A multidimensional scaling of the DSM-III personality disorders

Telerehabilitation proposal of mind-body technique for physical and psychological outcomes in patients with fibromyalgia

Fibromyalgia (FM) syndrome is characterized by the close correlation of chronic widespread pain and other non-pain related symptoms. Aim of this study was to investigate whether telerehabilitation that provides physical and psychological support services of the mind-body techniques can affect the clinical profile and pain relief of FM patients. The study included twenty-eight female FM patients, mean aged 56.61 ± 8.56 years. All patients underwent a rehabilitation treatment (8 sessions, 1/week, 1 h/each) through Zoom platform, with the following principles of rehabilitation treatment: Anchoring to a positive emotion; listen and perceive your “own” body; conscious breathing; improve interoceptive awareness; relax. All patients then underwent clinical assessment of the physical distress and fear of movement for the Numeric Rating Scale (NRS); the Fatigue Assessment Scale (FAS); the Fear Avoidance Belief Questionnaire (FABQ); with measures of physical and mental disability for the Fibromyalgia Impact Questionnaire (FIQ); the 12-Items Short Form Survey; the Resilience Scale for Adults and the Coping Strategies Questionnaire-Revised. The evaluations were performed at T0 (baseline), T1 (after 8 weeks of treatment), and T2 (after 1 month of follow-up). The main finding was that telerehabilitation reduced physical and mental distress, fear, and disability (p < 0.001). Resilience and coping ability were less affected by the rehabilitative treatment. Our attempt of mind-body technique telerehabilitation has shown good results in the improvement of painful symptoms and quality of life for the FM patients but showed fewer positive impacts for the resilience and coping abilities aspects.

Improving the Recognition of Borderline Personality Disorder in a Bipolar World

Both bipolar disorder and borderline personality disorder (BPD) are serious mental health disorders resulting in significant psychosocial morbidity, reduced health-related quality of life, and excess mortality. Yet research on BPD has received much less funding from the National Institute of Health (NIH) than has bipolar disorder during the past 25 years. Why hasn't the level of NIH research funding for BPD been commensurate with the level of psychosocial morbidity, mortality, and health expenditures associated with the disorder? In the present article, the author illustrates how the bipolar disorder research community has done a superior job of "marketing" their disorder. Studies of underdiagnosis, screening, diagnostic spectra, and economics are reviewed for both bipolar disorder and BPD. Researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, developed and promoted several screening scales, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these four issues and research efforts. Although BPD is as frequent as (if not more frequent than) bipolar disorder, as impairing as (if not more impairing than) bipolar disorder, and as lethal as (if not more lethal than) bipolar disorder, it has received less than one-tenth the level of funding from the NIH and has been the focus of many fewer publications in the most prestigious psychiatric journals. The researchers of BPD should consider adopting the strategy taken by researchers of bipolar disorder before the diagnosis is eliminated in a future iteration of the DSM or the ICD.

Field trial of a putative research algorithm for diagnosing ICD-11 personality disorders in psychiatric patients: 1. Severity of personality disturbance

This preliminary field trial examines the reliability and validity of a proposed research algorithm for diagnosing International Classification of Diseases (ICD)-11 personality disorders and its association with other psychiatric assessments for the primary classification of a single dimension of the five severity levels of personality dysfunction. In total, 137 psychiatric patients (119 with personality disorders and 18 without personality disorders) in Korea were assessed. In the first part of the study, inter-rater reliability was evaluated with an independent assessment of personality (personality assessment schedule). In the second part of the study, (1) the algorithm that identified any personality disturbance was compared with the ICD-10 and DSM-IV personality disorder diagnostic equivalents, and (ii) the four levels of severity were examined for their associations with clinical pathology and social functioning. The results showed good agreement between the algorithm and the test instruments for identifying a personality disorder. A graded increase in clinical pathology and social dysfunction was observed with increasing severity of personality disorder. These findings suggest that a simple algorithm for recording severity of a personality disturbance had both construct validity and was useful in practice, which supports severity classification as a valuable concept. These findings need to be confirmed in other cultures and ethnic groups.

Is dimensional scoring of borderline personality disorder important only for subthreshold levels of severity?

