Validity of the Personality Diagnostic Questionnaire-Revised: a replication in an outpatient sample

We report a replication study of the validity of the Personality Diagnostic Questionnaire-Revised (PDQ-R) in an outpatient sample. Fifty-nine applicants for psychoanalysis at a training institute completed the PDQ-R and were diagnosed by clinicians, blind to the PDQ-R results, using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Personality Disorder Examination (PDE). The PDQ-R showed high sensitivity and moderate specificity for most axis II disorders. Although not a substitute for a structured interview because it yields many false-positives, the PDQ-R is an efficient instrument for screening outpatients with DSM-III-R personality disorders.

Personality disorder diagnoses in patients with bulimia nervosa: clinical correlates and changes with treatment

BACKGROUND

In view of reports of a high incidence of Axis II disorders among patients with bulimia nervosa, we assessed personality diagnoses and traits in a sample of bulimic patients both preceding and following treatment for the eating disorder.

METHOD

The Personality Disorder Examination, a structured interview to assess DSM-III-R personality disorders, was administered to 34 in-patients and 49 outpatients with bulimia nervosa entering treatment. Thirty of 49 outpatients were reassessed after 6 weeks of treatment with desipramine or placebo.

RESULTS

At initial assessment, 38% of inpatients (N = 13) and 29% of outpatients (N = 14) fulfilled criteria for at least one personality disorder, most frequently borderline personality disorder. There were significant correlations between Personality Disorder Examination trait scores and clinical measures of eating disorder and depressive symptoms. Of 30 outpatients who were reinterviewed following treatment, 3 of 9 patients lost one or more personality diagnoses at post-treatment assessment, and 2 of 21 patients without initial Personality Disorder Examination diagnoses received one or more diagnoses at the second interview. Changes in Personality Disorder Examination trait scores, but not diagnoses, were correlated with changes in some clinical measures.

CONCLUSION

These data suggest that the assessment of Axis II disorders in patients with bulimia nervosa is problematic and raise the possibility that personality features in this group may be influenced by the course of their Axis I disorder.

Diagnosis of DSM-III-R personality disorders by two structured interviews: patterns of comorbidity

OBJECTIVE

The purpose of this study was to examine patterns of co-occurrence of axis II disorders in a group of consecutive patients evaluated with two contrasting structured interviews.

METHOD

One hundred of 106 consecutive applicants for long-term, inpatient treatment of severe personality psychopathology were assessed, face-to-face, by psychiatrists using the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II) and the Personality Disorder Examination (PDE). The percent of co-occurrence of pairs of disorders diagnosed by each structured interview separately was calculated, and significance levels were determined by using chi-square tests of independence. Finally, odds ratios were computed for the odds of each pair of disorders occurring together compared with the odds for the occurrence of each disorder alone.

RESULTS

The two interview methods revealed different comorbidity patterns. Significant covariation was found for 29 pairs of disorders diagnosed with the PDE, compared with 12 pairs diagnosed with the SCID-II. Six pairs of disorders covaried significantly and were associated with odds ratios greater than 4: histrionic with borderline, histrionic with narcissistic, narcissistic with antisocial, narcissistic with passive-aggressive, avoidant with schizotypal, and avoidant with dependent.

CONCLUSIONS

Substantial overlap occurred among personality disorders. In this group of patients, consistent patterns of comorbidity involving narcissistic, avoidant, and histrionic personality disorders suggest that categorical distinctions between them and certain other DSM-III-R personality disorders may be illusory. The question of which of two overlapping disorders is more valid, however, is left unanswered. For clinical purposes, a two-level diagnostic convention is proposed.

Diagnosis and treatment of personality disorders

This article touches on four current areas of controversy in the field of the personality disorders -- definition, etiology, assessment, and treatment. There is a tremendous amount of disability, personal distress, and public health expense as a result of the personality disorders. We are seeing steady progress in each of these areas. The implications of this progress are enormous, and the interest in this area is widespread, not just among psychiatric health professionals or among patients and their families and friends, but also among the public at large.

