Psychopathological Functioning Levels (PFLs) and their possible relevance in psychiatric treatments: a qualitative research project

Background Symptoms description is often not enough to provide clinicians with guidelines for treatments and patients’ clinical history does not represent an exhaustive source of data. Psychopathological dysfunctions are known to relate to the core disturbances that underlie different forms of psychopathology so the identification of such dysfunctions could be helpful for treatments. Some tools are available although highly complex and lengthy. This study aimed to provide clinicians with an easy-to-administer instrument able to capture different levels of impairment in psychopathological functioning, namely the Psychopathological Functioning Levels – Rating Scale (PFL-RS). Methods The Psychopathological Functioning Level - Research and Training Committee (PFL-RTC) has been established in Turin since 2002 including psychiatrists and clinical psychologists with extensive clinical and research experience. Our research was grounded on the Qualitative Research Criteria (QRC) 1-7 and conducted with subsequent steps in order to identify those core psychopathological dysfunctions to be rated by this tool. Results From 2002 until 2014, 316 outpatients were administered the clinical interview on at least two different occasions. Diagnoses were mixed and included: Schizophrenic and Psychotic Disorders, Depressive Disorders, Anxiety Disorders, Obsessive-Compulsive Disorder, Post- Traumatic Stress Disorder, Somatic Symptoms Disorders, Eating Disorders and Personality Disorders. Focus groups were conducted to identify those psychopathological dysfunctions which needed to be rated, according to two Phenomenological Selection Criteria (PhSC) and four Etiopathogenetic Selection Criteria (EtSC). As a result, five dysfunctional areas emerged: Identity (ID); Comprehension (CO); Negative Emotions (NE); Action-Regulation (AR); Social Skills (SS). After checking such dimensions for consistency with the existing instruments, 7 levels of severity were identified for each area. Finally, a provisional Italian schedule of Psychopathological Functioning Levels – Rating Scale (PFL-RS) was obtained and checked for semantic comprehension and then administered gathering preliminary data. Conclusions Psychopathological dysfunctions underlying mental disorders have been recognized in the present study with the PFL-RS. This instrument seems promising to inform in a specific way treatments strategies and goals, specifically concerning psychotherapy. Notwithstanding, further research is needed in order to confirm validity, sensitivity and reliability of this instrument.


Background
According to literature, symptoms description is not suitable to provide clinicians with guidelines for treatments [1,2]; similarly, patients' clinical history does not represent an exhaustive source of data able to guide therapists' reasoning [3].
Evidence showed that the comprehension of many psychic disorders can be increased by the identification not only of primary psychopathological dysfunctions underpinning each disorder [4][5][6], but also of those factors affecting their development [7,8].
To date, psychopathological dysfunctions are known to relate to core disturbances underlying different forms of psychopathology [9,10]. Therefore, the use of specific encoded features [11] to identify such dysfunctions could help plan treatments [12] and provide clinicians with individualized treatment options for their patients.
Unfortunately, the aforementioned instruments are highly complex and need further validation.
With more detail, some OPD dimensions [2] overlap thus are strictly interdependent; moreover, they are not enough sensitive when measuring patients' changes (i.e., Conflict Axis and Structure Axis). Similarly, some PDM Axis M categories [6] often overlap, since they aim to outline infinitely complex processes. Moreover, certain terms resulted to be either unfamiliar or relying excessively on a particular theoretical jargon [2,14]. So, greater detail and specificity in describing patients' psychopathology could be only pursued depending on time and experience [14].
Otherwise, the Five Factor Model (FFM) focuses on the variation of psychopathology at the adaptive poles, without explicitly measuring features located at the maladaptive ones [15].
Furthermore, the DSM-IV-TR Axis V-Global Assessment of Functioning (GAF) Scale does not have sufficient specificity to be useful in measuring severity of psychopathological dysfunctions [14].
Finally, the proposed criteria of the Appendix -Section 3 of the DSM-5 [16] try to represent in a novel way core psychopathological impairments in psychic functioning dimensions. However, they are proposed as crucial only with respect to personality disorders. Nevertheless, such criteria to date need further support and seem too complex to be successfully applied to every-day clinical work [17].
The overarching aim of this study was to provide clinicians with an easy-to-administer instrument able to capture different levels of impairment severity in psychopathological functioning, namely the Psychopathological Functioning Levels -Rating Scale (PFL-RS). This tool is characterized by the following features: 1. flexible use in order to maximize clinical utility; 2. clear expression of clinical and diagnostic guidelines in order to allow clinical assessments [2]; 3. use of an intermediate level of abstraction between behavior description and meta-psychological concepts [2]; 4. synthesis of the various concepts across self-other models to form a foundation for rating psychopathological functioning; 5. high formalization: an accurate description of those characteristics corresponding to each item is preferable when measuring the impairment in psychic functioning; 6. accessibility of language for clinical assessment [2]; 7. ease of administration: this tool is not designed to be used only by researchers with extensive training.
To our knowledge, no existing model and related assessment instrument encompasses this complete set of characteristics. This network includes: scientific promoter and coordinator (Andrea Ferrero), scientific supervisor (Secondo Fassino), scientific secretaries (Barbara Simonelli, Simona Fassina, Elisabetta Cairo, Giovanni Abbate-Daga), and researchers (psychiatrists, psychologists and psychotherapists).

