Concordance between personality disorder assessment methods

Impact of Personality Disorder Cluster on Depression Outcomes Within Collaborative Care Management Model of Care

BACKGROUND

Previous studies have suggested that having a comorbid personality disorder (PD) along with major depression is associated with poorer depression outcomes relative to those without comorbid PD. However, few studies have examined the influence of specific PD cluster types. The purpose of the current study is to compare depression outcomes between cluster A, cluster B, and cluster C PD patients treated within a collaborative care management (CCM), relative to CCM patients without a PD diagnosis. The overarching goal was to identify cluster types that might confer a worse clinical prognosis.

METHODS

This retrospective chart review study examined 2826 adult patients with depression enrolled in CCM. The cohort was divided into 4 groups based on the presence of a comorbid PD diagnosis (cluster A/nonspecified, cluster B, cluster C, or no PD). Baseline clinical and demographic variables, along with 6-month follow-up Patient Health Questionnaire-9 (PHQ-9) scores were obtained for all groups. Depression remission was defined as a PHQ-9 score <5 at 6 months, and persistent depressive symptoms (PDS) was defined as a PHQ-9 score ≥10 at 6 months. Adjusted odds ratios (AORs) were determined for both remission and PDS using logistic regression modeling for the 6-month PHQ-9 outcome, while retaining all study variables.

RESULTS

A total of 59 patients (2.1%) had a cluster A or nonspecified PD diagnosis, 122 patients (4.3%) had a cluster B diagnosis, 35 patients (1.2%) had a cluster C diagnosis, and 2610 patients (92.4%) did not have any PD diagnosis. The presence of a cluster A/nonspecified PD diagnosis was associated with a 62% lower likelihood of remission at 6 months (AOR = 0.38; 95% CI 0.20-0.70). The presence of a cluster B PD diagnosis was associated with a 71% lower likelihood of remission at 6 months (AOR = 0.29; 95% CI 0.18-0.47). Conversely, having a cluster C diagnosis was not associated with a significantly lower likelihood of remission at 6 months (AOR = 0.83; 95% CI 0.42-1.65). Increased odds of having PDS at 6-month follow-up were seen with cluster A/nonspecified PD patients (AOR = 3.35; 95% CI 1.92-5.84) as well as cluster B patients (AOR = 3.66; 95% CI 2.45-5.47). However, cluster C patents did not have significantly increased odds of experiencing persistent depressive symptoms at 6-month follow-up (AOR = 0.95; 95% CI 0.45-2.00).

CONCLUSIONS

Out of the 3 clusters, the presence of a cluster B PD diagnosis was most significantly associated with poorer depression outcomes at 6-month follow-up, including reduced remission rates and increased risk for PDS. The cluster A/nonspecified PD group also showed poor outcomes; however, the heterogeneity of this subgroup with regard to PD features must be noted. The development of novel targeted interventions for at-risk clusters may be warranted in order to improve outcomes of these patients within the CCM model of care.

The SAPAS, Personality Traits, and Personality Disorder

Many argue that current categorical personality disorder (PD) classification systems should be more dimensional and consider personality traits. The present study examined whether a brief PD screening tool, the Standardized Assessment of Personality: Abbreviated Scale (SAPAS) primarily screened for traits of low emotional stability, low extraversion, and low agreeableness, rather than PD per se. A general community sample (n = 237) completed the SAPAS, a personality trait measure, and the International Personality Disorder Examination (IPDE) screening questionnaire. Regressions showed that the SAPAS provided substantial incremental validity over personality trait scores in predicting total IPDE scores, indicating that the SAPAS captures variance unique to PD, rather than just extremes of general disposition. The SAPAS is an empirically valid rapid PD screen for nonclinical populations, correctly identifying 78% of individuals who screen positively for PD on the IPDE. However, the SAPAS was not effective for screening antisocial PD, limiting its utility in forensic settings.

Neither too much, nor too little. The dilemma of identifying personality disorders in adolescents patients with self-reports

The study aimed to compare methods of identification of Personality Disorders (PD) in adolescent patients with psychiatric disorders. A sample of 120 Spanish adolescents with clinical disorders was assessed using the International Personality Disorder Examination (IPDE) interview, its Screening Questionnaires (IPDE-SQ) comprising the ICD-10 and DSM-IV modules, and also the Temperament Character Inventory (TCI) to identify risk of PD. The IPDE-SQ identified a risk of PD around 92-97% of the sample; 61.7% when adjusting the stricter cut-off points. The TCI showed a PD risk of 20%, whereas the prevalence of PD identified by the IPDE clinical interview was around 36-38%. The differences between the IPDE, IPDE-SQ and TCI were significant, and a low agreement among instruments was obtained. Large discrepancy between self-report instruments in identifying PD with regard to the clinical interview raises several questions concerning the use of these instruments in clinical settings on adolescents with psychiatric disorders.

Convergent and incremental predictive validity of clinician, self-report, and structured interview diagnoses for personality disorders over 5 years

OBJECTIVE

Research has demonstrated poor agreement between clinician-assigned personality disorder (PD) diagnoses and those generated by self-report questionnaires and semistructured diagnostic interviews. No research has compared prospectively the predictive validity of these methods. We investigated the convergence of these 3 diagnostic methods and tested their relative and incremental validity in predicting independent, multimethod assessments of psychosocial functioning performed prospectively over 5 years.

METHOD

Participants were 320 patients in the Collaborative Longitudinal Personality Disorders Study diagnosed with PDs by therapist, self-report, and semistructured interview at baseline. We examined the relative incremental validity of therapists' naturalistic ratings relative to these other diagnostic methods for predicting psychosocial functioning at 5-year follow-up.

RESULTS

Hierarchical linear regression analyses revealed that both the self-report questionnaire and semistructured interview PD diagnoses had significant incremental predictive validity over the PD diagnoses assigned by a treating clinician. Although, in some cases, the clinicians' ratings for individual PDs did have validity for predicting subsequent functioning, they did not generally provide incremental prediction beyond the other methods. These findings remained robust in a series of analyses restricted to a subsample of therapist ratings based on clinical contact of 1 year or greater.

CONCLUSIONS

These results from a large clinical sample echo previous research documenting limited agreement between clinicians' naturalistic PD diagnoses and those from self-report and semistructured interview methods. They extend prior work by providing the first evidence about the relative predictive validity of these different methods. Our findings challenge the validity of naturalistic PD diagnoses and suggest the use of structured diagnostic instruments.