Assessment and diagnosis of borderline personality disorder

Borderline personality disorder is common in treatment settings and may be so in the general population. In this guide to assessment strategies for diagnosing borderline personality disorder, the authors discuss the reliability and validity of structured interviews and self-report instruments and suggest the use of a self-report questionnaire as a cost-effective screening test. Assessment problems, such as the need for longitudinal observation, are reviewed. Essential features of the recommended diagnostic approach include clarity about the diagnostic concept, consideration of the full range of diagnostic criteria, incorporation of recently developed diagnostic methodologies, care in distinguishing personality disorders from comorbid axis I syndromes, and complete assessment of the full range of axis II disorders.

Personality disorders in the public sector

Using a clinical data base for New York state hospitals, the authors examined the prevalence of DSM-III axis II personality disorders in state hospital patients and explored the patterns of comorbidity between axis I and axis II disorders. They found that 11 percent of the patients received a diagnosis of personality disorder and that these patients were more likely than other patients to have a primary diagnosis of schizoaffective disorder, major affective disorder, dysthymia, and substance use disorder other than alcoholism. Comparison of state hospital data with data from nonstate facilities showed different patterns of coexisting primary diagnoses and personality disorders and a much higher frequency of borderline personality disorder in nonstate patients. Based on the low percentage of state hospital patients diagnosed as having personality disorders, the authors conclude that axis II disorders are underreported in state facilities.

Influence of nutrition and bovine growth hormone (GH) on hepatic GH binding, insulin-like growth factor-I and growth of lambs

The effect on young lambs of 0.25 mg recombinant bovine GH (bGH)/kg per day on plasma concentrations of insulin-like growth factor-I (IGF-I), glucose, specific hepatic GH binding and body composition changes was examined at two levels of nutrition (lucerne pellets; 3 and 1.7% of body weight/day). Lambs on low levels of nutrition had low plasma IGF-I (P less than 0.001). Plasma concentrations of IGF-I were increased by bGH treatment at both levels of nutrition, with the high nutrition group showing the greatest IGF-I response after 3 and 40 days of bGH treatment. Plasma glucose, after 40 days, was higher overall (P less than 0.05) in lambs on high nutrition. bGH treatment increased plasma glucose, with the response being greater in the well-fed lambs. Specific binding of GH to liver membranes was highest in lambs on high nutrition and on bGH treatment; no significant interaction between nutrition and bGH treatment was detected, indicating that specific binding of GH was increased proportionally by bGH at both nutritional levels. The major change in body composition was the reduced level of fatness in lambs treated with bGH. There was no significant effect of bGH on body weight although bGH treatment tended to increase weight gain of well-fed lambs and decreased weight loss of poorly nourished lambs. The results show that, although there was a significant (P less than 0.05) bGH/nutrition interaction for IGF-I there was no such interaction for body weight/components or specific GH binding to the liver. The results indicate that an increase in plasma IGF-I does not necessarily result in increases in growth or changes in carcass composition.

Validity of the Personality Diagnostic Questionnaire--revised: comparison with two structured interviews

The authors gave the self-report Personality Diagnostic Questionnaire--Revised (PDQ-R) to 87 applicants for inpatient treatment of severe personality psychopathology and, blind to these results, diagnosed personality disorders in the applicants by using the Personality Disorder Examination and the Structured Clinical Interview for DSM-III-R Personality Disorders. The PDQ-R was not a substitute for a structured interview assessment of axis II disorders because many of its diagnoses were false positives. Its high sensitivity and moderate specificity for most of the axis II disorders suggest, however, that it is an efficient instrument for screening patients with DSM-III-R personality disorders.

Validating structured DSM-III-R personality disorder assessments with longitudinal data

The authors observed 20 patients over time for mal-adaptive personality traits during hospitalization and made longitudinal diagnoses to validate Structured Clinical Interview for DSM-III-R (SCID) assessments of personality disorders. The SCID assessments identified certain personality disorders better than others.