Research theoretical background
Qualitative research aims to broaden the understanding of clinical experiences and phenomena as they are lived through situations, rather than testing hypothesized relationships or causal explanations, that benefit best from quantitative methods [18,19]. This central purpose is common to different approaches that have been developed in qualitative research. Nevertheless, each of them have its own traditions and methods, and a specification of the researchers' conceptual frameworks is therefore required [18,19] and guidelines have been developed in this regard [20].
In order to conveniently assess and present the results of our research, the following Qualitative Research Criteria (QRC) have been taken into account: (QRC1) the range of persons and situations to which the findings might be relevant are described; (QRC2) authors specify their theoretical orientations; (QRC3) coherence of the understanding with underlying structure for the phenomenon or domain is explained; (QRC4) the way of accomplishing specific research task is described; (QRC5) credibility checks (comparing the results with two or more varied qualitative perspectives) are provided; (QRC6) reviewers' judgements are provided; (QRC7) some brief clinical examples are proposed.
They were adopted with reference to the "Evolving guidelines for publication of qualitative research studies in psychology and related fields" - Table 1/B: "Publishability Guidelines Especially Pertinent to Qualitative Research" [19]. In more detail, QRC1 refers to the criterion B2 of the aforementioned Guidelines, QRC2 to the criterion B1, QRC3 to the criterion B5, QRC4 to the criterion B6, QRC5 to the criterion B4, QRC6 to the criterion B7, and QRC7 to the criterion B3. Finally, also the Consolidated Criteria for Reporting Qualitative Research (COREQ) [20] checklist has been applied.

Project steps
In line with the procedures used by OPD-2 and DSM-5 [2,16], subsequent steps were taken to identify core psychopathological dysfunctions to be rated by the novel instrument and to refine the levels of impairment in order to be diagnosed by a specific rating scale.
(Step A) Describing subjects of investigation (QRC 1) with multiple research meetings aiming to ascertain the feasibility of the study also discussing which diagnoses could be eligible; (Step B) Defining clinical domain and psychopathological theoretical model (according to QRC 1-2) specifying the psychopathology areas that the Authors aimed to refer to (QRC2) referring to the Vulnerability Events Personality -Psychopathological Model (VEP-PM); (Step C) Identification of core psychopathological dysfunctions (according to QRC 3-4) with a detailed analysis of the literature on such aspects; (Step D) Consistency with current research of the "Five psychopathological dysfunctions -rating model" (according to QRC 5) with respect to neuroimaging studies, Psychodynamic Diagnostic Manual -Axis M (PDM-M) 16 items [6] and Operationalized psychodynamic -Axis 4 (OPD-4) 13 items [2], "Personality Functioning Levels" and "Psychopathological traits" according to DSM-5 Appendix -Section 3 [16]; (Step E) Identification of different rating levels of psychopathological dysfunctions (according to    The tool to be developed is intended to assess different levels of psychopathological functioning underlying a variety of psychiatric disorders (QRC1). To this end, it must be specified which psychopathology the Authors refer to (QRC2).
According to the VEP-PM, the following pathogenic factors are considered: a) biological and psychosocial vulnerability; b) relevance of significant life events; c) Personality Organization.
Factors a) and b) are combined to generate suffering (VEP-PM causative psychopathological factors), while factor (c) rises from the patient's attempt to face it (VEP-PM compensatory psychopathological factor).

(Step C) Identification of core psychopathological dysfunctions
A focus group of 8 experienced clinicians and researchers (3 males and 5 females) working at the APPs-TR network (3 psychiatrists and 5 clinical psychologists) discussed and proposed criteria to identify those psychopathological dysfunctions which needed to be rated, also considering those targets potentially helpful in managing treatments across a wide range of psychic disorders. Also, data saturation was discussed.
Two Phenomenological Selection Criteria (PhSC) and four Etiopathogenetic Selection Criteria (EtSC) were chosen to highlight significant specific dysfunctional areas.
Phenomenological selection criteria (PhSC) (PhSC1) The dysfunctional area relates to phenomenological subjective dimension of experiences. (PhSC2) The dysfunctional area relates to phenomenic objective dimension of behaviours.

Etiopathogenetic selection criteria (EtSC)
(EtSC1) The dysfunctional area relates to empirical studies of disordered personalities. (EtSC2) The dysfunctional area deals with intrapsychic and relational aspects. (EtSC3) The dysfunctional area includes both verbally and non-verbally expressed attitudes. (EtSC4) The dysfunctional area relates to vulnerability and subjective relevance of significant life events ("VEP-PM causative psychopathological factors").
As a result, five dysfunctional areas finally met the aforementioned required criteria.