Studies comparing dimensional and categorical representations of personality disorders (PDs) have consistently found that PD dimensions are more reliable and valid. While comparisons of dimensional and categorical scoring approaches have consistently favored the dimension model, two reports from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project have raised questions as to when dimensional scoring is important. In the first study, Asnaani, Chelminski, Young, and Zimmerman (2007) found that once the diagnostic threshold for borderline PD was reached the number of criteria met was not significantly associated with indices of psychosocial morbidity. In the second study, Zimmerman, Chelminski, Young, Dalrymple, and Martinez (2012) found that patients with 1 criterion of borderline PD had significantly more psychosocial morbidity than patients with 0 criteria. The findings of these two studies suggest that dimensional ratings of borderline PD may be more strongly associated with indicators of illness severity for patients who do not versus do meet the DSM-IV criteria for borderline PD. In this third report from the MIDAS project, we tested this hypothesis in a study of 3,069 psychiatric outpatients evaluated with semi-structured diagnostic interviews. In the patients without borderline PD the number of borderline features was significantly associated with each of 6 indicators of illness severity, whereas in the patients with borderline PD 3 of the 6 correlations were significant. The mean correlation between the number of borderline PD criteria and the indicators of illness severity was nearly three times higher in the patients without borderline PD than the patients with borderline PD (0.23 versus 0.08), and 4 of the 6 correlation coefficients were significantly higher in the patients without borderline PD. These findings suggest that dimensional scoring of borderline PD is more important for subthreshold levels of pathology and are less critical once a patient meets the diagnostic threshold. The implications of these findings for DSM-5 are discussed.

Personality and personality disorders in urban and rural Africa: results from a field trial in burkina faso

When conducting research in different cultural settings, assessing measurement equivalence is of prime importance to determine if constructs and scores can be compared across groups. Structural equivalence implies that constructs have the same meaning across groups, metric equivalence implies that the metric of the scales remains stable across groups, and full scale or scalar equivalence implies that the origin of the scales is the same across groups. Several studies have observed that the structure underlying both normal personality and personality disorders (PDs) is stable across cultures. Most of this cross-cultural research was conducted in Western and Asian cultures. In Africa, the few studies were conducted with well-educated participants using French or English instruments. No research was conducted in Africa with less privileged or preliterate samples. The aim of this research was to study the structure and expression of normal and abnormal personality in an urban and a rural sample in Burkina Faso. The sample included 1,750 participants, with a sub-sample from the urban area of Ouagadougou (n = 1,249) and another sub-sample from a rural village, Soumiaga (n = 501). Most participants answered an interview consisting of a Mooré language adaptation of the Revised NEO Personality Inventory and of the International Personality Disorders Examination. Mooré is the language of the Mossi ethnic group, and the most frequently spoken local language in Burkina Faso. A sub-sample completed the same self-report instruments in French. Demographic variables only had a small impact on normal and abnormal personality traits mean levels. The structure underlying normal personality was unstable across regions and languages, illustrating that translating a complex psychological inventory into a native African language is a very difficult task. The structure underlying abnormal personality and the metric of PDs scales were stable across regions. As scalar equivalence was not reached, mean differences cannot be interpreted. Nevertheless, these differences could be due to an exaggerated expression of abnormal traits valued in the two cultural settings. Our results suggest that studies using a different methodology should be conducted to understand what is considered, in different cultures, as deviating from the expectations of the individual’s culture, and as a significant impairment in self and interpersonal functioning, as defined by the DSM-5.

Trauma and violence: are women the weaker sex?

Posttraumatic stress disorder (PTSD) as a response to trauma is repeatedly found to be more common among women than men. This article explores prevalence rates and gender differences. Explanations for this gender bias and examined and the literature on trauma types and resulting PTSD is reviewed. Other disorders that may result from trauma that also have gender biases are considered as a potential way to understand this difference. Risk and resilience can perhaps more appropriately be considered specific to symptom picture rather than merely development of pathology.

Endophenotypes in the personality disorders

The identification of endophenotypes in the personality disorders may provide a basis for the identification of underlying genotypes that influence the traits and dimensions of the personality disorders, as well as susceptibility to major psychiatric illnesses. Clinical dimensions of personality disorders that lend themselves to the study of corresponding endophenotypes include affective instability impulsiwity aggression, emotional information processing, cognitive disorganization, social deficits, and psychosis. For example, the propensity to aggression can be evaluated by psychometric measures, interview, laboratory paradigms, neurochemical imaging, and pharmacological studies. These suggest that aggression is a measurable trait that may be related to reduced serotonergic activity. Hyperresponsiveness of amygdala and other limbic structures may be related to affective instability, while structural and functional brain alterations underlie the cognitive disorganization in psychoticlike symptoms of schizotypal personality disorder. Thus, an endophenotypic approach not only provides clues to underlying candidate genes contributing to these behavioral dimensions, but may also point the way to a better understanding of pathophysiological mechanisms.

