Assessing axis II disorders by informant interview

Acute stressors and clinical characteristics differentiate death by suicide, accident, or natural causes among illicit and prescription opiate users

BACKGROUND

Opiate misuse has reached epidemic levels. Prevention efforts depend on distinguishing opiate users from abusers. The current study compared opioid users who died by natural cases, accidents, and suicide using psychological autopsy methods. Groups were compared on substance use characteristics, treatment history, experiences of negative life events, and circumstances at the time of death.

METHODS

Substance use and suicide risk were evaluated using psychological autopsy methods in 63 decedents with positive toxicology for opiates at death divided into three groups: adults dying by suicide (n = 19), accident (n = 19), and natural causes (n = 25). Groups were compared on several dependent measures, using chi-square analyses to examine categorical variables and one-way analyses of variance (ANOVA) to examine continuous variables.

RESULTS

Individuals who died by suicide were similar in many ways to adults who died by an accidental overdose. However, suicide completers were more likely to have struggled with severe depression, and previously attempted suicide, whereas the accidental overdose sample was more likely to display a chronic pattern of severe drug abuse.

CONCLUSIONS

The current study helps to distinguish between opiate users who are at risk for death by an accidental or intentional overdose. In the ongoing opiate crisis, clinicians must understand the risk of overdose and the nuances of accidental behaviors compared to purposeful ones. Signs of suicidal planning, relevant psychopathology, and ongoing life stress may be useful points of intervention for stopping the increasing number of deaths among opiate users.

Risk-taking behaviors and stressors differentially predict suicidal preparation, non-fatal suicide attempts, and suicide deaths

Negative life events are elevated in suicidal populations. Diathesis-stress and kindling effects models suggest different mechanisms by which negative life events increase suicide risk. Different forms of negative life events - risk-taking behaviors and stressors - may have different effects on non-fatal suicide attempts and suicide. We assessed the effects of risk-taking behaviors and stressors on suicide, history of non-fatal suicide attempts, and active preparation for suicide in a sample of adults who died by suicide or other causes (N = 377). Psychological autopsy procedures using family member interviews and collateral record review were used to complete a risk-taking behaviors composite measure from the Structured Interview for DSM-IV Personality Disorders, the Modified Life Experiences Scale, and the planning subscale of the Suicide Intent Scale. Stressors were significantly associated with death by suicide, even when accounting for demographic and diagnostic characteristics. Risk-taking behaviors were significantly associated with non-fatal suicide attempts, even when accounting for demographic and diagnostic characteristics. Suicide decedents who did not actively prepare for suicide showed significantly higher risk-taking scores than suicide decedents who actively planned for suicide. Our results suggest that risk-taking behaviors and stressors impact suicide risk through separate mechanisms. Risk-taking behaviors may represent a longstanding vulnerability to act impulsively on suicidal thoughts. Stressors may impact risk for fatal suicidal behaviors in mood disordered populations.

Self- and informant-reported perspectives on symptoms of narcissistic personality disorder

Because narcissistic individuals tend to have an inflated view of themselves and their abilities, the reliance on self-reported information in the assessment and diagnosis of narcissistic personality disorder (NPD) is problematic. Hence, the use of informants in the assessment of NPD may be necessary. In the current study we examined self- and informant-reported features of NPD using agreement, frequency, and discrepancy analyses. The results indicated that informants tended to report more NPD features than selves, and that there were either low or nonsignificant levels of self-informant agreement among the 9 NPD diagnostic criteria and its categorical diagnosis. Informants were increasingly more likely to report higher raw scores relative to selves, indicating that the discrepancy between self- and informant reports increases with the NPD scale. Informants also reported NPD features that selves often did not, suggesting that current prevalence estimates of NPD, which use only self-reported information, are most likely underestimates. These results highlight the importance of gathering informant-reported data in addition to self-reported data when assessing NPD. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Level of agreement between self and spouse in the assessment of personality pathology

Informant reports can provide important information regarding the presence of pathological personality traits, and they can serve as useful supplements to self-report instruments. Ratings from a spouse may be a particularly valuable source of personality assessment because spouses are very well acquainted with the target person, have typically known the person for a long time, and witness behaviors across a variety of situations. In the current study, self- and spouse report measures based on the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) personality disorder criteria were collected from a nonclinical sample of 82 couples (N = 164). Agreement between self- and spouse report for several pathological personality factors was significant and somewhat higher than has been found for self and peer agreement. Nevertheless, the magnitude of self-spouse agreement was still moderate in size (mean r = .36). Findings are discussed with regard to using spouse report in the assessment of personality pathology.