Identity (ID)
This area refers to self and others' representations [39,40], and includes 2 sub-dimensions.
Anti-ambivalent (precarious) identity means that contradictory aspects of self and others' representations persist in a disconnected way [2,39]. Hyper-ambivalent identity represents constancy, cohesion, and sense of relatedness which are preserved in an oscillatory and ambivalent way [2,39].
1) Ability to differentiate and integrate thoughts. It is impaired by reduced empathy, and intrapsychic [6] or environmental stressors [2]. Impairment may result in fragmentation, polarized divergences, concrete and somatic representations [6,41]. 2) Reflection ability (e.g., executive functioning, attention and signals elaboration). It is impaired because of a conflicting over regulation [2] resulting in oversimplification, displacement, control of causes, and avoidance of effects [6]. 3) Planning ability.
The latter deals with evaluation of different values, objectives, expectations or contexts, with prevision of environmental reactions, with creativity.
Negative emotions (NE) It refers to relational hardwired emotional connections [43], and includes 3 sub-dimensions.
This first sub-dimension is represented by fear, rage and panic, as brain's systems that generate instinctual-emotional behaviors [44,45]. They are necessary but not sufficient to generate higher order emotional expressions.
2) The lack of positive basic emotional feelings.
They moderate negative basic emotions. 3) Higher order negative emotional feelings.
They include shame, guilt, jealousy, envy, distrust, anxiety, and sadness [46] that derive from the interaction of the basic emotional system with learning (e.g., higher cognitive processes and culture).
Action-regulation (AR) It refers to behaviors and impulse control dysregulations [47]. This area includes 3 sub-dimensions.

1) Dysregulated behaviors.
Solipsististic and social retirement, as well as harmful and damaging behaviours toward one's self and others [41] may be intentionally or impulsively acted [2], threatened or imagined. 2) Maladaptive behaviors.
They result from the inadequate evaluation of environmental requirements under regulation and integration [2], reduced prevision and reward delay [2], and inappropriate focusing [6].
Social skills (SS) It refers to relationships, epistemic trust and culture [48] and includes 3 sub-dimensions.
1) Basic social autonomy (self-care, nutrition, dwell, and rules of living together). This sub-dimension deals with proper or emotionally disturbed perception of a wide range of signals [6]. 2) Ability to participate in socio-relational projects.
It deals with life tasks: love, friendship, study, work, and leisure activities involving loss and satisfaction, attention and distance, flexibility and persistence [2,6].

3) Ability to promote socio-relational projects
This aspect determines the aforementioned life tasks but it involves also desire and investment, organization and determination [2,6], choices and ethics [41]. ( Step D) Consistency with current research of the "Five psychopathological dysfunctions -rating model" As a subsequent step, the consistency of the five-areas rating model with other models proposed in literature to evaluate specific dysfunctional aspects has been checked.
The identification of the aforementioned core psychopathological areas emerges as positively related to a number of current research findings.
1) Neuroimaging studies demonstrate that brain is not only active while when stimulated, but also during the resting state. Therefore, resting state's spatiotemporal structure is central and may serve as the neural predisposition of what psychodynamics describe as the psychological structure of the Self, interacting with several brain processes relating to sensorimotor, affective, cognitive and social domains [49]. Cognitive, affective and social neurosciences thus justify a dimensional approach to psychopathological dysfunctions focusing Identity (ID), which specifically refers to the resting-state intrinsic activity of the brain, as well as Cognition (CO), Negative Emotions (NE), Action-Reaction (AR) and Social Skills (SS), as dimensions which refer to specific levels of bottom-up processes of brain activity faced to extrinsic situations [49]. 2) Psychodynamic Diagnostic Manual -Axis M (PDM-M) 16 items [6] and Operationalized psychodynamic -Axis 4 (OPD-4) 13 items [2] are specifically devoted to the assessment of mental functioning and structure. Comprehensively, all the five selected areas of this model are considered by both manuals, and in turn there are no PDM and OPD items which are not included. Identity (ID) differentiation and constancy of self and others' representations, as well as the characteristics of anti-ambivalent or hyperambivalent identity are investigated in PDM-M Self-Observation, Internal Representations, and Defensive Patterns subscales rather than in OPD-4 Self-Perception and Defences subscales. Capacity of differentiating and integrate thoughts, reflection (executive functioning, attention, and signals elaboration) and planning, altogether refer to the Comprehension (CO) area of this model, and are described in PDM-M Self-Observation, Internal Representations, Differentiation-Integration and Regulation subscales [6], rather than in OPD-4 Self-Perception and Self-Regulation subscales [2]. Negative Emotions (NE), namely negative core (basic) emotional feelings, lack of positive basic emotional feelings and higher order negative emotional feelings, are included in PDM-M Internal Experience and Affective-Communicative Experiences subscales [6], as well as in OPD-4 Self-Perception subscale [2]. Dysregulated, maladaptive and restrained behaviours, as components of the Action-Regulation (AR) area, are assessed in PDM-M Internal Representations, Regulation, and Moral Sense subscales [6] and in OPD-4 Self-Regulation and Communication subscales [2].

