A review of the agreement between clinicians’ personality disorder diagnoses and those from other methods and sources

The 'revolving door' of mental illness: A meta-analysis and systematic review of current versus lifetime rates of psychological disorders

OBJECTIVES

Therapists have long observed a phenomenon referred to as the 'revolving door' of mental health services, in which individuals often develop, seek treatment for, and recover from multiple mental illnesses across their life. However, this has not been systematically examined. If this phenomenon is widespread, one would expect that the number of lifetime disorders would exceed that of current disorders. The aim of this meta-analysis was to test this hypothesis.

METHODS

A search was conducted of the following databases: MEDLINE, PsycINFO and Web of Science. In total, 38 studies were included in the current review; 27 of these contained sufficient quantitative data to be included in the meta-analysis, addressing the primary research aim. The remaining 11 studies were included in the systematic review only.

RESULTS

Meta-analyses of the 27 studies indicated that the average number of lifetime disorders was 1.84 times that of current disorders. Previous treatment significantly moderated this relationship, while the clinical nature of the sample did not. Examination of the remaining studies revealed common temporal sequences, indicating disorders which typically develop first or consequently to other disorders.

CONCLUSIONS

These findings provide support for the revolving door of mental illness, suggesting a need for transdiagnostic treatments and broader conceptualisation of relapse prevention.

Can personality disorder be accurately assessed in older age? A differential item functioning analysis of ICD-11 inventories

OBJECTIVES

The contested categorical personality disorder (PD) criteria are not well suited to inform PD diagnoses in older adults. Yet, the classification of PDs is undergoing a critical transition phase with a paradigm shift to a dimensional approach for diagnosing PDs. No special attention was given to the expression of PDs in older age when the dimensional ICD-11 model was developed. Given that PDs are highly prevalent in older adults, there is an urgent need to examine if ICD-11 related instruments are able to adequately assess for PDs in older adults.

METHODS

The age-neutrality of ICD-11 measures was examined in a sample of 208 Dutch community-dwelling adults (N = 208, M age = 54.96, SD = 21.65), matched on sex into 104 younger (age range 18-64) and 104 older (age range 65-93) adults. An instrument is considered not to be age-neutral if a collective large level of differential item functioning (DIF) exists in a group of items of an instrument (i.e., 25% or more with DIF). We therefore set out to detect possible DIF in the following ICD-11 self-report measures: the Standardized Assessment of Severity of Personality Disorder (SASPD), the Personality Inventory for ICD-11 (PiCD), and the Borderline Pattern Scale (BPS).

RESULTS

DIF analyses using a non-parametric odds ratio approach demonstrated that SASPD, PiCD, and BPS were age-neutral with less than 25% of items showing DIF. Yet, impact of DIF at scale level, examined by way of differential test functioning (DTF), indicated a DTF effect on the SASPD total score.

CONCLUSIONS

These results of age-neutrality of the PiCD and BPS are promising for measuring ICD-11 traits and the borderline pattern. Yet, the age-neutral measurement of PD severity requires further research. With a rapidly aging population, its accurate assessment across the entire adult life span, including older age, is a prerequisite for an adequate detection of PDs.

Personality disorders in older adults: Differences in self-informant ratings

Previous research on self-informant reports in assessing personality disorders (PDs) has been mainly focused on adults, leaving older adults under-studied. We examined self-informant agreement in PD screening among older adults (≥60 years) using the Gerontological Personality disorders Scale (GPS). Potential differences such as who reports more personality pathology on a PD screener (i.e., GPS), item accessibility and the effect of relational aspects were studied as well. Data of 326 older adult-informant dyads, of which the older adults were sampled from five general practices in the Netherlands, were used. Results indicate that self-informant agreement ranged from r = 0.26-0.73, with lower concordance on the GPS-subscale measuring intrapersonal aspects of personality pathology. Informants were more sensitive to habitual pathological personality features than older adults. Two GPS items showed differential item functioning across self- and informant-report. Of relational aspects, only congeniality affected the GPS-iv scores; lower ratings on congeniality were associated with higher GPS-iv scores (i.e., higher reporting of personality problems).

