An assessment of the Standardized Assessment of Personality as a screening instrument for the International Personality Disorder Examination: a comparison of informant and patient assessment for personality disorder

BACKGROUND

The International Personality Disorder Examination (IPDE) has been developed as a standardized interview for personality disorders. While it has good psychometric properties, its length makes it difficult to use in the community in population research, particularly outside psychiatric settings. The informant-based Standard Assessment of Personality (SAP), which has been in use since 1981, could serve as a valid screen to detect likely personality disordered individuals who would then receive a definitive diagnosis by IPDE. This study aimed to compare the two instruments in their capacity to detect personality disorder according to ICD-10 taxonomy and to estimate the efficiency of the use of the two together in a case-finding exercise.

METHOD

Ninety psychiatric out-patients in Bangalore, India, were assessed for personality disorder using the two methods. Assessment was conducted by a pair of trained interviewers in random order and by random allocation to interviewer.

RESULTS

Overall agreement between the two instruments in the detection of ICD-10 personality disorder was modest (kappa = 0.4). The level of agreement varied according to personality category, ranging from kappa 0.66 (dependent) to kappa 0.09 (dyssocial). The SAP proved to have a high negative predictive value (97%) for IPDE as the gold standard, suggesting its potential as a screen in samples where the expected prevalence of personality disorder is low.

CONCLUSION

A two-stage approach to epidemiological studies of personality disorder may be practicable.

Dyslexia among Swedish prison inmates in relation to neuropsychology and personality

Several investigations have reported high frequencies of reading and writing disabilities in criminal populations. The aims of the present study were to assess the frequency of dyslexia among Swedish prison inmates and to relate dyslexia to other indices of neuropsychological functions. Sixty-three prison inmates with Swedish as their native language, age 19 to 57 years, were examined by interviews, tests of academic achievement, and neuropsychological assessment. Twenty-six (41%) were diagnosed as dyslexic. As expected, the dyslexic group performed more poorly on verbal tests as compared to the normal readers among the prison inmates, but they also performed more poorly on tests measuring nonverbal abilities. The dyslexic group had higher frequencies of paranoid and avoidant personality disorders compared to the nondyslexics. They also reported higher levels of anxiety and suspicion and a lower degree of socialization. Previous studies report low IQ to be associated with criminal propensity, supporting the interpretation that a double handicap (dyslexia and low IQ) increases the risk of entering a criminal career and remaining in it.

Do personality disorders exist? On the validity of the concept and its cognitive-behavioral formulation and treatment

Since the introduction of personality disorders as important diagnostic categories in the DSM-III [APA (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association] the concept of personality disorder (PD) has met both skepticism and enthusiasm. This paper addresses criticisms, reviews theoretical and empirical evidence for the concept of personality disorders (PD), critically discusses widespread clinical ideas about PDs, and reviews cognitive-behavioral models and treatments of PDs. It is concluded that there is enough evidence for the usefulness of PDs as diagnostic categories. A confirmatory factor analysis for instance yielded very reasonable evidence for the categories hypothesized by the DSM. Contradicting widespread ideas, research indicates that PDs are not a contraindication for cognitive-behavioral treatments of axis-I problems, and that there are even indications that PD pathology itself can be successfully treated using modified CBT methods. In stark contrast to the generally rich empirical history of CBT, research on cognitive models and treatment of PDs is virtually absent. However, the sparse attempts indicate that cognitive models may be fruitful in this area. Future research should be directed at further developing and testing cognitive conceptualizations and treatment models.

Psychiatric assessment of candidates for bone marrow transplantation: a psychodynamically-oriented approach

OBJECTIVE

To seek possible relationships between psychological factors and survival after an intensive medical therapy, using bone marrow transplantation as a model.

METHOD

Candidates for bone marrow transplantation underwent two to three psychodynamically-oriented psychiatric interviews that explored family functioning ("F"), individual psychological maturity ("I"), and the capacity to form and communicate a mature psychological construct of the transplant ("T") process. The results were recorded in a semiquantitative manner, assigning a possible score of 1 to 3 for each parameter, for a possible total of 3 to 9 (the "F.I.T." assessment). Survival after the transplant was analyzed retrospectively in relation to the F.I.T. assessment.