A search for consensus on the dimensional structure of personality disorders

Previous attempts to elucidate the dimensional structure of personality disorders (PDs) have been based on single samples and measures. Like one-item tests, they are useful but scattered and potentially misleading glimpses at the true structure of PDs. Therefore, reanalyses of 33 previously published data sets were conducted using recommended statistical procedures to arrive at consensus structures. Similar reanalyses of published data were conducted on associations between PDs and the five-factor model of normal personality characteristics. High degrees of congruence were observed between the consensus PD structures and the consensus structures suggested by dimensions of normal personality. The analytic techniques used in the present study helped bypass methodological problems inherent in previous tests and revealed higher levels of support for both theoretically and empirically based representations of the five-factor model approach to PDs.

Concordance of DSM-IV Axis I and II diagnoses by personal and informant's interview

The validity and reliability of using psychological autopsies to diagnose a psychiatric disorder is a critical issue. Therefore, interrater and test-retest reliability of the Structured Clinical Interview for DSM-IV Axis I and Personality Disorders and the usefulness of these instruments for the psychological autopsy method were investigated. Diagnoses by informant's interview were compared with diagnoses generated by a personal interview of 35 persons. Interrater reliability and test-retest reliability were assessed in 33 and 29 persons, respectively. Chi-square analysis, kappa and intraclass correlation coefficients, and Kendall's tau were used to determine agreement of diagnoses. Kappa coefficients were above 0.84 for substance-related disorders, mood disorders, and anxiety and adjustment disorders, and above 0.65 for Axis II disorders for interrater and test-retest reliability. Agreement by personal and relative's interview generated kappa coefficients above 0.79 for most Axis I and above 0.65 for most personality disorder diagnoses; Kendall's tau for dimensional individual personality disorder scores ranged from 0.22 to 0.72. Despite of a small number of psychiatric disorders in the selected population, the present results provide support for the validity of most diagnoses obtained through the best-estimate method using the Structured Clinical Interview for DSM-IV Axis I and Personality Disorders. This instrument can be recommended as a tool for the psychological autopsy procedure in post-mortem research.

MULTIVARIATE ANALYSIS OF PERCEIVED DYSFUNCTION RATINGS OF PERSONALITY DISORDER SYMPTOMS

Dysfunction in personality disorder symptoms was assessed using multivariate techniques to analyse lay judges' (N = 216) ratings of occupational impairment, social impairment, and personal distress. Factor analysis revealed that ratings of occupational impairment and social impairment loaded onto distinct factors. Personal distress ratings loaded onto two separate factors: high distress and low distress. Multidimensional scaling revealed two dimensions for overall dysfunction among personality disorders: severity of dysfunction and internalization-externalization. The dimensions were independence-dependence and severity of dysfunction for occupational impairment, interpersonal involvement and dominance-submission for social impairment, and internalization-externalization and severity for personal distress.

A Taxometric Study of Borderline Personality Disorder

Taxometric methodology was used to determine whether borderline personality disorder (BPD) represents a taxon that is categorically distinct from normal personality or whether it falls on a dimensional continuum with normality. Two taxometric procedures were used with a sample of 1,389 outpatients assessed for BPD symptoms by semistructured interview. The procedures indicated that BPD does not represent a latent category. Implications are drawn for the conceptualization and etiology of BPD, and for the categorical versus dimensional status of personality disorders in general.

The borderline diagnosis I: psychopathology, comorbidity, and personality structure

Borderline personality disorder (BPD) is a complex and serious mental disorder associated with severe functional impairment, substantial treatment utilization, and a high rate of mortality by suicide. Recently, BPD has become a focus of intensifying study. In Part I of this three-part article meant to provide a foundation to researchers on the current status of the borderline diagnosis and prospects for its future development, we examine the psychopathology, comorbidity, and personality structure of BPD. Although the descriptive characteristics of BPD are well-represented by DSM-IV diagnostic criteria, other important aspects of BPD psychopathology are not included. The descriptive criteria in conjunction with semistructured interviews have, however, increased the ability of investigators to diagnose BPD as reliably as many Axis I disorders. Frequent comorbidity of BPD with Axis I disorders necessitates a broad assessment of psychopathology to help account for clinical heterogeneity. Because of the absence of evidence of the validity of the diagnostic threshold for a categorical diagnosis of BPD, and because of the heterogeneity within the diagnosis, investigators should also supplement their DSM-IV diagnoses with assessments of underlying personality trait structures. Although there are a number of competing models of personality structure, they have remarkable convergence on a set of three to five basic personality dimensions.