(Step E) Identification of different rating levels of psychopathological dysfunctions
Experts' consensus has been reached on the evaluation of severity in order to create a solid dimensional system of psychopathology [51]. According to recent research [52], there is a correlation between both severity and disability of a mental disorder and the level of impairment of individuals' psychopathological functioning. Relatedly, outcome is predicted in a more accurate way by severity than by a mere disorder classification [17,53]. More specifically, prior research with reference to "primitive", "intermediate", and "more advanced" levels of dysfunctions that characterize anaclitic and self-definitional disorders indicated that patients' response to treatment is consistent with their diverging Personality Organization [54].
According to the VEP-PM theoretical model, the APPs-TR network focus-group decided that different dysfunctional levels in these areas should consider Personality Organization in terms of mechanisms of defence, coping, and creative compensations. These mechanisms are overall considered to underlie the quality of patient's attempts to face and reduce pain and discomfort.
Different dysfunctional degrees in core psychopathological dysfunctions were therefore considered only if meeting the following Etiopathogenetic Selection Criterion (EtSC).
(EtSC5) The levels of psychopathological dysfunctions relate to Personality Organization ("VEP PM compensatory psychopathological factor"), that is each impairment level should correspond to a different Personality Organization (PO).
PO refers to a set of enduring, mostly unconscious, brain mechanisms [12,55] and psychological structures that dynamically organize mental processes and contents into a coherent organization. These dynamically organized structures and processes are assumed to be involved in self-structure, cognition, affect regulation, impulses, and quality of relationships [40,56,57], in turn determining the levels of impairment.
Nevertheless, PO is still a latent construct, which can only be inferred from manifest indicators [57].
Seven Psychopathological Functioning Levels (PFL) of each area met the required selection criterion.
They were ordered progressively [58] along a continuum [17] of pathological PO [59,60], according to Kernberg's model [61] and subsequent integrations provided by recent research focusing on defence mechanisms, sharing the assumption that levels of PO follow a developmental progression from severely undifferentiated and disorganized levels of PO to mature, integrated, and differentiated levels of PO [12].
In fact, the Borderline Personality Organization, which was originally divided in two levels [61], was classified in this study into three levels, according to prototypical descriptions of the Structured Interview of Personality Organization (STIPO) [Clarkin JF, Caligor E, Stern BL, Kernberg OF. Structured Interview of Personality Organization (STIPO). New York, unpublished document 2004] and to the Defence Mechanisms Rating Scale (DMRS) findings [62]: 1) with prevalent use of major image-distorting defences, 2) with prevalent use of minor image-distorting defences, 3) with prevalent use of both minor image-distorting and disawoval defences.
Additionally, a specific level was dedicated to the coexistence of Neurotic and Borderline Personality Organizations, namely when the use of the above mentioned immature defences is displayed only in situations characterized by severe threats and/or when it is widely intertwined with the use of neurotic defences (e.g., repression). In addition, this level significantly correlates with "Neurotic 2" PO, according to  1) According with more recent views of personality pathology as developmental delays as opposed to failures [63,64], PO is not conceived as a rigid (adaptive or maladaptive) structure, but as a flexible set of psychic dynamics that may vary along the lifespan, proceeding from early childhood interactions [65][66][67] and depending also from significant life events. Therefore, there is a correlation of PO with more stable character traits and more extemporaneous responses to state of mind [68]. PO not only describes different levels of defences, as they were ranked by several rating scales (DSM IV -TR Defense Functioning Scale-DFS [69], Defense Style Questionnaire -DSQ [70], Defense Mechanisms Rating Scales -DMRS [71]), but also the degree of creative exploration and mental transformation of experiences [42]; moreover, dysfunctional defences might be adaptive in certain circumstances [68]. 2) Defences may make dysfunctional areas resistant to change [62]. To provide a few examples, splitting defences may hinder self-cohesion, pertaining to Identity (ID); denial or repression may interfere with cognitive processes and beliefs, pertaining to Cognition (CO); introjection or affect isolation can relate to persistence of emotionally significant experiences (e.g., rage or feeling of emptiness), pertaining to Negative Emotions (NE); acting-out affects surface traits (e.g., impulsiveness or inhibition), individual quality of relationships, and specific behaviors (e.g., self-mutilation or attempt of suicide), that pertain to Action-Regulation (AR) and Social Skills (SS). These findings constitute an additional reason for distinguishing different levels of dysfunctional areas with reference to individuals' PO. 3) Furthermore, recent studies demonstrate [72] that PO has not only to be considered as a set of processes employed against particular impulses or wishes, but it may be seen as developing within the context of close relationships with relevant others, and may serve as a means for satisfying sociorelational goals [36,73]. Thus, PO can be reasonably also valued as a modulating factor of interpersonal style and coping, pertaining to the Social Skills (SS) area, behaviours dysregulation, pertaining to Action-Regulation (AR), and social cognition, pertaining to Cognition (CO). For example, idealization or projection mechanisms influence relationships. 4) From a clinical point of view, a significant differentiation of personality disorders, depression, and anxiety groups by defence use alone was repeatedly found [74,75]. 5) Pretreatment PO characteristics were found to be predictors of sustained therapeutic change [54]. A recent systematic review [12] suggests that higher initial levels of PO are moderately to strongly associated to better treatment outcome, and different levels of PO may interact with the type of psychotherapeutic intervention (e.g., interpretative vs. supportive). Defence style was found to be correlated with both the course of early phases and premature termination of psychotherapy [68] and to influence therapeutic alliance [76,77]. Finally, defence style can be seen as an outcome measure rather than a predictor [68] and PO could also lead the clinician to appreciate, by repeated measures, if patients' maladaptive attitudes will change over time towards a better or worse psychic functioning. ( Step G) Providing a provisional Italian schedule of psychopathological functioning levelsrating scale (PFL-RS) Finally, the schedule was based on the following steps. To date, a number of reliable and valid measures that assess personality functioning and psychopathology demonstrate that a self-other dimensional perspective has an empirical basis and significant clinical utility [81]. This approach was found to be informative in understanding those mental processes associated with psychopathology phenomenology, in planning treatment interventions, in anticipating treatment course and outcome, and in measuring change in treatment [81]. More in detail, current diagnostic and statistical research leads to consider that different degrees of maladaptive integration and balance of interpersonal relatedness and self-definition are involved across a variety of psychopathological pathways underlying symptoms [38]. These recent findings are also consistent with VEP-PM, strengthening Alfred Adler's assumption concerning the related relevance of social interest and striving for power as effective factors of psychic health or disease. The patient's emphasis on selfdefinition (internal perspective) or on relatedness (external perspective) delineates individual's identity, meanings, and forms of cognition, feelings and affects, behaviors and reactions, qualities of relationships [38].
Patients with psychotic, borderline, neurotic, and mature Personality Organization were included and the PFL-RS provisional schedule overall provided 14 definitions for each area, in a two by two order on a progressive scale.

