The undisordered personality: Normative assumptions underlying personality disorder diagnoses.

Clinical diagnoses are impossible without referring to normative assumptions about what is desirable functioning. In this paper, the authors explicate the implicit normative assumptions that seem to have guided the formulation of the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) personality disorder (PD) criteria. Then the authors discuss various conceptual reference frames in which such assumptions may be grounded: (1) a given diagnostician’s personal value system, (2) the expectations of the culture in which a person currently lives, (3) the expectations of the culture in which a person was raised, (4) models of “natural” personality functioning that are rooted in evolution theory, and (5) the presence of distress and/or impairment. In accordance with Wakefield (1992a, 2006), the authors argue that PD diagnoses necessarily involve both an evolutionary and a cultural component. If PDs were defined completely in cultural terms, investigating their biological underpinnings would be nonsensical. In addition, the values of any specific culture should not be given too much weight, because cultural expectations may themselves be harmful. Future editions of DSM should define personality pathology in less culture-relative terms, and address the inevitable issue of values more explicitly. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of systematic variation in retrospective conduct disorder reports on antisocial personality disorder diagnoses.

A diagnosis of antisocial personality disorder (ASPD) requires a conduct disorder (CD) diagnosis. A CD diagnosis is often obtained retrospectively. This study tested the influence of current behavior on CD recall and the association between recent behavior change and inconsistencies in contemporaneous and retrospective CD reports. Five hundred young adults reported ASPD; retrospective CD; current problem behavior; and, at ages 12 to 15 years, contemporaneous CD. True-positive, true-negative, false-positive, and false-negative CD and ASPD groups were identified. The results supported the hypotheses. Participants whose current behavior agreed with past behavior provided reliable retrospective CD reports. Inaccurate diagnoses occurred among participants whose current behavior was inconsistent with past behavior, either becoming more problematic (CD and ASPD false positives) or less problematic (CD and ASPD false negatives) over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The test-retest reliability of the Mini-Mental State Examination in chronic schizophrenic patients

Between 1984-1987, 50 patients with Ewing's sarcoma of the bone were entered on combined modality protocol at Tata Memorial Hospital. Protocol treatment involved induction therapy consisting of 6-week therapy with vincristine, Adriamycin (doxorubicin), and cyclophosphamide (VDC) followed by local radiotherapy 50 Gy to the involved bone. This was followed for six more cycles of VDC. Five patients had metastatic disease at presentation. Seventy-six percent (38/50) of patients had disease either at axial or proximal site. With a median follow-up of 48 months (range 14-87) 21 patients remained alive with disease-free survival of 38.0% +/- 2.5% at 5 years and overall survival of 36.0% +/- 2.6% at 5 years. Twenty-five patients relapsed with five patients developing local failure and four local and distant metastasis. Using Lee-Desu statistical methods, only response to therapy was a significant factor for survival. We conclude that more aggressive therapy with proper selection of local treatment modality including surgery and/or radiotherapy is required to produce more long-term survival in high-risk Ewing's sarcoma.     

Delusions and hallucinations in patients with borderline personality disorder

OBJECTIVE: Heat exposure has been shown to stimulate GH release, but the specificity and the reproducibility have not been determined, and the test has not been compared with validated GH stimulation tests in adulthood. We therefore tested the specificity and the reproducibility of the heat exposure test in healthy subjects and compared the results with those obtained with the insulin-tolerance test (ITT). DESIGN: Ten healthy non-obese men, aged 31.3+/-4.80 years, underwent four GH stimulation tests in random order: two ITTs and two heat exposure tests. In the heat test, subjects were placed in a hot bath with water temperature at 40.3+/-0.11 degrees C for 45 min, resulting in an identical (P = 0.477) significant increase in tympanic temperature of 1.26+/-0.05 and 1.41+/-0.07 degrees C in the two tests. RESULTS: Peak GH response to the heat exposure test was less than the peak GH response to ITT (5.25+/-1.72 vs 15.5+/-3.17 microg/l, P = 0.006). Furthermore the specificity (arbitrary cut-off level = 3 microg/l) of the heat test was lower than of the ITT (8/17 vs 18/20, P = 0.006). The coefficient of variation did not differ between the two tests (heat test 0.31, ITT 0.36, P = 0.77). Peak GH values in the individual tests were highly correlated (heat, r = 0.908, P = 0.002; ITT, r = 0.815, P = 0.004). Reproducible increments in the circulating levels of stress hormones were observed during ITT. but these hormones remained largely unchanged during heat exposure. CONCLUSIONS: The heat exposure test is not a reliable GH stimulation test compared with the ITT in adults. This study documents that the ITT has a high specificity and reproducibility in the diagnosis of GH deficiency in adulthood. We propose that the heat exposure test is not used in the diagnosis of this condition in adulthood.     

