Pathology versus statistical infrequency: potential sources of gender bias in personality disorder criteria

Clinician perception of pathological narcissism in females: a vignette-based study

The DSM-5 reports that up to 75% of those diagnosed with Narcissistic Personality Disorder (NPD) are males, which denotes that narcissism is a clinical phenomenon that operates differently in men and women. Vulnerable narcissism, which tends to be more prevalent in females and is currently under-appreciated in the DSM-5, may be diagnosed as other "vulnerable" disorders (e.g., Borderline Personality Disorder; BPD). The current study investigated gender differences in clinicians' perceptions of narcissistic pathology. Adopting an online vignette-based study, clinicians (N = 108; 79 females) read clinical case vignettes of hypothetical patients and provided diagnostic ratings of existing personality disorders. Clinicians' diagnostic ratings of NPD were concurrent with the vignette containing grandiose narcissism symptoms, irrespective of patient gender. However, when presented with a vulnerable narcissism vignette, clinicians were significantly more likely to attribute a BPD diagnosis in female patients, compared to male patients. Clinicians with a psychodynamic approach and more experience in practice were also more likely to label vulnerable narcissism symptoms as NPD, compared to those with a CBT approach and less experience in practice. The clinical implications of these results support the shift toward assessing personality dysfunction based on dimensional trait domains.

The role of migration processes and cultural factors in the classification of personality disorders

Migrants and ethnic minorities are at risk of being under- and overdiagnosed with personality disorders (PDs). A culturally informed approach to the classification of PDs guides clinicians in incorporating migration processes and cultural factors, to arrive at a reliable and valid assessment of personality pathology. In this article, we provide a tentative framework to highlight specific interactions between personality disorders, migration processes, and cultural factors. It is argued that migration processes can merely resemble personality pathology, activate certain (latent) vulnerabilities, and aggravate pre-existing personality pathology. We propose that these migration processes can include manifestations of grief about the loss of pre-migratory psychosocial and economic resources, and the struggle to attain psychosocial and economic resources in the host culture. Moreover, several cultural dimensions are outlined that can either resemble or mask personality pathology. The term "culturally masked personality disorder" is coined, to delineate clinical cases in which cultural factors are overused or misused to rationalize behavioral patterns that are consistently inflexible, distressing, or harmful to the individual and/or significant others, lead to significant impairment, and exceed the relevant cultural norms. Additionally, the role of historical trauma is addressed in the context of potential overdiagnosis of personality disorders in Indigenous persons, and the implications of misdiagnosis in migrants, ethnic minorities, and Indigenous populations are elaborated. Finally, clinical implications are discussed, outlining various diagnostic steps, including an assessment of temperament/character, developmental history, systemic/family dynamics, migration processes, cultural dimensions, and possible historical trauma.

Female Narcissism: Assessment, Aetiology, and Behavioural Manifestations

Despite putative gender differences in the expression of narcissism, prominent theories have virtually dismissed the role of females in the development and manifestation of narcissism. The contention that narcissism is a pathology of the self that may partly differ in males and females is further evident in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5 reports that up to 75% of those diagnosed with Narcissistic Personality Disorder (NPD) are men. Such figures suggest that the representation of narcissism as codified in the DSM-5 may only be marginally applicable to females, given its prominent focus and nature on capturing grandiose themes which closely resemble commonly masculine norms. The overemphasis on grandiose features extends to the empirical literature which defines narcissism as a normative personality trait and is widely assessed using the Narcissistic Personality Inventory (NPI), on which males obtain significantly higher scores than females. As this review will demonstrate, one limitation frequently occurring in the literature is the attempt to comprehend narcissistic manifestations in females through the lens of what has commonly been defined as narcissism (DSM/NPI). In this review, the literature concerning the diagnostic assessment and conceptualisation of narcissistic personality disorder, aetiological factors, aggression, and partner violence perpetration will be discussed in relation to the importance of gender. This is followed by a review of existing gaps in theory and research, and suggestions for fruitful directions that can aid a richer and more meaningful literature on narcissism inclusive of gender issues.