Pathological narcissism and narcissistic personality disorder

We review the literature on pathological narcissism and narcissistic personality disorder (NPD) and describe a significant criterion problem related to four inconsistencies in phenotypic descriptions and taxonomic models across clinical theory, research, and practice; psychiatric diagnosis; and social/personality psychology. This impedes scientific synthesis, weakens narcissism's nomological net, and contributes to a discrepancy between low prevalence rates of NPD and higher rates of practitioner-diagnosed pathological narcissism, along with an enormous clinical literature on narcissistic disturbances. Criterion issues must be resolved, including clarification of the nature of normal and pathological narcissism, incorporation of the two broad phenotypic themes of narcissistic grandiosity and narcissistic vulnerability into revised diagnostic criteria and assessment instruments, elimination of references to overt and covert narcissism that reify these modes of expression as distinct narcissistic types, and determination of the appropriate structure for pathological narcissism. Implications for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the science of personality disorders are presented.

[Prevalence, diagnosis and treatment of personality disorders in older adults]

AIM

This article addresses manifestation, course, diagnosis and treatment of personality disorders in older adults (>60 yrs).

METHOD

A literature search, using "Cochrane Central Register of Controlled Trials (CENTRAL)", Cochrane Database of Systematic Reviews (CDSR)", "PsychINFO 2000-present" and "PUBMED", concerning relevant literature from 1980-2009. Keywords were "personality disorder", "elderly", "older adults", "prevalence", "diagnosis" and "treatment". The combinations of these keywords resulted in 32 relevant hits.

RESULTS

Prevalence studies addressing specific personality disorders show that within different subpopulations personality pathology of clusters A and C (odd respectively anxious behaviour) are quite common in older adults whereas cluster B personality disorders (impulsive behaviour) is more prevalent in younger adults. Besides, it appears that the personality questionnaires and interviews used in adult care are not yet validated for older adults in mental health care and nursing homes. Furthermore, there is no convincing reason why psychotherapy variants proven to be effective for adults (<50 yrs) wouldn't be feasible for older adults. Particularly with respect to cognitive (behavioural) therapy and schema therapy, there is some evidence from case studies suggesting that these therapies are well applicable to the elderly.

CONCLUSION

Prevalence rates appear questionable since the assessment methods applied in the epidemiological studies correspond inadequately to the specific behavioural manifestations of elderly persons with personality pathology. In addition, the number of specific (test)diagnostic tools for older adults are scarce. Currently, there is a lack of empirical data concerning treatment of personality disorders in older adults. However, at this moment several studies are focussed to improve diagnostics and therapy of personality disorders in geriatric psychiatry in the Netherlands and Belgium.

The frequency of personality disorders in psychiatric patients

Community-based epidemiological studies of psychiatric disorders provide important information about the public health burden of these problems; however, because seeking treatment is related to a number of clinical and demographic factors, studies of the frequency and correlates of psychiatric disorders in the general population should be replicated in clinical populations to provide the practicing clinician with information that might have more direct clinical utility. Diagnosing co-occuring personality disorders in psychiatric patients with an Axis I disorder is clinically important because of their association with the duration, recurrence, and outcome of Axis I disorders. This article reviews clinical epidemiological studies of personality disorders and finds that in studies using semi-structured diagnostic interviews, approximately half of the patients interviewed have a personality disorder. Thus, as a group, personality disorders are among the most frequent disorders treated by psychiatrists.