(Step H) Checking semantic comprehension of PFL-RS definitions by mental health professionals
The semantic comprehension of the PFL-RS provisional schedule was refined by asking clinicians to read and provide feedback on the proposed definitions of the psychopathological dysfunctions.
All 70 definitions making up the schedule were evaluated for their comprehensibility by 20 reviewers (7 males and 13 females): 5 expert clinicians (2 psychiatrists and 3 clinical psychologists), 10 mental health professionals (MHP) (3 psychiatrists, 2 childhood and adolescence psychiatrists, 2 clinical psychologists, 3 nurses) and 5 trainee graduate psychologists. The task was carried out in two subsequent stages.
After the first reading, 20 corrections have been proposed by reviewers concerning ID area, 13 concerning CO area, 15 concerning NE area, 13 concerning AR area, and 5 concerning SS area. Furthermore, 7 of overall corrections were referring to dysfunctional level 1, 5 to dysfunctional level 2, 3 to dysfunctional level 3, 4 to dysfunctional level 4, 11 to dysfunctional level 5, 10 to dysfunctional level 6, and 1 to dysfunctional level 7.
These corrections were recognized as relevant and accepted by PFL-RTC scientific coordinator, supervisor and secretaries.
A second reading of the derivative revised version of the schedule was provided by reviewers. They added further corrections: 2 were concerning ID area, 1 was concerning CO area, 2 were concerning NE area, 4 were concerning SS area since no additional correction were proposed concerning AR area. Concerning dysfunctional levels, 1 correction was concerning level 3, 7 were concerning level 4, and 1 was concerning level 6, while no additional correction were proposed concerning levels 1,2 and 5. Also these corrections were afterwards implemented into the schedule.
For further details see Table 1.  [82]. Subsequently, an English translation of PFL-RS schedule was provided by a motherlanguage psychiatrist and psychotherapist; a back translation was then conducted to confirm the accuracy of the original text (Tables 7, 8, 9, 10 and 11). Patients were      Tables 2, 3, 4, 5 and 6. PFL-RS can be repeated multiple times to assess patient's psychopathological dysfunctions during the course of treatments.
Raters are asked to choose the definition that best describes patient's worst psychic functioning at that moment. PFL rating may be different in each area of the same patient. Although short, a specific training is recommended in order to provide guidelines to conduct this assessment.

