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)     

Reduced specificity of autobiographical memory in Cluster C personality disorders and the role of depression, worry, and experiential avoidance.

The study objective was to investigate whether, compared with nonclinical controls, participants with an avoidant, dependent, or obsessive–compulsive Cluster C personality disorder (PD) manifested reduced levels of memory specificity and whether the association of Cluster C PDs with memory specificity is mediated by repetitive negative thoughts and experiential avoidance. The Autobiographical Memory Test (R. J. McNally, N. B. Lasko, M. L. Macklin, & R. K. Pitman, 1995) was administered along with self-report measures (translated into Dutch) for repetitive, uncontrollable, and negative thinking in the form of worry (Penn State Worry Questionnaire; T. J. Meyer, M. L. Miller, R. L. Metzger, & T. D. Borkovec, 1990) and experiential avoidance (Acceptance and Action Questionnaire; S. C. Hayes et al., 2004) to 294 clinical participants diagnosed with Axis I disorders (assessed with the Structured Clinical Interview for DSM–IV Axis I Disorders [SCID-I]; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1994) and Axis II disorders (assessed with the SCID-II; M. B. First, R. L. Spitzer, M. Gibbon, & J. B. W. Williams, 1997)—202 with avoidant, 49 with dependent, and 120 with obsessive–compulsive PD—and to 108 matched nonclinical controls. Participants with a Cluster C PD showed lower levels of memory specificity than did nonclinical controls. Depression and worry mediated the effect of Cluster C PDs on memory specificity. Besides depression severity, repetitive, uncontrollable, and negative thinking may constitute a general mechanism mediating the association of various Axis I and II disorders with memory specificity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Borderline personality traits and disorder: Predicting prospective patient functioning.

Objective: Decisions about the composition of personality assessment in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–V) will be heavily influenced by the clinical utility of candidate constructs. In this study, we addressed 1 aspect of clinical utility by testing the incremental validity of 5-factor model (FFM) personality traits and borderline personality disorder (BPD) symptoms for predicting prospective patient functioning. Method: FFM personality traits and BPD features were correlated with one another and predicted 2-, 4-, 6-, 8-, and 10-year psychosocial functioning scores for 362 patients with personality disorders. Results: Traits and symptom domains related significantly and pervasively to one another and to prospective functioning. FFM extraversion and agreeableness tended to be most incrementally predictive of psychosocial functioning across all intervals; cognitive and impulse action features of BPD features incremented FFM traits in some models. Conclusions: These data suggest that BPD symptoms and personality traits are important long-term indicators of clinical functioning that both overlap with and increment one another in clinical predictions. Results support the integration of personality traits and disorders in DSM–V. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparing factor analytic models of the DSM-IV personality disorders.

There is little agreement about the latent factor structure of the Diagnostic and Statistical Manual of Mental Disorders (DSM) personality disorders (PDs). Factor analytic studies over the past 2 decades have yielded different results, in part reflecting differences in factor analytic technique, the measure used to assess the PDs, and the changing DSM criteria. In this study, we explore the latent factor structure of the DSM (4th ed.; IV) PDs in a sample of 1200 psychiatric outpatients evaluated with the Structured Interview for DSM–IV PDs (B. Pfohl, N. Blum, & M. Zimmerman, 1997). We first evaluated 2 a priori models of the PDs with confirmatory factor analysis (CFA), reflecting their inherent organization in the DSM–IV: a 3-factor model and a 10-factor model. Fit statistics did not suggest that these models yielded an adequate fit. We then evaluated the latent structure with exploratory factor analysis (EFA). Multiple solutions produced more statistically and theoretically reasonable results, as well as providing clinically useful findings. On the basis of fit statistics and theory, 3 models were evaluated further—the 4-, 5-, and 10-factor models. The 10-factor model, which did not resemble the 10-factor model of the CFA, was determined to be the strongest of all 3 models. Future research should use contemporary methods of evaluating factor analytic results in order to more thoroughly compare various factor solutions. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Reliability of personality disorder symptoms and personality traits in substance-dependent inpatients.

