The joint structure of DSM-IV Axis I and Axis II disorders.

The Diagnostic and Statistical Manual (4th ed. [DSM–IV]; American Psychiatric Association, 1994) distinction between clinical disorders on Axis I and personality disorders on Axis II has become increasingly controversial. Although substantial comorbidity between axes has been demonstrated, the structure of the liability factors underlying these two groups of disorders is poorly understood. The aim of this study was to determine the latent factor structure of a broad set of common Axis I disorders and all Axis II personality disorders and thereby to identify clusters of disorders and account for comorbidity within and between axes. Data were collected in Norway, through a population-based interview study (N = 2,794 young adult twins). Axis I and Axis II disorders were assessed with the Composite International Diagnostic Interview (CIDI) and the Structured Interview for DSM–IV Personality (SIDP–IV), respectively. Exploratory and confirmatory factor analyses were used to investigate the underlying structure of 25 disorders. A four-factor model fit the data well, suggesting a distinction between clinical and personality disorders as well as a distinction between broad groups of internalizing and externalizing disorders. The location of some disorders was not consistent with the DSM–IV classification; antisocial personality disorder belonged primarily to the Axis I externalizing spectrum, dysthymia appeared as a personality disorder, and borderline personality disorder appeared in an interspectral position. The findings have implications for a meta-structure for the DSM. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social phobia: Axis I and II correlates.

The presence of Axis I and Axis II disorders in 71 social phobic patients was examined. Generalized anxiety disorder was the common secondary Axis I disorder, followed by simple phobia. Avoidant personality disorder and obsessive-compulsive personality disorder were the most common Axis II diagnoses, and 88% of the sample exhibited features of these 2 personality styles. Ss with additional Axis I diagnoses were more anxious and depressed than those with no additional Axis I disorder. Social phobics with additional Axis II disorders were more depressed but not more anxious than those with no Axis II diagnosis. Furthermore, those with an additional Axis I disorder had higher scores on measures of neuroticism, interpersonal sensitivity, and agoraphobia. The prevalence and impact of additional Axis I and II disorders on the etiology, maintenance, and treatment outcome for persons with social phobia are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis II psychopathology as a function of Axis I disorders in childhood and adolescence

OBJECTIVE: To examine the occurrence of elevated personality disorder (PD) dimensional scores in a community sample of young adults as a function of the occurrence of Axis I disorders through age 18 years. METHOD: 299 individuals who had been interviewed regarding Axis I disorders twice while in adolescence (first when 14 through 18 years of age) were carefully assessed regarding Axis I and II psychopathology at age 24. RESULTS: The prevalence of PD diagnoses was relatively low (3.8% in participants with a history of Axis I versus 1.7% in participants with no Axis I history). The occurrence of all four Axis I diagnostic categories (major depression, anxiety disorders, disruptive behavior disorders, substance use disorders) in childhood and adolescence was associated with elevated PD dimensional scores. The likelihood of elevated PD dimensional scores increased as a function of the number of Axis I disorders. Elevated PD scores were significantly associated with a negative course of major depression. CONCLUSIONS: Although the rates of PDs were low, the findings suggest a substantial degree of association between early-onset Axis I disorders and Axis II psychopathology in young adulthood. More research is needed to develop assessment and treatment recommendations addressing the early manifestations of PDs.     

Axis I and II comorbidity in adults with ADHD.

Ongoing debate over the validity of the attention-deficit/hyperactivity disorder (ADHD) construct in adulthood is fueled in part by uncertainty regarding implications of potentially extensive yet incompletely described comorbid Axis I and II psychopathology. Three hundred sixty-three adults ages 18 to 37 completed semistructured clinical interviews; informants were also interviewed, and best estimate diagnoses were obtained. Results were as follows: First, ADHD combined type (ADHD-C) had an excess of externalizing and internalizing Axis I disorders, suggesting a gradient-of-severity relationship between it and ADHD inattentive type (ADHD-I). Second, ADHD-C and ADHD-I did not differ in frequency of Axis II disorders. Third, however, ADHD overall was associated with increased rates of Axis II disorders, compared with rates in non-ADHD control participants, including both Cluster B (primarily borderline personality disorder) and Cluster C disorders. Fourth, ADHD incrementally accounted for clinician-rated global assessment of functioning scores above and beyond comorbid conditions or symptoms on either Axis I or Axis II. Results further inform nosology of ADHD in adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of free radical production and scavengers on occlusion-reperfusion induced arrhythmias