Internal perspective
External perspective ARi-1 The individual shows alienated (and/or) stereotyped (and/or) self-destructive behaviors deriving from an impaired reality testing ARe-1 The individual shows alienated (and/or) stereotyped (and/or) destructive other-behaviors deriving from an impaired reality testing ARi-2 The individual commits suicidal attempts (and/or) self-harm (and/or) alienated behaviors that substitute other mental contents and expressions of needs ARe-2 The individual commits alienated (and/or) aggressive behaviors towards others that substitute other mental contents and expressions of needs The individual threatens to commit suicidal attempts (and/or) self-harm (and/or) alienated behaviors that substitute other mental contents and expressions of needs ARe-3 The individual shows clastic behaviors (and/or) threatens to commit alienated (and/or) aggressive behaviors towards others that substitute other mental contents and expressions of needs The individual daydreams to commit suicidal attempts (and/or) self-harm (and/or) alienated behaviors that substitute other mental contents and expressions of needs ARe-4 The individual daydreams to commit clastic (and/or) alienated (and/or) aggressive behaviors towards others that substitute other mental contents and expressions of needs In specific situations the individual's behavior does not consider the existing discrepancy between subjective meanings and environmental requests ARe-5 In certain situations the individual's behavior is impulsive (and/or) inhibited because he/she does not consider in a realistic way the favorable (and/or) unfavorable factors

ARi-6
The individual pursues his/her own realistic aims in an excessively reduced way and assumes avoidant (and/or) too resigned (and/or) too worried behaviors ARe-6 The discrepancies between subjective intentions and environmental requests produce defeatist (and/or) too passive (and/or) too preoccupied behaviors ARi-7 The individual pursues his/her own realistic aims without assuming avoidant (and/or) resigned behaviors and he/she can postpone satisfaction of his/her own needs ARe-7 The discrepancies between subjective intentions and environmental requests do not produce excessively defeatist (and/or) passive (and/or) stubborn behaviors The individual's ability to be autonomous and to engage in a comparison with others is a source of difficulty, even in the absence of negative events SSe-5 The individual has difficulties in alternating relational distance and closeness (and/or) effort and self-restraint (and/or) activation and asking for help (and/or) cooperation and opposition SSi-6 When establishing or continuing significant relationships the individual shows in some aspects an excessive tendency to avoidance (and/or) pessimism (and/or) excessive tension (and/or) passivity SSe-6 The individual imagines significant relationships but in case of need shows an excessive increase in the fear of promoting them (and/or) in the preoccupation about how they may proceed (and/or) in the tendency to adapt himself/herself to others SSi-7 The individual imagines significant relationships and copes with the difficulties without too defeatist (and/or) discouraged (and/or) preoccupied attitudes SSe-7 The individual appears sufficiently calm and trustful in the establishment (and/or) continuation of meaningful relationships processes can be inferred by contradictions and narrative structure.
Raters are also required to mark down the quality of patient-therapist relationship; this will be considered as a control variable during the evaluation, eventually suggesting absence of relationship, opposition versus willingness, idealized, dependent, supportive, fearful, preoccupate, dismissing, or cooperative relationship, only to name a few (see Tables 12 and 13).

(Step J) Preliminary data on the administration of the PPFLs, PFLs and PFL-RS to different clinical samples
In order to assess patients' dysfunctions, more than a decade ago, the clinicians of the Mental Health Department of the ASL Turin 4 in Italy started using the "Primary Psychotherapeutic Focus Levels" (PPFLs) and "Personality Functioning Levels" (PFLs), two sets of definitions pioneering the PFL-RS (see Step G).
More in detail, from 2004 to 2007, when conducting the Brief-Adlerian Psychodynamic Psychotherapy (B-APP) therapists based their treatment strategies on the description of patient's psychological functioning according to the PPFLs. Such a psychopathology-based psychotherapy showed efficacy and improved symptoms and global functioning in a sample of patients with Generalized Anxiety Disorder [83].
Furthermore, from 2006 to 2011, the multidisciplinary therapeutic team of Mental Health Service (MHS) in Chivasso (Turin, Italy) was trained and supervised to assess different PFLs which served as benchmark for the Supervised Team Management (STM) of clinical projects for patients with Borderline Personality Disorder in a community setting. Treatments included medications, unstructured psychological support (UPS) focused on socio-relational impairment or a specific time-limited psychotherapy (Sequential Brief-Adlerian Psychodynamic Psychotherapy -SB-APP), and rehabilitative interventions [22,80]. A set of definitions of different impairment levels concerning the same five core areas that will be envisaged to be investigated by PFL-RS (see Table 14) was evaluated by two independent raters, in order to adjust the modulations of the therapeutic relationship to fit each specific patient [22,23].  Come si manifesta: nei casi più gravi consiste nel chiedere una immediata disponibilità, cui segue la fuga quando il terapeuta può essere presente, oppure comporta un'alternanza tra grande soddisfazione se il terapeuta risponde alle funzioni che il paziente gli ha assegnato e grande oppositività e delusione se il terapeuta non soddisfa le attese.
Overall, STM had to consider that patients, when at PFL-1 and PFL-2, unconsciously fear that their fragile identity might collapse (ID 1-2). In this regard, empathic validation and, to a lesser degree, clarification and affirmation could effectively convey constructive experiences opposite to precarious self-cohesion (ID 1-2). The latter is represented by patient's inability to think when others are present (CO 1-2) and to tolerate (NE 1-2) the therapist as endowed of a separate existence (SS 1-2). At PFL-3, STM took into account that patients are largely engaged in denying self-other contradictory images (ID 3) as relevant for their life and behaviors (AR 3-4), since at PFL-4 this attitude only appears when facing specific tearing emotions and situations (ID 4). Treatments were aimed at reducing the sense of emptiness (NE 3-4; SS 3-4) and increasing continuity and adaptation: systematic consideration was paid to patients' concrete way of thinking (CO 3-4), actingout (AR 3-4), and discontinuities in their social relationships involving intimacy (SS 3-4).
In a preliminary clinical randomized study, thirty-five outpatients with BPD meeting inclusion criteria of service heavy users were evaluated. The study was aimed to evaluate the efficacy of PFLs informed clinical projects (STM), both including UPS and SB-APP, compared to Treatment As Usual (TAU) [80].
PFLs' scoring was not included as patients' assessment measure at baseline, since PFLs' set of definitions had not been validated yet. However, it was found that overall PFL's scoring distribution at baseline varied depending on each considered psychopathological area (see Table 15) and it did not overlap with the scores on Clinical Global Impression (CGI) [84], Symptom Checklist-90 Revised (SCL-90-R) [85] and Global Assessment of Functioning (GAF) [69], both in UPS and SB-APP group, thus providing specific additional clinical information (see Table 15). Compared to Treatment As Usual (TAU), after one year of treatment, STM showed an overall improvement in clinical severity (CGI) [84], global functioning (GAF) [69], and all nine psychopathological domains included in the diagnosis of BPD (CGI-