Dimensional models of personality disorders: Challenges and opportunities

Categorical models of personality disorders have been beneficial throughout psychiatric history, providing a mechanism for organizing and communicating research and treatment. However, the view that individuals with personality disorders are qualitatively distinct from the general population is no longer tenable. This perspective has amassed steady criticism, ranging from inconsequential to irreconcilable. In response, stronger evidence has been accumulated in support of a dimensional perspective that unifies normal and pathological personality on underlying trait continua. Contemporary nosology has largely shifted toward this dimensional perspective, yet broader adoption within public lexicon and routine clinical practice appears slow. This review focuses on challenges and the related opportunities of moving toward dimensional models in personality disorder research and practice. First, we highlight the need for ongoing development of a broader array of measurement methods, ideally facilitating multimethod assessments that reduce biases associated with any single methodology. These efforts should also include measurement across both poles of each trait, intensive longitudinal studies, and more deeply considering social desirability. Second, wider communication and training in dimensional approaches is needed for individuals working in mental health. This will require clear demonstrations of incremental treatment efficacy and structured public health rebates. Third, we should embrace cultural and geographic diversity, and investigate how unifying humanity may reduce the stigma and shame currently generated by arbitrarily labeling an individual's personality as normal or abnormal. This review aims to organize ongoing research efforts toward broader and routine usage of dimensional perspectives within research and clinical spaces.

Validity and utility of Hierarchical Taxonomy of Psychopathology (HiTOP): III. Emotional dysfunction superspectrum

The Hierarchical Taxonomy of Psychopathology (HiTOP) is a quantitative nosological system that addresses shortcomings of traditional mental disorder diagnoses, including arbitrary boundaries between psychopathology and normality, frequent disorder co-occurrence, substantial heterogeneity within disorders, and diagnostic unreliability over time and across clinicians. This paper reviews evidence on the validity and utility of the internalizing and somatoform spectra of HiTOP, which together provide support for an emotional dysfunction superspectrum. These spectra are composed of homogeneous symptom and maladaptive trait dimensions currently subsumed within multiple diagnostic classes, including depressive, anxiety, trauma-related, eating, bipolar, and somatic symptom disorders, as well as sexual dysfunction and aspects of personality disorders. Dimensions falling within the emotional dysfunction superspectrum are broadly linked to individual differences in negative affect/neuroticism. Extensive evidence establishes that dimensions falling within the superspectrum share genetic diatheses, environmental risk factors, cognitive and affective difficulties, neural substrates and biomarkers, childhood temperamental antecedents, and treatment response. The structure of these validators mirrors the quantitative structure of the superspectrum, with some correlates more specific to internalizing or somatoform conditions, and others common to both, thereby underlining the hierarchical structure of the domain. Compared to traditional diagnoses, the internalizing and somatoform spectra demonstrated substantially improved utility: greater reliability, larger explanatory and predictive power, and greater clinical applicability. Validated measures are currently available to implement the HiTOP system in practice, which can make diagnostic classification more useful, both in research and in the clinic.

Actigraphic patterns, impulsivity and mood instability in bipolar disorder, borderline personality disorder and healthy controls

OBJECTIVES

To differentiate the relation between the structure and timing of rest-activity patterns and symptoms of impulsivity and mood instability in bipolar disorder (BD), borderline personality disorder (BPD) and healthy controls (HC).

METHODS

Eighty-seven participants (31 BD, 21 BPD and 35 HC) underwent actigraph monitoring for 28 days as part of the Automated Monitoring of Symptom Severity (AMoSS) study. Impulsivity was assessed at study entry using the BIS-11. Mood instability was subsequently longitudinally monitored using the digital Mood Zoom questionnaire.

RESULTS

BPD participants show several robust and significant correlations between non-parametric circadian rest-activity variables and worsened symptoms. Impulsivity was associated with low interdaily stability (r = -0.663) and weak amplitude (r = -0.616). Mood instability was associated with low interdaily stability (r = -0.773), greater rhythm fragmentation (r = 0.662), weak amplitude (r = -0.694) and later onset of daily activity (r = 0.553). These associations were not present for BD or HCs. Classification analysis using actigraphic measures determined that later L5 onset reliably distinguished BPD from BD and HC but did not sufficiently discriminate between BD and HC.

