In the years following FDA approval of direct-to-consumer, genetic-health-risk/DTCGHR testing, millions of people in the US have sent their DNA to companies to receive personal genome health risk information without physician or other learned medical professional involvement. In Personal Genome Medicine, Michael J. Malinowski examines the ethical, legal, and social implications of this development. Drawing from the past and present of medicine in the US, Malinowski applies law, policy, public and private sector practices, and governing norms to analyze the commercial personal genome sequencing and testing sectors and to assess their impact on the future of US medicine. Written in relatable and accessible language, the book also proposes regulatory reforms for government and medical professionals that will enable technological advancements while maintaining personal and public health standards.

If the arguments of the preceding chapters are to be practically useful, it is necessary to move beyond claims about ‘personal bioinformation’ as a broad category, to locate how and why different bioinformation encounters may impact our identities in a variety of ways. It is also necessary to unpack further what attending to identity interests adds to the ethical and regulatory landscape. The chapter addresses each of these aims. It starts by reviewing the nature and strength of our identity-related interests – both in accessing personal bioinformation that supports the development and maintenance of inhabitable embodied self-narratives and in doing so in waysthat support this inhabitability. The discussion then explores the factors affecting when and why different information encounters engage or serve this fundamental interest. This entails examining why some kinds of bioinformation are experienced as having particular identity-significance at all and the factors shaping whether it then supports or undermines the inhabitability of our self-narratives. The chapter concludes by demonstrating that our narrative identity interests are neither coextensive nor reducible to the kinds of ethical concerns that currently dominate bioethical debates and information disclosure policies and the need to attend to identity impacts in their own right.

This is a commentary on Miller and Widiger’s (this volume) excellent chapter on personality disorders from the perspective of five factor personality models. In this commentary, the author discusses several issues of importance as the field moves forward with respect to dimensional personality-based diagnosis of personality disorder, most of which center on clinical application. First, a question is posed as to what level of personality abstraction is necessary for optimal formulation of personality disorders; although most five-factor models are established at the domain level, proposed personality disorder trait profiles appear at a much narrower facet level for which less scholarly consensus exist. Moreover, the author calls for more research into determining at what threshold on various trait dimensions clinical dysfunction begins to emerge. He also notes that most assessment devices currently available for dimensional trait models do not meet the Standards for Educational and Psychological Testing, which needs to be rectified prior to clinical application. Such tests also need to include validity scales to assess for noncredible responding. Finally, the author recommends that proposed personality inventories for these dimensional personality models show incremental utility above and beyond already well-established clinical assessment instruments.

The purpose of this rejoinder is to emphasize several important areas of future research that were mentioned by one or both commentaries. First, the authors discuss issues related to multi-source assessment, such as the importance of further research on informant bias, andargue that the information gleaned from multiple sources is worth the added assessment burden. Second, they underscore the importance of longitudinal assessment both in capturing the treatment-relevant within-person processes through which personality pathology unfolds, as well as tracking therapeutic progress. They assert that a given measure’s ability to reliably and validly measure change over time should be considered when evaluating its clinical utility. Finally, they emphasize the need for greater attention to clinical utility of dimensional PD assessment measures.

The authors of this commentary aim to expand on particular points covered in the chapter by Evans, Williams and Simms, and discuss other issues that were not covered there. First, they discuss future research directions for, and the potential utility of, multisource assessments of personality pathology. Second, they emphasize the need for aspects of clinical utility within some of the reviewed measures (e.g., norms, validity scales). Third, they discuss the need for further examinations into the feasibility and utility of longitudinal assessments of personality pathology (e.g., dynamics in the context of treatment). Fourth, they describe two recent measures of personality pathology that warrant further validation. Lastly, they emphasize the need for a conceptual and measurement-based consensus regarding the multidimensional nature of personality pathology as a whole.