T-OD: ALTERNATION OF DEMONSTRATION OF OPPOSITIONAL BEHAVIORS AND OPENNES TOWARDS THE THERAPIST
The therapist is not considered as a whole but only concerning some partial functions as imagined by the patient: mirroring, accepting weaknesses or threats, being present without a relationship.
How it can be shown: in most severe cases this consists in asking an immediate availability and then run away when the therapist can be present or as an alternation between great satisfaction when the therapist responds to the functions that the patient assigned to him/ her and great oppositional behaviors when the therapist does not fulfill the patient's expectations.

T-ID: IDEALIZED RELATIONSHIP WITH THE THERAPIST
The most stable relationship of the patient is with his/her therapist who is imagined as always comprehensible since completely positive and not entailing any risks of abandonment.
How it can be shown: it is recognizable because the patient seems to be unable to do without the therapist and the patient has to continuously verify the therapist's presence and tolerates exceptions to being accepted only in favor of people who are perceived as in strict harmony with the therapist.

T-DI: DEPENDENT RELATIONSHIP WITH THE THERAPIST
The patient lives the therapist in a realistic way but in the context of a relationship which is imagined as absolutely privileged and stable.
How it can be shown: it is recognizable because the patient seems to be unable to do without the therapist although the therapist's absence is tolerated, and exceptions to being accepted are tolerated only favor of people who are perceived as not in contrast with the therapist.

T-SU: THERAPEUTIC RELATIONSHIP WITH EXCESSIVE NEED OF SUPPORT
It is a relationship between two distinct persons but the individual is afraid that the relationship with the therapist is weak and fragile.
How it can be shown: the supportive relationship is recognizable because the patient is mainly characterized by an attitude of need (e.g., child, schoolchildren, sufferer).

T-AL: DIALOGIC THERAPEUTIC RELATIONSHIP, WITH EXCESSIVE APPREHENSION
It is a relationship between two different persons but the individual is afraid of the relationship with a poorly reliable therapist.
How it can be shown: the dialogic relationship is sufficiently dialogic but, in order to be accepted, the patient avoids to value the therapist's positions.

T-RC: DIALOGIC THERAPEUTIC RELATIONSHIP, WITH EXCESSIVE NEED FOR REWARD
It is a relationship between two different persons but the individual is afraid of the relationship with a therapist who is too far.
How it can be shown: the relationship is sufficiently dialogic but, in order to be accepted, the patient extremely values the therapist's positions.