Inter-rater and test-retest reliability of the Revised Diagnostic Interview for Borderlines

The baseline inter-rater reliability, test-retest reliability, follow-up inter-rater reliability, and follow-up longitudinal reliability (interrater reliability between generations of raters) of borderline symptoms and the diagnosis of borderline personality disorder (BPD) were assessed using the Revised Diagnostic Interview for Borderlines (DIB-R). Excellent kappa s (> .75) were found in each of these reliability substudies for the diagnosis of BPD itself. Excellent kappa s were also found in each of the three inter-rater reliability substudies for the vast majority of borderline symptoms assessed by the DIB-R. Test-retest reliability for these symptoms was somewhat lower but still very good. More specifically, one-third of the BPD symptoms assessed had a kappa in the excellent range and the remaining two-thirds had a kappa in the fair-good range (.57-.73). The dimensional reliability of BPD symptom areas was somewhat higher than for categorical measures of the subsyndromal phenomenology of BPD. More specifically, all five dimensional measures of borderline psychopathology had intraclass correlation coefficients in the excellent range for all four reliability substudies. Taken together, the results of this study suggest that both the borderline diagnosis and the symptoms of BPD can be diagnosed reliably when using the DIB-R. They also suggest that excellent reliability, once achieved, can be maintained over time for both the syndromal and subsyndromal phenomenology of BPD.

Personality and personality disorders in chronic pain

Personality characteristics and disorders have long been noted in the chronic pain population. Clinicians and researchers alike will attest to the high rates of personality difficulties encountered in these individuals. Historically, it has been found that certain personality styles such as hypochondriasis and hysteria are common in chronic pain suffers. In addition, the prevalence of personality disorders (PDs) is significantly greater in the pain population than in the general population or in medical or psychiatric populations. A diathesis-stress model has been suggested to account for this finding and is discussed in this article, with implications for both treatment and research.

The Collaborative Longitudinal Personality Disorders Study: reliability of axis I and II diagnoses

Both the interrater and test-retest-retest reliability of axis I and axis II disorders were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) and the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV). Fair-good median interrater kappa (.40-.75) were found for all axis II disorders diagnosed five times or more, except antisocial personality disorder (1.0). All of the test-retest kappa for axis II disorders, except for narcissistic personality disorder (1.0) and paranoid personality disorder (.39), were also found to be fair-good. Interrater and test-retest dimensional reliability figures for axis II were generally higher than those for their categorical counterparts; most were in the excellent range (> .75). In terms of axis I, excellent median interrater kappa were found for six of the 10 disorders diagnosed five times or more, whereas fair-good median interrater kappa were found for the other four axis I disorders. In general, test-retest reliability figures for axis I disorders were somewhat lower than the interrater reliability figures. Three test-retest kappa were in the excellent range, six were in the fair-good range, and one (for dysthymia) was in the poor range (.35). Taken together, the results of this study suggest that both axis I and axis II disorders can be diagnosed reliably when using appropriate semistructured interviews. They also suggest that the reliability of axis II disorders is roughly equivalent to that reliability found for most axis I disorders.

Pattern of comorbidity among anxious and odd personality disorders: the case of obsessive-compulsive personality disorder

The aim of this study was to examine the pattern of comorbidity among obsessive-compulsive personality disorder (OCPD) and other personality disorders (PDs) in a sample of 400 psychiatric inpatients. PDs were assessed using the Semistructured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Odds ratios (ORs) were calculated to determine significant comorbidity among OCPD and other axis II disorders. The most elevated odds ratios were found for the cooccurrence of OCPD with cluster A PDs (the "odd" PDs, or paranoid and schizoid PDs). These results are consistent with those of previous studies showing a higher cooccurrence of OCPD with cluster A than with cluster C ("anxious") PDs. In light of these observations, issues associated with the nosologic status of OCPD within the Diagnostic and Statistical Manual of Mental Disorders clustering system remain unsettled.