The authors compared the internal consistency, 1-year temporal stability and self-informant agreement of ratings of personality trait (NEO Five-Factor Inventory; NEO-FFI; P. T. Costa & R. R. McCrae, 1992) and personality disorder symptom severity (Structured Clinical Interview for DSM-III-R personality Disorders Questionnaire; SCID-II-Q ; R. L. Spitzer, J. B. W. Williams, M. Gibbon, & M. First, 1990) in 131 substance-dependent inpatients. Internal consistency coefficients were acceptable to very good for most NEO-FFI and SCID-II-Q scales, and temporal stability correlations were significant for all measures. Agreement between patient and informant ratings was more modest. Substance abuse and depression symptom severity moderated the temporal stability and self-informant agreement of several personality trait and disorder ratings. The authors did not find that the five factors were more reliable than the Axis II symptoms. Issues related to the reliability of personality assessment in multiply diagnosed patients are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"An item response theory integration of normal and abnormal personality scales": Correction to Samuel et al (2010).

Reports an error in "An item response theory integration of normal and abnormal personality scales" by Douglas B. Samuel, Leonard J. Simms, Lee Anna Clark, W. John Livesley and Thomas A. Widiger (Personality Disorders: Theory, Research, and Treatment, 2010[Jan], Vol 1[1], 5-21). In the acknowledgments, Douglas Samuel was incorrectly listed as the author of the DAPP-BQ instrument. John Livesley is the correct author of the DAPP-BQ instrument. (The following abstract of the original article appeared in record 2010-01479-005.) The Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR) currently conceptualizes personality disorders (PDs) as categorical syndromes that are distinct from normal personality. However, an alternative dimensional viewpoint is that PDs are maladaptive expressions of general personality traits. The dimensional perspective postulates that personality pathology exists at a more extreme level of the latent trait than does general personality. This hypothesis was examined using item response theory analyses comparing scales from two personality pathology instruments—the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ; Livesley & Jackson, in press) and the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993; Clark, Simms, Wu, & Casillas, in press)—with scales from an instrument designed to assess normal range personality, the NEO Personality Inventory–Revised (NEO PI-R; Costa & McCrae, 1992). The results indicate that respective scales from these instruments assess shared latent constructs, with the NEO PI-R providing more information at the lower (normal) range and the DAPP-BQ and SNAP providing more information at the higher (abnormal) range. Nevertheless, the results also demonstrated substantial overlap in coverage. Implications of the findings are discussed with respect to the study and development of items that would provide specific discriminations along underlying trait continua. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The comorbidity of alcoholism and personality disorders in a clinical population: Prevalence and relation to alcohol typology variables.

This study assessed prevalence rates and overlap among Diagnostic and Statistical Manual of Mental Disorders ( 3rd ed., revised; DSM-III—R; American Psychiatric Association, 1987) personality disorders in a multisite sample of 366 substance abusers in treatment. In addition, the relation of antisocial personality disorder (APD), borderline personality disorder (BPD), and paranoid personality disorder (PPD) to alcohol typology variables was examined. Structured diagnostic interviews and other measures were administered to participants at least 14 days after entry into treatment. Results indicated high prevalence rates for APD and non-APD disorders. There was extensive overlap between Axis I disorders and personality disorders, and among personality disorders themselves. APD, BPD, and PPD were linked to more severe symptomatology of alcoholism and other clinical problems. However, only APD and BPD satisfied subtyping criteria, after controlling for other comorbidity. Implications for classifying alcoholics by comorbid disorders are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Proposed changes in personality and personality disorder assessment and diagnosis for DSM-5 Part II: Clinical application.

The four-part assessment of personality psychopathology proposed for DSM-5 focuses attention on identifying personality psychopathology with increasing degrees of specificity, based on a clinician's available time, information, and expertise. In Part I of this two-part article, we described the components of the new model and presented brief rationales for them. In Part II, we illustrate the clinical application of the model with vignettes of patients with varying degrees of personality psychopathology, selected from the DSM–IV–TR Casebook, to show how assessments might be conducted and diagnoses reached. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder.