The DSM-IV section of the DSM-IV and ICD-10 Personality Questionnaire (DIP-Q) was used to screen for personality disorders in 448 subjects from three clinical samples (general and forensic psychiatric patients and candidates for psychotherapy) and a sample of 139 healthy volunteers. Differences between the samples with regard to patterns of personality pathology in relation to concurrent Axis I disorders and sociodemographic variables were analysed. The prevalence of personality disorders according to DIP-Q was 14% among the healthy volunteers, compared to 59% in the general psychiatric sample, 68% in the forensic psychiatric sample and up to 90% among psychotherapy candidates. Moreover, from a dimensional perspective (i.e. the number of fulfilled Axis II criteria), all clinical groups differed significantly from the control group in all specified personality dimensions and clusters. Dimensional DIP-Q cluster scores also discriminated significantly between the three clinical samples. Unexpectedly, the odds ratio for an Axis II disorder was nearly five times higher among psychotherapy applicants than among general psychiatric patients, independent of concomitant Axis I disorders, gender or age. The strongest association between DIP-Q score and Axis I disorders was found for depressive disorders, which more than doubled the odds ratio for a personality disorder diagnosis. This association could result from high true comorbidity, but could also be due to the fact that a concomitant depressive state can increase self-reported personality difficulties. The high prevalence among psychotherapy candidates may to some extent reflect help-seeking exaggeration of problems. These are aspects to consider when using the DIP-Q, which overall appears to discriminate well between different samples.     

Associations in the Course of Personality Disorders and Axis I Disorders Over Time.

In this study, the authors examined time-varying associations between schizotypal (STPD), borderline (BPD), avoidant (AVPD), or obsessive-compulsive (OCPD) personality disorders and co-occurring Axis I disorders in 544 adult participants from the Collaborative Longitudinal Personality Disorders Study. The authors tested predictions of specific longitudinal associations derived from a model of crosscutting psychobiological dimensions (L. J. Siever & K. L. Davis, 1991) with participants with the relevant Axis I disorders. The authors assessed participants at baseline and at 6-, 12-, and 24-month follow-up evaluations. BPD showed significant longitudinal associations with major depressive disorder and posttraumatic stress disorder. AVPD was significantly associated with anxiety disorders (specifically social phobia and obsessive-compulsive disorder). Two of the four personality disorders under examination (STPD and OCPD) showed little or no association with Axis I disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship between the five-factor model of personality and Axis I disorders in a nonclinical sample.

The relationship between the 5-factor model (FFM) of personality and Axis I disorders was evaluated in a nonclinical sample of 468 young adults. In general, scores on the 5 personality dimensions of neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness (assessed via the NEO Five-Factor Inventory) distinguished Ss with and without a variety of Axis I diagnoses from the Diagnostic and Statistical Manual of Mental Disorders-III-Revised (DSM-III-R). In several instances, results indicate that scores on these dimensions were differentially sensitive to diagnosis. Furthermore, scores on these 5 personality dimensions accounted for unique variance in several Axis I diagnoses above and beyond that accounted for by a general measure of current psychopathological symptoms. These results support the utility of the FFM of personality in Axis I diagnostic assessment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Personality disorders among alcoholics and alcohol-comorbid subtypes with a Vietnam-era military sample.

Promotes the enhancement of the alcohol and psychiatric comorbidity typology by including the full range of Axis II personality disorders in addition to Axis I disorders. Data from 3,210 male Vietnam-era veterans were used to document the prevalence of personality disorders in male alcoholic Ss with and without other psychiatric comorbidity. Ss were classified into 1 of 6 groups. The results of the personality disorder scales of the MMPI demonstrate increased Axis II comorbidity in alcoholic Ss across a wide range of personality disorders compared with no-diagnosis control Ss and across alcoholic subtypes based on psychiatric comorbidity. In addition, a relationship was found between personality dysfunction and multiple comorbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Axis I and Axis II disorders as predictors of prospective suicide attempts: Findings from the Collaborative Longitudinal Personality Disorders Study": Correction to Yen et al (2003).