Patterns of covariation of DSM-IV personality disorders in a mixed psychiatric sample

The covariation patterns of DSM-IV personality disorders (PDs) were studied in 431 consecutively admitted psychiatric patients. The co-occurrence rate was greater than 50% for all DSM-IV PDs. Both bivariate association tests and loglinear models showed distinct significant covariation patterns among PDs which were stable across confounder strata. DSM-IV PD clusters were not replicated, with the exception of cluster A. Principal-component analysis (PCA) showed the presence of 3 latent dimensions, thus explaining the DSM-IV PD covariation patterns. These results seem to stress the inadequacy of the DSM-IV categorical model of PD assessment. The need for a reduction of axis II categories and the inclusion of a dimensional model in the diagnostic assessment of DSM-IV PDs are discussed.

The cancer patient with borderline personality disorder: suggestions for symptom-focused management in the medical setting

Medically ill cancer patients with borderline personality disorder (BPD) face formidable emotional challenges as they cope with cancer diagnosis and treatment. The anxiety and discomfort associated with medical treatment can lead them to have difficulties with medical caregivers, distort reality for emotional protection, or exhibit outright aggression and self-destructiveness. Co-morbid substance abuse or a history of physical or sexual trauma may further complicate cancer treatment. These patients may be in particular need of symptom-focused psychotherapeutic management, which must include comprehensive assessment and treatment of psychiatric symptoms, measures to limit aggression and self-destructiveness, and staff education and support. These interventions can reduce patients' distress and maximize cancer treatment outcomes.

A profile analysis of personality disorders: beyond multiple diagnoses

The authors applied cluster analysis and multidimensional scaling to the analyses of 59 patients with personality pathology. Cluster analysis yielded eight typologies of patients: detached, anankastic, phobic, dramatic, erratic, emotional, milder emotional, and masochistic negativistic. Multidimensional scaling identified the dimensions of classifying patients: anxious rumination versus behavioural acting out, overall severity of personality pathology, and assertiveness versus withdrawal. Considering the distinction between personality disorder (dysfunctional personality) and abnormal personality (extreme personality), the following changes in current classification system are proposed: use of a hierarchy and exclusion criteria in a categorical-type model or use of a personality profile in a dimensional-trait model, in either case, with a dimensional rating for severity of psychopathology to define personality 'disorder'.

Passive-aggressive personality disorder: the demise of a syndrome

This article presents an explanation and critique of the rationale for dropping passive-aggressive personality disorder (PAPD) from DSM-IV. The clinical and research literature on PAPD is reviewed along with the historical changes in definition, diagnostic criteria, and usage. PAPD can be reliably diagnosed, is fairly prevalent, and has good internal consistency. Because PAPD is no less valid than other personality disorders, and describes clinical phenomena that are unique among personality disorders, we recommend the reinstatement of PAPD in the official diagnostic nomenclature.

Axis II comorbidity of borderline personality disorder

The purpose of this study was to assess the prevalence of a full range of DSM-III-R axis II disorders in a sample of criteria-defined borderline patients and axis II controls. The axis II comorbidity of 504 personality-disordered inpatients was assessed blind to clinical diagnosis using a semistructured research interview. Odd, anxious, and dramatic cluster disorders were each common among borderline patients. However, only odd and anxious cluster disorders were significantly more common among borderline patients (N = 379) than axis II controls (N = 125). Paranoid, avoidant, and dependent personality disorders were the most highly discriminating disorders between borderline patients and controls. In addition, male and female borderline patients exhibited somewhat different patterns of comorbidity. Although the rates of avoidant and dependent personality disorders were similar, male borderlines were significantly more likely than female borderlines to meet DSM-III-R criteria for paranoid, passive-aggressive, narcissistic, sadistic, and antisocial personality disorders. These results suggest that there is a particularly strong relationship between anxious cluster disorders and borderline personality disorder (BPD). They also suggest that gender plays an important role in the expression of axis II comorbidity, particularly with respect to dramatic cluster disorders.

Suggestions for a framework for an empirically based classification of personality disorder

BACKGROUND

The classification of personality disorder is one of the least satisfactory sections of contemporary psychiatric classification. Fundamental problems with current classifications include extensive diagnostic overlap, limited evidence of validity, and poor empirical support.