RESULTS

In a series of 112 candidates interviewed prior to transplant, those with the lowest F.I.T. assessment tended not to survive as long. By one year, 95 percent of individuals assigned the lowest score (F.I.T. = 3) had died, whereas 96 percent of those assigned the highest scores (F.I.T. = 7-9) remained alive. The strongest predictors were the "I" and "T" parameters.

CONCLUSION

This approach to assessment of candidates for bone marrow transplantation may identify individuals who require added, supportive measures, both medical and psychological. Furthermore, the results suggest possible leads in the search for how psychological factors might influence the physiologic response to a toxic stress.

Diagnostic viability of depressive personality disorder: theoretical and conceptual issues

Depressive personality disorder (DPD) is being considered for inclusion in future editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In this paper, we review the theoretical and empirical literature on DPD, and examine a number of issues concerning its viability as an Axis II disorder. Three criteria were used as necessary preconditions for the inclusion of DPD on Axis II: (a) substantial theoretical distinctiveness from other disorders, (b) established empirical distinctiveness from other disorders, and (c) sufficient deviation from a "normal temperament." We argue that it is improbable that this disorder could be diagnosed independently of dysthymia, and that there is also considerable symptom overlap with several Cluster C disorders. Although there appears to be sufficient deviation from normality among the entire group of individuals with DPD, those persons whose symptoms are not severe enough to cause overlap with dysthymia may not so deviate. We conclude that the current conceptualization of DPD does not have sufficient discriminative validity or clinical utility to warrant inclusion in future editions of the DSM.

Selecting the most informative items in the IIP scales for personality disorders: an application of item response theory

The first goal of the present analyses was to shorten the five scales (Pilkonis, P. A., Kim, Y., Proietti, J. M., & Barkham, M. [1996]. Journal of Personality Disorders, 10, 355-369) for personality disorders (PDs) developed from the Inventory of Interpersonal Problems (IIP), thereby increasing their attractiveness for screening purposes. The second goal was to illustrate, for more general purposes, the utility of item response theory (IRT) for such scale refinement. IRT analyses were performed using data collected from six different samples (N = 1149) at five sites and a two-parameter (2P) graded model designed for multiple response items like those on the IIP. The five most informative items from each scale were identified, based on the magnitude of item discrimination parameters and the range and elevation of individual item information functions. Preliminary analyses of the reliability and validity of the short forms of the scales (totaling 25 items) supported their value as alternatives to the longer forms (consisting of 47 items), although definitive tests of their psychometric properties await crossvalidation in independent samples. Analyses of the quality receiver operating characteristics (QROC) of the long and short forms showed that both versions can be useful in predicting the presence versus absence of any PD diagnosis arrived at by using either a "best estimate" clinical consensus method or a structured Axis II interview.

Sadistic personality disorder in sex offenders: relationship to antisocial personality disorder and sexual sadism

To investigate the relationship of sadistic personality disorder (SPD), as defined in the appendix of DSM-III-R, to other personality disorders and to sexual sadism, 70 sex offenders (27 child molesters, 33 rapists, and 10 murderers) were assessed by the International Personality Disorder Examination. In 19 subjects (27.2%) from the total sample, SPD was diagnosed. The highest overlap appeared with borderline personality disorder (31.6%) and antisocial personality disorder (42.1%). However, in four cases SPD was the only personality disorder diagnosed. Factor analysis of the antisocial and sadistic criteria resulted in four major factors--one factor with high loadings on the sadistic criteria and the violent criteria of antisocial personality disorder, two factors with different forms of adult and juvenile aggression, and a fourth factor with high loadings on the antisocial criteria covering exploitative behavior. The results do not support SPD as a discrete disorder. Nevertheless, SPD may be seen as an important subdimension of antisocial personality disorder, distinct from more exploitative forms of antisocial behavior with less violence. Of those patients with SPD, 42.1% also had a DSM-III-R diagnosis of sexual sadism, which may be the most dangerous configuration.

CSF 5-HIAA levels are lower in impulsive as compared to nonimpulsive violent suicide attempters and control subjects

BACKGROUND

We studied CSF 5-HIAA and HVA concentrations in violent suicide attempters and examined their relationship with depression, anxiety, and impulsivity.