CONCLUSIONS

Rest-activity pattern disturbance indicative of perturbed sleep and circadian function is an important predictor of symptom severity in BPD. This appears to validate the greater subjective complaints of BPD individuals that are sometimes regarded as exaggerated by clinicians. We suggest that treatment strategies directed towards improving sleep and circadian entrainment may in the future be investigated in BPD.

Comparative Content Analysis of Self-Report Scales for Level of Personality Functioning

Content validity analyses of eight self-report instruments for assessing severity of personality disorder (PD), also known as Level of Personality Functioning (LPF), were conducted using the conceptual scheme of the Alternative Model for Personality Disorders (AMPD; APA, 2013). The item contents of these eight inventories were characterized for the LPF constructs of Identity (ID), Self-Direction (SD), Empathy (EM), and Intimacy (IN) along with the pathological personality trait domains of Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism. Severity of pathology (SV) reflected in item content was also rated. Raters demonstrated robust agreement for AMPD and SV constructs across instruments. Similarity between instrument AMPD construct profiles was quantified by intraclass correlations (ICC). Results showed the instruments were generally similar in AMPD-construct coverage, but some important differences emerged. The subscales of the instruments also were characterized for the degree to which they reflect the four LPF (ID, SD, EM, IN) domain constructs. Collectively, these content validity comparisons clarify the equivalence of instruments for AMPD constructs and the relative proportions of construct coverage within instrument subscales. These results can inform future research with LPF self-report instruments and guide clinicians in selecting an LPF-related instrument for use in practice.

The assessment of personality disorder: methodological, developmental, and contextual considerations

The reliable and valid assessment of personality disorders (PDs) faces several challenges in different domains. In particular, the variety of methods, settings, and informants relevant for PD assessment raises questions about best practices. Additionally, issues surrounding assessment across the lifespan, including youth and the elderly, further complicate PD assessment. We review these issues here and point toward future directions in PD assessment, with an emphasis on the utility of dimensional PD assessment.

Validation of an Adapted French Form of the Structured Interview for the Five-Factor Model (SIFFM) in a Swiss Sample

Abstract. We analyzed the psychometric properties of the Structured Interview for the Five-Factor Model (SIFFM) in a French-speaking Swiss sample and compared the French version to the original English version. A community-based sample of 260 participants (183 women and 77 men, aged 20 to 88 years, Mage = 46.23, SDage = 16.37) were assessed using the SIFFM and the NEO-FFI-R. Forty of the participants agreed to be filmed or to be assessed by two investigators simultaneously. The internal consistency coefficients of the five dimensions of SIFFM ranged from .63 to .84. An exploratory factor analysis within the confirmatory factor analysis framework showed that the structure of the French version of the SIFFM was in line with the structure suggested by the Five-Factor Model. Except for the modesty and dutifulness subscales, each facet scale had its highest factor loading on the factor representing the targeted domain. Moreover, a principal axis joint factor analysis of the SIFFM and NEO-FFI-R domains suggested that the convergent validity between the two instruments was adequate. Furthermore, the interrater reliability coefficients for the SIFFM scores were high. The French version of the SIFFM shows acceptable psychometric properties, comparable to those of the English version, and may be an informative assessment method and an alternative to self-report measures.

A Preliminary Probe of Personality Predicting Psychotherapy Outcomes: Perspectives from Therapists and Their Clients

BACKGROUND

It is widely established that personality disorder has as broad negative impact on psychotherapy outcomes. Given the increased emphasis on dimensional traits for personality pathology in the DSM-5 and the proposal for the ICD-11, it is important to understand how traits are linked to treatment outcomes. Building on past research with general traits, we hypothesized that more nuanced and specific relations would be apparent. Furthermore, much of the past research has relied upon self-reports of personality and little is known about how ratings from therapists might be related to outcomes.

SAMPLING AND METHODS

The present paper examined how dimensional traits from the Five-Factor Model predicted outcomes in a case series of 54 therapist-client dyads within a doctoral training clinic. Importantly, this extends past research as dimensional traits were rated by both therapists and clients at intake as well as sequentially over the course of therapy.