Personality disorders and the "difficult" dermatology patient: Maximizing patient satisfaction

Personality disorders (PDs) are stable and enduring patterns of thought, feeling, and behavior that deviate from one's cultural norms and cause impairment in functionality. Patients with PDs are commonly encountered in the dermatologic setting and can be perceived by providers as "difficult." Given that PDs are chronic, rigid, and frustrating to deal with, it is important to be skillful in the approach to such patients, especially in the era of the value-based reimbursement system, in which patient satisfaction is crucial for reimbursement. This contribution discusses four PDs most commonly encountered in the dermatology setting: Borderline, histrionic, obsessive-compulsive, and narcissistic. Although the details regarding the approach to patients for each PD differ as discussed, once a PD is identified, there are few key management strategies that can be helpful in minimizing conflict and enhancing outcomes. In patients with PD, the presenting skin complaint is often a secondary problem, as there may be an underlying psychologic issue (somatization). Understanding the underlying psychologic aspect of the patients' dermatologic complaints and adapting behaviors to the patients' needs are fundamental for maximizing patient satisfaction.

A psychometric investigation of gender differences and common processes across borderline and antisocial personality disorders

The comorbidity between borderline personality disorder (BPD) and antisocial personality disorder (ASPD) is well-established, and the 2 disorders share many similarities. However, there are also differences across disorders: most notably, BPD is diagnosed more frequently in women and ASPD in men. We investigated if (a) comorbidity between BPD and ASPD is attributable to 2 discrete disorders or the expression of common underlying processes, and (b) if the model of comorbidity is true across sex. Using a clinical sample of 1,400 drug users in residential substance abuse treatment, we tested 3 competing models to explore whether the comorbidity of ASPD and BPD should be represented by a single common factor, 2 correlated factors, or a bifactor structure involving a general and disorder-specific factors. Next, we tested whether our resulting model was meaningful by examining its relationship with criterion variables previously reported to be associated with BPD and ASPD. The bifactor model provided the best fit and was invariant across sex. Overall, the general factor of the bifactor model significantly accounted for a large percentage of the variance in criterion variables, whereas the BPD and AAB specific factors added little to the models. The association of the general and specific factor with all criterion variables was equal for men and women. Our results suggest common underlying vulnerability accounts for both the comorbidity between BPD and AAB (across sex), and this common vulnerability drives the association with other psychopathology and maladaptive behavior. This in turn has implications for diagnostic classification systems and treatment. (PsycINFO Database Record

Beyond Description in Interpersonal Construct Validation: Methodological Advances in the Circumplex Structural Summary Approach

The interpersonal circumplex is a well-established structural model that organizes interpersonal functioning within the two-dimensional space marked by dominance and affiliation. The structural summary method (SSM) was developed to evaluate the interpersonal nature of other constructs and measures outside the interpersonal circumplex. To date, this method has been primarily descriptive, providing no way to draw inferences when comparing SSM parameters across constructs or groups. We describe a newly developed resampling-based method for deriving confidence intervals, which allows for SSM parameter comparisons. In a series of five studies, we evaluated the accuracy of the approach across a wide range of possible sample sizes and parameter values, and demonstrated its utility for posing theoretical questions on the interpersonal nature of relevant constructs (e.g., personality disorders) using real-world data. As a result, the SSM is strengthened for its intended purpose of construct evaluation and theory building.

Sex Bias in Classifying Borderline and Narcissistic Personality Disorder

This study investigated sex bias in the classification of borderline and narcissistic personality disorders. A sample of psychologists in training for a post-master degree (N = 180) read brief case histories (male or female version) and made DSM classification. To differentiate sex bias due to sex stereotyping or to base rate variation, we used different case histories, respectively: (1) non-ambiguous case histories with enough criteria of either borderline or narcissistic personality disorder to meet the threshold for classification, and (2) an ambiguous case with subthreshold features of both borderline and narcissistic personality disorder. Results showed significant differences due to sex of the patient in the ambiguous condition. Thus, when the diagnosis is not straightforward, as in the case of mixed subthreshold features, sex bias is present and is influenced by base-rate variation. These findings emphasize the need for caution in classifying personality disorders, especially borderline or narcissistic traits.