Complex cognitive therapy treatment for personality disorder patients

Preliminary studies have found cognitive therapy to be a promising treatment for personality disorder patients. Therapy is based on an individualized formulation of the case and is generally much more complex and potentially more lengthy than the treatment for patients with Axis I disorders alone. Modifications of treatment include a greater focus on the therapeutic relationship, increased emphasis on developmental events, variations in session structure, and utilization of specialized strategies to alter dysfunctional beliefs and compensatory behavioral strategies.     

Five-factor model personality disorder prototypes in a community sample: Self- and informant-reports predicting interview-based DSM diagnoses.

The need for an empirically validated, dimensional system of personality disorders is becoming increasingly apparent. While a number of systems have been investigated in this regard, the five-factor model of personality has demonstrated the ability to adequately capture personality pathology. In particular, the personality disorder prototypes developed by Lynam and Widiger (2001) have been tested in a number of samples. The goal of the present study is to extend this literature by validating the prototypes in a large, representative community sample of later middle-aged adults using both self and informant reports. We found that the prototypes largely work well in this age group. Schizoid, Borderline, Histrionic, Narcissistic, and Avoidant personality disorders demonstrate good convergent validity, with a particularly strong pattern of discriminant validity for the latter four. Informant-reported prototypes show similar patterns to self reports for all analyses. This demonstrates that informants are not succumbing to halo representations of the participants, but are rather describing participants in nuanced ways. It is important that informant reports add significant predictive validity for Schizoid, Antisocial, Borderline, Histrionic, and Narcissistic personality disorders. Implications of our results and directions for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Rethinking the comparison of borderline personality disorder and multiple personality disorder

This article has made a number of points that assert what is today a minority position within the fields of MPD/DID and BPD. We hope our views will stimulate attempts by others to rethink their positions and test our assertions, so that issues surrounding these two disorders can be sharpened. For the sake of the clarity of future work, we summarize in outline form the essence of our viewpoint. 1. BPD and MPD/DID have similar appearing symptoms, such as identity problems, unstable affect modulation, self-destructive behaviors, chaotic impulse control, and troubled interpersonal relationships, but they have decisive differences in underlying dynamics, process, and structure. 2. DSM tends to blur these two disorders by its emphasis on phenomenology over inner structure, thus fostering misleading conclusions when DSM criteria are used to test for comorbidity or overlap between BPD and MPD/DID. 3. BPD and MPD/DID are both described dynamically as using the defense of splitting, but we contend that the splitting in each disorder is fundamentally different from the splitting in the other. BPD uses a polarization form of splitting, whereas MPD/DID uses ego splitting or identity division. 4. Both disorders partake in the process of dissociation, but the quality of dissociation in BPD is a "low-tech" spaced out type, whereas that of MPD/DID is a "high-tech" waking dream. 5. BPD structure is also "low tech," with polarization of self, object, and relationship. MPD/DID structure is "high tech," with heavily symbolic, highly nuanced variations of self, object, and relationship. 6. Although both conditions have etiologic elements of trauma, BPD has a larger degree of developmental deficiency, with a failure to complete the task of entering a repression hierarchy of defenses. MPD/DID, by use of primary process-linked symbolic dissociation, is able to continue development to the repression hierarchy, although at a profound cost of simultaneous suspension of reality testing. BPD patients suffer from the rigid use of too few defenses; MPD/DID patients suffer from the obsolete use of too many defenses. 7. BPD patients grow up in homes in which overtly expressed aggression is more tolerated, or at least more openly experienced. MPD/DID patients grow up in homes in which the fact of aggression is kept a secret. This has consequences for the formation of psychic structure in each disorder.(ABSTRACT TRUNCATED AT 400 WORDS)     