METHODS

CSF 5-HIAA and HVA concentrations were determined very shortly after hospital admission and compared to those of a matched control population. Clinical evaluation was performed concomitantly; the level impulsivity was evaluated by the Impulsivity Rating Scale (IRS).

RESULTS

Twenty-three patients and 23 control subjects were included. According to the IRS, 14 patients were classified as impulsive, including all patients suffering from personality disorders, and 9 as nonimpulsive, with a main DSM-IIIR diagnosis of melancholia. CSF 5-HIAA concentrations in the suicide group were significantly lower than in control subjects. This difference was entirely due to the impulsive suicide attempters. There was an inverse correlation between the IRS score and CSF 5-HIAA (r = -.47, p = .02) and only a trend for HVA (r = -.41, p = .078) levels in the suicide group.

CONCLUSIONS

This study of a group of violent suicide attempters distinguished a subgroup of patients diagnosed with personality disorder with high impulsivity scores and a subgroup of patients with the main diagnosis of severe depression. CSF 5-HIAA was significantly lower in impulsive violent attempters than in nonimpulsive violent attempters, therefore desintangling violence from impulsivity and linking this biologic abnormality to impulsivity.

Personality dimensions and substance misuse: relationships in adolescents, mothers and fathers

The research addressed the question of whether relationships exist between personality dimensions, antisocial behavior, and alcohol or other substance misuse (AOSM) in adolescents and in their fathers and mothers, who often also have histories of AOSM. One hundred male adolescents (mean age 15.8 years) entering a residential treatment center for youths with AOSM, their mothers (n = 88, mean age 39.4 years), their fathers (n = 36, mean age 44.9 years), and community controls (n = 100 adolescents, mean age 16.5 years; n = 96 mothers, mean age 43.8 years; n = 87 fathers, mean age 45.9 years) were recruited. All participants completed a personality questionnaire and were interviewed on several measures, including structured interviews for psychopathology and substance misuse. The findings indicated that novelty seeking (NS), one of the personality dimensions, was significantly correlated with substance misuse in adolescent probands, adolescent controls, and proband fathers and mothers, but not in control fathers and mothers. Regression analyses that included conduct disorder (CD) or antisocial personality disorder (APD) symptoms indicated that both NS and CD or APD symptoms made significant contributions to the prediction of substance misuse in treatment group probands and in their fathers and mothers. The findings further suggest that NS and antisocial behaviors contribute independently to substance misuse in severely impaired adolescents and their fathers, but not in their mothers.

Is an organic/functional distinction psychologically meaningful in patients with dysphonia?

Dysphonia (hoarseness) is a common clinical condition and, if persistent, patients are referred to otolaryngology clinics for clinical examination. During the examination, a clinical distinction is often made among three types of patients: (1) those with a clear organic basis for dysphonia (cancer, vocal cord palsy): (2) those with some degree of organic pathology; and (3) those with an apparently functional etiology. Functional patients are often characterized as having a psychogenic disorder. This study assessed the psychological validity of the functional category in 204 out-patients (aged 17 to 87 years) with persistent hoarseness of types (2) and (3). Following clinical examination, a consultant otolaryngologist categorized patients as having functional or organic etiology. Subjects were then compared on measures of personality and psychological distress. Dysphonic subjects showed marked psychological distress compared with norms, and reported significantly more previous psychosomatic symptoms than norms, but there were no differences in personality or psychological distress between organic and functional subgroups of dysphonics.

Psychiatric symptoms endorsed by somatization disorder patients in a psychiatric clinic