Factorial Invariance of the Five-Factor Model Rating Form Across Gender

The Five-Factor Model Rating Form (FFMRF) provides a brief, one-page assessment of the Five-Factor Model. An important and unique aspect of the FFMRF is that it is the only brief measure that includes scales for the 30 facets proposed by Costa and McCrae. The current study builds on existing validity support for the FFMRF by evaluating its factorial invariance across gender within a sample of 699 undergraduate students. Consistent with other measures of the Five-Factor Model, men scored lower than women on the domains of neuroticism, extraversion, agreeableness, and conscientiousness but slightly higher on openness. The novel contribution of the current study is the use of exploratory structural equation modeling to determine that the FFMRF displayed a five-factor structure that demonstrated strong measurement invariance across gender. This factorial invariance adds important support for the validity of the FFMRF as a self-report measure as it indicates that the scores assess the same latent constructs in men and women. Although future work is needed to clarify some facet-level findings and evaluate for potential predictive biases, the present results add to the increasing body of research supporting the validity of the FFMRF as a self-report measure of personality.

Antisocial and borderline personality disorders revisited

Antisocial personality disorder (ASPD) and borderline personality disorder (BPD) have an overlap in both symptoms and risk factors, suggesting that they might reflect the same form of psychopathology, shaped by gender. However other lines of evidence point to the presence of partly unique, albeit overlapping, trait dimensions, specifically affective instability which differentiates BPD from ASPD. Our conclusion is that ASPD and BPD are separate disorders.

Gender differences in the endorsement of symptoms for depression and anxiety: are gender-biased items responsible?

Gender-biased items are one explanation for the gender difference in reports of depression and anxiety symptoms. This hypothesis was explored using responses from the Goldberg Anxiety and Depression scales. Responses were drawn from 2 waves of a community-based survey with participants in 3 age cohorts: 20 to 25, 40 to 44, and 60 to 64 at wave 1. The results showed that a 2-factor model fitted the scales well. Multiple group analyses showed that that for all 3 age groups and both time points the fit indices changed minimally between a model that constrained parameters to be equal across gender and a model that permitted variation. These findings indicate that gender differences in the endorsement of items from the Goldberg scales are not because of gender-biased items. This study points to alternate biopsychosocial explanations and highlights the importance of choosing appropriate methods of analysis when assessing item bias.

Gender bias in diagnostic criteria for personality disorders: an item response theory analysis

The authors examined gender bias in the diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision; American Psychiatric Association, 2000) personality disorders. Participants (N=599) were selected from 2 large, nonclinical samples on the basis of information from self-report questionnaires and peer nominations that suggested the presence of personality pathology. All were interviewed with the Structured Interview for DSM-IV Personality (B. Pfohl, N. Blum, & M. Zimmerman, 1997). Using item response theory methods, the authors compared data from 315 men and 284 women, searching for evidence of differential item functioning in the diagnostic features of 10 personality disorder categories. Results indicated significant but moderate measurement bias pertaining to gender for 6 specific criteria. In other words, men and women with equivalent levels of pathology endorsed the items at different rates. For 1 paranoid personality disorder criterion and 3 antisocial criteria, men were more likely to endorse the biased items. For 2 schizoid personality disorder criteria, women were more likely to endorse the biased items.

Repetitive skin-cutting: parental bonding, personality and gender

OBJECTIVES

This study examines (a) the extent to which repetitive skin-cutting is most prevalent among women and those with a history of trauma; and (b) among those skin-cutters without a history of trauma, the extent to which borderline personality disorder (BPD) features as a primary diagnosis and whether disturbed parental bonding might be associated with this form of self-harm.

METHOD

Details of gender and reported experiences of trauma were recorded for a large, consecutive sample of skin-cutters (N=517) who attended a general hospital. Psychiatric diagnoses and parental bonding instrument (PBI) scores were obtained for a subsample of skin-cutters (N=81) and comparison group participants without experiences of trauma.