The purpose of this chapter is to review the current state of the dimensional assessment of personality disorder (PD). The first part of the chapter serves as a review of the most well-established and commonly used measures of maladaptive personality traits. Measures that assess the psychosocial impairment associated with personality pathology also are reviewed. Areas of discontinuity among these measures (e.g., theoretical origin, method of scale construction, degree of correspondence with well-known trait dimensions, attention received in the empirical literature, degree of bipolarity of underlying dimensions) are emphasized, and the clinical utility of measures is evaluated. The second part of the chapter focuses on several controversial issues with which the field of dimensional PD assessment now is grappling. These issues include (a) the psychometric distinction of personality traits from personality functioning, (b) the incremental utility of adaptive trait assessment, (c) the question of maladaptive trait bipolarity, (d) facet-level differences versus domain-level similarity across competing PD trait models, and (e) the value of multi-source assessment.

Evans et al. (this volume) reviewed prominent dimensional measures of personality, discussed the clinical usefulness of these measures, and provided an overview of personality assessment issues. This commentary focuses on the clinical utility and applications of personality traits and assessment, as well as factors relevant to bridging the research-to-practice gap. In order to adequately disseminate and implement evidence-based personality assessments into practice, personality pathology researchers should be taking active steps to move the empirical base (e.g., validated models of personality, evidence-based assessments, aspects of clinical utility) into application. The process of translating these traits and measures into practice may include assessing barriers to use among practitioners, addressing matters of acceptability and feasibility, and providing training and consultation to practitioners. The authors review benefits of including adaptive traits in assessment and practice (e.g., assist with collaborative treatment planning, decrease stigma), provide commentary on the incremental utility of dysfunction including the use of external correlates, and outline the importance of bipolarity of dimensional trait measures.

For over a decade a transdiagnostic clinical staging framework for youth with anxiety, mood and psychotic disorders (linked with measurement of multidimensional outcomes), has been utilised in over 8,000 young people presenting to the enhanced primary (headspace) and secondary care clinics of the Brain and Mind Centre of the University of Sydney. This framework has been evaluated alongside a broad range of other clinical, neurobiological, neuropsychological, brain imaging, circadian, metabolic, longitudinal cohort and controlled intervention studies. This has led to specific tests of its concurrent, discriminant and predictive validity. These extensive data provide strong preliminary evidence that: i) varying stages of illness are associated with predicted differences in a range of independent and objectively measured neuropsychological and other biomarkers (both cross-sectionally and longitudinally); and, ii) that earlier stages of illness progress at variable rates to later and more severe or persistent disorders. Importantly, approximately 15-20% of those young people classed as stage 1b or ‘attenuated’ syndromes at presentation progress to more severe or persistent disorders. Consequently, this cohort should be the focus of active secondary prevention trials. In clinical practice, we are moving to combine the staging framework with likely pathophysiological paths (e.g. neurodevelopmental-psychotic, anxiety-depression, circadian-bipolar) to underpin enhanced treatment selection.

For over a decade a transdiagnostic clinical staging framework for youth with anxiety, mood and psychotic disorders (linked with measurement of multidimensional outcomes), has been utilised in over 8,000 young people presenting to the enhanced primary (headspace) and secondary care clinics of the Brain and Mind Centre of the University of Sydney. This framework has been evaluated alongside a broad range of other clinical, neurobiological, neuropsychological, brain imaging, circadian, metabolic, longitudinal cohort and controlled intervention studies. This has led to specific tests of its concurrent, discriminant and predictive validity. These extensive data provide strong preliminary evidence that: i) varying stages of illness are associated with predicted differences in a range of independent and objectively measured neuropsychological and other biomarkers (both cross-sectionally and longitudinally); and, ii) that earlier stages of illness progress at variable rates to later and more severe or persistent disorders. Importantly, approximately 15-20% of those young people classed as stage 1b or ‘attenuated’ syndromes at presentation progress to more severe or persistent disorders. Consequently, this cohort should be the focus of active secondary prevention trials. In clinical practice, we are moving to combine the staging framework with likely pathophysiological paths (e.g. neurodevelopmental-psychotic, anxiety-depression, circadian-bipolar) to underpin enhanced treatment selection.