Patients with somatization disorder (SD) endorse high rates of psychiatric symptoms. However, prior studies have not addressed whether these endorsed symptoms reflect underlying psychiatric illness or whether they represent symptom overendorsement mirroring somatic complaints in patients with SD. Thirty-two female outpatients with SD and 101 with other psychiatric disorders completed a checklist of current and lifetime psychiatric symptoms. These findings were analyzed with respect to the diagnoses given by their treating psychiatrists. Patients with SD displayed significantly more current and lifetime psychiatric symptoms than did patients without either SD or cluster B personality disorder. Patients with SD endorsed a large number of psychotic, manic, depressive, and anxiety symptoms; however, they endorsed few alcohol use disorder symptoms. Psychotic and manic symptoms endorsed by patients with SD did not reflect their clinical diagnoses: only two patients with SD carried an additional clinician diagnosis of either schizophrenia or bipolar disorder, despite high rates of endorsed symptoms by the group. Patients with cluster B personality disorders but without SD showed a symptom profile similar to that of patients with SD. Psychiatric outpatients with SD endorse many more psychiatric symptoms than do other psychiatric patients. Patients with SD in the psychiatric treatment setting may mimic other psychiatric illnesses; therefore, SD should be considered in the differential diagnosis for a wide variety of psychiatric illness, including psychotic and mood disorders.

Associations of self-regulation with personality traits and self-efficacy in Japanese elementary school children

This study was conducted to investigate the associations of scores on four self-regulation subscales identified by Nakata and Shiomi in 1998 with those on personality traits measured on the Shimoda Personality Inventory and self-efficacy with 123 Japanese elementary school children. Scores on the self-regulation subscales had significant positive correlations with scores on immodithymic and syntonic traits, and significant negative correlations with scores on schizothymic, nervous, and uncertain traits. Correlations with self-efficacy were also positive and significant. From these results higher scorers on self-regulation may have more positive personality traits and higher self-efficacy scores.

Approaching psychotherapy of the personality disorders from the Millon perspective

Millon's integrative model for a clinical science begins with a theory that is consistent with current knowledge, establishes a taxonomy for classification, develops a coordinated assessment system, and develops and implements interventions with the guidance of the preceding elements of the model. In recent years, work on the last step of the model, clinical interventions, has accelerated rapidly, and the model now permits the therapist to directly extrapolate specific treatment goals, objective, and techniques to the practice of therapy with the individual patient. This article summarizes how treatment planning and implementation flows logically from the Millon model.

Assessment and importance of personality disorders in medical patients: an update

BACKGROUND

Personality disorders in medical patients have received less attention than depression, anxiety, or somatization.

METHOD

We conducted a selective literature search to assess the role of personality disorders in medical patients.

RESULTS

Review of recent studies suggests a high prevalence and morbidity of personality disorders in medical populations. Important correlates in selected groups are depression, somatization, noncompliance, sexual risk taking, and substance abuse. Difficulties in physician-patient relationships are also frequently reported. Psychiatric interventions are considered beneficial, though no single treatment of choice is available.

CONCLUSIONS

We recommend that physicians consider the possibility of personality disorders in medical patients to choose appropriate treatments for selected symptoms. Training in interviewing skills may enhance recognition of personality disorders and management of associated psychiatric conditions.

Comorbidity in schizophrenia: a prognostic study of personality disorders in recovered and non-recovered schizophrenia patients

Symptoms and outcome in schizophrenia are heterogeneous. Part of the variation in outcome might be due to the coexistence of other forms of psychopathology. In the present study the prevalence of personality disorders in a group of recovered and non-recovered schizophrenia patients was focused to examine the prognostic implications of comorbidity for the outcome of the disorder. The results showed no significant differences in prevalence of personality disorders in the two groups at first admission to the hospital, but the difference at the time of interview was close to significance. Emotional and conduct difficulties in adolescence were significantly more prevalent in the non-recovered group. Schizoid features and emotional and conduct disorders in childhood were also more often reported among the non-recovered subjects. The results confirm that comorbidity contributes to the variation in outcome for schizophrenia patients, but does not confirm its prognostic significance.

MMPI variables predictive of schizophrenia in the Copenhagen High-Risk Project: a 25-year follow-up

Moldin et al. (1) have identified a cluster of Minnesota Multiphasic Personality Inventory (MMPI) scales that discriminate adolescents at risk for schizophrenia from those not at risk. The present study examines how well Moldin's scales predict schizophrenic decompensation in a sample of 207 Danish adolescents at high genetic risk for schizophrenia. Subjects were assessed using a modified, 304-item MMPI in 1962 (mean age= 15.1 years) and diagnosed in 10-year and 25-year follow-ups. Premorbidly, schizophrenic subjects (n=31) scored higher than subjects with no mental illness on the frequency (F) and psychoticism (PSY) scales. When paranoid and non-paranoid preschizophrenics were separated, three scales (F, Pz (paranoid schizophrenia) and PSY) significantly discriminated paranoid preschizophrenics. Discriminant function analyses confirmed these results. It is concluded that the MMPI may be useful for identifying schizophrenia premorbidly.