Assessing normal and abnormal personality functioning: strengths and weaknesses of self-report, observer, and performance-based methods

Assessing personality characteristics; distinguishing the boundaries between normal and abnormal functioning; identifying impairment in the domains of work, interpersonal relationships, and emotional state due to maladaptive personality traits; and translating these findings into effective, appropriate treatment interventions is a complicated endeavor. Valid, reliable conclusions about an individual's personality functioning and adjustment cannot be reached unless one has accurate information about that person's patterns of behavior, cognitions, emotions, and interpersonal relationships. I discuss strengths and weaknesses of assessment approaches utilizing explicit assessment methods, such as self-report measures and clinical interviews; information obtained from knowledgeable observers; and performance-based, implicit assessment methods such as the Rorschach Comprehensive System (Exner, 2003). In contrast to explicit methods of assessment, implicit methods can provide salient information about a personality construct whether or not individuals have accurately conceptualized that construct, have weighed how the construct describes them, are self-aware, and are willing to openly provide information relevant to that construct. I propose that the accuracy of conclusions about an individual's personality style, problems in adjustment, and treatment needs may be improved if conclusion are based on a multimethod assessment approach that incorporates information gathered using explicit assessment methods, information provided by significant others, and data from performance-based or implicit measures of personality.

Assessment of Adult Psychopathology: Meta-Analyses and Implications of Cross-Informant Correlations

Assessment of adult psychopathology relies heavily on self-reports. To determine how well self-reports agree with reports by "informants" who know the person being assessed, the authors examined 51,000 articles published over 10 years in 52 peer-reviewed journals for correlations between self-reports and "informants" reports. Qualifying correlations were found in 108 (0.2%) of the articles. When self-reports and informant reports were obtained with parallel instruments, mean cross-informant correlations were .681 for substance use, .428 for internalizing, and .438 for externalizing problems. When based on different instruments, the mean cross-informant correlation was .304. The moderate sizes of the correlations argue for systematically obtaining multi-informant data. National survey findings were used to illustrate practical ways to obtain and use such data.

Evidence-based assessment of personality disorders

The purpose of this article is to provide a foundation for the development of evidence-based guidelines for the assessment of personality disorders, focusing in particular on integrated assessment strategies. The general strategy recommended herein is to first administer a self-report inventory to alert oneself to the potential presence of particular maladaptive personality traits followed by a semistructured interview to verify their presence. This strategy is guided by the existing research that suggests particular strengths of self-report inventories and semistructured interviews relative to unstructured clinical interviews. However, the authors also consider research that suggests that further improvements to the existing instruments can be made. The authors emphasize, in particular, a consideration of age of onset, distortions in self-perception and presentation, gender bias, culture and ethnicity, and personality change.

Five-factor model prototypes for personality disorders: the utility of self-reports and observer ratings

The current study examined the prototype-matching technique for using the five-factor model (FFM) of personality to assess personality disorders (PDs) and their correlates. The sample was composed of 69 psychiatric patients, most of whom suffered from affective or anxiety disorders. The participants were predominantly outpatients (78%), Caucasian (94%), and women (58%). NEO Personality Inventory (NEO-PI) data from these patients and informants were available for deriving PD prototype scores. The results supported four conclusions. First, the FFM prototype-matching method is useful for clinical samples. Second, agreement between self-reports and information from significant others (SOs) using this method is good compared to previous results. Third, this agreement varies systematically with the observability of the PD criteria. Fourth, the value of self- and other-reported personality information depends on the rating source of the outcome variables. Other-reported information provides incremental utility in predicting impairment and interpersonal distress rated by clinicians and significant others.

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.

Abuse and neglect in childhood: relationship to personality disorder diagnoses

BACKGROUND

Childhood history of abuse and neglect has been associated with personality disorders and has been observed in subjects with lifetime histories of suicidality and self-injury. Most of these findings have been generated from inpatient clinical samples.

METHODS

This study evaluated self-rated indices of sustained childhood abuse and neglect in an outpatient sample of well-characterized personality disorder subjects (n=182) to determine the relative associations of childhood trauma indices to specific personality disorder diagnoses or clusters and to lifetime history of suicide attempts or gestures. Subjects met criteria for ~2.5 Axis II diagnoses and 24% reported past suicide attempts. The Childhood Trauma Questionnaire was administered to assess five dimensions of childhood trauma exposure (emotional, physical, and sexual abuse, and emotional and physical neglect). Logistic regression was employed to evaluate salient predictors among the trauma measures for each cluster, personality disorder, and history of attempted suicide and self-harm. All analyses controlled for gender distribution.