Changes in attachment organization and reflective function (RF) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder (BPD). Ninety patients reliably diagnosed with BPD were randomized to transference-focused psychotherapy (TFP), dialectical behavior therapy, or a modified psychodynamic supportive psychotherapy. Attachment organization was assessed with the Adult Attachment Interview and the RF coding scale. After 12 months of treatment, participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments. Significant changes in narrative coherence and RF were found as a function of treatment, with TFP showing increases in both constructs during treatment. No changes in resolution of loss or trauma were observed across treatments. Findings suggest that 1 year of intensive TFP can increase patients' narrative coherence and RF. Future research should establish the relationship between these 2 constructs and relevant psychopathology, identify treatment components responsible for effecting these changes, and examine the long-term outcome of these changes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prevalence of personality disorders among patients with anxiety disorders

Outpatients with a principal diagnosis of an anxiety disorder (n = 347) were administered the Structured Clinical Interview for DSM-III-R/Axis II Disorders (SCID-II) during their intake evaluation. At least one personality disorder was found in 35% of these patients. Patients with social phobia (61%) and generalized anxiety disorder (49%) were most often diagnosed with a personality disorder. Patients with simple phobia were rarely diagnosed with a personality disorder (12%). The most commonly diagnosed personality disorders were from the "anxious/fearful" cluster (27% received at least one diagnosis from cluster C), most notably avoidant and obsessive-compulsive personality. Our findings suggest that personality disorders, in general, are less prevalent among anxious patients than among depressive patients.     

An item response theory integration of normal and abnormal personality scales.

[Correction Notice: An erratum for this article was reported in Vol 1(3) of Personality Disorders: Theory, Research, and Treatment (see record 2010-17135-005). In the acknowledgments, Douglas Samuel was incorrectly listed as the author of the DAPP-BQ instrument. John Livesley is the correct author of the DAPP-BQ instrument.] The Diagnostic and Statistical Manual of Mental Disorders (DSM–IV–TR) currently conceptualizes personality disorders (PDs) as categorical syndromes that are distinct from normal personality. However, an alternative dimensional viewpoint is that PDs are maladaptive expressions of general personality traits. The dimensional perspective postulates that personality pathology exists at a more extreme level of the latent trait than does general personality. This hypothesis was examined using item response theory analyses comparing scales from two personality pathology instruments—the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ; Livesley & Jackson, in press) and the Schedule for Nonadaptive and Adaptive Personality (SNAP; Clark, 1993; Clark, Simms, Wu, & Casillas, in press)—with scales from an instrument designed to assess normal range personality, the NEO Personality Inventory–Revised (NEO PI-R; Costa & McCrae, 1992). The results indicate that respective scales from these instruments assess shared latent constructs, with the NEO PI-R providing more information at the lower (normal) range and the DAPP-BQ and SNAP providing more information at the higher (abnormal) range. Nevertheless, the results also demonstrated substantial overlap in coverage. Implications of the findings are discussed with respect to the study and development of items that would provide specific discriminations along underlying trait continua. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnostic efficiency among psychiatric outpatients of a self-report version of a subset of screen items of the Structured Clinical Interview for DSM–IV–TR Personality Disorders (SCID-II).

This article describes the identification of a 10-item set of the Structured Clinical Interview for DSM–IV Personality Disorders (SCID–II) items, which proved to be effective as a self-report assessment instrument in screening personality disorders. The item selection was based on the retrospective analyses of 495 SCID–II interviews. The psychometric properties were studied in a prospective validation study in a random sample of Dutch adult psychiatric outpatients, using the SCID–II interview as the gold standard. First, all patients completed the short questionnaire. One week later, they were interviewed with the full SCID–II. After another week, the short questionnaire was readministered. According to the scores obtained with the full SCID–II, 97 patients (50%) had a personality disorder. The set of 10 SCID–II items correctly classified 78% of all participants. The sensitivity, specificity, and positive and negative power were 0.78, 0.78, 0.78, and 0.78, respectively. The results based on the retrospectively obtained data were rather similar to those obtained in the prospective validation study. Therefore, it is concluded that the set of 10 SCID–II items can be useful as a quick self-report personality disorder screen in a population of psychiatric outpatients. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Borderline personality disorder and personality traits: A comparison of SCID-II BPD and NEO-PI.

62 hospitalized female patients (aged 18–43 yrs) with a clinical diagnosis of borderline personality disorder (BPD) were assessed for Axis II disorders by the SCID-II and for personality traits with the NEO-Personality Inventory (NEO-PI). The predominant personality trait profile for these patients involved a very high Neuroticism score and low Agreeableness score. Five of the 8 BPD criteria had significant correlations with NEO-PI scales. The combination of BPD severity and personality traits as measured on the NEO-PI had a significant relationship to the patients' social adjustment. The utility of gathering information on both borderline personality pathology and personality traits is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

The Shedler-Westen Assessment Procedure-200 as a basis for modifying DSM personality disorder categories.