RESULTS

No gender differences were observed among skin-cutters, most of whom reported experiences of trauma. BPD was recorded for a minority of those skin-cutters without a history of trauma. PBI scores discriminated between non-BPD skin cutters and non-BPD comparison participants without a history of trauma.

CONCLUSIONS

Although these results provide further confirmation of a potential association between prior trauma and repetitive skin-cutting, they rigorously challenge the validity of reported gender differences for this behaviour. Further, this study has identified that repetitive skin-cutting can arise independently of BPD and prior trauma. Clinical implications of these results and suggested directions for future research are discussed.

Developmental psychopathology and neurobiology of aggression

The aim of this paper is to clarify how neural mechanisms at the molecular level, specifically the serotonergic (5-HT) system and the hypothalamic-pituitary-adrenal axis system (HPA) in conjunction with early life stress may contribute to the emergence of aggression, self-directed and otherwise, in borderline personality disorder (BPD). Chronic dysregulation of these biological systems, which function to regulate stress and emotion, may potentiate the development of impulsive aggression in borderline personality conditions. Our central premise in this paper is that brain development, stress regulation, and early pathonomic experience are interactive and cumulative in their mutual influence on the development of impulsive aggression in BPD. We review the parameters of impulsive aggression in BPD, followed by a discussion of the neurobiological and neuroendocrine correlates of impulsive aggression with and without BPD. We then focus on the developmental continuities in BPD with attention to brain maturation of 5-HT and HPA axis function during the life span and the influence of early adverse experiences on these systems. Finally, we comment on the data of the relative stability of aggression in BPD, adolescence as a developmental stage of potential vulnerability, and the course of aggressive behavior during the life span.

Gender differences in personality traits and disorders

Personality disorders differ in prevalence by gender. The most striking findings concern antisocial personality disorder, which is more common in men, and borderline personality disorder, which is more common in women. These differences are not artifacts, but reflect gender differences in the personality traits that underlie Axis II diagnoses.

The neurobiological consequences of early stress and childhood maltreatment

Early severe stress and maltreatment produces a cascade of neurobiological events that have the potential to cause enduring changes in brain development. These changes occur on multiple levels, from neurohumoral (especially the hypothalamic-pituitary-adrenal [HPA] axis) to structural and functional. The major structural consequences of early stress include reduced size of the mid-portions of the corpus callosum and attenuated development of the left neocortex, hippocampus, and amygdala. Major functional consequences include increased electrical irritability in limbic structures and reduced functional activity of the cerebellar vermis. There are also gender differences in vulnerability and functional consequences. The neurobiological sequelae of early stress and maltreatment may play a significant role in the emergence of psychiatric disorders during development.

Personality disorders at the crossroads

Personality disorders are now at a crossroads with respect to theory, research, and conceptualization. In this article, we review relevant and current issues within the personality disorder field. After reviewing changes in the conception of personality disorders across the past half century (1952 to 2002), we focus on the issue of continuity versus discontinuity methodologies for assessing personality, interactionism, treatments, resolved and unresolved issues, and future directions. The issue of continuity versus discontinuity is a theme in this article. We conclude that the evidence is in favor of a reapprochment between a categorical classification system and a dimensional system and we also outline the difficulties in achieving this change.

Perceived dysfunction of male-typed and female-typed DSM-IV personality disorder criteria

To determine whether female-typed personality disorders are associated with a different pattern of dysfunction than male-typed disorders, lay judges (N = 216) estimated the amount of social impairment, occupational impairment, and personal distress related to symptoms of personality disorders. Results for both the subset of six disorders originally rated by clinician judges in the research of Funtowicz and Widiger (1999) and for a larger set of nine disorders revealed a pattern originally reported by Funtowicz and Widiger where female-typed disorders were associated with relatively higher ratings of personal distress, whereas male-typed disorders were associated with relatively higher ratings of social (and sometimes occupational) impairment. Findings are discussed with respect to the emphasis of different forms of dysfunction for male- and female-typed disorders, lay versus clinician judgments, and directions for future research.