Structured interviews and borderline personality disorder

A study was designed to determine whether the Diagnostic Interview for Borderlines (DIB) might be scored from the Schedule for Affective Disorders and Schizophrenia (SADS), and also whether DIB scores predicted the clinical diagnosis of DSM-III borderline personality disorder. One pair of clinicians interviewed patients with the DIB, and another pair interviewed the same patients with a slightly modified version of the SADS. Both interviews diagnosed virtually the same patients as borderline according to the criteria of Gunderson and Singer. The sensitivity of DIB scores in predicting a DSM-III diagnosis of borderline was 70%, while the specificity was 90%; the intraclass correlation coefficient was .75. Although there is a substantial concordance, the disparity between the DSM-III and DIB systems of diagnosing borderline patients is sufficiently great to preclude the generalization of findings from studies employing one set of criteria to those employing the other.

Medical students' learning as primary therapists or as participant/observers in a psychiatric clerkship

The authors assessed two different inpatient models of clinical clerkships in psychiatry on the basis of both an examination assessing amount of learning and a survey of student attitudes. One clerkship model placed the third-year medical student in the role of primary therapist; the other model assigned each student to join a psychiatrist as a participant/observer. No overall difference in objective assessment of learning was found between the two groups of students, and student attitudes generally favored the participant/observer model. These findings suggest that the widespread bias favoring the primary therapist model may not be justified.

Seclusion. Patterns and milieu

Patterns of locked seclusion use were reviewed on an inpatient service caring for both voluntary and involuntary patients. Hospital records of 313 sequentially admitted patients were studied, comparing those patients requiring one or more episode of seclusion with those never secluded. Eighteen per cent of the patients studied were secluded, a group significantly younger, more likely to have a manic-like illness, more often never married, and more frequently involuntarily hospitalized than the nonsecluded group. Patterns of seclusion frequency, duration, and numbers of episodes per patient are discussed in the context of the milieu. The modal pattern of seclusion in our study was for it to occur in the first week of hospitalization, for there to be one or two episodes per patient, and for total seclusion time to be 3 hours or less. The authors conclude that early and judicious use of seclusion with both voluntary and involuntary patients is compatible with modern hospital work and that the pattern of use reflects both clinical and milieu parameters.

Familial transmission of DSM-III borderline personality disorder

A comparison was made of the types of mental disorders occurring in the first-degree relatives of 83 female patients with DSM-III borderline personality disorder, 100 female patients with DSM-III schizophrenia, and 100 female patients with DSM-III bipolar disorder. Diagnosis of the relatives was made independently by two clinicians who were blind to the diagnosis of the probands. The relative of a borderline patient was about ten times more likely to have been treated for a borderline or borderlinelike personality disorder than was the relative of a schizophrenic or bipolar patient. The borderline patients' relatives were also treated for more unipolar depression than the schizophrenics' relatives. However, the relatives of the borderline patients did not have a higher morbid risk for treated mania or schizophrenia than that usually reported for the population at large.

The structure and technique of community meetings: the short-term unit

Most psychiatric inpatient units call themselves therapeutic communities and hold community meetings where patients and staff meet for a specified period of time (Clark 1977; Joint Commission on Mental illness and Health 1961; Jones et al. 1953; Moline 1976; Wessen 1964). On short-term units which receive a wide spectrum of patients, including involuntary, acutely disturbed and demented patients, the structure and techniques used in running community meetings must be altered from the ways initially described by Jones et al. Certain patients do not function well if the more traditional, less structured model is followed. We will describe specific structural and technical parameters which permit the accommodation of the community meeting to the needs of these patients and result in fewer "failures." These parameters are in part based on the experimental studies by Abramczuk (1972), Daniels and Rubin (1968), and Rubin (1979), who demonstrated the need for more structure. We will describe a typical community meeting on a short-term unit, discussing recurrent themes and patient government.

Neuropsychiatric diagnosis on a short-term treatment service

The evaluation of suspected neuropsychiatric disorder in a series of 17 patients is described. The heuristic value of DSM-III's multiaxial approach is noted. The use of routine and neuropsychological tests, EEGs, CAT scans, T-3 and T-4 tests, and lumbar puncture, in conjunction with prolonged behavioral observation in a stable, therapeutic milieu, provided the means for clarification of neuropsychiatric illness in this series of complex cases. The value of CAT scans, neuropsychological tests and of prolonged behavioral observation in selected cases is discussed.