RESULTS

Correlations and regression analyses indicated that traits predicted a variety of outcomes including initial engagement in treatment as well as overall symptom reduction across therapy. Specifically, preliminary evidence suggests that therapist-rated conscientiousness at intake was positively related to clients' early engagement in therapy. In addition, openness to experience after the 4th session - particularly as rated by the client - was predictive of long-term therapy outcomes.

CONCLUSIONS

Broadly, these results provided preliminary information about the promise of dimensional models for improving the clinical utility of personality disorder diagnoses. More specifically, these results reinforced the relevance of personality assessment during therapy and indicated the potential predictive value of ratings by therapists and their clients.

The Goldwater Rule: Perspectives From, and Implications for, Psychological Science

When, if ever, should psychological scientists be permitted to offer professional opinions concerning the mental health of public figures they have never directly examined? This contentious question, which attracted widespread public attention during the 1964 U.S. presidential election involving Barry Goldwater, received renewed scrutiny during and after the 2016 U.S. presidential campaign, when many mental health professionals raised pointed questions concerning the psychiatric status of Donald Trump. Although the Goldwater Rule prohibits psychiatrists from offering diagnostic opinions on individuals they have never examined, no comparable rule exists for psychologists. We contend that, owing largely to the Goldwater Rule's origins in psychiatry, a substantial body of psychological research on assessment and clinical judgment, including work on the questionable validity of unstructured interviews, the psychology of cognitive biases, and the validity of informant reports and of L (lifetime) data, has been overlooked in discussions of its merits. We conclude that although the Goldwater Rule may have been defensible several decades ago, it is outdated and premised on dubious scientific assumptions. We further contend that there are select cases in which psychological scientists with suitable expertise may harbor a "duty to inform," allowing them to offer informed opinions concerning public figures' mental health with appropriate caveats.

Incremental Validity of Self- and Informant Report of Personality Disorders in Later Life

Research shows moderate agreement between different sources of information when assessing personality disorders (PDs) in older adults. The differences between measurement methods appear to be not only the result of measurement error, but also an indication that each source holds nonredundant information relevant to PD diagnosis. The current article examines three sources of diagnostic information (self-report, informant report, and clinical interview) and the utility of these instruments in predicting important outcomes in older adulthood. We analyzed data from 1,630 adults between the ages of 55 and 64 years participating in a longitudinal study of later life. PD symptomatology was assessed using multiple methods, which were then used to predict health, marital satisfaction, and cognitive decline. All three sources contributed significantly to the prediction of these outcomes, with important implications for the assessment of older adults in research and clinical settings.

Psychotherapy Expertise Should Mean Superior Outcomes and Demonstrable Improvement Over Time

How the field understands psychotherapy expertise is important. It affects how we practice and how we prepare others for practice. As in our other work, we argue that the most meaningful definition of expertise must involve steady improvement over time to achieve superior performance on some meaningful measure, which typically is client outcome. We also argue that the best means by which a therapist can achieve this is through ongoing deliberate practice. We contrast our position with not only Hill, Spiegel, Hoffman, Kivlighan, and Gelso’s preferred definition, in which they anchor expertise in therapist performance, but also with the various other possible definitions of expertise (e.g., therapist experience, therapist self-assessment of expertise) that they proffer as options.

Development and Examination of the Five-Factor Obsessive-Compulsive Inventory–Short Form

The Five-Factor Obsessive-Compulsive Inventory (FFOCI) is an assessment of obsessive-compulsive personality disorder (OCPD) that is based on the conceptual framework of the five-factor model (FFM) of personality. The FFOCI has 12 subscales that assess those five-factor model facets relevant to the description of OCPD. Research has suggested that the FFOCI scores relate robustly to existing measures of OCPD and relevant scales from general personality inventories. Nonetheless, the FFOCI’s length—120 items—may limit its clinical utility. This study derived a 48-item FFOCI–Short Form (FFOCI-SF) from the original measure using item response theory methods. The FFOCI-SF scales successfully recreated the nomological network of the original measure and improved discriminant validity relative to the long form. These results support the use of the FFOCI-SF as a briefer measure of the lower-order traits associated with OCPD.