Reports an error in "Axis I and Axis II disorders as predictors of prospective suicide attempts: Findings from the Collaborative Longitudinal Personality Disorders Study" by Shirley Yen, Tracie Shea, Maria Pagano, Charles A. Sanislow, Carlos M. Grilo, Thomas H. McGlashan, Andrew E. Skodol, Donna S. Bender, Mary C. Zanarini, John G. Gunderson and Leslie C. Morey (Journal of Abnormal Psychology, 2003[Aug], Vol 112[3], 375-381). On p. 378, the values in the "95% CI" column of Table 1 are incorrect. The correct values are given in the far right column of the table provided in the erratum. (The following abstract of the original article appeared in record 2003-05990-006.) This study examined diagnostic predictors of prospectively observed suicide attempts in a personality disorder (PD) sample. During 2 years of follow-up, 58 participants (9%) reported at least 1 definitive suicide attempt. Predictors that were examined include 4 PD diagnoses and selected Axis I diagnoses (baseline and course). Multivariate logistic regression analyses indicated that baseline borderline personality disorder (BPD) and drug use disorders significantly predicted prospective suicide attempts. Controlling for baseline BPD diagnosis, proportional hazards analyses showed that worsening in the course of major depressive disorder (MDD) and of substance use disorders in the month preceding the attempt were also significant predictors. Therefore, among individuals diagnosed with PDs, exacerbation of Axis I conditions, particularly MDD and substance use, heightens risk for a suicide attempt. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An empirical study of the issue of sex bias in the diagnostic criteria of DSM-III Axis II Personality Disorders.

Responds to M. Kaplan's (see record 1984-06847-001) assertion that society encourages women to behave histrionically and dependently and then through the use of sex-biased diagnostic criteria, such as the DSM-III, labels these same women as mentally ill. To test Kaplan's hypothesis, the sex ratios of all of the DSM-III Axis II personality disorders were determined in 2 samples of 2,712 and 531 patients. Histrionic and dependent personality disorders were more commonly diagnosed in females, and antisocial personality disorder was more commonly diagnosed in males. The finding that there was no overall tendency for a female S to receive a personality disorder diagnosis more often than a male S provides no support for Kaplan's theory of sex bias in the DSM-III. (7 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Relationship of sociotropy/autonomy and dependency/self-criticism to DSM-III—R personality disorders.

Relationships between A. T. Beck's (1983) constructs of sociotropy/autonomy and S. J. Blatt's (see record 1976-12367-001) constructs of dependency/self-criticism and the Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III) Axis II personality disorders were examined. Two measures of personality styles and a structured diagnostic interview for personality disorders were administered to 138 outpatients. Significant relationships were found between both sets of constructs and a number of personality disorders using both categorical and dimensional measures of Axis II psychopathology. These relationships were consistent with previous theory, supporting recent conceptualizations extending the range of psychopathology associated with these personality styles from depression to the personality disorders. However, the autonomy/self-criticism dimension was correlated with a broader range of personality disorder traits and diagnoses than anticipated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The construct validity of depressive personality disorder.

This study examined the construct validity of depressive personality disorder (DPD; American Psychiatric Association, 1994). Adult Psychiatric outpatients (N=900) underwent comprehensive Axis I and II evaluations and provided data on 4,768 of their 1st-degree relatives. Despite modest overlap, DPD was not redundant with any Axis I or II disorder. Participants with DPD exhibited more Axis I and Axis II comorbidity, and greater psychosocial dysfunction, than participants without DPD. Relatives of participants with DPD had higher rates of mood disorders, alcohol abuse, and antisocial personality. Results are consistent with findings of several other similar investigations. The authors argue that DPD is a valid construct and should be conceptualized as a personality disorder as opposed to a mood disorder. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis I and Axis II disorders as predictors of prospective suicide attempts: Findings from the Collaborative Longitudinal Personality Disorders Study.

[Correction Notice: An erratum for this article was reported in Vol 113(2) of Journal of Abnormal Psychology (see record 2007-16710-001). On p. 378, the values in the "95% CI" column of Table 1 are incorrect. The correct values are given in the far right column of the table provided in the erratum.] This study examined diagnostic predictors of prospectively observed suicide attempts in a personality disorder (PD) sample. During 2 years of follow-up, 58 participants (9%) reported at least 1 definitive suicide attempt. Predictors that were examined include 4 PD diagnoses and selected Axis I diagnoses (baseline and course). Multivariate logistic regression analyses indicated that baseline borderline personality disorder (BPD) and drug use disorders significantly predicted prospective suicide attempts. Controlling for baseline BPD diagnosis, proportional hazards analyses showed that worsening in the course of major depressive disorder (MDD) and of substance use disorders in the month preceding the attempt were also significant predictors. Therefore, among individuals diagnosed with PDs, exacerbation of Axis I conditions, particularly MDD and substance use, heightens risk for a suicide attempt. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Axis I comorbidity of borderline personality disorder