One-day test-retest reliability of neuropsychological tests in a personal injury case.

The difficulties inherent in differentiating practice effects from meaningful changes in neuropsychological retest data are well known to clinicians. Although gross actuarial guidelines are available on the basis of group studies, the application of such information to individual cases presents many interpretive complexities. This is particularly true when litigation is involved or the retest interval is very short. The case presented here involved examinations performed independently on successive days by 2 diplomate neuropsychologists. The majority of tests produced clinically equivalent results in both examinations. Increases of more than 2 SEMs were found on only 4 measures in the retesting and were associated with practice effects. Both neuropsychologists independently concluded that the examination did not reveal neuropsychological impairment, suggesting that clinical prediction is possible and may be valid in the forensic context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Depressive response to physostigmine challenge in borderline personality disorder patients

The purpose of this study was to examine the relationship between mood and hormonal responses to cholinergic challenge with physostigmine in order to assess cholinergic system responsiveness in borderline personality disorder (BPD) patients, other non-BPD personality disorder patients, and normal controls. Thirty-four personality disorder patients, 10 of whom met criteria for BPD and 24 of whom met criteria for other, non-borderline, personality disorders, and 11 normal controls participated in a double blind, placebo controlled physostigmine challenge paradigm. The Profile of Mood States depression subscale (POMS-D) self report measure was obtained at baseline and following the physostigmine or placebo infusions. A repeated measures ANOVA of POMS-D scores in placebo and drug conditions indicated a significantly greater depressive response in the total cohort of personality disorder patients than in the normal comparison group (p < 0.05). However, the depressive response to physostigmine was significantly greater in BPD patients, but not other personality disorder patients, compared to normal controls (p < 0.05). There was a correlation between the peak placebo-corrected depressive response to physostigmine and a group of BPD traits related to affective instability but not a group of BPD traits related to impulsivity. There was no correlation in any group between mood response to physostigmine and changes in plasma cortisol, prolactin, or growth hormone, or to nausea or other side effects following physostigmine infusion. These data suggest that there is an association between BPD and acute depressive responses to physostigmine challenge, and that the cholinergic system may be involved in the regulation of affect in Axis II disorders.     

The relationship of DSM-III-R personality disorder to clinical variables in patients with major depression: possible difference between personality disorder clusters

The authors evaluated in 1987-1994 the incidence of nosocomial rotavirus infections during hospitalization in 1718 junior children, 450 senior children and adults admitted with diarrhoeal diseases. Rotavirus infection was revealed in 6.2 and 1.3% of the patients resp. During hospitalization the rotaviruses were the most frequent causal agent of nosocomial infections. Hospital infection was contracted regardless of the initial diagnosis most frequently by patients aged 0-12 months. The majority of nosocomial rotavirus infections was associated with symptoms of diarrhoeal disease, on average symptomatic infections prolonged the hospitalization period by 4.2 days. The authors discuss the possibility to influence the incidence of these infections.     