METHODS

Conceptual analysis and the results of empirical studies are used to propose a framework for organizing an empirically based classification.

RESULTS

First, personality disorder is a form of mental disorder and, therefore, should be classified as a single diagnostic entity on Axis I along with other mental disorders. A preliminary definition of personality disorder as a tripartite failure involving the self system, kinship relationships, and societal relationships is proposed. The evidence suggests that this definition can be translated into a reliable set of items. Second, the diagnosis of personality disorder should be separated from the assessment of clinically relevant personality traits. Given the consistent evidential support for a dimensional model of personality disorder, it is suggested that personality be coded on a set of trait dimensions selected to provide a systematic representation of the domain of behaviours represented by current diagnostic concepts. Third, given that personality traits are hierarchically organized, it is suggested that an axis for coding personality include basic or lower-order dimensions as the primary level of assessment and a few higher-order patterns to summarize information for some purposes.

CONCLUSION

A preliminary list of 16 basic dispositional traits is proposed to describe the more specific components of personality disorder based, in part, on the convergence of evidence across studies: anxiousness, affective lability, callousness, cognitive dysregulation, compulsivity, conduct problems, insecure attachment, intimacy avoidance, narcissism, oppositionality, rejection, restricted expression, social avoidance, stimulus seeking, submissiveness, and suspiciousness. Three higher-order patterns were proposed: emotional dysregulation, dissocial behaviour, and inhibitedness, which may occur independently or in combination.

Temporal stability of antisocial personality disorder: blind follow-up study at 8 years

The study objective was to examine the temporal stability of the antisocial personality disorder (ASPD) diagnosis based on whether specific antisocial symptoms were considered to be related to substance abuse. A total of 407 adults who were initially part of a family study of alcoholism and sociopathy were blindly reassessed an average of 8 years later, using the Home Environment and Lifetime Psychiatric Evaluation Record (HELPER) and basing diagnoses on the clinician's best final estimate using all sources of data. "Narrow" and "broad" ASPD diagnoses were made at both times based on whether individual symptoms were counted toward diagnosis if they occurred in the setting of significant substance abuse. kappa values varied from 0.31 to 0.68, with more restrictive methods of diagnosis being less stable. After deriving estimates of sensitivity and specificity of diagnosis, the probability of being a "case" could be assigned based on the reported number of conduct problems occurring before age 15 as a clinical covariate for diagnosis. We conclude that diagnosing ASPD without attempting to attribute the cause of individual symptoms to substance abuse results in substantially greater temporal stability. Using a broader definition, the diagnosis of ASPD is highly sensitive (P = .97) and specific (q = 0.93). These findings may allow more accurate diagnosis of ASPD in drug-abusing individuals.

Dimensional Models of Personality: A Framework for Systematic Clinical Assessment1

Personality research has made considerable progress in developing dimensional models. This article reviews the application of these trait models to clinical theory and practice. Assessment of traits is useful for understanding the individual client, for diagnosis and therapy, and for tailoring the clinical interview to the needs of the patient. Dimensional models have been applied to several areas of pathology. Neuroticism and a variety of other traits are implicated in subclinical stress reactions. At the process level, the effects of traits such as neuroticism may be mediated by maladaptive coping strategies. Traits such as neuroticism may also have a causal effect on more severe mood and anxiety disorders, although it is likely that there are reciprocal linkages between personality and pathology. As with subclinical stress, traits may influence depression and anxiety through abnormality of cognitive processes, the clinical significance of which should be assessed in the light of the individual's trait characteristics. A further area of application is personality disorder: Dimensional models capture and clarify the principal clinical features of conditions such as schizoid and antisocial disorders. It is concluded that the dimensional approach provides a framework for the systematic understanding of clinical expressions of abnormality in personality and their implications for diagnosis and treatment.

Personality disorder among first ever admissions to an Irish public and private hospital

Objective: The identification of personality disorder among psychiatric in-patients is important because of the effect on the course and outcome of illness. The introduction of a multiaxial approach to diagnosis, has resulted in a higher than previously reported rate of occurrence of personality disorder in a variety of psychiatric settings. A prevalence of personality disorder of 4.9% is reported in the official statistics for Irish psychiatric hospitals. The aim of this study is to determine the true prevalence of personality disorders in two Irish psychiatric hospitals, one public and one private, using a multiaxial approach to diagnosis.