RESULTS

Seventy-eight percent of subjects met dichotomous criteria for some form of childhood trauma; a majority reported emotional abuse and neglect. The dichotomized criterion for global trauma severity was predictive of cluster B, borderline, and antisocial personality disorder diagnoses. Trauma scores were positively associated with cluster A, negatively with cluster C, but were not significantly associated with cluster B diagnoses. Among the specific diagnoses comprising cluster A, paranoid disorder alone was predicted by sexual, physical, and emotional abuse. Within cluster B, only antisocial personality disorder showed significant associations with trauma scores, with specific prediction by sexual and physical abuse. For borderline personality disorder, there were gender interactions for individual predictors, with emotional abuse being the only significant trauma predictor, and only in men. History of suicide gestures was associated with emotional abuse in the entire sample and in women only; self-mutilatory behavior was associated with emotional abuse in men.

CONCLUSION

These results suggest that childhood emotional abuse and neglect are broadly represented among personality disorders, and associated with indices of clinical severity among patients with borderline personality disorder. Childhood sexual and physical abuse are highlighted as predictors of both paranoid and antisocial personality disorders. These results help qualify prior observations of the association of childhood sexual abuse with borderline personality disorder.

Patients' versus informants' reports of personality disorders in predicting 7 1/2-year outcome in outpatients with depressive disorders

Concordance between patients' and informants' reports of personality disorders (PDs) is low, raising the questions of which source provides more valid data and whether both contribute unique information. This study compared patients' and informants' reports of PDs in predicting outcome in a 7 1/2-year follow-up of 85 depressed outpatients. Patients and informants were independently evaluated using structured interviews; outcome was assessed using structured interviews with patients. Both patients' and informants' reports of PD diagnoses and dimensional scores independently predicted depression symptoms and global functioning at follow-up. However, only informants' reports made a unique contribution to predicting social adjustment. This finding indicates that both patients and informants provide unique information on Axis II psychopathology and argues for the use of both sources in the assessment of PDs.

Current issues in the assessment of personality disorders

Most patients will have clinically significant maladaptive personality traits. These personality traits can substantially complicate the effective treatment of other mental disorders, and they can also be the focus of effective treatment. The assessment of personality disorders is of considerable clinical importance. However, this assessment can also be highly problematic. This article discusses the major issues in the assessment of personality disorders (eg, differentiation from other mental disorders, from normal personality functioning, and gender bias) and summarizes existing research on the convergent and discriminant validity of the semistructured interviews and self-report inventories, which have been developed to improve the reliability and validity of personality disorder assessment.

Psychiatric patient- and informant-reported personality: predicting concurrent and future behavior

The authors investigated the criterion and incremental validity of personality reports from psychiatric patients and knowledgeable informants in predicting patient substance use, social and risky behaviors, and psychological distress. Patient and informant reports of patient personality and behavior were collected from an adult psychiatric sample (N = 94). Hierarchical regressions indicated that patient reports of personality accounted for significant variance in both concurrent (17%-42%) and future behavior assessed 1 year later (17%-40%). Informant reports contributed significantly to the prediction of several behaviors and most strongly to social behaviors. Behaviors were predicted equally well by self-reports and informant reports in prospective as in concurrent regressions. Thus, both patient and informant reports of personality contribute importantly to prediction of behavior, and predictive ability is stable across time.

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.

Validity of the family history method for identifying schizophrenia-related disorders

We examined the family history method's validity for identifying schizophrenia related disorders (SRD) by comparing family history and family study derived diagnoses. First degree relatives (n = 284) of 48 psychiatrically disordered probands, predominantly with schizophrenia, were diagnosed using the Family History RDC (FH-RDC) which include three psychotic schizophrenia related disorders (P-SRD): schizophrenia, chronic SAD and chronic unspecified functional psychosis (CUFP). Supplementary criteria for schizophrenia related personality disorders (SRP), derived to identify schizotypal and paranoid personality disorders (PD), were also assessed. About two thirds of these relatives (n = 196; 69.0%) were independently diagnosed by RDC and DSM-III-R on both axis I and axis II in a family study. The specificity was 1.0 (178/178) and the sensitivity of the family history derived diagnosis for P-SRD was 0.72 (13/18). Sensitivity for P-SRD was improved, however, by inclusion of SRP which captured three of the five false negative relatives. The sensitivity of SRP for schizotypal or paranoid PD was 0.39 (15/38) and the specificity was 0.92 (127/138). The FH-RDC have moderately good sensitivity and excellent specificity for the psychotic schizophrenia related disorders. While family history criteria for SRP are not a good proxy for schizotypal or paranoid PD, they can enhance the family history method's sensitivity for SRD.