Suicidality in borderline personality disorder

Pathogenic fungi that cause systemic mycoses retain several factors which allow their growth in adverse conditions provided by the host, leading to the establishment of the parasitic relationship and contributing to disease development. These factors are known as virulence factors which favor the infection process and the pathogenesis of the mycoses. The present study evaluates the virulence factors of pathogenic fungi such as Blastomyces dermatitidis, Coccidioides immitis, Cryptococcus neoformans, Histoplasma capsulatum and Paracoccidioides brasiliensis in terms of thermotolerance, dimorphism, capsule or cell wall components as well as enzyme production. Virulence factors favor fungal adhesion, colonization, dissemination and the ability to survive in hostile environments and elude the immune response mechanisms of the host. Both the virulence factors presented by different fungi and the defense mechanisms provided by the host require action and interaction of complex processes whose knowledge allows a better understanding of the pathogenesis of systemic mycoses.     

Treatment outcome for substance misuse patients with personality disorder

Treatment outcome was compared for three groups of patients in a chemical dependency unit--14 patients with personality disorder, 16 patients with traits of personality disorder, and 34 patients with no personality disorder. Patients with personality disorder were as likely as other patients to complete the 4-month aftercare program and to maintain abstinence while in the aftercare program.     

Inter-observer and test-retest reliability of the Italian version of the Karolinska Psychodynamic Profile in two groups of psychiatric patients

A total of 64 psychiatric patients were tested with the Italian version of the Karolinska Psychodynamic Profile in order to investigate interobserver and test-retest reliability. The mean inter-observer agreement coefficients (rho) ranged from 0.75 to 0.80 with less experienced psychiatrists, while the mean rho value was higher (0.96) with more experienced raters. Test-retest values were good, ranging from 0.53 to 0.93. Overall, reliability was comparable with that reported in the original Swedish study.     

The relationship between patient, informant, social worker, and consensus diagnoses of personality disorder in elderly depressed inpatients

The A. nidulans cysD gene encoding homocysteine synthase (O-acetyl-L-homoserine sulphydrylase) has been isolated by functional complementation of a cysD11 mutation. The gene contains five short introns and codes for a protein of 437 amino acids. The protein shows homology with bacterial and yeast O-acetyl- and O-succinyl-homoserine sulphydrylases, particularly from Schizosaccharomyces pombe, Saccharomyces cerevisiae and Kluyveromyces lactis. The cysD cDNA is able to complement a S. cerevisiae mutation impairing homocysteine synthase. Synthesis of the cysD mRNA is down-regulated by a high concentration of methionine in growth medium without sulphate and up-regulated under sulphur limitation. A comparison of cysD genomic and cDNA copies, derived from different A. nidulans strains, revealed a marked DNA-sequence polymorphism manifested mostly by silent point mutations. There was, however, much less polymorphism in the protein sequence.     

Divalproex sodium for impulsive aggressive behavior in patients with personality disorder

OBJECTIVE: Divalproex sodium, an anticonvulsant and antimanic agent, has recently been studied for its antiaggressive effects in patients with brain injuries, dementia, and borderline personality disorder. Since patients with other personality disorders also exhibit impulsive aggressive behavior, we conducted a preliminary open-label trial of divalproex sodium as a treatment for irritability and aggression in patients with a variety of personality disorders. METHOD: Ten patients meeting DSM-IV criteria for at least one personality disorder were treated with divalproex sodium in an 8-week open clinical trial. All patients had failed a trial of a selective serotonin reuptake inhibitor (SSRI). Divalproex sodium was increased as tolerated using a flexible dosing schedule. Clinician ratings for impulsive aggressive behavior and irritability were made every 2 weeks using the modified Overt Aggression Scale (OAS-M). RESULTS: Six of 8 completers reported significant decreases in irritability (p = .003) and impulsive aggressive behavior (p = .019). For the entire sample, improvement on OAS-M irritability and overt aggression scores was noted by the end of 4 weeks and continued to occur through week 8. CONCLUSION: This study suggests that divalproex sodium is an effective treatment for impulsive aggressive behavior in some patients with personality disorder who fail to respond to other antiaggressive agents (i.e., SSRIs). Controlled studies are needed to determine which patients are most likely to benefit from divalproex sodium and to evaluate the differential effectiveness of various agents in reducing impulsive aggressive behavior.     