Methods: The Standardised Assessment of Personality (SAP) is a validated, semistructured, informant based instrument that reliably generates diagnoses of personality disorder irrespective of current mental state. Over a four month period, 78 consecutive, first ever admissions to two hospitals were examined using the SAP.

Results: The prevalence of personality disorder in this population was 26%. There was no significant difference in the rate of personality disorder between the public and private institutions.

Conclusions: The prevalence of personality disorder amongst in-patients in both public and private psychiatric hospitals in Ireland is far higher than previously reported. This highlights the importance of a multiaxial approach to diagnosis in order to establish the true extent of psychiatric morbidity.

Biology of personality disorders

Since the introduction of international psychiatric classification systems, systematic diagnostic methods have become available for personality disorders. Recent developments in the dimensional diagnostic approach of personality disorders have yielded relationships between this type of disorders and neurobiological processes including both monoaminergic and stress-hormonal systems. It is hypothesized that the pathogenesis of borderline personality disorders is related to an enhanced serotonergic tone in septo-hippocampal structures. Preliminary clinical data are suggestive for potential therapeutic effects of serotonin-modulating compounds in borderline personality disorders.

Dimensional classification and behavioral pharmacology of personality disorders; a review and hypothesis

Nosological orientation in psychiatry has severely hampered the progress of research in biological psychiatry, especially in the case of personality disorders. Dimensional approaches have redefined the characteristics of these disorders and their possible pathogenetic factors. The significance of arousal and stress, so far relatively neglected in clinical research, and its important function in adaptive and coping strategies has to be included in the study of the behavioral pharmacology of personality disorders. Some preliminary clinical data are available suggesting the potential therapeutic use of serotonin modulating agents in the key symptomatology of certain personality disorders such as disturbed impulsive regulation and increased stress reactivity.

Multiple axis-II diagnoses of personality disorder

BACKGROUND

Simultaneous diagnosis of more than one personality disorder (PD) has been termed 'comorbidity' or 'co-occurrence' implying that single diagnoses are the norm and multiple diagnoses interesting exceptions. Surveys of PD subjects in fact show 1.5-5.6 diagnoses per subject. Our study explores the hypothesis that multiple PD diagnosis is common and increases with increasingly personality disordered populations.

METHOD

The PDQ-R questionnaire was administered to three UK samples: referrals for specialist PD in-patient treatment (n = 275); high tariff offenders attending a probation centre (n = 57); and undergraduate students (n = 274).

RESULTS

Means of 6.0 (95% CI 5.7-6.3), 4.0 (3.1-5.0) and 3.4 (3.0-3.8) PDQ-R diagnoses per subject were found respectively. High rates of PD diagnosis in individual subjects suggest that multiple diagnosis is the norm rather than the exception.

CONCLUSIONS

Multiple diagnosis of PD is better construed as 'breadth' of psychopathology rather than comorbidity and is a function of sampling frame. High rates of multiple diagnoses question the interpretation of studies of any single PD. The graded construct of 'breadth' of axis-II pathology may further our understanding of PD.

A comparison of the differential diagnostic efficiency of three personality disorder inventories

This study was a comparison of the relative diagnostic efficiency of the Millon Clinical Multiaxial Inventory-II, the MMPI Personality Disorder Scales, and the Personality Disorder Questionnaire-Revised. The Structured Clinical Interview for DSM-III-R, Axis II was used as the criterion measure. The operating characteristics of all three objective instruments revealed a high rate of false-positive diagnoses, but negative test results were generally valid. Each instrument was found to possess clinical utility in its ability to improve diagnostic efficiency over base rate predictions for most disorders. It is suggested that many of the psychometric limitations revealed in this study reflect the limitations of DSM-III-R, Axis II.

Personality disorders in DSM-III-R as categorical or dimensional

Despite the atheoretical approach of the DSM-III-R, the personality disorders have their roots in specific theoretical schools. Due to clinical tradition, analogies with Axis I and the tradition in psychiatry and medicine, the personality disorders are presented as categories although there is more empirical support for a dimensional approach. This study attempted to determine whether the separate personality disorders meet Kendell's criteria for distinct entities, i.e., bimodality with distinct points of rarity. None of the personality disorders met the criteria for a distinct disease entity. Instead, all of the personality disorders presented as continuous, dimensional personality traits present among healthy subjects and more pronounced in patients with mental disorders.