The Shedler-Westen Assessment Procedure-200 (SWAP) is a Q-sort instrument designed to assess personality pathology on the basis of clinician ratings. On the basis of research with the SWAP, its creators have proposed a group of 12 personality disorder (PD) diagnoses that can be used to replace or modify current Axis II categories of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The authors discuss conceptual and empirical issues that require clarification before this proposal can be properly evaluated. They identify problematic psychometric features of the SWAP, including its unrepresentative normative sample, its reliance on a fixed skewed distribution, and anomalies in its T-score approach to diagnoses. In addition, a review of research on SWAP-based PD categories indicates that important information regarding diagnostic coverage, validity, and temporal stability is presently lacking. The authors conclude that research evidence is currently insufficient to justify the use of SWAP-based PD categories to guide revision of the DSM. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emotional granularity and borderline personality disorder.

This study examined the affective dysregulation component of borderline personality disorder (BPD) from an emotional granularity perspective, which refers to the specificity in which one represents emotions. Forty-six female participants meeting criteria for BPD and 51 female control participants without BPD and Axis I pathology completed tasks that assessed the degree to which participants incorporated information about valence (pleasant–unpleasant) and arousal (calm–activated) in their semantic/conceptual representations of emotions and in using labels to represent emotional reactions. As hypothesized, participants with BPD emphasized valence more and arousal less than control participants did when using emotion terms to label their emotional reactions. Implications and future research directions are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Comparing the temporal stability of self-report and interview assessed personality disorder.

Findings from several large-scale, longitudinal studies over the last decade have challenged the long-held assumption that personality disorders (PDs) are stable and enduring. However, the findings, including those from the Collaborative Longitudinal Personality Disorders Study (CLPS; Gunderson et al., 2000), rely primarily on results from semistructured interviews. As a result, less is known about the stability of PD scores from self-report questionnaires, which differ from interviews in important ways (e.g., source of the ratings, item development, and instrument length) that might increase temporal stability. The current study directly compared the stability of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV) PD constructs assessed via the Schedule for Nonadaptive and Adaptive Personality (SNAP–2; Clark, Simms, Wu, & Casillas, in press) with those from the Diagnostic Interview for DSM–IV Personality Disorders (Zanarini, Frankenburg, Sickel, & Yong, 1996) over 2 years in a sample of 529 CLPS participants. Specifically, we compared dimensional and categorical representations from both measures in terms of rank-order and mean-level stability. Results indicated that the dimensional scores from the self-report questionnaire had significantly greater rank-order (mean r = .69 vs. .59) and mean-level (mean d = 0.21 vs. 0.30) stability. In contrast, categorical diagnoses from the two measures evinced comparable rank-order (mean κ = .38 vs. .37) and mean-level stability (median prevalence rate decrease of 3.5% vs. 5.6%). These findings suggest the stability of PD constructs depends at least partially on the method of assessment and are discussed in the context of previous research and future conceptualizations of personality pathology. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The stability of personality traits in individuals with borderline personality disorder.

Although stability and pervasive inflexibility are general criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th edition (American Psychiatric Association, 1994) personality disorders (PDs), borderline PD (BPD) is characterized by instability in several domains, including interpersonal behavior, affect, and identity. The authors hypothesized that such inconsistencies notable in BPD may relate to instability at the level of the basic personality traits that are associated with this disorder. Five types of personality trait stability across 4 assessments over 6 years were compared for BPD patients (N = 130 at first interval) and patients with other PDs (N = 302). Structural stability did not differ across groups. Differential stability tended to be lower for 5-factor model (FFM) traits in the BPD group, with the strongest and most consistent effects observed for Neuroticism and Conscientiousness. Growth curve models suggested that these 2 traits also showed greater mean-level change, with Neuroticism declining faster and Conscientiousness increasing faster, in the BPD group. The BPD group was further characterized by greater individual-level instability for Neuroticism and Conscientiousness in these models. Finally, the BPD group was less stable in terms of the ipsative configuration of FFM facet-level profiles than was the other PD group over time. Results point to the importance of personality trait instability in characterizing BPD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)