DSM-IV Cluster A personality disorder diagnoses among young adults with a 2-7-8 MMPI profile

The Ethical Principles exhort psychologists "to encourage ethical behavior by students, supervisees, employees, and colleagues, as appropriate" (American Psychological Association, 1992, p. 1599). In spite of a clear directive to attempt resolution of unethical conduct by colleagues, research indicates that satisfactory resolution or actual reporting of misconduct is infrequent. This paper will address some of the forces that discourage psychologists from dealing responsibly and appropriately with professional misconduct by colleagues. The goals of this paper are to promote understanding of factors that interfere with the effective resolution of ethical misconduct, to identify possible signs of reluctance to address misconduct, and to propose strategies to combat those forces that keep us in silent collusion with colleagues who engage in unethical practices. A flowchart of steps for addressing possible misconduct by a colleague is provided, and educational, organizational, and professional considerations are discussed.     

Clinical evaluation and test-retest reliability of the IHR-McCormick Automated Toy Discrimination Test

The IHR-McCormick Automated Toy Discrimination Test (ATT) measures the minimum sound level at which a child can identify words presented in quiet in the sound field. This 'word-discrimination threshold' provides a direct measure of the ease with which a child can identify speech and a surrogate measure of auditory sensitivity. This paper describes steps taken to maximize the test-retest reliability of the ATT and to enable it to measure word-discrimination thresholds in noise as well as in quiet. It then describes the results of a clinical evaluation of the ATT in which paediatric audiologists measured word-discrimination thresholds in quiet from 215 successive attendees (in the age range 2 to 13 years) at a paediatric audiology clinic presenting over a 2-month period. When children with atypical cognition or delayed development of language were excluded, 72% of the children provided two word-discrimination thresholds and 83% provided at least one word-discrimination threshold. Children who failed to provide word-discrimination thresholds were generally younger than four years of age. Although a few children who could not perform pure-tone or warble-tone audiometry managed to provide word-discrimination thresholds, most children who could perform the ATT could also perform pure-tone audiometry. The average pure-tone threshold in the better-hearing ear could be predicted from the word-discrimination threshold with a 95% confidence interval of +/- 13 dB. The test-retest reliability of the ATT was measured in two ways. First, to enable comparison with published results, the within-subjects standard deviation of word-discrimination thresholds was calculated. It varied as a function of age and degree of impairment, but was never worse than 3.3 dB. Children of four years of age and older displayed the adult reliability of 2.3 dB. Second, the variability of absolute differences between word-discrimination thresholds was calculated. It was such that a change of 7 dB between two runs of the test (e.g. aided and unaided) would be expected to occur by change less than one time in 20. These results extend previous evaluations of the ATT to a clinically representative population and confirm that word-discrimination thresholds provide a useful complement to warble-tone and pure-tone audiometry.     

Repeating items to estimate the test-retest reliability of task inventory ratings.

Little is known about the test–retest reliability of task inventories. Because they typically take hours to complete and require rating hundreds of job tasks, repeating an entire inventory after a short interval is unlikely to produce motivated raters; conversely, increasing the time interval between administrations may result in actual changes in job content that would underestimate the true reliability. By repeating only a portion of the inventory with a very small test–retest interval, rater motivation should not be seriously affected, and changes in job content can be ruled out as a determinant of the results. The repeated item approach was used on 207 respondents and 3 task inventories. For most of the rating scales studied, reliabilities were slightly lower (.70s to .80s) than those reported in a previous study (.90s). (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Misdiagnosis of bipolar affective disorder as personality disorder

Patients with longstanding recurrent behavioural disturbance, unstable interpersonal relationships and periodic affective symptoms are often diagnosed as having a cluster B personality disturbance using DSM-III-R criteria. Two women are described who were diagnosed as having a personality disorder on several admissions to hospital, but in whom closer inquiry revealed evidence of bipolar affective disorder. Since treatment with lithium and adjunctive mood-stabilizing drugs neither patient has required further admissions to hospital within the past five years.