The TRH-stimulation test in DSM-III personality disorder

The authors examined thyrotropin-releasing hormone (TRH) stimulation testing in the neuroendocrine evaluation of DSM-III major depressive disorder in 26 consecutive medication-free, medically healthy patients meeting a primary DSM-III diagnosis of axis II personality disorder. Thyroid-stimulating hormone (TSH) responses to TRH challenge were not significantly different between patients with or without major depression at time of study, or between patients with or without a life history of major affective disorder. Further, TSH responses to TRH among 11 healthy male nonpsychiatric controls were not significantly different from those in patients with personality disorders. Comparison of those patients with blunted TSH responses (< 7.0 microU/ml) versus those without blunted response (< or = 7.0 microU/ml) also did not reveal a significant difference. In addition, the TSH response to TRH did not correlate with dimensional assessments of state or trait depression, anxiety, or with past history of suicide attempt or alcohol abuse. These data suggest that TRH stimulation testing has limited utility in the evaluation of major depression or other relevant affective states/traits in personality-disordered patients. Affective symptoms in personality-disordered patients do not seem to be associated with dysregulation of the hypothalamic-pituitary-thyroid axis.

MMPI assessment of the DSM-III-R histrionic personality disorder

This study investigated the MMPI characteristics of a group of 25 Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987) histrionic personality disorder patients, contrasted with a mixed group of 57 other personality disorder patients. All patients were diagnosed by means of a semistructured interview (SCID-II; Spitzer, Williams, & Gibbon, 1987). Effects for diagnostic category were found for MMPI Scales 9 (Ma), 0 (Si) and for the HST scale, developed by Morey, Waugh, and Blashfield (1985) for the diagnosis of the histrionic personality disorder. Further analysis of the results revealed that these MMPI scales, and especially the HST scale, mainly assess a social introversion-extraversion dimension, on which histrionic inpatients can be differentiated from nonhistrionic inpatients. This study does not offer direct empirical support for the use of the HST scale as a measurement of the DSM-III-R histrionic personality disorder concept.

Personality disorders in alcoholics and drug addicts

This report examines the prevalence of personality disorders among hospitalized alcoholics and polydrug addicts and the extent and nature of the overlap between different axis II disorders. Subjects were 178 alcoholics admitted to a diagnostic unit of an addiction treatment institute and 86 polydrug addicts admitted to the therapeutic community of the same institute. Substance abuse was diagnosed according to DSM-III-R, and patients were assessed with the Structured Interview for DSM-III Personality Disorders (SIDP). In the alcohol group, 78% of the patients had at least one personality disorder and the average number of personality disorders was 1.8 per patient. In the polydrug group, 91% of the patients met criteria for at least one personality disorder and the average number of personality disorders was 4.0 per patient. No single "addictive personality" emerged. These findings raise questions about the validity and usefulness of the distinction between axis I and axis II disorders in patients with substance use disorders, and do not lend support to the validity of the categorical classification of personality pathology.

Personality and psychopathology: an application of the five-factor model

Our review is concerned with the relationship of the five-factor model of personality to psychopathology, focusing in particular on Axis II personality disorders and depression. The five factors provide a particularly compelling model for interpreting the Axis II personality disorders as maladaptive variants of normal personality traits. However, we also discuss methodological and conceptual limitations of this application. There has been little research on the relationship of Openness, Agreeableness, and Conscientiousness to Axis I mental disorders, but considerable attention has been given to Neuroticism and Extraversion. We focus in particular on the difficulty in distinguishing between the various ways in which personality can relate to depression, either as a predisposition to, a complication of, a pathoplastic effect upon, or a spectrum variant of the mental disorder. We conclude with recommendations for future research.

The interrater reliability of a Dutch version of the Structured Clinical Interview for DSM-III-R Personality Disorders

This study presents data on the interrater reliability of a Dutch version of the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Seventy outpatients were interviewed before the start of their treatment by one rater, while a second rater observed. Both raters were instructed to make independent ratings and the second rater was not allowed to participate in the discussion. On criterion level, interrater reliabilities appear to be very good, with a few exceptions (most reliabilities are higher than 0.75). However, all 5 observation criteria had poor interrater reliabilities. Agreement on personality disorder, on the whole, was excellent (overall kappa = 0.80). The possible reasons why relatively lower reliabilities are found with some criteria are discussed. Finally, problems encountered during the interviews are addressed and possible adjustments of the SCID-II are suggested.