T-AS: DIALOGIC THERAPEUTIC RELATIONSHIP, WITH EXCESSIVE NEED FOR ASSERTIVENESS
It is a relationship between two different persons but the individual is afraid that the relationship with the therapist is very competitive and demanding. How it can be shown: the relationship is sufficiently dialogic but, in order to affirm himself/herself, the patient reduces the importance of the therapists' positions.
T-CO: COOPERATIVE DIALOGIC THERAPEUTIC RELATIONSHIP It is a relationship between two different persons who cooperate with understanding and confrontation.
How this can be shown: the relationship is sufficiently dialogic and the patient is open to consider the therapist's positions.
M items 1-9) [80]. Both compliance to treatments and quality of therapeutic alliance were greater as well.
More in detail, one large (and also statistically significant) effect size was found for the outcome of identity disturbance (SMD 0.88, 95 % CI 0.16 to 1.60), a core dysfunctional area assessed by previous research [86].
This area was negatively correlated with self-harm and hospitalization rates. The reduction of dramatic occurrences and unscheduled interventions could highlight that a significant component of symptoms might be reduced by treatments informed by a specific assessment of underlying psychopathological dysfunctional areas [80].
Finally, the overall improvement in global functioning (GAF) [69] seems particularly important because patients' quality of life remained poor, even after well-designed therapeutic interventions [80].
To date, PLS-RS was randomly administered to a small sample of 54 outpatients consecutively recruited at the Psychotherapy Unit in Settimo Torinese, Turin, Italy, together with the Temperament and Character Inventory (TCI) [37], Spielberger State and Trait Anxiety Inventory [87], Beck Depression Inventory [88], and the State-Trait Anger Expression Inventory [89]. Sixty % of the sample was composed by males and 40 % by females and their mean age was 29.03 ± 13.2 years (range: 17-64 years). The interviewers were either male (A.F.) or female researchers (S.F., E.C., B.S.) with MD or PhD credentials and extensive training (i.e., at least 5 years) in research. At the time of the study they were all working at the same facility (i.e., Psychotherapy Unit in Settimo Torinese, Turin, Italy) and all interviews were conducted there. Before starting this study, the researchers did not know the potential participants and contacted them using a face-to-face approach. Eight people refused to take part in this study because of lack of time. Before starting the interview, all participants were informed about the main goals of the study with the interviewers clarifying the main assumptions of this work. During the interview, only the researcher and the participant were present. Audio recording was not used because of research feasibility reasons; however the interviewer took notes of the interview during the assessment. Transcripts were not shared with participants and their feedback on the interview was encouraged but not formally required.
Three data coders coded the data according to the coding scheme provided by the authors. The Statistical Package for Social Sciences 21.0 (SPSS, SPSS Inc., Chicago, IL) was used for analysing the data. Concerning internal consistency, all PFL-RS subscales correlate strongly to each other. For example, Pearson's correlation coefficient between internal and external perspectives of ID is r = .904, of CO is r = .901, NE is r = .922, AR is r = .614, SS is r = .,892. Moreover, HA on the TCI correlates positively with ID, CO, NE, and AR; finally, correlations have been also found between PFL-RS subscales and measures of depressive symptoms, anxiety, and anger. With more detail, ARe was inversely correlated with BDI (r = −.319, p = .024), STAI-trait (r = −.296, p = .035), and STAXI (r = −.396, p = .004). Also ARi was negatively correlated with STAI-trait (r = −.457, p = .001) and STAXI (r = −.431, p = .002). IDe was found to negatively correlate with STAXI (r = −.309, p = .029) as well as NE e (r = −.291, p = .040).
Finally, given the clinical use of this instrument considering each psychopathological areas and its global dimension, Cronbach's alpha was .971. However, exhaustive  research in order to assess PFL-RS validity, sensitivity and reliability is currently needed.

Discussion
The comprehensive approach of this research aimed to ascertain to what extent psychopathological dysfunctions underlying mental disorders can be recognized considering seven different levels of PO [90], resulting from patients' attempts to cope with suffering caused by vulnerabilities and life events.
PO cannot be directly assessed [12] and its definition was conveniently obtained by considering five primary PO manifestations that have been recognized as crucial. Some instruments assessing PO use self-report questionnaires. Such an approach jeopardizes the ability to capture psychopathological dysfunctions since selfreport tools are insufficiently tailored to describe mental contents and processes that are warded off through defences and self-serving biases [12]. Rating scales can be useful for standardized and comparable observations along with statistical analysis, although they are less detailed when compared to intensive research conducted on small samples or single cases [91].
PFL-RS will be first tested in Italy but it is likely that it will be used in different Countries since differences in personality patterns among individuals with mental disorders do not vary widely across cultures [92].
Although empirical foundations of psychodynamicoriented classification of mental disorders is still far from being conclusive [93], preliminary findings suggest that PFL-RS could provide clinicians with a way to better understand specific aspects of patients' psychopathological dysfunctions, using detailed features in a convenient way and without receiving extensive training.
Furthermore, according to previous research (PPFLs, PFLs), PFL-RS seems promising to inform in a specific way treatments strategies and goals, specifically concerning psychotherapy [22,23,90]; in fact, literature highlights that level of PO may interact with the type of treatment interventions [12].

Conclusions
Guidelines for treatments can only rarely be obtained by a mere symptoms description of patients' clinical condition and history. Different forms of psychopathology are underpinned by certain core disturbances which can relate to psychopathological dysfunctions with the latter being particularly helpful to guide treatments. However, it is not easy to identify such psychopathological dysfunctions; to date, some tools are available although highly complex and time consuming. To bridge this gap, with this study we aimed to develop the Psychopathological Functioning Levels -Rating Scale (PFL-RS), an easy-to-administer instrument focused on the identification of different levels of impairment in patients' psychopathological functioning. This instrument investigates five dysfunctional areas: Identity (ID); Comprehension (CO); Negative Emotions (NE); Action-Regulation (AR); Social Skills (SS) providing 7 levels of severity for each area. The preliminary sample considered showed some limitations including a broad age range; however, further research is needed to perform a full validation of this tool. Notwithstanding, this instrument showed encouraging results with respect to the plan of treatment strategies although further research is warranted to confirm its psychometric properties and clinical adaptability.