factor loadings were statistically significant. The self functioning factor explained an average of 50.4 percent of observed variance, while the interpersonal factor explained 46.1 percent. Internal consistency was excellent for self functioning (Cronbach’s alpha = 0.819) and good for interpersonal functioning (Cronbach’s alpha = 0.786). The two latent factors correlated strongly at r = .794, p < .001, and factor scores were normally distributed. Bivariate correlations showed that both factors were robustly associated with attention-deficit/hyperactivity disorder, depression, anxiety, and all functional impairment domains. Prior to regression modeling, variance inflation factors were confirmed to be below 3.0, indicating acceptable collinearity.

Simultaneous multiple regression analyses in SPSS 29 revealed that personality functioning factors explained unique variance in daily impairment while controlling for attention-deficit/hyperactivity disorder, depression, and anxiety. The interpersonal factor uniquely predicted impairment in relationships with peers, parents, general family, coworkers, and supervisors. In contrast, the self functioning factor uniquely predicted impairment in self-esteem, romantic relationships, and general family functioning. Notably, the self functioning factor was the sole significant unique predictor of overall functional impairment when controlling for all psychiatric covariates. The authors noted that intimate romantic relationships demand substantial self-disclosure, which may explain their specific vulnerability to self-identity impairment.

The authors noted several study limitations, including virtual recruitment relying on self-reported attention-deficit/hyperactivity disorder diagnoses without clinical interviews or informant ratings. The exclusion of bipolar disorder, autism spectrum disorder, and psychosis may limit generalizability, while the modest cross-sectional sample of 171 women precluded longitudinal testing or invariance evaluations across gender groups. Additionally, the correlation between items 5 and 7 suggests potential wording redundancy or shared emotion recognition deficits. Nonetheless, the findings demonstrate that the LPFS-BF 2.0 is a reliable, valid instrument for assessing personality pathology in adult women with attention-deficit/hyperactivity disorder, supporting its integration into clinical assessments to guide comprehensive care.

Subject of Research: Psychometric evaluation of the Level of Personality Functioning Scale-Brief Form 2.0 in adult women diagnosed with ADHD

Article Title: Psychometric properties of the Level of Personality Functioning Scale- Brief Form 2.0 (LPFS-BF 2.0) in women with attention-deficit/hyperactivity disorder

Article References: Babinski, D. E., & Waschbusch, D. A. (2026). Psychometric properties of the Level of Personality Functioning Scale- Brief Form 2.0 (LPFS-BF 2.0) in women with attention-deficit/hyperactivity disorder. Borderline Personality Disorder and Emotion Dysregulation, 13(1), Article 1. https://doi.org/10.1186/s40479-025-00334-y

Image Credits: AI Generated

DOI: 10.1186/s40479-025-00334-y

Keywords: ADHD in women, LPFS-BF 2.0, personality functioning, Alternative Model of Personality Disorders, Criterion A, self functioning, interpersonal functioning, confirmatory factor analysis, psychometric properties, functional impairment, borderline personality disorder, psychiatric comorbidity, Adult Self-Report Scale, CES-D, GAD-7, Impairment Rating Scale for Adults, dimensional assessment