OBJECTIVE: The purpose of this study was to assess the lifetime rates of occurrence of a full range of DSM-III-R axis I disorders in a group of patients with criteria-defined borderline personality disorder and comparison subjects with other personality disorders. METHOD: The axis I comorbidity of 504 inpatients with personality disorders was assessed by interviewers who were blind to clinical diagnosis and who used a semistructured research interview of demonstrated reliability. RESULTS: Four new findings emerged from this study. First, anxiety disorders were found to be almost as common among borderline patients (N=379) as mood disorders but far more discriminating from axis II comparison subjects (N=125). Second, posttraumatic stress disorder (PTSD) was found to be a common but not universal comorbid disorder among borderline patients, a finding inconsistent with the view that borderline personality disorder is actually a form of chronic PTSD. Third, male and female borderline patients were found to differ in the type of disorder of impulse in which they "specialized." More specifically, substance use disorders were significantly more common among male borderline patients, while eating disorders were significantly more common among female borderline patients. Fourth, a lifetime pattern of complex comorbidity (i.e., met DSM-III-R criteria for both a disorder of affect and a disorder of impulse at some point before the patients' index admission) was found to have strong positive predictive power for the borderline diagnosis as well as a high degree of sensitivity and specificity. CONCLUSIONS: These results suggest that the lifetime pattern of axis I comorbidity characteristic of borderline patients and distinguishing for the disorder is a particularly good marker for borderline personality disorder.     

Discriminant validity of the Psychopathy Checklist in a forensic psychiatric population.

The association between psychopathy and other mental disorders was investigated in 80 male forensic patients. Psychopathy was assessed with the Psychopathy Checklist (PCL; R. D. Hare [see PA, Vol 67:2477]). Diagnoses of other mental disorders were based on Axis I and Axis II criteria listed in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and on two standardized psychiatric rating scales. PCL diagnoses were significantly related only to antisocial and histrionic personality disorder (PD) and to nonalcohol substance abuse disorders. PCL ratings were also positively correlated with prototypicality ratings of antisocial, histrionic, and narcissistic PD and negatively correlated with ratings of avoidant PD. The results provide evidence for the convergent and discriminant validity of the PCL and are consistent with the view that psychopathy is a distinct clinical syndrome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Narcissism in the Rorschach revisited: Some reflections on empirical data.

This study investigates the extent to which the Rorschach was able to identify accurately pathological expressions of narcissism according to the methodological recommendations offered by T. Nezworski and J. Wood (1995) . Ninety-one patients who were found to meet DSM-IV criteria for an Axis II disorder (Cluster A personality disorders/&=/&10; antisocial/&=/&20, borderline/&=/&25, histrionic/&=/&5, narcissistic [NPD]/&=/&15; Cluster C personality disorders/&=/&16) and 50 nonclinical participants were compared on 5 Rorschach variables: reflection, pair, personalization, idealization, and the egocentricity index. The results of this study indicate that selected Rorschach variables can be used effectively to differentiate NPD patients from a nonclinical sample and from Cluster A, Cluster C, and other Cluster B personality disorders. Also, the reflection and idealization variables were found to be empirically related to DSM-IV diagnostic criteria for NPD and a self-report measure of NPD. Finally, these 2 variables could be used for classification purposes in ways that were clinically meaningful in the diagnosis of NPD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbid psychopathology in binge eating disorder: Relation to eating disorder severity at baseline and following treatment.

Individuals with binge eating disorder (BED) have high rates of comorbid psychopathology, yet little is known about the relation of comorbidity to eating disorder features or response to treatment. These issues were examined among 162 BED patients participating in a psychotherapy trial. Axis I psychopathology was not significantly related to baseline eating disorder severity, as measured by the Structured Clinical Interview for DSM-III-R (SCID-I and SCID-II) and the Eating Disorder Examination. However, presence of Axis II psychopathology was significantly related to more severe binge eating and eating disorder psychopathology at baseline. Although overall presence of Axis II psychopathology did not predict treatment outcome, presence of Cluster B personality disorders predicted significantly higher levels of binge eating at 1 year following treatment. Results suggest the need to consider Cluster B disorders when designing treatments for BED. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depressive personality: Associations with DSM-III-R mood and personality disorders and negative and positive affectivity, 30-month stability, and prediction of course of Axis I depressive disorders.

The authors addressed 5 issues bearing on the validity of the construct of depressive personality disorder (DPD): its relationship with the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association. 1987) mood and personality disorders and normal personality dimensions of negative and positive affectivity, its stability over 30-months, and its impact on the course of Axis I depressive disorders. Two samples were used: 156 outpatients with mood disorders, personality disorders, or both, and 267 of their 1st-degree relatives. The association between DPD and dysthymia was fairly modest, whereas the associations with major depression and the personality disorders were quite low. DPD was moderately correlated with both negative and positive affectivity; however it contributed unique information beyond that available from the 2 emotional superfactors. Finally, DPD was moderately stable over a 30-month period and was associated with a poorer course of depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)