[Personality changes in children treated by the Ilizarov device]

The treatment of children and youth by Ilizarov's method is very long. During this treatment there appear psychological problems which, on the one hand, are the effects of the features of personality but, on the other hand, they are the effects of emotional lability which is characteristic of adolescence. This paper basing on analysis of questionnaires and chosen personality features attempts to find correlation between these features and the effects of treatment. The obtained findings suggest that patients who are treated by Ilizarov's method should undergo psychological therapy.

Personality, personality disorders, and defense mechanisms

The prototype approach was used to assess the presence of personality features associated with borderline, narcissistic, histrionic, and psychopathic personality syndromes in a sample of 91 young adults from the Block and Block (1980) longitudinal study. These personality prototypes were found to be related to the use of denial and projection, and especially to the immature manifestations of those defenses, in ways consistent with theory.

Personality disorders in primary care

Managing patients with personality disorders is an unfortunate, yet inevitable, aspect of the primary care practice. The epidemiology and origin of these disorders are briefly discussed. This article discusses both formal criteria for diagnosis and informal indicators that are clues for the physician to consider these disorders. In addition, relevant clinical cases are presented and reviewed. This article also outlines some practical management strategies to help the physician more effectively and efficiently deal with these troublesome patients.

Assumptions in borderline personality disorder: specificity, stability and relationship with etiological factors

The specificity and stability of a set of assumptions hypothesized to be characteristic of Borderline Personality Disorder (BPD) was investigated. BPD patients (n = 16) were compared to cluster-C personality disorder patients (n = 12) and to normal controls (n = 15). All subjects were female and diagnosed with SCID-I and -II. Subjects rated a short version of the Personality Disorder Beliefs Questionnaire (PDBQ), with six sets of 20 assumptions each, hypothesized to be characteristic of avoidant, dependent, obsessive-compulsive, paranoid, histrionic and borderline personality disorder. The BPD assumptions (Cronbach alpha = 0.95) proved to be the most specific to BPD patients. Subjects rated the shortened PDBQ again after viewing an emotional video fragment one week later. Despite increased negative emotions, the PDBQ ratings remained relatively stable. Confirming the cognitive hypothesis, regression analyses indicated that the BPD assumptions mediate the relationship between self-reported etiological factors from childhood (sexual abuse and emotional/physical abuse) and BPD pathology assessed with the SCID-II. It is suggested that a set of assumptions is characteristic of BPD, and is relatively stable despite the instability of the behaviour of people diagnosed as having BPD.

Comparison of MMPI-A, Marks and Briggs, and MMPI-2 norms for juvenile delinquents

A study was conducted to compare scores of juvenile delinquents on the new MMPI-A to previous research and to compare 3 sets of norms for adolescents: the MMPI-A, the Marks-Briggs adolescent norms, and the MMPI-2 adult norms. Subjects, 11 boys and 11 girls, were hospitalized adolescents, aged 14 to 17 years, with a history of conduct problems. Analysis of MMPI-A scale scores for boys indicated elevated T-score means on scales F (64), Hs (64), Pd (65), Pa (68), Pt (68), Sc (70), and Ma (66). Mean T scores for girls on the MMPI-A were elevated on scales of F (62), Pd (64), and Sc (62). The findings that the mean T score for scales Pd, Sc, and Ma are elevated for this population is consistent with previous research on juvenile delinquents. In general, the MMPI-A scale elevations were lowest, followed by the Marks-Briggs norms. The MMPI-2 T-score means were the most elevated. One of the limitations of the present investigation is an extremely small sample. Until further research is conducted on larger samples, clinicians concerned about the different norms are encouraged to plot MMPI-A scores on both adolescent and adult norms. It is also recommended that the MMPI-A be included as part of an assessment battery with other objective tests, clinical observation, and patient report.

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'.